Classical Periodontal Literature Review


Study Questions:

  • What effect do malposed teeth have on periodontal health?
  • Can orthodontic therapy improve malposition? What affect does orthodontic movement have on the periodontium?
  • What can patients expect during and after orthodontics?
  • Can patients with periodontitis safely have orthodontics?
  • What tooth movements can be offered for periodontally involved teeth?
  • When can orthodontics be a detriment to periodontal health? How would this change how we treat or manage patients?
  • If flap surgery is indicated in the orthodontic patient, when should open flap debridement be utilized? bone grafting? soft tissue grafting? osseous surgery?
  • When should orthodontics be considered as an alternative to periodontal surgery? In which cases is this indicated?
  • What are some considerations for teeth that undergo extrusion?
  • When else might a fiberotomy be considered?
  • How should extractions be managed in conjunction with orthodontic therapy?
  • Are there any long term effects moving teeth into extraction sites? How can this theory of accelerated movement affect ortho therapy?
  • What is the significance of keratinized tissue during orthodontic movement?
  • What is the relationship between mucogingival problems and tooth position? What is the relationship between mucogingival problems and tooth movement?
  • Is prophylactic gingival grafting ever indicated?
  • What specific challenges are encountered with impacted/unerupted permanent teeth?
  • Are there different approaches based on where and how the tooth is impacted? How should these patients be managed? Are there long term issues with the periodontal health of these teeth?
  • How are implants utilized in ortho therapy?
  • Do Temporary Anchorage Devices (TADs) have the same healing pattern as other titanium based implants?


(References without links have not been added yet)

Effects of malposed teeth and orthodontics on periodontal health

  1. Ainamo J. Relationship between malalignment of the teeth and periodontal disease. Scand J Dent Res. 80:104-110, 1972.
  2. Chung C-H, et al. Comparison of microbial composition in the subginigval plaque of adult crowded versus non-crowded dental regions. Int J Ortho Orthognath Surg 15:321-330,2000.
  3. Artun J, Osterberg SK, Kokich VG. Long-term effect of thin interdental alveolar bone on periodontal health after orthodontic treatment. J. Periodontol. 57:341-346, 1986
  4. Brown IA. The effect of orthodontic therapy on certain types of periodontal defects. I. Clinical findings. J. Periodontol. 44:742-756, 1973.
  5. Kraal JH, et al. Periodontal conditions in patients after molar uprighting. J Prosthet Dent 43:156 – 1980.
  6. Guo R, Lin Y, Zheng Y, Li W. The microbial changes in subgingival plaques of orthodontic patients: a systematic review and meta-analysis of clinical trials. BMC Oral Health. 2017 Jun 2;17(1):90. doi: 10.1186/s12903-017-0378-1.
  7. Guo L, Feng Y, Guo HG, Liu BW, Zhang Y. Consequences of orthodontic treatment in malocclusion patients: clinical and microbial effects in adults and children. BMC Oral Health. 2016 Oct 28;16(1):112.
  8. Zoizner R, Yael Arbel , Nirit Yavnai , Tal Becker , Galit Birnboim-Blau. Am J Orthod Effect of Orthodontic Treatment and Comorbidity Risk Factors on Interdental Alveolar Crest Level: A Radiographic Evaluation. Dentofacial Orthop. 2018 Sep;154(3):375-381.
  9. Alsulaiman A , Elizabeth Kaye , Judith Jones , Howard Cabral , Cataldo Leone , Leslie Will , Raul Garcia. Incisor Malalignment and the Risk of Periodontal Disease Progression. Am J Orthod Dentofacial Orthop 2018 Apr;153(4):512-522
  10. Gorbunkova A , Giorgio Pagni , Anna Brizhak , Giampietro Farronato , Giulio Rasperini. Impact of Orthodontic Treatment on Periodontal Tissues: A Narrative Review of Multidisciplinary Literature. Int J Dent 2016;2016:4723589.

Effects of orthodontic therapy on perio involved teeth. Timing for orthodontic therapy

  1. Ong MA, Wang H-L, Smith FN. Interrelationship between periodontics and adult orthodontics. J Clin Perio 25:271-277,1998. (Review)
  2. Ericsson I : The combined effects of plaque and physical stress on periodontal tissues. J. Clin. Periodontol. 13:918 -, 1986. (Review)
  3. Ericsson I, Thilander B, Lindhe J, Okamoto H. The effect of orthodontic tilting movements on the periodontal tissues of infected and non-infected dentitions in dogs. J Clin Perio 4:278 – 1977.
  4. Corrente G et al: Orthodontic Movement into Intrabony Defects in Patients with Advanced Periodontal Disease: A Clincial and Radiological Study. J Periodontol 2003;74:1104-1109
  5. Polson A, et al. Periodontal response after tooth movement into intrabony defects. J. Periodontol. 55:197-202, 1984.
  6. Cardaropoli D: Reconstruction of the maxillary midline papilla following a combined orthodontic-periodontic treatment in adult periodontal patients. J Clin Periodontol 2004; 31:79-84.
  7. Wennstrom J, Stokland B, Nyman S, Thilander B. Periodontal tissue response to orthodontic movement of teeth with infrabony pockets. Amer J Ortho Dento Orthop 1993; 103:313-319.
  8. Araujo M et al: Orthodontic movement in bone defects augmented with Bio-Oss. An experimental study in dogs. J Clin Periodontol 28:73-80,2001
  9. Melsen B, Agerback N, Markenstam G: Intrusion of incisors in adult patients with marginal bone loss. Am J Orthod Dent Orthoped. 96: 232 – 241, 1989.
  10. Ghezzi C, Masiero S, Silvestri M, Zanotti G, Rasperini G. Orthodontic treatment of periodontally involved teeth after tissue regeneration. Int J Periodontics Restorative Dent. 2008 Dec;28(6):559-67
  11. Roccuzzo M, Marchese S, Dalmasso P, Roccuzzo A. Periodontal Regeneration and Orthodontic Treatment of Severely Periodontally Compromised Teeth: 10-Year Results of a Prospective Study. Int J Periodontics Restorative Dent Nov/Dec 2018; 38(6):801-809.
  12. Verrusio C, Iorio-Siciliano V, Blasi A, Leuci S, Adamo D, Nicolò M. The effect of orthodontic treatment on periodontal tissue inflammation: A systematic review. Quintessence Int. 2018;49(1):69-77.
  13. Gkantidis N, Christou P, Topouzelis The orthodontic-periodontic interrelationship in integrated treatment challenges: a systematic review. N.J Oral Rehabil. 2010 May 1;37(5):377-90. doi: 10.1111/j.1365-2842.2010.02068.x. Epub 2010 Feb 25.

Orthodontics as an alternative to perio surgery

  1. Ingber JS. Forced eruption: Part I. A method of treating isolated one- and two-wall infrabony osseous defects. Rationale and case report. J. Periodontol. 45:199-206, 1974.
  2. Ingber J. Forced eruption. Part II. A method of treating nonrestorable teeth -periodontal and restorative considerations. J. Periodontol 47:203-216, 1976.
  3. Salama H, Salama M. The role of orthodontic extrusive remodeling in the enhancement of soft and hard tissue profiles prior to implant placement: a systematic approach to the management of extraction site defects. Int J Periodontics Restorative Dent. 1993 Aug;13(4):312-33.
  4. Bellamy L et al: using orthodontic intrusion of abraded incisors to facilitate restoration: The technique’s effects on alveolar bone level and root length. J Am Dent Assoc 2008;139;725-733
  5. Carvalho et al: Orthodontic extrusion with or without circumferential fiberotomy and root planing. Int J Periodontics Restorative Dent 2006; 26:87-93
  6. Taner T, Haydar B, Kavuvlu I, Korkmaz A. Short-term effects of fiberotomy on relapse of anterior crowding. Am J Ortho Dentofac Orthop 118:617-623,2000.
  7. Yáñez-Vico RM, Iglesias-Linares A, Ballesta-Mudarra S, Ortiz-Ariza E, Solano-Reina E, Perea EJ. Short-term effect of removal of fixed orthodontic appliances on gingival health and subgingival microbiota: a prospective cohort study. Acta Odontol Scand. 2015;73(7):496-502. doi: 10.3109/00016357.2014.993701
  8. Ogihara S, Tarnow DP. Efficacy of forced eruption/enamel matrix derivative with freeze-dried bone allograft or with demineralized freeze-dried bone allograft in infrabony defects: A randomized trial. Quintessence Int. 2015 Jun;46(6):481-90. doi: 10.3290/j.qi.a33936.
  9. Kang P, Ramy Habib Case Reports. Possible Complications With Implant Site Development Utilizing Orthodontic Extrusion: Three Case Reports. Compend Contin Educ Dent 2019 May;40(5):292-297.
  10. Sachiko Maeda , Takeshi Sasaki. Modality and Risk Management for Orthodontic Extrusion Procedures in Interdisciplinary Treatment for Generating Proper Bone and Tissue Contours for the Planned Implant: A Case Report Int J Implant Dent 2015 Dec;1(1):26.

Teeth moved into extraction sites via orthodontics

  1. Reed B, Polson AM, Subtelny JD. Long-term periodontal status of teeth moved into extraction sites. Am J Orthod Dent Orthoped. 88:205-, 1985.
  2. Hasler R, Schmid G, et al. A clinical comparison of the rate of maxillary canine retraction into healed and recent extraction sites – a pilot study. Euro J Orthod 1997;19: 711-719
  3. Liou E, Huang CS. Rapid canine retraction through distraction of the periodontal ligament. Am J Orthod Dentofac Orthop 1998; 114: 372-380.
  4. Ahn HW, Ohe JY, Lee SH, Park YG, Kim SJ. Timing of force application affects the rate of tooth movement into surgical alveolar defects with grafts in beagles. Am J Orthod Dentofacial Orthop. 2014 Apr;145(4):486-95.
  5. Wilcko MT, Wilcko WM, et al. Accelerated osteogenic orthodontics technique: a 1-stage surgically facilitated rapid orthodontic technique with alveolar augmentation. J Oral Maxillofac Surg. 2009 Oct;67(10):2149-59.
  6. Ru N, Liu SS, Bai Y, Li S, Liu Y, Wei X. BoneCeramic graft regenerates alveolar defects but slows orthodontic tooth movement with less root resorption. Am J Orthod Dentofacial Orthop. 2016 Apr;149(4):523-32. doi: 10.1016/j.ajodo.2015.09.027

Accelerated Orthodontics

  1. Mathews DP, Kokich VG: Accelerating tooth movement: The case against corticotomy-induced orthodontics. Am J Orthod Dentofacial Orthop 144:5, 2013. http://www.ajodo.org/article/S0889-5406(13)00418-6/abstract
  2. Wilcko W, Wilcko MT: Accelerating tooth movement: The case for corticotomy-induced orthodontics. Am J Orthod Dentofacial Orthop 144:4, 2013. http://www.ajodo.org/article/S0889-5406(13)00419-8/abstract
  3. Zimmo N1, Saleh MH2, Mandelaris GA3, Chan HL4, Wang HL5. Corticotomy-Accelerated Orthodontics: A Comprehensive Review and Update. Compend Contin Educ Dent. 2017 Jan;38(1):17-25; quiz 26.
  4. Mota-Rodríguez AN, Olmedo-Hernández O, Argueta-Figueroa L. A systematic analysis of evidence for surgically accelerated orthodontics. J Clin Exp Dent. 2019 Sep 1;11(9):e829-e838.

Keratinized Tissue & Orthodontic Therapy

  1. Suter VG, Heinzmann AE, Grossen J, Sculean A, Bornstein MM. Does the maxillary midline diastema close after frenectomy? Quintessence Int. 2014 Jan;45(1):57-66. doi: 10.3290/j.qi.a30772.
  2. Coatoam GW, et al. The width of keratinized gingiva during orthodontic treatment. Its significance and impact on periodontal status. J. Periodontol. 52:307-313, 1981.
  3. Edwards JG. The diastema, the frenum, the frenectomy: A clinical study. Amer J Orthod Dent Orthoped. 71: 489-508, 1977.
  4. Pini Prato, et al: Mucogingival interceptive surgery of buccally – erupted premolars in patients scheduled for orthodontic treatment I : A 7-year longitudinal study. J Periodontol 71:172-181, 2000
  5. Pini Prato et al: Mucogingival interceptive surgery of buccally-erupted premolars in patients scheduled for orthodontic treatment II: Surgically treated versus non-surgically treated versus non-surgically treated cases. J Periodontol 71:182-187, 2000
  6. Artun J, et al. Periodontal status of mandibular incisors after pronounced orthodontic advancement during adolescence: A follow-up evaluation. Am J Orth Dent Orthop 119:2-10,2001
  7. Karring T, et al. Bone regeneration in orthodontically produced alveolar bone dehiscences. J. Periodontal Res. 17:309-315, 1982.
  8. Rasperini G, Acunzo R, Cannalire P, Farronato G. Influence of Periodontal Biotype on Root Surface Exposure During Orthodontic Treatment: A Preliminary Study. Int J Periodontics Restorative Dent. 2015 Sep-Oct;35(5):665-75. doi: 10.11607/prd.2239.
  9. Godtfredsen Laursen Morten , Mette Rylev , Birte Melsen The Role of Orthodontics in the Repair of Gingival Recessions. Am J Orthod Dentofacial Orthop 2020 Jan;157(1):29-34.
  10. Stappert Dina, Robert Geiman , Zahra Heidari Zadi , Mark A Reynolds. Gingival Clefts Revisited: Evaluation of the Characteristics That Make One More Susceptible to Gingival Clefts. Am J Orthod Dentofacial Orthop 2018 Nov;154(5):677-682.

Orthodontic Management of Impacted Teeth

  1. Kokich V: Surgical and orthodontic management of impacted maxillary canines. Am J Orthod Dentofac Orthoped 2004; 126: 278-283
  2. Artun J, Osterberg SK, Joondeph DR. Long-term periodontal status of labially erupted canines following orthodontic treatment. J Clin Periodontol. 13:856-861, 1986.
  3. Burden D, Mullally B, Robinson S. Palatally ectopic canines: Closed eruption versus open eruption. Am J Ortho Dento Orthop 115:640-644, 1999.
  4. Quiryen M, Op Heij DG, et al. Periodontal health of orthodontically extruded impacted teeth. J Periodontol 71:1708-1714, 2000.
  5. Crescini A et al: Combined Surgical and Orthodontic Approach to Reproduce the Physiologic Eruption Pattern in Impacted Canines: Report of 25 Patients Int J Periodontics Restorative Dent 2007; 27:529-537
  6. Incerti-Parenti S, Checchi V, Ippolito DR, Gracco A, Alessandri-Bonetti G. Periodontal status after surgical-orthodontic treatment of labially impacted canines with different surgical techniques: A systematic review. Am J Orthod Dentofacial Orthop. 2016 Apr;149(4):463-72. doi: 10.1016/j.ajodo.2015.10.019. Review.
  7. Evren AD, Nevzatoğlu Ş, Arun T, Acar A. Periodontal status of ectopic canines after orthodontic treatment. Angle Orthod. 2014 Jan;84(1):18-23. doi: 10.2319/041513-290.1. Epub 2013 Jul 11
  8. Smailiene D, Kavaliauskiene A, Pacauskiene I, Zasciurinskiene E, Bjerklin K. Palatally impacted maxillary canines: choice of surgical-orthodontic treatment method does not influence post-treatment periodontal status. A controlled prospective study. Eur J Orthod. 2013 Dec;35(6):803-10. doi: 10.1093/ejo/cjs102. Epub 2013 Jan 24.

Implants used during Orthodontic Therapy

  1. McGuire M et al: Temporary anchorage devices for tooth movement: A review and case reports. J Periodontol, 2006;Oct:77(10)1613-24
  2. Wiechmann, D et al: Success rate of mini- and micro- implants used for orthodontic anchorage: A prospective clinical study. Clin Oral Impl Res 18, 2007;263-267
  3. Celenza F. Implant interactions with orthodontics. J Evid Based Dent Pract. 2012 Sep;12(3 Suppl):192-201.
  4. Jambi S, Walsh T, Sandler J, Benson PE, Skeggs RM, O’Brien KD. Reinforcement of anchorage during orthodontic brace treatment with implants or other surgical methods. Cochrane Database Syst Rev. 2014 Aug 19;(8):CD005098. doi: 10.1002/14651858.CD005098.pub3. Review


Pediatric Dentistry / Periodontics

Discussion Topics

What are some of the anatomical differences in the jaws and periodontium between children and adults? Is the evaluation, etiology, prevalence, and treatment of mucogingival defects different in children as compared to adults?

  1. Maynard JG Jr, Wilson RD. Diagnosis and management of mucogingival problems in children. Dent Clin North Am. 1980 Oct;24(4):683-703
  2. Andlin-Sobocki A, Marcusson A, Persson,M : 3-year observations on gingival recession in mandibular incisors in children. J. Clin. Periodontol. 18:155-159, 1991.
  3. Addy M, Dummer PM, et al.. A study of the association of fraenal attachment, lip coverage, and vestibular depth with plaque and gingivitis. J Periodontol. 1987 Nov;58(11):752-7.
  4. Renkema AM, Navratilova Z, Mazurova K, Katsaros C, Fudalej PS. Gingival labial recessions and the post-treatment proclination of mandibular incisors. Eur J Orthod. 2015 Oct;37(5):508-13. doi: 10.1093/ejo/cju073.
  5. Delli K, Livas C, Sculean A, Katsaros C, Bornstein MM. Facts and myths regarding the maxillary midline frenum and its treatment: a systematic review of the literature. Quintessence Int. 2013 Feb;44(2):177-87

Do periodontal diseases occur at the same rate and with the same frequency in children as in adults? What are some of the periodontal diseases that appear to be specific to children? Are there differences in the composition of microbial plaque in children as compared to adults?

  1. Oh TJ, Eber R, Wang HL Periodontal diseases in the child and adolescent. J Clin Periodontol. 2002 May;29(5):400-10. Review.
  2. Kumar PS. Sex and the subgingival microbiome: do female sex steroids affect periodontal bacteria? Periodontol 2000. 2013 Feb;61(1):103-24

How effective are tooth transplants? What factors govern the success of tooth transplants?

  1. Atala-Acevedo C, Abarca J, Martínez-Zapata MJ, Díaz J, Olate S, Zaror C. Success Rate of Autotransplantation of Teeth With an Open Apex: Systematic Review and Meta-Analysis. J Oral Maxillofac Surg. 2017 Jan;75(1):35-50. doi: 10.1016/j.joms.2016.09.010.



Effects of malposed teeth and orthodontics on periodontal health

What effect do malposed teeth have on periodontal health? Can orthodontic therapy improve malposition? What affect does this have on the periodontium? What can patients expect during and after orthodontics?

Ainamo 1972

P: Retrospective study looking at the relationship between malaligned teeth and periodontal disease in different groups of teeth.

M&M: The dentitions of 154 Army recruits (age 19-22) were examined clinically and radiographically. The occurrence and degree of displacement and rotation was recorded in 4,316 teeth. PI, GI, retentive calculus index, and CAL loss were recorded. The teeth were bilaterally pooled and grouped into maxillary and mandibular anterior teeth, premolars and molars.

R: Only 60% of subjects brushed 1 or more times /day, and brushing was limited to anterior teeth and facial surfaces. The maxillary laterals and mandibular second premolars were most commonly malaligned teeth. In the maxillary anterior areas, the mean scores for plaque, gingivitis, dental calculus and loss of attachment increased with increasing severity of malalignment. In mandibular anterior teeth a similar association was found between malalignment and extensive plaque formation, gingivitis and loss of attachment but not with calculus accumulation. In the premolar area, the difference was less and it became non-existent in the molar regions.

BL: The incisors and canines showed the most favorable retentive calc index scores, and was the only area that showed a positive correlation between malalignment, gingivitis and CAL loss. The other areas showed no correlation.

Chung 2000

P: To investigate and compare the presence and proportional distribution of periodontal pathogens in the subgingival plaque of adult crowded versus non-crowded dental regions.

M+M: 30 orthodontic patients (19M, 11F; 18-56 years old). Criteria for anterior crowding had to be at least 2mm crowding. Orthodontic records taken: lateral ceph, pano, and FMX; periodontal exam done. PI recorded. Subgingival plaque samples taken from crowded and non-crowded regions (Test and Control of same patient). Supragingival plaque removed with a curette, and subgingival plaque sampled with sterile paper points. 9 bacteria studied: Aggregatibacter actinomycetemcomitans (Aa), P. intermedia, E. Corrodens, C. rectus, Capnocytophaga species. Fusobacterium species, Peptstreptococcus micros. P. Gingivalis and B. forsythus determined using culture and immunoflorescence.

R: Supragingival plaque accummulation in crowded regions was SS greater than non-crowded. Crowded regions contained more species of periodontic pathogens than the samples from non-crowded regions. More spirochetes and motiles were present in the crowded region samples. Fusobacterium species, Capnocytophaga species, C. rectus and P. micros were more common in crowded regions. Amount of crowding was not linearly related to the number of pathogens. Patients with extremely good OH have less pathogens regardless of crowding.

BL: Subgingival plaque of crowded regions provide a more favorable environment for the colonization and growth of the periodontal pathogens.

Artun 1986 (root proximity)

P: To assess the long-term effect of thin interdental alveolar bone on periodontal health after orthodontic treatment.

M&M: 25 adult patients, ages 28 to 55 years, with at least 16 years after orthodontic treatment were selected for exam based on the following criteria: 1) radiographic evidence with root proximity 2) models showing well-aligned teeth (ej. no open contacts), 3) closed interproximal contacts. Measurements were made on PA radiographs projected on a screen and clinical evaluation of predominantly anterior dentition. The position of the CEJ and the level of the alveolar bone (AB) were determined and the distance between CEJ-AB was measured. Also, the distance between the roots was measured. Root proximity was diagnosed when the roots were closer than 0.8mm.Adjacent or contralateral interproximal areas with more than 1mm between the roots were used as controls. Gingival health, level of attachment and bone in sites of thin interproximal bone were measured and compared with neighbouring control sites having normal bone width.

R: No SSD were observed in hygiene, tissue health or attachment and bone levels between areas with thin interproximal bone and controls with normal interproximal bone. However, when measured radiographically, the distance between CEJ-AB was significantly longer in the root proximity sites. This discrepancy was most likely due to radiographic distortion according to the authors. The study indicates that root proximity between anterior teeth after ortho treatment has no long-term detrimental effect on the periodontium as long as the teeth are well aligned.

D: Too few molar sites were included to draw conclusions for posterior teeth.

BL: In anterior areas, marginal periodontal breakdown is unrelated to the thickness of bone between the roots when the crown of the tooth is in the proper position.

Cr: Pas not standardized

Brown 1973

Purpose: To study the effects of a certain type of orthodontic tooth movement (uprighting molars) on existing periodontal osseous defects in humans.

Materials and methods: 5 patients were selected that 1) were Tx planned for extraction of all or many of remaining teeth and mandibular removable prosthesis, 2) advanced periodontal disease with vertical subcrestal osseous lesions and 3) loss of a mandibular posterior tooth, mesial inclination of the distal tooth and osseous defect associated with the mesial surface of that tooth. One patient served as control.

Standardized radiographs were taken at the beginning and the end of the experimental period, after metal endosseous reference points were inserted in order to evaluate the defects. Photographs were taken and casts from alginate impressions were also made. An assessment of the soft tissues was performed (evaluation of marginal gingiva, amount of attached gingiva, recession).

In the experimental group SRP was performed in the beginning of the experiment only and in the control patient it was repeated twice a week.

Orthodontic forces were applied to the test group that resulted in movement of the tooth in more distal and upright position. Following the completion of orthodontic procedures, the experimental teeth were stabilized for a minimum of 3 months to allow the remodeling of the bone. Patients were administered TTC until 14 days before the tooth extraction, which allowed complete clearance of the labeling medium from all tissues except the bone. Teeth in the experimental group were removed in block section and histologic analysis was performed.

Results: Patients had deep defects on the mesial of mandibular 2nd molars. They exhibited substantial plaque deposition, gingival inflammation and proliferative changes in gingival architecture. Slight improvement was observed after SRP. As the orthodontic treatment progressed, gingival margin was positioned more apically and reduction in plaque retention, inflammation and edema was observed.

In all patients the molars were uprighted within a period of 90-120 days.

The experimental group showed 2.5 mm PD reduction more than the control patient. There was 0.63mm gain in bone height clinically and 1mm radiographically.

The histologic results would be subject of a forthcoming publication.

Conclusion: Orthodontic movement resulted in teeth with favorable axial inclination, significant reduction in the depth of the defects and desirable changes in the gingiva. Lesions would be more amenable to conventional periodontal techniques and complete pocket elimination could be achieved.

Kraal 1980

Purpose: To assess periodontal conditions in patients after molar uprighting.

Materials and methods:

  • 22 patients who had molar uprighting an average of 3 1/2 years prior were examined.

  • 15 patients received unilateral uprighting and 7 received bilateral uprighting.

  • Contralateral molars or adjacent molars served as controls.

  • Changes in bone levels, inflammation (gingival index) and probing depths were recorded.


  • Changes in alveolar height mesial to uprighted molars were not different from changes on the mesial of control teeth.

  • Gingival index scores around uprighted molars were not different from controls.

  • Pockets mesial to uprighted molars were shallower than mesial pockets in control (3.3 vs 3.9).

  • Gingival scores were worse around teeth with submarginal restorations regardless whether it was control or test.

BL: Because the periodontium adjacent to molars which were uprighted and retained with fixed partial prostheses was in no worse condition than that around equivalent teeth in a continuous dentition, it is concluded that molar uprighting is a reasonable mode of treatment.


Topic: malposition

Authors: Guo R, Lin Y, Zheng Y, Li W.

Title: The microbial changes in subgingival plaques of orthodontic patients: a systematic review and meta-analysis of clinical trials. BMC Oral Health.

Source: 2017 Jun 2;17(1):90. doi: 10.1186/s12903-017- 0378-1.

Type: systematic review

Keywords: Periodontopathogens, Orthodontic appliance, Periodontal disease, Systematic review

Purpose: to investigate the microbial changes in subgingival plaques of orthodontic patients.

Methods: The PubMed, Cochrane Library, and EMBASE databases were searched up to November 20, 2016. Longitudinal studies observing microbial changes in subgingival plaques at different time points of orthodontic treatment are included. The methodological quality of the included studies was assessed by Methodological index for non-randomized studies (MINORS). The studies that reported the frequency of subgingival periodontopathogens were used for quantitative analysis. Other studies were analysed qualitatively to describe the microbial changes during orthodontic treatment.

Results: Thirteen studies were selected, including two controlled clinical trials, three cohort studies and eight selfcontrolled studies. Four periodontopathogens, including Aggregatibacter actinomycetemcomitans (Aa), Porphyromonas gingivalis (Pg), Prevotella intermedia (Pi) and Tannerella forsythia (Tf), were analysed. Following orthodontic appliance placement, the frequencies of Pg and Aa showed no significant change (P = 0.97 and P = 0.77), whereas the frequency of Tf significantly increased (P < 0.01) during short-term observation (0–3 months). The frequency of Pi showed a tooth-specific difference, as it presented no SS difference at the site of the first molar but was SS increased at the incisor. During long-term observation (> = 6 months), two studies reported that the levels of subgingival periodontopathogens exhibited a transient increase but decreased to the pretreatment levels afterwards. After removal of the orthodontic appliance, the four periodontopathogens showed NSSD compared with before removal.

Conclusion: The levels of subgingival pathogens presented temporary increases after orthodontic appliance placement, and appeared to return to pretreatment levels several months later. This indicates that orthodontic treatment might not permanently induce periodontal disease by affecting the level of subgingival periodontal pathogen levels. Further studies of high methodological quality are required to provide more reliable evidence regarding this issue.


Topic: Malocclusion

Author: Guo L, Feng Y, Guo HG, Liu BW, Zhang Y

Title: Consequences of orthodontic treatment in malocclusion patients: clinical and microbial effects in adults and children

Source: BMC Oral Health. 2016 Oct 28;16(1):112

Type: Randomized controlled trial

Keywords: Malocclusion; Orthodontic treatment; Fixed orthodontic appliances; Pathogens

Purpose: To investigate level changes of periodontal pathogens (P.gingivalis, F. nucleatum, P. intermedia and T. forsythensis) in malocclusion patients before, during and after orthodontic treatments, and to confirm the difference between adults and children.


  • 108 malocclusion patients were included: 46 adults (18-32 years old) and 62 children (8-15 years old)
  • Patients had no history of periodontal disease, caries or dental fillings.
  • All patients were treated by straight wire appliance after diagnosis. The first molars and the premolars were all attached with 1.1mm diameter stainless steel retaining wires.
  • Both sides of mandibular central incisors and the mandibular 1st and 2nd PMs were selected as the observed teeth.
  • Subgingival plaques were collected at medial and distal buccal axial ridge of the observed teeth at three different time points (before ortho treatment, one month and three months after treatment).
  • Clinical indices, including plaque index (PI), gingival index (GI), bleeding on probing (BOP), probing depth (PD and attachment loss (AL) of observed teeth were examined.


  • Detection rate of P.gingivalis, F. nucleatum, P. intermedia and T. forsythensis inc from baseline to the third month with NSSD between them, and then returned to pre-treatment levels 12 month after applying orthodontic appliances.
  • Adults’ percentage content of the 4 periodontal pathogens was SS higher than those of children at baseline and the first month, but NSSD was seen by month 3.
  • Children showed upward trends in the amount of periodontal pathogens at 3 months, whereas all the adults were stable by 3 months.
  • PI and BOP were SS increased from baseline to the first and to the third month in both adults and children.
  • PD were increased from baseline to first month, followed by a downward trend in the third month; however, all patients failed to detect with AL.

Bottom Line: Fixed orthodontic appliances may have an influence in the periodontal and microbiological statuses of malocclusion patients in both adults and children. The effect of fixed orthodontic appliances may be more significant in children than in adults. The effect of fixed orthodontic appliances still need further research for long term outcomes.


Effects of orthodontic therapy on perio involved teeth. Timing for orthodontic therapy

Can patients with periodontitis safely have orthodontics? What tooth movements can be offered for periodontally involved teeth? When can orthodontics be a detriment to periodontal health? How would this change how we treat or manage patients? If flap surgery is indicated, when should open flap debridement be utilized? Grafting? Osseous surgery?
Ong MA 1998

P: Review article on the interrelationship between periodontics and orthodontics in adults.

D: Ortho can be used to improve the perio condition via 1. Uprighting or repositioning teeth to improve parallelism of abutment teeth 2. Improving future pontic spaces, 3. Correcting cross-bites, 4. Extruding teeth (if fractured)/ Intruding teeth, 5. Correcting crowding of teeth, 6. Achieving adequate embrasure space and proper root position, 7. Repositioning teeth for placement of implants, 8. Restoring lost vertical dimension, 9. Increasing or decreasing overjet/ overbite, 10. Closure of diastemas

  • Ortho forces influence on bone (Reitan 1985, Proffit 1993a): resorption in areas of pressure and new bone formation where there is tension. When pressure is applied to a tooth, there is an initial period of movement for 6-8 days as the PDL is compressed. Compression of the PDL results in blood supply being cut off to an area of the PDL and this produces an avascular cell-free zone by a process termed “hyalinization”. When hyalinization occurs, the tooth stops moving. Light forces will cause only a short delay in txt, whereas heavier forces might cause a longer period of delayed movement. The PDL must be regenerated for movement to occur again. This regeneration cannot occur in areas of inflammation.

  • Lindhe (1989) recommends that in the initial stage of ortho txt in adults, an interrupted force of 20-30 g be used. Later on the force may be increased (up to 30-50 g in tipping and 50-80 g in bodily movements, corresponding to a distance of movement of 0.5-1.0 mm. per month) depending on the degree of marginal bone loss and the amount of remaining alveolar bone. Melsen (1989) published that intrusion can be done in perio healthy patients at a rate of 5-15g/tooth (lower force).

  • Multiple studies show that teeth can be moved into adjacent osseous defects, have extrusion and labial tipping of the anterior teeth without jeopardizing the perio support if there is adequate plaque control.

  • Ericsson has published multiple studies showing that ortho treatment in the presence of perio dz can worsen the perio condition, whereas even in reduced periodontium if the plaque control is adequate, teeth can be moved with no consequence to the perio apparatus.

  • With derotation, circumferential superficial fiberotomies can be done, even multiple times and decrease the possibility of relapse. This procedure should be done very close to the end of ortho txt. Another indication for CSF is forced eruption when the perio apparatus needs to remain at the same apico-coronal dimension as the tooth moves more coronally.

  • Ortho bands on periodontium: short-term: gingivitis and gingival hyperplasia NOT associated w/CALoss in children (Baer & Coccaro 1964, Zachrisson & Zachrisson 1972, Kloehn & Pfeifer 1974, Alexander 1991). There are differing opinions on adults, in that there is no long term effect (Sadowsky & BeGole 1981, Poison & Reed 1984, Poison et al. 1988); some effect – loss of attachment in adolescents (Alstad & Zachrisson 1979); – root resorption in adults (Trossello & Gianelly 1979)

  • Although a higher amt of periopathogenic bacteria can be seen after band placement, neither adults nor adolescents appear to be at a higher risk for developing perio dz.

  • Open and closed SRP and/or gingival augmentation should be performed as appropriate prior to any tooth movement (Glickman 1964, Prichard 1965, Proffit 1993d). Any pocket reduction surgery including osseous should be delayed until the end of txt b/c tooth movement itself might modify the gingival or osseous morphology. (Goldman and Cohen 1968). Close monitoring and shorter SPT intervals might be indicated.

  • Implants and ortho: successful cases have been reported using implants to: retract and realign teeth (Odman et al. 1988, Arbuckle et al. 1991, Block & Hoffman 1995), close edentulous spaces (Shapiro & Kokich 1988, Roberts et al. 1989, Roberts et al. 1994), correct midline and anterior tooth spacing (Odman et al. 1988), reestablish proper A-P and mediolateral positions for malposed molar abutments (Arbuckle et al. 1991, Haanaes et al. 1991), intrude and/ or extrude teeth (Odman et al. 1988, Haanaes et al. 1991, Salama & Salama 1993, Southard et al. 1995), correct a reverse occlusal relationship (Shapiro & Kokich 1988, Van Roekel 1989, Higuchi & Slack 1991), correct an anterior open bite (Roberts et al. 1984), protract a single arch or the entire dentition (Higuchi & Slack 1991) and provide stabilization for teeth with reduced bone support (Odman et al. 1988).

BL: Perio health is essential for any dental treatment. Adult patients must undergo OHI and perio maintenance during active ortho treatment. Close monitoring of adults with reduced perio support is mandatory. Adult orthodontic teeth movement can be performed on both healthy and diseased periodontiom with few detrimental effects (root resorption) if perio inflammation is controlled and meticulous OH maintained throughout active therapy.

Ericsson 1986

P: A review to report on studies performed in beagle dogs attempting to evaluate the effect of orthodontic and jiggling-type trauma on the supporting structures of premolars.

D: The reports have unanimously demonstrated that in situations where orthodontic or jiggling forces were inflicted on teeth with a normal periodontium, or on teeth with overt signs of gingivitis, the PDL tissue reacted by transitory signs of inflammation. These phenomena occurred without the concomitant loss of clinical attachment and development of pathologically deepened periodontal pockets. If jiggling trauma was inflicted on teeth with an ongoing plaque-associated destructive periodontitis, the resulting inflammatory reactions caused enhanced loss of attachment and angular bony defects. When orthodontic type of trauma is allowed to act on a single tooth or a group of teeth, separate pressure and tension zones within the PDL will develop and later alveolar bone and root cementum also involved. Orthodontic tilting movement of teeth (ie. Intrusion) in a plaque-infected dentition may shift a supra-gingival located plaque into a sub-gingival position resulting in periodontal tissue breakdown. Forces causes bodily movement will not affect the supra alveolar tissue and not cause AL even with the presence of supraG plaque.

Ericsson 1977

P: To study whether it is possible, by orthodontic movement, to shift a supragingival plaque into a subgingival plaque situation and to test the tissue reactions around tilted and intruded plaque-infected teeth.

M&M: 5 beagle dogs had mandibular 3rd PM’s extracted and had defects surgically created on lower 4th PM’s and copper bands placed with plaque accumulation for 21 days. Cotton ligatures were placed for 210 days. The dogs were fed a plaque inducing diet during this period. APF was then performed at day 210 (after perio breakdown had occur), a notch placed at the level of the alveolar bone and OH instructed for 60 days. Ortho appliances producing tipping and intrusion forces were placed. A spring with 40-50 grams of force was installed to tip the lower 4th PM mesial and apical. Plaque was allowed to accumulate on right side (test group), the other side (control group) received OH bid until day 450 when dogs were sacrificed. Standardized radiographs and CAL measurements at days 210 & 450, as well as histometry was performed.

R: Both test and control teeth were tilted and intruded, with NSSD. The size of the CT infiltrate and PDL area was SS greater for the test group. In 4 out of 5 dogs of the test group resulted in the apical shift displacement of CT attachment. Plaque-infected teeth showed subgingival plaque and pocket epithelium, a large supra- & sub-gingival infrabony cell infiltrate, and angular widening of the PDL. Control teeth showed no subgingival plaque and the epithelium had the appearance of a junctional epithelium. Clinical measurement, control group gain attachment and test group loss some attachment (+1.2mm vs. -0.5mm), but histologically in the attachment level no sig difference was found.

BL: Ortho intrusion may shift a supragingival plaque into a subgingival position. This movement in plaque-infected teeth may result in infrabony pocket formation.

Corrente 2003

P: To evaluate the effect of a combined approach (periodontal surgery and orthodontic intrusion) in treating adult periodontal patients with infraosseous defects in extruded maxillary central incisors

M&M: 10 adult patients with advanced periodontal disease with extruded maxillary central incisor with infrabony defect at its mesial aspect and probing depth (PD) > 6 mm were included. Patients were treated by SRP and then orthodontic intrusion. Maintenance therapy was performed every 2 to 3 months until the orthodontic treatment was completed. At baseline, PD and clinical attachment level (CAL) were measured. The vertical distance between the horizontal projection of the bone crest on the root surface (TD) and the most apical point of the bone defect, and the horizontal distance from the bone crest and TD were assessed on standardized radiographs.

R: Mean PD reduction was 4.35 mm, with a residual mean PD of 2.80 mm (Mean initial 7.15 mm). Mean CAL gain was 5.50 mm (Mean initial 8.95 mm, final 3.45 mm). The mean radiological vertical and horizontal bone fills were 1.35 mm (initial 4.3 mm, final 2.95 mm) and 1.40 mm (initial 3.4 mm, final 2 mm) respectively. All differences were of statistical significance (P<0.001).

B/L: The combined orthodontic and periodontic therapy resulted in the realignment of extruded teeth with infrabony defects, obtaining a significant probing depth reduction, clinical attachment gain, and radiological bone fill.

Polson 1984

P: To evaluate the effect of tooth movement on the osseous morphology and CTA level of intrabony defects.

M&M: 4 rhesus monkeys, all but one incisor in each arch removed and allowed to heal for 6 months. Orthodontic bands were placed on the cuspids (anchoring teeth) and fitted with a rectangular arch wire. The arch wire was connected to the incisor via a bonded bracket. Intrabony pockets (mesial or distal) were created around the incisors by placing elastics around the necks of the teeth. After 5 months of active pocket formation, 7 to 8mm deep pockets could be probed (approximately 50% attachment loss) and radiographs demonstrated the presence of mesial and distal angular defects. The elastics were removed 2 months later, the teeth were root planed to the bottom of the angular defect. OH program (toothbrushing and topical application of 2% CHX 3 times/week) was maintained until the end of the study. 3 weeks after the initiation of OH program, the orthodontic appliance was activated to move the experimental tooth in either a mesial or distal direction into the osseous defect associated with the intrabony lesion. 4 incisors were moved into the defect and the other four incisors with induced intrabony pockets were left as controls (no tooth movement). 3 months after initiation of treatment the teeth had moved 6mm. Retained for 2 months and removed for histology.

R: Controls exhibited angular defect morphology with the epithelial lining extending apical to the level of instrumentation. The end of the epithelium was located 2 to 3 mm apical to crestal bone. Experimental group at pressure side exhibited narrowing of the defect with epithelial lining of the root surface to the apical extent of root instrumentation. The root exhibited some resorption apical to the area of instrumentation. New bone was present adjacent to the PDL space. No new CTA was demonstrated. Tension side: the angular defects were not present and the crest of the bone was apical to the level of root planing. There was no evidence of new CTA to the instrumented portion of the root. New bone and normal PDL were apparent.

CON: Histology is necessary to critically evaluate the remodeling process. Definitive changes in osseous morphology occur without any changes in CTA levels. Ortho may be carried out on compromised teeth without further CAL loss when plaque and inflammation are controlled.

Cardaropoli 2004

P: To evaluate the predictability of a combined orthodontic–periodontic treatment in determining

the reconstruction of the interdental papilla between maxillary central incisors.

M+M: 28 healthy patients (22F, 6M) with infrabony defect on #8 or #9 w/ PD of at least 6mm; and extrusion of one maxillary central incisor were treated. All defects were treated w/ OFD (no graft or membrane placed)- FTF was reflected extending from the distal of both centrals w/ vertical releasing if needed- intrasulcular incisions only, no attempt for papilla preservation technique. At 7-10 days post-op, ortho movement was begun. Teeth were intruded, realigned, and diastemas closed via contiguous and light forces of 10-15g/tooth. Ortho therapy lasted 6-18 months, w/ a mean time of 11.7 months and pts had maintenance appts every 3-4 months during therapy. PD, CAL, and papilla presence index were assessed at baseline, at end of treatment, and at 1 year.

R: All parameters showed statistical improvement between the initial and final measurements, and showed no changes at follow up time.

The mean residual probing depth was 2.5 with a decrease of 4.3 mm, while the mean CAL gain was 5.93mm. The average distance from bone to contact point was 6.46mm (range 5-9mm).

The initial papilla presence index (used Nordland & Tarnow classification system) mean was 1.57 at baseline and 0.61 at the end of observation.

NSSD in reconstruction of papilla in thin vs thick biotypes.

BL: At the end of orthodontic treatment, a predictable reconstructions of the papilla was reported, both in pts with thin and thick biotypes.

Wennstrom 1993

P: To evaluate the effect of orthodontic tooth movement on the level of the connective tissue attachment in sites with infrabony pockets.

M&M: 4 beagle dogs had 2nd and 4th premolars extracted. No plaque control measures at any point in the study. Angular bony defects were sx created at the mesial of 3rd premolars with a notch placed at base of defect on the root. Cotton ligatures were placed for 3 weeks and an additional 2 months of plaque accumulation occurred before ortho movement began. In each dog, one premolar moved through the defect and one moved away from the defect. Maxillary teeth 3rd PM served as controls (no ortho movement). After 5-6 months of ortho movement, teeth were stabilized for 2 months before biopsy, then removal of appliances. Clinical assessment (PPD, CAL and tooth position) with radiographic and histological analysis was done.

R: Plaque accumulation and BOP present in both experimental and control group. Average sagittal movement 5 mm. The stationary control teeth gained some attachment levels at 5 months and had decreased PD, while the experimental teeth experienced some pocket depth increase and a loss of clinical attachment. However, the variance was high for both groups (1-1.5mm standard deviation). Histological evaluations for both groups showed presence of inflammatory cell infiltrate in the CT adjacent to the pocket epithelium extending apical to the crest of the alveolar bone. In the test group, all teeth had the apical level of the JE apical to the notch. This only occurred in 2/8 control teeth (most were at the notch) and the difference was SS.

BL: Orthodontic therapy involving bodily tooth movement with inflamed, infrabony pockets may enhance the rate of loss of the connective tissue attachment. Perio treatment should occur prior to initiating ortho treatment and oral hygiene should be maintained during treatment.

Araujo 2001

Purpose: To study if it is possible by orthodontic means to move a tooth in an alveolar ridge augmented with Bio-Oss and the tissue reactions associated with such a movement.

Materials and methods: 5 beagle dogs. After 1st, 2nd and 4th mandibular premolars were extracted in both sides, the interradicular septa of the 4th premolars were resected and the defect of the 4th premolar on the left side was filled with Bio-Oss. Flaps were then adjusted to achieve full coverage on both sides. 3 months later, orthodontic appliances were inserted. The force resulted in tooth displacement of 1mm/month on both test and control sides and treatment continued until the distal root of the 3rd premolar on the sides had been moved into the previous extraction sockets of the 4th premolar. 2 weeks after the final activation dogs were sacrificed and histologic analysis was performed.

The following regions were identified:

  1. Zone A: bone tissue within the distal portion of the previous 4th premolar site, 4x6mm
  2. Zone B: distal aspect of the distal root of the 3rd premolar, pressure side and a 300μm wide area adjacent to it
  3. Zone C: the mesial aspect of the distal root of the 3rd premolar, tension side

Results: All sites healed uneventfully. The mean movement of the 3rd premolars was 3.85±0.57mm in the test group and 3.37±0.45 mm in the control group.

Zone A: In the test side it was comprised of a relatively dense mineralized bone, in continuity with the cortical bone of the alveolar ridge. This tissue contained lamellar bone, Bio-Oss particles and small amounts of immature bone and bone marrow. Some of the particles that were found above the alveolar ridge were encapsulated in connective tissue. In the control side, the marginal region of the extraction sites was occupied by a relatively thin layer of cortical, lamellar bone and cancellous bone apical to it.

Zone B: Same characteristics in both groups (arrested resorption, cellular cementum with fibers on the resorbed root surface, PDL with fibers organized in different directions and osteoclasts on the bony wall facing the PDL). On the test side Bio-Oss particles were found within the PDL, but not in contact with the root surface.

Zone C: Similar features in both groups. Newly formed woven bone and the trabeculae were perpendicular to the long axis of the tooth. Root surface was covered by layers of cellular cementum. No particles of Bio-Oss found.

In Zone A, the alveolar ridge of the test group consisted of 43.5% of mineralized bone, 14.8% Bio-Oss particles and 41% bone marrow. On the control group the ridge included 44.4% mineralized bone and 55.7% bone marrow.

In zone B, Bio-Oss occupied 8.9% of the space. Bone marrow was 23.7% in the test group and 38.8% in the control group.

The width of the PDL ranged between 0.28 – 0.38mm at the tension side (Zone C) in both groups.

Conclusion: Bio-Oss degradation and elimination occurs during orthodontic movement. The detailed mechanism is still not totally understood.

Melsen 1989

Purpose: to orthodontically intrude elongated teeth in adult pts with varying degrees of periodontal damage and evaluate the effects of treatment on the periodontal condition.

Materials and methods:

  • 30 adult pts, characterized by marginal bone loss & deep overbites, were treated by intrusion of the upper incisors.

  • Four different appliances for intrusion were placed:

    • a) J hooks & extraoral highpull headgear, b) utility arches, c) intrusion bent into a loop in a 0.17x 0.25inch wire, & d) base arch as described by Burstone.

  • Before treatment all patients received adequate periodontal treatment involving instruction, cleaning, and curettage. 15 pts had a MWF so pockets were <3 mm.

  • The intrusion was evaluated from the displacement of the apex, incision, and the center of resistance of the most prominent or elongated central incisor.

  • Change in the marginal bone level and the amount of root resorption were evaluated on standardized intraoral radiographs. The pockets were assessed by standardized probing and the clinical crown length was measured on study casts.


  • The results showed that the true intrusion of the center of resistance varied from 0 to 3.5mm and was most pronounced when intrusion was performed with a base arch.

  • The clinical crown length was generally reduced by 0.5 to 1.0 mm.

  • The marginal bone level approached the CEJ in all but six cases.

  • All cases demonstrated root resorption varying from 1 to 3 mm.

  • The total amount of alveolar support, that is the calculated area of the alveolar wall, was unaltered or increased in 19 of the 30 cases.

  • The dependency of the results on the oral hygiene, the force distribution, and the perioral function was evaluated in relation to the individual cases.

BL: Intrusion works best when (1) forces were low (5 to 15 gr per tooth) with the line of action of the force passing through or close to the center of resistance, (2) the gingiva status was healthy, and (3) no interference with perioral function was present. Root resorption occurred in all cases.

Topic: ortho in perio pts

Authors: Ghezzi C, Masiero S, Silvestri M, Zanotti G, Rasperini G.

Title: Orthodontic treatment of periodontally involved teeth after tissue regeneration

Source: Int J Periodontics Restorative Dent. 2008 Dec;28(6):559-67

Type: clinical

Keywords: orthodontic movement, guided tissue regeneration, periodontal treatment.

Purpose: to evaluate the validity of orthodontic movement of teeth treated with GTR.

Methods: 14 patients with severe intrabony defects and pathologic tooth migration were treated with guided tissue regeneration (GTR) and subsequent orthodontic therapy. Clinical decision-making on the treatment of the infrabony defect was made according to the protocol described by Cortellini and Tonetti; 3-wall defects were treated with EMD alone, whereas two-wall and one-wall defects were treated with a resorbable membrane and bone graft. Orthodontic treatment started 1 yr after surgery. Probing pocket depths (P PD), clinical attachment levels (CAL), and gingival recessions were assessed at baseline, 1 year after GTR, and at the end of orthodontic therapy. Radiographs were obtained at all time points. Esthetic parameters were recorded with the papilla presence index (PPI). Statistical analyses were carried out to compare the data at each time point.

Results: From baseline to 1 year after GTR, the mean PPD reduction was 5.57 mm, with a residual mean PPD of 2.71 mm; mean CAL gain was 5.86 mm. Both differences were statistically significant. There were no statistically significant differences between 1 year after GTR and the end of orthodontic therapy (mean PPD reduction 0.07 mm; mean CAL gain 0.43 mm). The reduction in PPI reflected the enhancement of papilla height that was observed in 9 of the 14 patients.

Conclusion: Within the limits of this research, this study affirms the possibility of a combined orthodontic-periodontal approach that prevents damaging the regenerated periodontal apparatus and produces esthetic improvements as a result of realignments and enhancement of papilla height.

Orthodontics as an alternative to perio surgery

When should orthodontics be considered as an alternative to periodontal surgery? In which cases is this indicated? What are some considerations for teeth that undergo extrusion? When else might a fiberotomy be considered?


Ingber (I) 1974

P: To provide a biologic rationale and clinical evidence of forced eruption to alter osseous defects.

R/DISC: Forced eruption is eruption of a tooth with its attachment apparatus. It readily occurs in health but is unpredictable in the presence of inflammation. The technique is used to alter/ eliminate isolated 1 to 2 wall defects where other therapies are contraindicated.

CASE REPORT: 50 YO female with isolated 8 mm 1-walled defect distal of #20 w/ class II mobility. Pt received curettage, proximal movement (which narrowed the defect) to close contacts, then forced eruption was employed. 2 to 3mm was reduced occlusally. In 15 days, 2-3 mm of eruption was achieved. Crestal apposition of alveolar bone was seen and preop PD of 8 mm was reduced to 3 mm postop. No time for completion of forced eruption was noted.

BL: Forced eruption is an alternative method when osseous Sx (resection or regeneration) is not indicated for treatment of 1-2wall osseous defects.

Ingber (II) 1976

P: Discussion on forced eruption as a useful treatment to manage the isolated non-restorable tooth

Disc: Forced eruption is suggested as an alternative method to manage root fractures in region of alveolar crest for treating non-restorable teeth. The mechanical procedure of acceleration the eruption of a tooth produces an alteration of the gingival and supporting tissues. Forced eruption will bring the gingiva and the alveolar bone towards the occlusal plane. The resultant change in the position of the soft tissue is not due to a displacement of the mucogingival junction but rather to an increase in the zone of the attached gingiva.

After forced eruption, periodontal surgery is done after a period of stabilization (2-6 months) to reposition the gingival complex to approximate the pre-operative state at a level constant with the adjacent teeth. Forced eruption results in uneven marginal ridges. Although “angular crests” are not considered infrabony defects, they may be unstable and predispose to breakdown. So, recontouring the osseous altered crest must be part of the surgical procedure. Also, perio surgery is performed to expose adequate tooth structure for restorative procedures. It is mentioned that there is high incidence of fenestration of the facial bone after eruption which may influence the design of the surgical procedure.

Restorative procedures post-eruption require great comprehension from the restorative dentist. In a tooth that has been erupted the diameter of the root decreases as the preparation moves apically, while the space between the teeth remains constant. The final restoration therefore will exhibit a greater degree of taper from the gingival margin to the incisal edge and will require greater attention to the gingival areas to avoid overcontoured margins.

Case Reports: 5 cases presented with clinically acceptable post-extrusion results.

Salama 1993

P: Introduce a new perspective, of orthodontic extrusion of “hopeless” teeth to enhance the soft and the hard tissue dimensions of potential implant recipient sites.

Discussion: Extraction sites of compromised teeth exhibit a socket environment at the apical end and some defect in the coronal aspect.

Classification system of residual defect morphology and the regenerative potential of the extraction defect:

Type I extraction site: 4 wall socket or 3 wall with a dehiscence (5mm or less). Adequate bone beyond the apex (4 to 6mm) for initial stabilization of an implant. Osseous crest harmonious (3-5mm offset is better for optimal emergence profile of the restoration). Labial plate adequate. Recession is manageable. Low smile line or post quadrants. Recommendation: Immediate implant placement with GTR can be used in this type I.

Type II extraction site: Moderate compromised regenerative and esthetic environment. Defect extends to middle third of root or dehiscences >5mm. discrepancy b/w bone crest and the neck of adjacent teeth. Significant recession. Moderate labial plate loss. Anterior area or high smile line. Regeneration potential is limited. Recommendation: Orthodontic modification of the defect. The remaining apparatus of hopeless teeth will be used to manipulate tissue through movement, altering the implant recipient site. A tooth has ability to affect its environment across the entire length of its attachment. When feasible the hopeless tooth will be extruded almost to extraction to achieve maximal benefits. Besides extrusion, other ortho movement (protrusion or retrusion) can be applied to improve the site. Regeneration of papilla can be expected because the lip of bone that follows the erupting tooth can create or maintain the papilla. Crown of the tooth is removed and pulpectomy is performed, provisional is placed and root is debrided. Eruptive phase usually requires 4-6w, followed by 6 weeks of stabilization (less than GTR). Contraindications: Uncontrollable inflammatory lesions, combined endo-perio lesions, fractured roots, when the integrity of remaining attachment apparatus is not ideal.

Type III extraction site: Severely compromised site. Inadequate vertical and B-L dimensions. Recession is present and labial plane bone loss is severe. Recommendation: 1st step: GTR. 2nd step: Implant placement.

Bellamy 2008

Background: Orthodontic intrusion is valuable alternative approach to facilitate restoration.

Purpose: To determine the effect of orthodontic intrusion of abraded incisors in adult patients to facilitate restoration, focusing specifically on changes in alveolar bone level and root length.

M&M: 43 consecutively treated adult patients (27 men and 16 women; age > 19 yrs) were treated by intrusion on incisors to create interocclusal space for restorative treatment. The cephalometric radiographs were obtained to measure bone level and root length pre and post-treatment.

Results: Bone level followed the tooth during intrusion, but a small amount of bone loss occurred. No significant associations with age, sex, treatment time, intrusion or pre-treatment bone level. All intruded teeth exhibited significant root resorption during treatment (mean = 1.48 mm). However, the change was similar to that seen in incisors that were not intrusion suggesting the amount of apical resorption may be related to displacement of the apex rather than direction of movement. There was a positive relationship between pre-treatment root length and root resorption.

Con: Intrusion is a valuable adjunct to restorative management of incisor wears. Consequences of alveolar bone loss and root resorption are minimal and comparable with the consequences of other orthodontic tooth movements.

Carvalho 2006

P: To compare orthodontic extrusion (OE) to orthodontic extrusion combined with circumferential supracrestal fiberotomy and root planning (OEFRP).

M&M: Randomized clinical trial. 18 non-smoker patients, 20 single rooted teeth. Based on radiographic and clinical evaluation, crown lengthening was indicated. No periodontal pockets present. Teeth with crown destruction received fixed provisional restorations. All patients received initial periodontal treatment and professional plaque control every 2 weeks. Acrylic stents were used to standardize measurements. Six marks were made around the tooth to be extruded to serve as guides: distobuccal, buccal, mesiobuccal, distolingual, lingual, mesiolingual. Measurements made: 1) guide mark to healthy tooth structure (M-T), 2) guide mark to gingival margin (M-GM), 3) guide mark to top of alveolar bone crest (M-AC) via transulcular probing. Measurements were made at baseline, after extrusion 21 days, after retention (8 weeks after the end of extrusion). Two groups: Group A teeth received 50 gm of force extrusion movement for 3 weeks with weekly activation combined with fiberotomy performed with 15C blade followed by SRP using Gracey curettes. Following active period of extrusion, teeth were maintained for 8 weeks using the same ortho appliance to prevent relapse. No need for complimentary surgery. Group B: Only forced extrusion at 50 gm for 3 weeks with weekly activation without fiberotomy or SRP. Extruded teeth maintained for 8 weeks. Teeth received surgical crown lengthening to re-establish biologic width.

R: There was SS greater amount of extrusion (exposed tooth structure) in Group A, whereas in the Group B the bone and gingival margin followed- the gingiva migrated coronally 2 mm and the bone margin 1.5 mm.

The gingival margin and bone did not erupt in Group A.

BL: When crown lengthening is desired without bringing the bone and gingival margin coronally, then extrusion with fiberotomy and SRP weekly is indicated. If the aim is to bring the gingival margin and bone crest coronally, no fiberotomy or SRP should be done.

Taner 2000

P: To evaluate the effects of fiberotomy in alleviating dental relapse of incisors in the short-term after orthodontic treatment.

M+M: 23 pts (15-16 years old) with crowding of maxillary and mandibular incisors that were classified according to Little’s irregularity index, showing 2.3-25.5 mm of crowding. All pts were treated with fixed appliances: half had premolar extraction, half were treated as non-extraction cases. Each of these groups had half of the patients with a circumferential supracrestal fiberotomy (CSF) on upper and lower anterior segments 1wk prior to debonding. The CSF procedure consisted of a number 15 surgical blade inserted into the sulcus, and a circumferential incision tracing the alveolar crest was made, severing all fibrous attachments as well as the supragingival fibers surrounding the tooth to a depth approximately 3 mm below the alveolar crest of the alveolar bone. The blade also transsected the transseptal fibers by interdentally entering the periodontal ligament space.

In total, 11 had the CSF while 12 served as controls. All pts were given Hawley appliances and instructed to wear 24 hours every day. Cephalograms and casts were used to measure vertical skeletal incisor position changes at intial exam (T1), during active treatment (T2), 6 months post active treatment (T3), and 1yr following active treatment (T4). PD, recession, and AL also noted.

R: NSSD in PD, recession, or AL for both groups.

Mean relapse for mandibular anterior teeth: control 39% at T3 and 64% at T4 compared to CSF group 0.6% at T3, 1.5% at T4.

Mean relapse for maxillary teeth: control 14% at T3 and 25% at T4 compared to CSF group 0.8% at T3 and 1% at T4.

D: Other studies show that relapse is reported to be greatest during the first 24 hours, and approximately 50% of the total relapse occurs during the first week after closure of extraction spaces. Long term, crowding in anterior is multifactorial and might be affected by other factors than CSF prior to debonding.

BL: Although it has been recognized that relapse may continue in subsequent years, especially in mandibular arch, the results of this study indicate that CSF procedure was effective in minimizing relapse for retention periods of 6 months to 1yr.

Topic: Ortho alternative to periodontal surgery

Authors: Yáñez-Vico RM, Iglesias-Linares A, Ballesta-Mudarra S, Ortiz-Ariza E, Solano-Reina E, Perea EJ.

Title: Short-term effect of removal of fixed orthodontic appliances on gingival health and subgingival microbiota: a prospective cohort study.

Source: Acta Odontol Scand. 2015; 73(7):496-502

Type: prospective cohort study

Keywords: Periodontopathogens, orthodontics, microbiology, gingivitis

Purpose: To assess and compare the microbiological and clinical parameters of patients wearing fixed orthodontics appliance, as opposed to 10 days after the bracket had been removed following treatment.

Methods: 122 patients with no visible bone loss, no PD >4mm at one or more sites, healthy systemic condition, not currently pregnant, no periodontal treatment within the last 6 months, non-smokers, and no history of diabetes. 61 evaluated at baseline wearing a fixed orthodontic appliance (T1) and 10 days after bracket removal (T2). The other 61 patients had never worn any orthodontic appliance and served as controls (CT). Subgingival plaque samples obtained via sterile paper points were assessed for BOP and PI. Polymerase chain reaction (PCR) of 16s rDNA and reverse species-specific hybridization for Aggregatibacter actinomycetemcomitans, Porphyromonas gingivalis, Prevotella intermedia, Tannerella forsythia and Treponema denticola were performed.

Results: The BOP and PI clinical parameters showed significant difference between T1 and T2, T1 and CT, and T2 and CT groups. The prevalence of T.denticola decreased in the T2 group. Also, the T2 group showed a positive correlation between BOP and A.actinomycetemcomitans and P.intermedia. In both T2 and CT groups there was a positive correlation between T.forsythia and BOP. In summary, the results of looking for the presence of pathogens that form the red complex in any of the three groups revealed that young adults wearing orthodontic appliances were associated with the presence 2 or 3 pathogens when compared to the control group.

Discussion: No studies to date have focused on changes in gingival inflammation and subgingival microbiota a few days after orthodontic treatment has finished. The most obvious clinical feature a few days after removing the orthodontic appliance is the improvement of gingival inflammation. T.denticola was found to be the only pathogen that decreased significantly following appliance removal.

BL: Local factors associated with wearing fixed orthodontic appliances influence changes in subgingival plaque that leads to more inflammation and bleeding.


Topic: Orthodontics

Authors: Ogihara S, Tarnow DP

Title: Efficacy of forced eruption/enamel matrix derivative with freeze-dried bone allograft or with demineralized freeze-dried bone allograft in infrabony defects: A randomized trial.

Source: Quintessence Int. 2015 Jun;46(6):481-90

Type: Clinical

Keywords: bone, clinical trial, enamel matrix protein, forced eruption, randomized, tissue regeneration

Purpose: To determine the efficacy of enamel matrix derivative (EMD) and forced eruption alone or in combination with freeze-dried bone allograft (FDBA) or demineralized FDBA (DFDBA) when managing infrabony defects.

Method: 74 patients with an inadequate biologic width due to subgingival caries were randomly assigned to one of three intervention groups: Ortho/EMD/FDBA (OEF) (n = 25), Ortho/EMD/DFDBA (OED) (n = 24), and Ortho/EMD alone without graft material as a control (OE) (n = 25). Each patient had an infrabony defect. The primary outcomes were absolute change in probing depth (PD) reduction and clinical attachment level (CAL) gain from baseline to 1- and 3-year follow-up. Infrabony defects were surgically treated with EMD/FDBA, EMD/DFDBA, or EMD alone 4 weeks before orthodontic extrusive force was applied to re-establish a biologic width of 2 mm.

Results: Patients were analyzed. All groups demonstrated significant improvement in PD reduction and CAL gain from baseline. The changes at 1 year for PD were: OEF (mm, 95% CI), 4.3; OED, 4.2; and OE, 3.4; for CAL, changes were: OEF, 4.3; OED, 3.9; and OE, 3.3. Longer follow-ups showed similar findings.

Conclusion: This study showed that both forced eruption/EMD/FDBA and forced eruption/EMD/DFDBA combination therapies result in greater soft tissue improvements at 1- and 3-year follow-up in addition to greater hard tissue improvements at 6-month re-entry compared with forced eruption/EMD alone.

Teeth moved into extraction sites via orthodontics

How should extractions be managed in conjunction with orthodontic therapy? Are there any long term effects moving teeth into extraction sites?

Reed 1985

P: To assess the long-term periodontal status of teeth moved into extraction sites.

M&M: 12 patients with prior ortho treatment, at least 10 years earlier with bilateral premolar extractions in the maxillary arch (test group) and no premolar extractions in the mandiblular arch (control). Perio evaluation in the interproximal areas mesial and distal to extraction site were analyzed via plaque index, visual inflammation, BOP, FGM, PD. Radiographic exam included: crestal bone levels with bitewings & PA’s (not standardized) as well as alveolar bone height. Root resorption was also recorded.

R: Visual Inflammation: Significantly fewer inflamed sites adjacent to extraction sites (55% exp vs. 84% con)

Plaque Index, BOP, FGM, PD, Radiographic bone levels: NSSD between groups.

Author seemed to suggest a greater loss of bone adjacent to exp sites (1.37 vs. l.15) than con sites.

Root resorption was evident on 21% of the teeth adjacent to extraction sites, none in control sites.

BL: Article supports no major differences in long-term perio status between teeth orthodontically moved into extraction sites and those teeth having ortho in absence of extraction sites. Extraction of premolars for orthodontic treatment does not predispose patients to future periodontal problems.

Hasler 1997

Purpose: To compare in humans the rate of maxillary canine retraction into an extraction site where healing had taken place with that of a recent extraction site.

Materials and methods: 22 subjects 10-26 years old were included in the study. 1st premolar was extracted on one side of the arch, and impressions and a PA radiograph were taken at the same day or up to 23 days thereafter (T1). The contralateral 1st max premolar was extracted 52-151 days after the extraction on the other side, impressions and radiographs were taken 0-21 days after the 2nd extraction (T2).

At T2 the distalization of both max canines was initiated with a canine retraction spring delivering a force of 100g. Care was taken to achieve the same degree of activation in both sides. Pts were seen every 4-5 weeks for checking and reactivation of the springs. Final recordings (T3) were made when the canine on one side o the dental arch was sufficiently distalized. This occurred within 56-266 days. The radiographs taken at the 3 different time intervals were standardized. They were superimposed to measure the differences in tooth movement and the angle of the canine axis. Movement was classified as uncontrolled tipping, controlled tipping or parallel. The engagement of the extraction alveolus by the canine was also recorded.

Results: There was a minor mesial movement of the first throughout the study, NSSD between two groups.

During the observation period (T1-T2) the canine on the healed site on average moved more posterior than the one on the side without extraction.

During the active retraction period (T2-T3) the canine on the recent extraction site was distalized significantly more than on the healed site (median difference 1.14mm, range -0.22 to 2.84mm).

The median difference between the two sides for the total time span (T1-T3) was 0.75mm.

The type of tooth movement did not differ significantly between the two sides.

On the recent extraction site the canine engaged at T3 somewhat more than the upper half of the alveolus and on the healed sites the upper ¾.

Rotation of the canine between the two groups was comparable.

Conclusion: Faster tooth movement was observed on the recent extraction side. Possible reasons may be less calcified bone which would resorb faster or the presence of more cells with a potential for bone resorption.

Liou 1998

Purpose: To present a new technique of rapid canine retraction through distracting the PDL with a distraction device. Distraction osteogenesis is a process of growing new bone by mechanical stretching of preexisting bone.

Materials and methods:

  • 15 orthodontics patients (15 uppers and 11 lowers) who needed canine retraction and 1st premolar extraction were included in the study.
  • A fixed ortho appliance was placed before the 1st premolar extraction. Canine was to be distracted and 1st molar and 2nd premolar were anchor units.
  • Right after the 1st premolar extraction the interseptal bone distal to canine was undermined with bone bur, grooving vertically inside the extraction socket, along buccal and lingual sides, & extending obliquely toward the base of interseptal bone to weaken its resistance.
  • The interseptal bone was not cut mesiodistally toward the canine. A custom-made intraoral distraction device activated 0.5-1 mm/day right after extraction until canine was distracted into desired position.
  • The patients were seen every week. Cephalometric and periapical xrays were taken before and after the canine retraction. Apical & lateral root resorption was evaluated.


  • All patients reported no severe pain.
  • Both upper and lower canines were distracted distally 6.5-6.6 mm in 3 weeks.
  • The rate of tooth movement per week was not significantly different between the maxillary and mandibular canines.
  • The average mesial movement of 1st molars was <0.5mm in 3 weeks. On the periapical radiographs, the apical or lateral surface root resorption was minimal.
  • No periodontal defect or endodontic lesion was observed throughout and after distraction.
  • The radiographic changes of PDL on the mesial side of the canines could be classified into 5 stages:
    • 1) Stretching and widening of PDL (1st week after initiating the distraction),
    • 2) Active growing of striated bone in the distracted PDL (2nd week after initiation to the end of distraction)
    • 3) Recovery of the distracted PDL (1st to 4th week after completing the distraction)
    • 4) Remodeling of the striated bone (4th week to 3rd month after completing the distraction)
    • 5) Maturation of the striated bone was 3 months after completing the distraction.

D: The PDL can be distracted just like the midpalatal suture in the rapid palatal expansion. With this concept, canines can be distracted distally 6.5mm in 3 weeks without significant complication. The long-term effects on root resorption, subsequent development of a developing root, pulp vitality, periodontal tissues and possible root ankylosis of the canine should be closely monitored.

Ahn 2014

P: To investigate the influence of the timing of orthodontic force application on the rates of orthodontic tooth movement into surgical alveolar defects with bone grafts in beagle dogs.

M&M: 12 beagle dogs were randomly divided into 2 groups according to the surgical procedure: alveolar osteotomy alone (control) or osteotomy with bone graft (experimental group). The maxillary second premolars were protracted for 6 weeks into the surgical sites: immediately, at 2 weeks, and at 12 weeks after surgery. 6 Groups total: O-0 (osteotomy only and immediate mvmt), O-2 (osteotomy only and mvmt at 2 wks), O-12 (osteotomy only and mvmt at 12 wks), OG-0 (osteotomy+graft and immediate mvmt), OG-2 (osteotomy+graft and mvmt at 2 wks), and OG-12 (osteotomy+graft and mvmt at 12 wks). Defects were grafted with Bio-Oss.

The orthodontic tooth movement rates and alveolar remodeling with surgical defect healing were evaluated by model measurements and histomorphometry as well as microcomputed tomography and histology. Satistical analysis performed for investigating the rates of orthodontic tooth movement and mineralized bone formation.

R: Both the orthodontic tooth movement rate and the mean appositional length of mineralized bone in the tension side of teeth were significantly accelerated when force was applied at 2 weeks in the control group and immediately in the experimental group (P <0.001). The 2-week control group showed a dramatic increase in apposition rate during 4 to 6 weeks after force application, whereas the immediate protraction experimental group did within the first 3 weeks (P <0.001). Decreased orthodontic tooth movement rates and reduced bone remodeling activities were apparent in the 12-weeks groups, especially in non-grafte

d defects. Groups O-2 and OG-0 showed rapid OTM, whereas the 12-week groups, particularly group O-12, showed the slowest rate.

C: Optimal timing of orthodontic force application toward the surgical defect depended on its healing state, which was influenced by the alveolar bone graft. A bone graft into the surgical defect can not only allow immediate force application for accelerating orthodontic tooth movement with favorable periodontal regeneration, but also decrease the risk of inhibited orthodontic tooth movement in case of delayed force application after surgery.

Topic: Orthodontics

Author: Ru N, Liu SS, Bai Y, Li S, Liu Y, Wei X

Title: BoneCeramic graft regenerates alveolar defects but slows orthodontic tooth movement with less root resorption.

Source: Am J Orthod Dentofacial Orthop. 2016 Apr;149(4):523-32

Type: Animal study

Keywords: Orthodontics, animal study/rats, BoneCeramic, BioOss, resorption, tooth movement

Purpose: To evaluate whether it is feasible to move a tooth in an alveolar ridge augmented with BoneCeramic, and to evaluate real-time 3-dimensional changes in root resorption and bone microarchitectures, and tissue responses when moving teeth into Bone Ceramic and Bio-Oss grafts after extractions.

Methods: 60 rats had the maxillary left first molar extracted. A 3x2x2 mm defect was created in the socket. Animals were assigned to 3 groups to receive BoneCeramic (60% hydroxyapatite, 40% beta tricalcium phosphate granules), Bio-Oss (natural bovine spongiosa granules, 0.25-1 mm), or no grafting. Sockets were covered with reflected gingival tissue to prevent leakage. After 4 weeks, a spring was used to apply 10 g of force to the neighboring tooth in order to push it into the extraction space. Animals were scanned with a microcomputed tomography system on days 0, 7, 14, 21, and 28. Tooth movement distance was measured 3 times and averaged at each time point, and tooth movement rate was calculated. Bone was evaluated in the cervical and apical halves of the root. Bone volume fraction (ratio of bone to total volume), mean trabecular thickness, trabecular number, and trabecular separation were evaluated. Total root volume was also measured at each time point to assess root resorption. At 28 days, the animals were killed and the maxilla sectioned for analysis.

Results: The greatest amount of tooth movement was seen in the control group, followed by the Bio-Oss and then BoneCeramic. In all groups, tooth movement rates accelerated from 0-7 days and slightly decelerated from days 7-14, a trend which repeated with acceleration from days 14-21, followed by deceleration from days 21-28. Bone volume fraction and trabecular thickness/number significantly decreased from days 0-7 but increased from days 14-28. Trabecular separation decreased from days 0-7 but fluctuated from days 14-28. In the BoneCeramic group, bone volume fraction and trabecular thickness/number were significantly higher at each time point compared to Bio-Oss and control groups. Root volumes reduced in all groups over time, with small isolated lacunae seen on the mesial surfaces and wide shallow resorption craters seen on the distal at day 28. The greatest root resorption was seen in the apical portion of the mesial buccal root. Root resorption was lowest in teeth moved into sites grafted with BioCeramic.

Discussion: Bone density increased more in the regions of BoneCeramic grafting compared with Bio-Oss grafting, and both grafting methods showed tooth movement. Although BoneCeramic slows orthodontic movement, it has better osteoconductive potential and induces less root resorption compared to Bio-Oss grafting and naturally recovered extraction sites.

Accelerated Orthodontics


Topic: accelerated orthodontics

Author: Mathews DP, Kokich VG

Title: Accelerating tooth movement: The case against corticotomy-induced orthodontics

Source: I Am J Orthod Dentofacial Orthop 2013; 144:5-13

Type: Discussion, Point/Counterpoint

Keywords: corticotomy, orthodontics, periodontally accelerated osteogenic orthodontics

Purpose: To present the opposing viewpoint to the “Point” article written by Drs. Wilcko and Wolcko on the subject of accelerated osteogenic orthodontics. The author discusses several questions addressing the efficacy, effectiveness and efficiency of corticotomy-induced orthodontics.

Does alveolar corticotomy result in acceleration of tooth movement?

  • Author agrees with Drs. Wilko and Wilko that alveolar corticontomy does accelerate tooth movement. Most studies show the amount of movement is doubled during the time of the expirement.

How does corticotomy produce accelerated tooth movement?

  • Wilko and Wilko describe a regional acceleratory phenomenon that results in increased movement through a demineralization process.
  • The author here argues that this is an over-generalization of the process and sheds doubt on the ability to translate the research in animals to the actual events in human bone.
  • The author proposes that instead of a demineralization process with the teeth moving “through” the bone, it should be viewed as a translational process originating in the PDL.
  • The author suggests that evidence supports the idea of rapid removal of the hyaline in the PDL by macrophages which enables rapid tooth movement.

How long does the regional acceleratory phenomenon persist after the corticotomy?

  • The literature suggests that the time period of rapid movement is about 4 months, after that point tooth movement returns to normal.

Does corticotomy result in reduced treatment time for adults?

  • There are no studies documenting the claim that corticotomy results in shorter treatment time, although we do know that the teeth are moving faster. An RCT is necessary to evaluate this aspect.

Does grafting of the alveolus enhance the orthodontic treatment?

  • There is a lack of evidence to support this claim. The best evidence comes from case reports and expert opinions.
  • There is some evidence from CT analysis of cases that there is a greater volume of bone but it appears to be a fibro-osseous encapsulation on the outside of the cortical plate and not incorporated into native bone.
  • The author notes the increased morbidity and cost associated with this procedure.

What is the financial cost of the corticotomy procedure?

  • Costs are often not discussed but may be a contributing factor in the acceptance of the case by the patient.


  • The author concludes that in order to determine the true efficacy of corticotomy-facilitated orthodontics highly controlled trials are necessary.
  • The author notes that while corticotomy is effective at increasing tooth movement, there is little evidence to suggest that it significantly reduces treatment time.
  • The author questions the efficiency of this procedure due to:
    • The limited duration of the accelerated phenomenon
    • The additional cost
    • The lack of evidence supporting reduced treatment time


Topic: Corticotomy induced orthodontics

Author: Wilcko W, Wilcko MT

Title: : Accelerating tooth movement: The case for corticotomy-induced orthodontics.

Source: Am J Orthod Dentofacial Orthop 144:4, 2013. http://www.ajodo.org/article/S0889-5406(13)00419-8/abstract

Type: Description article

Purpose: To describe the use of corticotomy induced rapid movement of teeth.

Background: Corticotomy-related surgeries evolved in Europe with rapid correction of sever maxillary protrusion with orthodontic appliances in 1931. Wedges of bone were first removed to reduce the volume of bone through which the roots of the maxillary teeth would need to be retracted. In 1959 Kole expaned this philosophy by addressing additional movements, including space closure and crossbite correction. A reduction in bane thickness was used and major movements were corrected in 6 to 12 weeks without significant root resorption. This did produce the appearance of outlined blocks of bone; when taken in conjunction with the incorrect assumption that the mineralized bone was moving with the roots of the teeth. Consequently corticotomy surgery evolved mostly into circumscribing cuts, and bone thinning was deemphasized. In 2007, Sebaoun et al. reported that intramarrow penetrations in rats resulted in a transient deminerlization-remineralization process and increased bone turnover. When closing extraction spaces, if it is performed at first premolar sites with only circumscribing corticotomy cuts or with inadequate bone thinning such as partial ostectomies, the space closure can take 7 or more months to complete. However, if the bone is thinned adequately in the direction of the intended tooth movement, premolar site closure can be accomplished in 3 to 4 weeks with orthopedic forces or in 6 to 8 weeks with lighter orthodontic forces.

Conclusion: this procedure is gaining in popularity with patients because it can result in from one-third to one-quarter the time of normal orthodontic treatment. But many misunderstandings and misconceptions about this procedure are being dispelled as knowledge of the technique and results are becoming better known. This technique belongs in a specialty arena where both orthodontists and periodontists work together from diagnosis through treatment and retention.


Topic: Accelerated Orthodontics

Authors: Zimmo N1, Saleh MH2, Mandelaris GA3, Chan HL4, Wang HL5.

Title: Corticotomy-Accelerated Orthodontics: A Comprehensive Review and Update.

Source: Compend Contin Educ Dent. 2017 Jan; 38(1):17-25

Type: review

Keywords: corticotomy-accelerated orthodontics; orthodontic treatment time

Background: Corticotomy-accelerated orthodontics (CAO) also known as Wilckodontics or periodontally accelerated osteogenic orthodontics (PAOO), accelerated osteogenic orthodontics (AOO), accelerated orthodontics (AO), selective alveolar decortication (SAD), surgically facilitated orthodontic therapy (SFOT), or corticotomy-facilitated orthodontics (CFO). SFOT, AOO, and PAOO involve bone grafting in addition to corticotomy.

Osteotomy: surgical cut made through both cortical and medullary components of bone to free a bone segment.

Corticotomy: cortical bone is injured with some injury extending into medullary bone; may be shallow or deep.

PAOO: combines selective alveolar corticotomy, bone grafting, and orthodontic force.

Wilckos’ concepts:

-alveolar bone loses structural integrity because of transient demineralization after corticotomy.

– healing pattern after corticotomy and dentoalveolar decortication insult is coupled with demineralization-remineralization process.

– teeth move with dentoalveolar bone segment that is being displaced in total during its demineralization state.

Purpose: to review the available evidence and to summarize the pros and cons of corticotomy-accelerated orthodontics.

Methods: Articles published in the last 15 years related to CAO were screened and assessed.

Results: CAO results in acceleration of orthodontic treatment as much as three times on average. CAO is effective and safe for shortening the orthodontic treatment time and enhancing interdisciplinary results beyond conventional treatment alone.


  • Lower rate of loss of anchorage
  • Borderline orthognathic surgery cases
  • Treatment of anterior open bite in conjunction with skeletal anchorage
  • Minimizing post orthodontic relapse


  • Signs of active periodontal disease
  • Inadequately treated endodontic problems
  • Prolonged corticosteroid use
  • Medications that may slow bone metabolism (bisphosphonates/ NSAIDs)

BL: More data is needed to validate and verify the long-term implications to treatment from both a periodontal and orthodontic outcome.

Wilcko 2009

P: demonstrate the usefulness of the accelerated osteogenic orthodontics technique in de-crowding and space closing for the correction of dental malocclusions.

The Accelerated Osteogenic Orthodontics (AOO) technique is a combination of “bone activation” (selective alveolar decortication, ostectomies, and bone thinning with no osseous mobilization), alveolar augmentation using particulate bone grafting material, and orthodontic treatment.
Rational: Demineralization of a thin layer of bone over a root prominence after corticotomy surgery can optimize the response to applied orthodontic forces. When combined with alveolar augmentation, one is no longer strictly at the mercy of the original alveolar volume and osseous dehiscences, and fenestrations can be corrected over vital root surfaces.

  1. Enhanced scope of malocclusion treatment
  2. Decreased treatment times
  3. Increased alveolar volume and more structurally complete periodontuim
  4. Alveolar reshaping for the subtle enhancement of a pt’s profile
  5. Simultaneous rapid recovery of shallow unrerupted teeth.

AOO Surgical Technique:

  • Treatment plan by the orthodontist/surgeon to determine the teeth will undergo bone activation.
  • Ortho brackets are placed and a light wire engaged.
  • Full-thickness flaps are reflected labially and lingually.
  • Reflect Interdental papilla with the full-thickness flap except b/w the upper central incisors.
  • Releasing incision can be made at the base of the gingival attachment (MGJ).
  • A vertical incisions can be used
  • Bone activation (circumscribing corticotomy cuts and intramarrow penetrations)
  • Bone grafting with material (FDBA, DFDBA, mixture…) is layered over the activated bone + PRP
  • CAF to cover the grafting materials, sutured with an interrupted loop nonresorbable suture (Gortex)
  • 4-5 days post-op visits, Removed sutures in min of 2 weeks.

Special considerations and Limitations:

  • Long term corticosteroid therapy – devitalized areas within the bone.
  • Slow bone turnover meds (bisphosphonates)
  • Long term use of NSAIDS for pain control – prostaglandin inh – Decrease osteoclastic activity. However, NSAIDS can be rx for the 1st week after surgery.
  • Unresolved endodontics problems.

C: The AOO technique provides for efficient and stable orthodontic tooth movement. Frequently, the teeth can be moved further in one third to one fourth the time required for traditional orthodontics alone. This is a physiologically based treatment consistent with a regional acceleratory phenomenon and maintaining an adequate blood supply is essential.

Keratinized Tissue & Orthodontic Therapy

What is the significance of keratinized tissue during orthodontic movement? What is the relationship between mucogingival problems and tooth position? What is the relationship between mucogingival problems and tooth movement? Is prophylactic gingival grafting ever indicated?


Topic: Orthodontics

Authors: Suter VG, Heinzmann AE, Grossen J, Sculean A, Bornstein MM

Title: Does the maxillary midline diastema close after frenectomy?

Source: Quintessence Int. 2014 Jan;45(1):57-66

Type: Clinical

Keywords: CO2, frenectomy, frenum, laser, midline diastema, maxillary diastema

Purpose: To analyze the closure, persistence or reopening of the maxillary midline diastema after frenectomy in patients with and without subsequent orthodontic treatment.

Method: All patients undergoing frenectomy with a CO2 laser were included in this retrospective study during the period of September 2002 to June 2011. Age and sex, the dimension of the diastema, eruption status of the maxillary canines, and the presence of an orthodontic treatment were recorded at the day of frenectomy and during follow-up.

Results: Of the 59 patients fulfilling the inclusion criteria, 31 (52.5%) had an active orthodontic therapy, while 27 (45.8%) had a frenectomy without orthodontic treatment. For one patient, information concerning orthodontic treatment was not available. In the first follow-up (2 to 12 weeks), only four diastemas closed after frenectomy and orthodontic treatment, and none after frenectomy alone. In the second follow-up (4 to 19 months), statistically significantly more diastemas (n = 20) closed with frenectomy and orthodontic treatment than with frenectomy alone (n = 3). At the long-term (21 to 121 months) follow-up, only four patients had a persisting diastema, and in three patients orthodontic treatment was ongoing.

Conclusion: Closure of the maxillary midline diastema with a prominent frenum is more predictable with frenectomy and concomitant orthodontic treatment than with frenectomy alone. This study demonstrates the importance of an interdisciplinary approach to treat maxillary midline diastemas, ideally including general practitioners, oral surgeons, periodontists, and orthodontists.

Coatoam 1981

P: To examine the effects of orthodontic therapy on the width of KG.

M&M: The labial surfaces of 966 teeth in a sample of 100 orthodontic patients (14-16 years old at the end of the treatment) were studied. Pre- and post-treatment photographic slides, study casts and cephalograms were examined. Measurements were performed on the 12 anterior teeth. Three measurements were performed on each tooth before and after ortho treatment: 1) length of clinical crown from the study cast 2) length of clinical crown from the projected slides 3) width of KG from the projected slides. Measurements were done on the cephalograms to indicate the amount, direction and type of tooth movement that occurred during the orthodontic treatment.

Results: There was an evident bilateral symmetry to the length of the clinical crown both before and after ortho therapy. Each of the groups of anterior teeth showed a statistically significant increase in the length of the clinical crown. The greatest increase was found in the mandibular canines (average 0.95mm) and the smallest increase was found in the maxillary central incisors (average 0.18mm). The KG ranged in width from 0mm to 8mm before treatment. The range after treatment was 0mm to 7.7mm. There was a significant decrease in KG over the maxillary and mandibular lateral incisors, but a significant increase over the maxillary canines and central incisors. In the mandibular central incisors and canines there were decreases in KG but the decreases were not statistically significant. Teeth with less than 2mm of KG before orthodontic treatment showed a greater percentage of increased width (67.8%) than teeth with more than 2mm of pre-existing KG (44.8%). Teeth with less than 2mm of KG also showed a greater incidence of complete loss of KG (that was most common in the mandibular arch). Teeth with 0 KG before treatment ended with 0mm of KG after treatment.


  • Increases in KG may occur on some teeth during the course of ortho treatment.

  • SS increases in clinical crown during ortho therapy are not reflected in SS decreases in KG.

  • Study failed to support that clinical health can be maintained in teeth w no KG (probably due inadequate OH.

  • Minimal width of KG (<2mm) is capable of withstanding the stresses of ortho mechanics.

  • Teeth that are lacking in any KG prior to ortho treatment will not form any keratinized tissue during the course of ortho therapy.

  • Mucogingival problems noted after ortho are often a result of a preexisting mucogingival problem.

  • Changes in KG dimensions correlate statistically with the ortho movement of maxillary central incisors and with maxillary and mandibular canines.

Edwards 1977

P: To study the maxillary anterior frenum as it relates to the relapse phenomenon observed after orthodontic closure of diastemas.

Disc: The maxillary labial frenum originates as post-eruptive remnants of the tectolabial bands which appear at 3 months in utero and connect the tubercle of the upper lip to the palatine papilla. The pre-treatment relationship between a clinically “abnormal” appearing maxillary midline frenum and a midline diastema showed a strong, but not absolute, relationship. Diastema cases with “abnormal” pre-treatment frenums had a decidedly stronger potential for relapse after orthodontic closure. A 3-stage surgical procedure consisting apical repositioning of the frenum (frenotomy) 3mm into the mucosal tissue with denudation of alveolar bone; destruction of the transseptal fibers between the approximated central incisors; and gingivoplasty or recontouring of the labial (performed in 7% of cases) and /or palatal gingival papillae (performed in 17% of cases) in case of excessive tissue accumulation is very effective (but not 100%) in alleviating the relapse phenomenon following orthodontic treatment of diastemas (the pts were followed for 3 months after sx to determine the rate of relapse). Not every excessively wide band of frenal tissue located too near the gingival margin will cause or be associated with a relapse. There were 20% of the cases with an aberrant frenum that showed no relapse. There were 9% of pts with normal frenums that did have a recurrent diastema.

Pini Prato (1) 2000

BG: Buccally erupting teeth tend to show reduced dimensions of the gingiva since the abnormal eruption of the permanent tooth restricts of eliminates KG, this might be viewed as a risk of future recession due to poor plaque control or traumatic brushing.

P: To study the effect of mucogingival therapy and orthodontics on buccally erupting teeth.

MM: 29 subjects 10-13 years of age with a buccally erupting premolar on one side and a normally erupting premolar on the contralateral side. The deciduous tooth corresponding to the bucally erupting premolar had to be present on the test side. The gingiva entrapped between the cusp of the erupting premolar and the crown of the deciduous tooth had to be healthy, thick without any signs of inflammation. Three different surgical techniques utilized to reposition the entrapped KG between the deciduous and the buccally erupting permanent.

Double pedicle flap: indicated when the tip of the cusp of the permanent tooth erupts in keratinized tissue close to the mucogingival junction. Intrasulcular incision is performed extending to the gingival crevice of the adjacent teeth. FTF is reflected and moved apically to the erupting cusp.

Apically positioned flap: when the cusp of the permanent tooth is erupting in the alveolar mucosa slightly apical to the mucogingival junction. Intrasulcular incision is performed along the deciduous tooth, two lateral releasing incisions are made which extend apically to the mucogingival junction, a full-partial thickness flap is elevated.

Free gingival graft: when the cusp of the permanent tooth is erupting very apically to the mucogingival junction, an apically positioned flap is not practical because of overextended releasing incisions. The entrapped gingiva are completely removed and used as an epithelialized connective tissue graft.

Orthodontic treatment: started 3 months after surgery and duration ranged from 14 months to 2 years.

Baseline measurements made on the deciduous tooth of the test site and on the normally erupted premolar of the control site. Clinical parameters: BOP, PD, REC, KT, PI. Post-op measurements: collected on the premolars 3 months, 2 years and 7 years post-sx. (PD, KG, REC).

R: NSSD between the amount of KT in the control and test sites at any time interval. 7 years after sx both test and control sites exhibited a mean PD of 1.3mm. None of the examined cases showed gingival recession on 3 months post-sx. One patient treated with apically positioned flap showed an apical shift of the gingival margin in the test site after 2 years and at 7 years the same tooth showed 1 mm of recession, the contralateral premolar in the same patient had 1 mm recession as well.

BL: Mucogingival correction of buccally erupting permanent teeth is indicated and results are stable up to 7 years.

Pini Prato (2) 2000

BG: Three different surgical procedures, double pedicle flap (DPF), apically positioned flap (APF) and free gingival graft (FGG) can be performed to maintain the width of KT on buccally erupted permanent teeth.

P: To compare the width of KT after orthodontic treatment in buccally erupted permanent teeth, pretreated with mucogingival interceptive surgery on one side of the mouth and extraction of the deciduous tooth on the contralateral side.

M+M: 8 patients (9-12 years old , 5M, 3F) were included in the study. Bilateral buccally eruption of premolars were randomly assigned to mucogingival interceptive surgery (2 DPF, 4 APF and 2 FGG) on one side and extraction of the deciduous molars on the other side. 3 months after initial observation orthodontic treatment was initiated. PD and KT were evaluated at baseline, 3 months and 2 years. PI, BOP and recession were evaluated at 2 years post-op. Statistical analysis was done.

R: NSSD in KT at baseline. Test had SS more KT at 3 months (1.7mm) and 2 years (1.6mm). At 3 months and 2 years the mean recession in control sites was 1.8mm (61.5%) and 1.6mm (53.2%) respectively. There was NSSD for PD, BOP and PI between the two groups at any time interval.

BL: A certain amount of KT is beneficial in patients scheduled for orthodontics. In cases with buccal erupting permanent teeth, mucogingival interceptive surgery should be performed before orthodontic tooth repositioning.

Artun 2001

P: To analyze the frequency and severity of gingival recession forming during and after Class II correction among patients who were treated with pronounced mandibular dentoalveolar advancement in the mixed dentition.

M&M: Through mandibular superimposition of the pre-treatment and post-treatment cephalograms of 67 Class II patients who were treated with reverse headgear to the mandibular dentition, 45 patients had a minimum of a 1mm advancement of the cementoenamel junction (CEJ; mean, 2.18 +/- 0.87) and a minimum of a 2mm advancement of the incisal edge (mean, 3.87 +/- 1.34). Using the same protocol in Class II patients, 30 individuals who finished treatment at a similar time and age, but without reverse headgear and with no advancement of the CEJ (mean -0.43, SD 0.53) and a maximum of 1mm advancement of the incisal edge (mean -0.26, SD 1.15) were identified. Before treatment, the mandibular incisors were more retruded, relative to the line from point A to pogonion and relative to the mandibular plane in the patients with pronounced advancement than in those with no advancement of the mandibular incisors; no differences were found at the time of appliance removal.

R: A total of 30 patients with pronounced advancement and 21 patients with no advancement could meet for a follow-up examination a mean period of 7.83 years (SD, 4.44) and 9.38 years (SD, 4.39) after treatment, respectively. Recession was present on 12 teeth in 8/30 pts (range 0.5-3mm) with pronounced advancement versus on 2 teeth in 2/21 pts with no advancement after tx (NSS). There were no differences in the width of KG, CTA, PD, and GBI or visible PI of the mandibular incisors between the patients in the 2 groups. An examination of color slides demonstrated no differences in the number of mandibular incisors that developed recession from before treatment to after treatment and from after treatment to follow-up (recession not progressive). Measurement of mandibular incisor crown height on the study models demonstrated no difference in the increase in clinical crown height from after treatment to follow-up between the patients in the 2 groups. Pts in whom recession developed on individual teeth during appliance therapy are at risk of having recession on other teeth after treatment.

D: Although incisors were advanced extensively during tx, the actual position of the teeth was not anterior to that found in the control subjects at time of appliance removal. Recession that occurred during active treatment was not progressive.

BL: Pronounced advancement of the mandibular incisors may be performed in adolescent patients with dento-alveolar retrusion without increasing the risk of recession.

Cr: Not SS, but may be clinically significant

Karring 1982

Purpose: 1) To produce dehiscences in the buccal alveolar bone by facial tipping of the teeth and to examine if bone reforms when teeth are moved back to their original position in the dental arch and 2) to evaluate the effect of these tooth movements on the level of connective tissue attachments.

Materials and methods: Three beagle dogs were used. Plaque control was applied for one month and gingival tissues were healthy at that point.

2nd and 3rd central incisors on the right side were tipped in facial direction through the alveolar bone plate during a 5 month period. For the next five months the same teeth on the left side were tipped out through the buccal plate and on the right side the teeth were moved back to their original position. Orthodontic appliances were then used to retain the teeth in these positions for 5 months. Animals were sacrificed 15 months after the beginning of the study and histology was performed.

Results: Clean teeth and clinically healthy gingivae were maintained during the entire experimental period. No significant attachment loss was observed.

In all teeth the apical termination of JE was at CEJ. The distance between JE and bone crest was 2.2+/-0.5mm for the control teeth, 4.1+/-2.1mm for the teeth that were retained facially (Group I) and 1.8+/-0.4mm for the teeth that were moved back to their original position (Group II). Differences were SSD between Group I and II but not between Group II and controls.

Buccal root surfaces were characterized by resorption to a varying degree and in the repositioned teeth they were partly filled with newly formed cementum.

CT fibers in the root portions of the teeth devoid of alveolar bone, had a course parallel to the roots. In the corresponding portions in Group II where bone had reformed, PDL was organized and the fibers were inserted into the cementum and adjacent bone mainly at right angles.

Conclusion: 1) Dehiscences can be produced in the buccal bone by tipping teeth in facial direction and bone tissue will reform when teeth are moved back to their original position and 2) these tooth movements are not necessarily accompanied by loss of CT attachment.

Topic: Orthodontics

Author: Rasperini G, Acunzo R, Cannalire P, Farronato G

Title: Influence of Periodontal Biotype on Root Surface Exposure During Orthodontic Treatment: A Preliminary Study

Source: Int J Periodontics Restorative Dent. 2015 Sep-Oct;35(5):665-75

Type: Preliminary study

Keywords: Biotype, recession, orthodontics

Purpose: To assess the effect of periodontal biotype on root surface exposure during orthodontic treatment, and to test the clinical usefulness of a new device in making a qualitative assessment of the gingival thickness.

Methods: 16 healthy subjects (mean age 21, ranged 14-38 years old) were included in this study. Patients did not have any gingival recession, were non-smokers, and had no periodontal treatment in the past. OHI instructions were given and reinforced every month for the study. Clinical exam focused on the 4 mandibular incisor teeth, which are more prone to developing recessions. Clinical parameters (probing pocket depth, recession depth, clinical attachment level, keratinized tissue width, full mouth bleeding score, and full mouth plaque score) were assessed at baseline and 9 months after treatment began and compared statistically. Biotype assessment was carried out with a biotype probe (Hu-Friedy) and was classified as follows:

  • Thin biotype: White color of probe clearly visible through the tissue
  • Medium biotype: The green portion of the probe was clearly visible through the tissue, and the white was not visible.
  • Thick biotype: The blue was clearly visible though the tissue, but neither the white or green.
  • Very thick biotype: No colors visible through the tissue.

Results: Incisors were undergoing either proclincation, retroinclination or alignment. No differences were noted between baseline and 9 month parameters for PD, CAL, or KTW. Only 1 patient with thin biotype undergoing proinclination had a recession of 1.5 mm at 9 months. With regard to biotype influence on variables, a significant loss of KTW was observed in patients with thin biotype.

Discussion: Periodontal biotype should be properly identified before orthodontic treatment and can be accurately identified with a biotype probe. When biotype is thin, all types of orthodontic movement are potentially unfavorable, leading to loss of KTW and increasing risk of gingival recession. Among movements, proinclination was most associated with soft tissue loss.

Orthodontic Management of Impacted Teeth

What specific challenges are encountered with impacted/unerupted permanent teeth? Are there different approaches based on where and how the tooth is impacted? How shOrthodontic Management of Impacted Teethould these patients be managed? Are there long term issues with the periodontal health of these teeth?

Kokich 2004

Purpose: Discussion article on impacted maxillary canines.


  • After 3rd molars, maxillary canines are the most commonly impacted permanent tooth. 2/3 are located palatally.

Labial impaction:

  • 3 techniques for uncovery: excisional, Apically positioned flap (APF) and closed eruption techniques.

  • When referring, orthodontist should evaluate 4 things

    • Labiolingual position (easier if more labial and no bone covering)

    • Vertical position of the tooth relative to MGJ – if coronal to MGJ, any of these techniques can be used. If apical to MGJ, excisional technique is inappropriate, because it would not result in any gingiva over the labial surface of the tooth after it had erupted. APF is not appropriate in case of the crown were positioned significantly apical to the MGJ, because it would result in instability of the crown.
    • Amount of KG in the area – better if > 2-3 mm KG, any techniques can be used. If less than that, APF is recommended
    • Mesiodistal dimension of the tooth (more difficult if over the root of the lateral incisor).
  • Orthodontic mechanics should mimic the normal eruption process, don’t try to erupt labially because this will cause dehiscence.
  • Esthetically, an APF can cause the tooth to have more recession than contralateral side. Also, high labial impaction uncovered with an APF tend to reintrude after orthodontic treatment. However some cases benefit from an APF. With conventional radiograph, use buccal object rule or SLOB to see if it is buccally positioned.

Palatal impaction:

  • Most common for maxillary canine. Early detection best way to have normal eruption.

  • If crown of canine is positioned over the root of the maxillary lateral incisor but not past the mesial surface of the root, self correction can occur if deciduous canine is extracted.

  • Root resorption of both the canine and the incisor can occur. They often have bone loss between lateral and canine when compared to contralateral teeth. Most orthodontists refer the patient’s palatal impaction after space has been created.

  • Kokich and Mathews recommended uncovering the palatal canine before starting orthodontic treatment during mixed dentition phase: full thickness flap elevation and removing all the bone over the crown down to the CEJ. Once the flap is replaced a hole is made in the gingiva. These canines will erupt on their own at which point a bracket can be bonded.

  • This technique minimizes resorption, has less bone loss in between canine and lateral incisor and has better matching gingiva.

Artun et al 1986

P: To assess the long-term periodontal status of canines initially erupted in a severely labial position and subsequently were subjected to orthodontic repositioning into arch alignment and remained in this position.

M&M: 400 sets of study models and radiographs taken before and after orthodontic treatment, and at least 10 years of retention. Sample selection was limited to pts presenting with one canine in a severely labial position and a contralateral canine in good arch alignment. All pts were treated with extraction of 4 1st PMs due to arch length deficiency. Pts were recalled for additional records, casts, FMX and clinical exams. Traced the midpalatal raphe (as a reference for superimposition) and the position of the cusp tips of the canines and superimposed the pre-treatment on the post-treatment tracings. Clinical exam included GI, PI, PD, recession, bone sounding, KG and mobility.

R: PAL at midbuccal aspect for control: 1.32 mm vs. 2.07 mm for ectopic canines (SSD). The ectopic canine group showed more recession than the control group -0.16 mm vs 0.5 mm (SSD). NSD in PD between the 2 groups. The ectopic canine group had less AG than the control (1.93 vs 2.43 mm; SSD).

BL: SSD between the canines that erupted ectopically and those that were erupted in a favorable position in PD, PAL, and width of AG. This difference however is not significant clinically considering the amount of it and the length of the observation period.

Burden 1999
Discussion: 2 different methods of exposure of palatally ectopic canines. The closed eruption method (a bonded attachment is placed at operation and the palatal flap is sutured back intact) is compared with the open eruption method (a window of palatal mucosa is excised and the canine allowed to erupt naturally).

2 Methods:

Closed eruption method– flap the palate then bond an orthodontic bracket. Suture the palatal flap back intact.

Open eruption method– a window of palatal mucosa is excised and the canine is allowed to erupt naturally.

A review of the literature reveals that palatally ectopic canines surgically exposed by either method have a small and clinically insignificant reduction in periodontal support compared with contralateral canines. Evidence does not support the view that one technique has an advantage over the other in terms of long-term periodontal health. Some evidence shows the volume of bone removed and the type of orthodontic movement needed to align ectopic canines may be more important variable on influence of periodontal health. The literature reports repeated surgery mostly associated w/ the closed technique (was attributed to bonding / moisture control). With regard to treatment time, conflicting evidence exists whether open or closed is superior.

BL: With regard to long-term periodontal implications, the rate of repeat surgery, and treatment time; conflicting evidence exists on which exposure technique is better.

Quiryen 2000

P: Retrospective study on the long-term periodontal outcome of a combined perio-orthodontic approach as treatment for impacted teeth (test) compared with spontaneously erupted contralateral teeth (Control).

M&M: Retrospective study of 38 patients treated by one periodontist and 2 orthodontist always following the same procedure. 26 patients had one impacted maxillary canine and 3 had bilaterally impacted maxillary canines. 5 had an impacted central or lateral incisor in the maxilla and 4 had an impacted premolar or canine in the mandible. Exam was done after 4-10years. PI,GI,PD,BOP, recession and width, bone level and root resorption were measured.

Procedure for closed eruption technique: 1. Palatal FTF reflected, 2. Crown located by sounding w/ a sharp explorer, 3. Crown was exposed by curreting the overlying bone w/ care not to damage the crown. 4. Enamel was cleaned, dried, etched.. Eyelet was bonded as close to the incisal edge as possible to give maximum control of movement. Guaze saturated w. vasoconstrictor was placed in the surrounding area 5. Site irrigated and flap re-approximated, leaving a space for the wire to exit. After 1wk, movement was applied. Apically repositioned flap for labially impacted canines: Labially located tooth (not too far apically), PTF from the edentulous area. After exposure of ½ crown flap was apically repositioned (at least 3mm over CEJ).

Results: Nearly all parameters were slightly higher for extruded teeth but NSSD between test and control teeth except for KG, which was 1mm larger for spontaneously erupted teeth. There was also a higher frequency of root resorption for the neighbouring teeth of extruded tth.

BL: The closed eruption technique with conservative periodontal surgery and careful orthodontics is a treatment with excellent long-term results, and should be advocated as the treatment of choice for impacted teeth.

Crescini 2007

P: To describe a combined surgical-orthodontic approach for the treatment of impacted maxillary canines associated with presence of the corresponding primary canines and to evaluate the periodontal status of the treated canines for 2-5yrs.

M&M: 25 patients with unilateral impacted maxillary canines were treated with combined surgical flap and orthodontic traction; directed to the center of the crest (tunnel technique). Diagnosis was confirmed using conventional panoramic radiograph and lateral cephalograms. Combined treatment included initial orthodontic treatment, sx treatment and orthodontic traction and final orthodontic treatment.

Periodontal evaluation was done at the end of treatment and follow-up visit 2-5 yrs after completion of active therapy. Pocket depth, KG, and gingival recession were recorded.

R: All 25 (9 males, 16 females) treated canines presented with normal probing depth and amount of KG. No sites showed gingival recession. At the follow-up visit, both probing depths and KG were slightly reduced (PD from 2.0 to 1.6 mm, DG from 4.9 to 3.8 mm).

Con: This technique permits traction of the impacted canines to the center of the crest, simulating the physiologic eruption pattern and may result in optimal dental alignment and healthy periodontium.


Topic: Impacted/ Unerupted permanent teeth

Authors: Incerti-Parenti S, Checchi V, Ippolito DR, Gracco A, Alessandri-Bonetti G.

Title: Periodontal status after surgical-orthodontic treatment of labially impacted canines with different surgical techniques: A systematic review

Source: Ortho Dentofacial Orthop. 2016 Apr;149(4):463-72.

Type: systematic review

Keywords: maxillary canine impaction; periodontal surgery; canine exposure; labially impacted canines

Background: Surgical technique used for tooth uncovering has been shown not to affect the final periodontal status of palatally impacted canines, but the effect is unclear on labially impacted canines.

Purpose: Review the literature on the periodontal status of labially impacted canines after combined surgical-orthodontic treatment with different surgical approaches to clarify whether there is sufficient evidence to support one technique over others in term of periodontal health.

Methods: Population consisted of patients receiving surgical treatment to correct labially impacted maxillary canines. The studies included at least one of the following surgical techniques: closed surgical technique, excisional uncovering, or apically positioned flap. The studies had to include at least one of the following parameters: plaque accumulation, gingival inflammation, recession, periodontal probing depth, clinical attachment level, keratinized gingiva width, attached gingiva width, or crestal bone loss. The study designs must have been randomized controlled trials, controlled clinical trials, or observational studies. PubMed, Cochrane Central Register of Controlled Trials, LILACS, and Scopus were databases searched and two authors independently screened titles and abstracts. No meta-analysis performed due to too few articles selected for review. A narrative synthesis was carried out.

Results: 14 full articles evaluated after screening process and 11 were excluded, leaving 3 articles that fully met the eligibility criteria.

One prospective study evaluated periodontal tissues after either radical exposure or partial exposure (2-3mm of KG maintained with APF or tissue excision). 24 patients total; plaque accumulation, gingival inflammation, recession, CAL and AG width were evaluated 6-24 months. The radical exposure group had more gingival inflammation, recession, and loss of attachment than both the contralateral control group or the partial exposure group.

The 2nd article evaluated only provided box-and-whisker plots without medians indicated, so no review was made of the effects of radical exposure when compared to untreated canines.

The 3rd article evaluated periodontal health of 23 canines that were exposed with an apically positioned flap. Periodontal parameters were measured at least 1 year after surgery. No significant different values in plaque index, gingival index, PD, width of attached gingiva, clinical crown length, or crestal bone was found compared to untreated contralateral canines.

The 4th articles evaluated was the only study to directly compare excisional uncover to apically positioned flap technique. 21 participants received radical exposure, while 29 had APF, and contralateral untreated canines served as controls. No significant differences in clinal parameters were found between APF and control groups, however, periodontal status was less favorable in the excisional uncover compared to untreated canine groups having more gingival inflammation, recession, and less KG width.

BL: Excisional uncovering resulted in a worse periodontal outcome than an apically positioned flap. The current literature is insufficient to determine which surgical procedure is better for periodontal health to uncover labially impacted canines.


Topic: Orthodontics

Authors: Evren AD, Nevzatoğlu Ş, Arun T, Acar A

Title: Periodontal status of ectopic canines after orthodontic treatment.

Source: Angle Orthod. 2014 Jan;84(1):18-23

Type: Clinical

Keywords: periodontal health, tooth vitality, long term, ectopic canines, palatally impacted canines

Purpose: To evaluate the periodontal health and tooth vitality of palatally impacted and buccal ectopic maxillary canines after completion of orthodontic treatment.

Method: Fifteen patients who had unilateral, palatally impacted canines and 15 patients who had unilateral, buccal ectopic canines comprised the subjects of the study. Clinical and radiographic data was collected by recalling the patients in both groups after a mean period of 3.82 ± 1.54 years following completion of their orthodontic treatment. In both groups, the contralateral, normally placed canines served as controls.

Results: Palatally impacted canines had greater pocket depths, higher gingival levels, higher electric pulp testing scores, and reduced bone levels compared to their contralaterals. Buccal ectopic canines had increased plaque and gingival bleeding index, greater pocket depths, reduced attached gingival width, higher gingival levels, increased clinical crown lengths, and higher electric pulp testing scores compared to their contralaterals. Buccal ectopic canines had lower electric pulp testing scores and higher bone levels compared to palatally impacted canines.

Conclusion: All ectopic canines had increased plaque and gingival bleeding index, greater pocket depths, reduced attached gingival width, higher gingival levels, increased crown lengths, higher electric pulp testing scores, and reduced bone levels compared to their contralaterals.


Topic: Connective tissue grafting

Authors: Smailiene D, Kavaliauskiene A, Pacauskiene I, Zasciurinskiene E, Bjerklin K.

Title: Palatally impacted maxillary canines: choice of surgical-orthodontic treatment method does not influence post-treatment periodontal status. A controlled prospective study.

Source: DL Eur J Orthod. 2013 Dec;35(6):803-10.

Type: Prospective study

Keywords: Dental esthetics; dental restoration; permanent; gingival recession; glass ionomer cements; tooth abrasion; tooth cervix

Purpose: To evaluate post-treatment periodontal status of palatally impacted canines treated by open technique with free eruption and closed flap technique and compare it with naturally erupted canines.

Methods and Materials: The subjects comprised 43 patients treated for unilateral palatally impacted maxillary canines and examined 4.19±1.44 months (3-6 months) after removal of the fixed appliance. The group 1 comprised subjects treated by open technique with free eruption (n = 22) and group 2 by closed technique (n = 21). Post-treatment examination comprised periodontal and radiographic examination.

Results: There were no significant intergroup differences with respect to periodontal pocket depth or bone support. However, compared with contralateral quadrants with normally erupted canines, quadrants with impacted canines exhibited significant bone loss at the distal contact point of the lateral incisor and the mesial contact point of the canine. The duration of treatment was 28.41±4.96 months for group 1 and 32.19±11.73 months for group 2 (P > 0.05). The mean treatment time required to achieve eruption/extrusion of the impacted canine was 3.05±1.07 months for group 1 and 6.86±4.53 months (P < 0.01) for group 2.

BL: Choice of surgical method is not associated with any significant differences in post-treatment periodontal status of palatally impacted canines and adjacent teeth.

Implants used during Orthodontic Therapy

How are implants utilized in ortho therapy? Do TADs have the same healing pattern as other titanium based implants?

M cGuire 2006

P: To introduce Temporary Anchorage Devices (TADs) to periodontal community by explaining how they have altered orthodontic treatment planning, describing the various systems, reviewing techniques and reporting the clinical experiences.


TADs given clinicians and patients treatment alternatives.

Implant Anchorage system:

– Osseointegrated implants: Technique sensitive and challenging since difficult to determine the exact location for implant placement because the final movement of the natural dentition cannot precisely predicted. This implant can only be placed in an edentulous and retromolar area. May not be practical for fully dentate adults or younger pts with deciduous or mixed dentition.

– Palatal Implants/onplants: Miniature, osseointegrated devices. Considered as TADs because they are removed after orthodontic treatment. Palatal implants are titanium self-tapping with 4-6 mm long and 3.3mm in diameter with transmucosal collar in different length, but 4.1 mm fixed in diameter. They can be placed in fully dentate patients and remove after orthodontic treatment.

– Miniplates: Titanium plates in several shapes (L, I, T and Y) with monocortical screws (2 mm diameter x 5 mm length). They can be placed outside the dentition after reflecting a FTF and secured with 2-3 screws. Orthodontic forces are loaded after healing and plates are removed after treatment. They do not interfere with tooth movement and multiple screws provide more secure anchorage.

– Miniscrew implants (microscrews/screw-type implants/microimplants): diameter of 2.5 mm or less All systems are made from either titanium or surgical-grade stainless steel and employ a conical or cylindrical screw design with asymmetric or symmetric thread pitch. The principle variation is in the head shape, which is either a sphere with holes or a flat, slotted surface. Most of the systems on the market are self-tapping, although some of the more recently introduced ones are also self-drilling. Regardless of the design, the implant is usually placed after creating a pilot hole and can be immediately loaded with the orthodontic appliance.

Treatment plan and site selection:

The orthodontist informs the periodontist of the selected site and the preferred placement angle. Radiographs are needed to evaluate the amount of bone available and to ensure that there is adequate space to insert the TAD without damaging the tooth root or other anatomic structures. Although pre-treatment pano and ceph may be available from the referring orthodontist, clinicians may want to take periapical radiographs of the involved region. In some case CT scan is recommended. Palatal and miniscrew implants are placed under local anesthesia. Depending on the site and system used, TADs are placed using a flapless approach or miniflap. The site is prepared under continuous sterile water or saline irrigation, the implant is screwed into place, the site is closed, if necessary.

Because TADs are not osseointegrated, miniscrew implants are usually easily removed with the same driver used to place them, often only using topical anesthesia. Soft tissue closure is not necessary, and the wound heals within a few days. Palatal implants are removed using an osseous trephine under local anesthesia.

Wiechmann 2007

P: To evaluate the success rate of micro-implants used for ortho anchorage.

M+M: 49 pts (36F, 13M; 26.9 years old) received 133 screw-type implants (Abso Anchor: 79 – 1.1 mm, Dual Top: 54 – 1.6 mm) ranging from 5-10 mm. All implants were placed in the attached gingiva and then immediately loaded with 100-200cN transverse forces (depending on the ortho needs, mostly on maxillary). Follow up every 21 days.

Criteria for success: Absence of inflammation, absence of clinically detectable mobility, and capability of sustaining the anchorage function throughout the orthodontic treatment. Survival duration measured from from placement to time of failure or implant retrieval on completion of treatment.

R: 23.2% of all implants failed. 13% of Dual Top failed, 30.4% of Abs Anchor failed.

Cumulative survival of Dual Top was SS higher than for Abs Anchor micro-implants.

Cumulative survival of both was SS higher in the maxilla.

The most common site to fail was mandibular lingual.

BL: 1.6 mm Dual Top implants appear to have a better survival. Micro-implants in mandibular lingual do not have a good prognosis.

Celenza 2012

P: To delineate some interactions between orthodontics and dental implants.


Orthodontics interactions preparatory to implant placement

-For tissue management: since eruption is purely a vertical movement, and occurs such that the existing attachment around a tooth is placed under pure tension, it does not seem to be insulting to the periodontal attachment apparatus if there is pathology present. Therefore, hopeless teeth may be used to prepare a site for implant placement and achieve a more positive clinical result. The tissue developed from orthodontic extrusion is vital tissue, which may present an advantage over allografts.

For Spatial Relations: orthodontics can help with creating spaces to have more esthetic implant-crown restorations. Also, orthodontics can create space for future implants by moving roots to create proper inter-radicular space as well as creating parallelism of adjacent teeth.

Orthodontic interactions after implant placement

Advantages of using implants for anchorage include: no dependence on patient compliance (ej headgear, lip bumpers, transpalatal arches, etc.), implants do not move (natural teeth that you do not want to move may in fact change their position due to forces they receive as a result of trying to move other teeth in an unwanted position), one implant can move several teeth (reversing the rules of anchorage in natural dentition). Since implants do not rely on patient compliance, the term “absolute anchorage” is utilized for implants because the operator has complete control of the situation, greatly enhancing the results of therapy. Implants allow for greater expediency and predictability not by allowing greater force application to the active teeth, but because they themselves can withstand greater force. As a result, they act as perfect anchors and can be used to move multiples of teeth simultaneously, and that is where the efficiency is realized.

Mini-implants and mini-screws (more popular) can also be utilized to aid orthodontic therapy. Mini-screws are the most common of the 3 types of implants due to the variety of places they can be placed..

BL: Implant therapy has expanded the possibility for orthodontic therapy.

Topic: TADS

Authors: Jambi S, Walsh T, Sandler J, Benson PE, Skeggs RM, Brien KD

Title: Reinforcement of anchorage during orthodontic brace treatment with implants or other surgical methods.

Source: Cochrane Database Syst Rev. 2014 Aug 19;(8):CD005098.

Type: Review

Rating: good

Purpose: To assess the effects of surgical anchorage techniques compared to conventional anchorage in the prevention of unwanted tooth movement in patients undergoing orthodontic treatment by evaluating the mesio-distal movement of upper first molar teeth. A secondary objective was to compare the effects of one type of surgical anchorage with another.

Methods: A search was conducted in Cochrane and MEDLINE, randomized controlled trials comparing surgical anchorage with conventional anchorage in orthodontic patients. Trials comparing two types of surgical anchorage were also included.

Results: Fourteen new studies were added in this update resulting in a total of 15 studies reporting data from 561 randomised patients. The studies were conducted in Europe, India, China, South Korea and the USA. The age range of patients was commonly restricted to adolescents or young adults, however the participants of two studies were from a much wider age range (12 to 54 years). The distribution of males and females was similar in eight of the studies, with a predominance of female patients in seven studies. Eight studies were assessed to be at high overall risk of bias; six studies at unclear risk of bias; one study at low risk of bias. Ten studies with 407 randomized and 390 analyzed patients compared surgical anchorage with conventional anchorage for the primary outcome of mesio-distal movement of upper first molars. We carried out a random-effects model meta analysis for the seven studies that fully reported this outcome. There was strong evidence of an effect of surgical anchorage on this outcome. Compared with conventional anchorage, surgical anchorage was more effective in the reinforcement of anchorage by 1.68 mm (95% confidence interval (CI) -2.27 mm to -1.09 mm; seven studies, 308 participants analyzed) with moderate quality of evidence (one study at high overall risk of bias, five studies at unclear risk of bias, one study at low risk of bias). This result should be interpreted with some caution, however, as there was a substantial degree of heterogeneity for this comparison. There was no evidence of a difference in overall duration of treatment between surgical and conventional anchorage (-0.15 years; 95% CI -0.37 years to 0.07 years; three studies, 111 analyzed patients) with low quality of evidence (one study at high overall risk of bias and two studies at unclear risk of bias). Information on patient-reported outcomes such as pain and acceptability was limited and inconclusive. When direct comparisons were made between two types of surgical anchorage, there was a lack of evidence to suggest that any one technique was better than another. No included studies reported adverse effects.

Conclusions: There is moderate quality evidence that reinforcement of anchorage is more effective with surgical anchorage than conventional anchorage, and that results from mini-screw implants are particularly promising. While surgical anchorage is not associated with the inherent risks and compliance issues related to extraoral headgear, none of the included studies reported on harms of surgical or conventional anchorage.

Pediatric Dentistry / Periodontics

Discussion Topics

  1. What are some of the anatomical differences in the jaws and periodontium between children and adults? Is the evaluation, etiology, prevalence, and treatment of mucogingival defects different in children as compared to adults?


Topic: Pediatrics

Author: Maynard JG Jr, Wilson RD

Title: Diagnosis and management of mucogingival problems in children

Source: Dent Clin North Am. 1980 Oct;24(4):683-703

Type: Clinical study

Rating: Good

Keywords: Pediatrics; mucogingival defects; prevalence

Purpose: The purpose of this study is to:

1) Illustrate clinical findings relative to mucogingival problems in children, leading to the hypothesis that they may progress to more extensive recession.

2) Determine the prevalence of mucogingival problems in children

3) Suggest and report preventative therapy by free autogenous gingival grafts


  • As part of comprehensive exam, width of KG was measured, as well as the labial/lingual position of the incisor teeth relative to their alveolar housing and labiolingually width of the alveolar process were assessed.
  • To establish prevalence, 100 children were randomly selected and assessed for mucogingival defects, and the gingival index
  • Separate from this study in private practice, the use of FGGS in the treatment of mucogingival problems in children was documented and case reports were compiled.


  • Less variation in the width of the KG from patient to patient in deciduous incisors than in the permanent incisors. Rarely there was less than 4 to 5mm noted for primary teeth, as opposed to a range of 0 to 6mm in the permanent dentition.
  • Greater incidence of marginal gingivitis was observed in permanent when compared to deciduous dentitions.
  • The narrower the zone of KG in the permanent dentition, the more frequently marginal gingivitis was observed (in accordance with Lang)
  • After observing 200 children, the width of KG is affected by:
    • 1) Eruption pattern of permanent incisors
    • 2) Labio-lingual width of the alveolar process
  • If a tooth is in a labially prominent position and has no KG, the marginal tissue will not become keratinized with time.
  • Orthodontic movement of the tooth into its proper arch position will not create additional KG.
  • Prevalence of mucogingival problems in children was found to be between 12 and 19% in the sample of 100 patients examined.
  • There appears to be no relationship between the necessity for a gingival graft and the age of the patient.
  • Grafts were recommended in 61% of the patients with <1mm of AG, 17% in patients with 1mm AG. Grafts were never recommended in cases with >1mm AG.
  • Where orthodontic therapy is anticipated and there is insufficient KG, an FGG is recommended prior to tooth movement.

Maynard 1975 ARTICLE

Purpose: 1) To illustrate clinical findings relative o mucogingival problems in children, leading to the hypothesis that they may progress to more extensive recession, 2)determine the prevalence of mucogingival problems in children and 3) suggest and report preventive therapy by free autogenous gingival grafts.

Materials and methods: Patients were seen in private practice. Width of KG, MGJ was identified, labial or lingual position of incisor teeth and width of alveolar process were recorded and photographs were taken. 100 children from pedodontic clinic of VCU School of dentistry also participated in the study. GI was recorded as well as PD and position of MGJ for right mandibular incisors or any other tooth that would require therapy. The use of gingival grafts if needed was documented.

Results/Discussion: Less variation in the width of keratinized tissue from individual to individual was observed in the deciduous incisors than in permanent incisors. Permanent incisors had less width of KG and more PDs.

Greater incidence of marginal gingivitis was observed in the permanent dentition. Authors feel it was related with the more limited width of KG.

The existence of adequate width of KG in the deciduous dentition does not mean adequate KG in the permanent also. The dimension of KG depends on the eruption pattern of permanent incisors (buccal – lingual position) and labio-lingual width of alveolar process.

If a patient at the age of 7 starts with an inadequate dimension KG and/or thin labial bone in the presence of inadequate oral hygiene, the result will be recession.

The teeth most commonly needing graft were mandibular central incisors (12-19%). The cases where gingival graft was needed had higher Gingival Index (1.25 vs 1). Of those cases with 1mm or less KG, the graft was indicated 100%, if it was more than 2mm it was never indicated. The factor that should dictate the judgment as to whether a graft should be performed was the dimension of keratinized tissue and not attached gingiva. Orthodontic movement to gain an increase in keratinized tissue does not appear to be a solution. Lingual movement of a labially prominent root does no increase the width of keratinized tissue on the labial aspects of a given tooth. Recession may increase during orthodontic movement, that’s the reason that treatment of the mucogingival problems should be done prior to the orthodontic treatment. Autogenous gingival grafts would be the treatment of choice. Post-op findings suggest that results are stable for at least six years. “Predictable treatment that may be preventive is more acceptable than necessary treatment that may fail.”

Powell and McEniery 1982 ARTICLE

Purpose: To study the importance of plaque control and relief of anterior crowding in relation to isolated gingival recession of mandibular central incisor region of children (6-8yrs).


  • 34 children 6-8 years, with isolated gingival recession were studied for 2 years.

  • Gingival inflammation was controlled by supervised brushing or professional plaque control (2 week intervals).

  • Mandibular anterior crowding was untreated in 11 patients and treated in13 by serial extractions with no attempt to correct the frenal involvement in those subjects (9 patients).


  • After 2 years improvement in gingival contours was most apparent in those subjects whose gingival inflammation had been controlled.

  • This was achieved more readily with professional plaque control than with supervised tooth brushing. Improvement in arch alignment and gingival contour was greater in untreated subjects than in those receiving serial extractions.

  • When gingival inflammation was controlled evidence of frenal involvement declined.


  • Marginal inflammation is a prime factor in the development of localized gingival recession in the mandibular central incisor region.

  • Improvement of gingival health appeared to halt further recession while allowing an improvement in the contour of the gingival tissue.

  • It is suggested that by age of 16 years gingival maturation is still proceeding. So they should not be subjected to mucogingival surgery (frenectomy and grafting) until the normal reparative potential has been fully realized.

BL: Control of gingival inflammation appears to be the most important factor in the treatment of isolated gingival recession in the mandibular central incisor region in young children.

Person 1986 NO ARTICLE

P: To test whether or not improvement in isolated areas of recession in children may occur spontaneously.

M&M: Looked at 18 study casts for gingival recession on mandibular anterior teeth and then recalled the patients (mean of 10yrs). Mean age of 9 years old at initial recording and 20.1 years old at follow-up. Recession = >1mm apical from the gingival level of the adjacent incisor. The height of the gingival margin was measured by first: calipers set at a fixed distance were used to make a mark on the cast on the buccal surface (couldn’t use the incisal edge due to abrasion) then measured from the ref point to the ginigval margin height.

R: The test teeth initially showed 7.3mm from the reference point, and control teeth were 5.7mm. . At follow up, the test teeth were at 7.8mm and the control 7.3mm. The margin was found to be lower by 1.6mm avg on the test tth. 6 cases showed more incisal position of the gingival margins on the test group, 12 cases showed more coronal position.

NSD in sulcus depth, bleeding, width of KG or AG, or alveolar bone height between affected and control (adjacent) teeth at the follow up.

BL: The study supports that local recession in the mandibular anterior of children may improve without treatment when compared to adjacent teeth. Improvement was mostly due to lowering of the margin on control teeth while simultaneously halting changes in test teeth.

Cr: comparing adjacent gingival margins is not the same as recession

Bimstein 1988 ARTICLE

P: To describe the developmental changes that occur in the morphology of the gingival unit in children, based on a 5-year longitudinal examination.

M&M: 54 children aged 7 to 9 years at the first examination were examined 5 years after the baseline examination. In every child, sulcus probing depth, attached gingiva and keratinized gingiva were examined at the buccal aspect of the incisors and either right or left canines and posterior areas. R: With the exception of mandibular incisors, a significantly deeper probing depth was evident in the permanent teeth, than in their primary predecessors. Significantly larger widths of KG were evident in some maxillary permanent teeth than in their predecessors while in the mandibular teeth no significant differences were found. The attached gingiva for the permanent teeth was found to be narrower than the primary teeth. When a permanent tooth was present at both examinations, there was SS increase in width of the attached gingiva with a corresponding decrease in PD, and a slight beginning of an increase in the width of KG.

D: This study confirms the deeper PD of the permanent successor and the decrease in PD, with time.

Andlin-Sobocki 1991 ARTICLE

P: To observe longitudinally (over 3 years) any changes in the labial tissues in young children initially appearing with gingival recession at 1 or more of their mandibular permanent central incisors.

M+M: 28 children (20 boys, 8 girls, mean 9.1 years old), 38 permanent mandibular central incisors with localized ginigival recession. Measured PI, GI, recession, PD, probing attachment level, KG, and attached gingiva performed at baseline, 1, 2 and 3 years.

R: Gingival recession in 25 out of 38 incisors were totally reversed. Reductions in gingival recession and probing attachment levels occurred in all but 1 child who had a severely malpositioned tooth. PD, KG, & AG were unchanged. Coronal shift of tissues was not accompanied by increasing KG, which would suggest a coronal shift of the MGJ. This contradicts Ainamo 1976 study that showed, in adults, that the MGJ remains stable, but this has not been investigated in children.

BL: Reparative surgical treatment may not be necessary and decisions about treatment should be postponed until spontaneous improvement has been allowed to take place.

Addy 1987 ARTICLE

P: To determine whether any relationship exists between plaque and gingivitis associated with the anterior teeth and vestibular depth, frenal attachment, and lip coverage of the gingival tissues at rest.

M&M: 1015 children ages 11.5 to 12.5. Children were assessed for plaque, gingival bleeding, frenal attachment, lip coverage, vestibular depth. Frenal attachment (max. and mand.) was based on: 1) below the attached gingiva, 2) into the attached gingiva, 3) into the attached gingiva and between the central incisors. Lip coverage was based on: 1) total coverage, 2) partial coverage, 3) maxillary labial gingiva exposed. Vestibular depth was based on: 1) shallow, 2) moderately deep, 3) deep.

R: Mean maxillary buccal plaque score decreased significantly as the height of attachment of the maxillary labial frenum increased in all 3 codes (P<0.05). Mean bleeding scores also decreased significantly in the maxillary anterior segment as height of the maxillary labial frenum increased. In contrast, mean bleeding scores in the mandibular anterior segment increased significantly in the group with frenal attachments into the attached gingiva compared with the group with frenal attachments below the attached gingiva. As the coverage of the maxillary incisors and gingiva by the upper lip decreased, the mean maxillary buccal plaque score significantly increased. The mean maxillary palatal plaque score significantly decreased in groups with higher lip lines. In the mandibular anterior segment, there was a SS increase in both mean buccal and lingual plaque scores as the height of the upper lip line increased. Gingivitis and maxillary palatal bleeding increased significantly with decreased lip coverage. The same was shown in the mandibular anterior segment.

B/L: Frenal attachment, lip coverage, and vestibular depth may influence plaque accumulation and gingivitis in anterior segments. The effects of maxillary frenum and upper lip coverage and mandibular frenum and mandibular vestibular depth on plaque and gingivitis were independent of each other, with no significant two way interaction. In the mandibular anterior segment, plaque and gingivitis could be expected to increase when a shallow vestibule and a high frenal attachment coincided. The differences depended on the frenal attachment, vestibular depth, and lip coverage were small, and the influence of these soft tissue variables up on plaque and gingival disease appear of small clinical significance.


Topic: Post-treatment of proclined mandibular incisors and recession

Author: Renkema AM, Navratilova Z, Mazurova K, Katsaros C, Fudalej PS.

Title: : Gingival labial recessions and the post-treatment proclination of mandibular incisors.

Source: Eur J Orthod. 2015 Oct;37(5):508-13. doi: 10.1093/ejo/cju073.

Type: Retrospective

Rating: Good

Purpose: To assess an association between proclination of mandibular incisors at the end of orthodontic treatment followed by a permanent retention with fixed retainers and an increase of the clinical crown heights and development of gingival recession.

Methods: Patients were from 11-14 years old at the start of orthodontic treatment, all mandibular incisors were fully erupted before treatment, fixed lower retainer was bonded directly after treatment, there was no visible wear of incisal edger and no orthodontic re-treatment was performed. Patients were followed from the beginning of treatment to 5 years after treatment. A total of 179 subjects were included. Three types of assessments of post-treatment changes were made: measurement of clinical crown heights (distance between the incisal edge and the deepest points of the vestibule-gingival margin) they were measured on plaster models. Scoring the presence of gingival recession sites as either present of not on plaster models by two calibrated examiners (5 year measurements were only made at the mandibular incisors), cephalometric analysis. To determine the reliability of determination of the clinical crown heights, inclination of the lower incisors, and presence of gingival recessions, 80 dental casts and 20 lateral cephalograms of 20 randomly selected subjects were re-evaluated by two observers after more than 1 month.

Results: Pre-treatment Inc_Incl was larger in the proclined group (98.55°) than in the non-proclined group (89.48°); end-of-treatment (T0) Inc_Incl was also larger in the proclined group (105.19°) than in the non-proclined group (91.39°). From T0 to T5, Inc_Incl remained constant in both groups. No gingival recession sites were found before treatment in any of the subjects from the non-proclined and proclined group. Five years after treatment (T5), there was no difference in the number of subjects with gingival recession—seven subjects (12.3%) from the non-proclined and seven subjects (11.7%) from proclined group had labial recession. The mean increase of clinical crown heights of the lower incisors during treatment was 0.1 mm and −0.12 mm in the non-proclined and proclined group, respectively. The mean increase of clinical crown heights of the lower incisors after treatment ranged from 0.58 to 1.12mm in the non-proclined and proclined group, respectively. NSSD was found between the groups for mandibular incisors.

Conclusion: Based on the findings of this study we conclude that 5 years after orthodontic treatment gingival recession sites were present, on aver- age, in 12% subjects; however, overall the amount of proclination of lower incisors at the end of treatment seemed not to affect the development of labial gingival recession nor the change of clinical crown heights in this patient group.


Topic: Pediatrics and Periodontics

Authors: Delli K, Livas C, Sculean A, Katsaros C, Bortnstein MM.

Title: Facts and myths regarding the maxillary midline frenum and its treatment: a systematic review of the literature.

Source: Quintessence Int. 2013 Feb; 44(2):177-87.

Type: systematic review

Rating: good

Keywords: frenectomy, gingival recession, maxillary frenum, midline diastema, peri-implantitis

Background: Mirko classification is commonly used and is based on interaction between the frenum and the periodontium of the maxillary incisors. 4 types of frena according to the site of attachment: mucosal, gingival, papillary, or papillary penetrating.

There is limited data available focusing on various phenotypes of maxillary frenum, their associated problems and conditions, or the recommended treatment strategies. Clinicians make their decisions based on experience and low-evidence data.

Purpose: To systematically review the current literature on the maxillary midline frenum and associated conditions and complications, as well as the recommended treatment.

Methods: 206 initial articles were searched through MEDLINE database and 48 articles met the inclusion criteria.

Results: A hypertrophic frenum may be involved in the etiology of the midline diastema. Orthodontists tend to suggest a frenectomy after orthodontic treatment due to this finding. This review found inconclusive evidence that gingival recession is due to the maxillary frenum. There is a clinical interest regarding lasers for treatment of maxillary frenum, but laser use has not been demonstrated to be superior in this treatment compared to conventional surgery. Also, an injured frenum in combination with other trauma may indicate child abuse.

Conclusion: A maxillary frenum is a clinical symptom in numerous syndromic conditions and plays a role in the development of the median midline diastema. However, the contribution to gingival recession and peri-implant diseases in the region of the maxillary incisors is controversial. Laser techniques are reported as the method of choice for the surgical removal, but this needs to be further researched by appropriate prospective controlled studies.

Do periodontal diseases occur at the same rate and with the same frequency in children as in adults? What are some of the periodontal diseases that appear to be specific to children? Are there differences in the composition of microbial plaque in children as compared to adults?


Topic: Pediatrics

Authors: Oh TJ, Eber R, Wang HL

Title: Periodontal diseases in the child and adolescent

Source: J Clin Periodontol. 2002 May;29(5):400-10.

Type: Clinical

Rating: Good

Keywords: periodontal disease; children; pedodontics; early onset periodontitis; aggressive periodontitis; localized juvenile periodontitis

Purpose: To review the current literature concerning the most common periodontal diseases affecting children: chronic gingivitis and early onset periodontitis, including prepuber-tal and juvenile periodontitis.

Method: This paper reviews the current literature concerning the most common periodontal diseases affecting children: chronic gingivitis (or dental plaque-induced gingival diseases) and early onset periodontitis (or aggressive periodontitis), including prepubertal and juvenile periodontitis. In addition, systemic diseases that affect the periodontium and oral lesions commonly found in young children are addressed. The prevalence, diagnostic characteristics, microbiology, host- related factors, and therapeutic management of each of these disease entities are thoroughly discussed.


Diagnostic characteristics of prepubertal periodontitis

Localized prepubertal periodontitis (LPP)

  • Onset: around 4 years of age or older
  • Affected teeth: either few or many teeth
  • Gingival manifestation: minor inflammation, if any
  • Microbial plaque: minimal
  • Alveolar bone destruction: faster than adult periodontitis but much slower than
  • generalized form of PP
  • Functional defects: either neutrophils or monocytes but not both
  • Otitis media and upper respiratory infections in some cases
  • Amenable to mechanical and antibiotic therapy

Generalized prepubertal periodontitis (GPP)

  • Onset: at the time of tooth eruption
  • Affected teeth: all primary teeth; the permanent dentition may or may not be affected
  • Gingival manifestation: fiery red gingiva with acute inflammation around all teeth; gingival proliferation, cleft formation, and recession
  • Alveolar bone destruction: rapid
  • Functional defects: both neutrophils and monocytes
  • Absence of PMNs in the gingival tissue and marked increase in peripheral blood white cell count
  • Otitis media and upper respiratory infections in most cases
  • Refractory to mechanical and antibiotic therapy

Diagnostic characteristics of juvenile periodontitis

Localized juvenile periodontitis (LJP)

  • Onset: around puberty
  • Affected teeth: permanent incisors and/or first molars
  • Associated microorganism: Actinobacillus actinomycetemcomitans
  • Greater prevalence in blacks
  • Neutrophil dysfunction and high IgG2 response
  • Familial distribution

Generalized juvenile periodontitis (GJP)

  • Onset: during late teen years
  • Affected teeth: generalized involvement of permanent teeth
  • Associated microorganism: not clear (P. gingivalis may be involved)
  • Greater prevalence in blacks
  • Neutrophil dysfunction
  • Familial distribution

Common Intraoral Lesions:

Therapeutic management of common pediatric oral lesions

Primary herpetic gingivostomatitis

The primary etiology of this disease is herpes simplex virus (HSV) type 1.

  • Topical anesthetics/coating agents:
    • 1 to 1 mixture of diphenhydramine (Benadryl) elixir & Maalox [OTC]
    • diphenhydramine (Benadryl)/lidocaine/Maalox mouth rinse
    • Acyclovir elixir
  • Systemic acyclovir antiviral therapy

Recurrent herpes simplex

Following primary infection by herpes simplex virus, the virus ascends through sensory or autonomic nerves and persists in neuronal ganglia. It becomes dominant within the nucleus and is present as a latent HSV

  • Avoidance of perpetuating factors
  • Acyclovir (Zovirax) 5% ointment or elixir
  • Systemic acyclovir as active treatment or prophylaxis for immunosuppressed patients

Recurrent aphthous stomatitis

The etiology is unknown, yet suggested etiologies include the L-form of streptococcus and/or an immunopathic process involving cell-mediated cytolytic activity in response to HLA or foreign antigens. Precipitating factors may include trauma, stress, menstruation, nutritional deficiencies, food allergies, and endocrinopathies.

  • Topical anesthetics/coating agents: Zilactin-B [OTC], Orabase-B [OTC], or Oraloe [OTC]
  • Antimicrobial mouthrinses: 0.12% chlorhexidine gluconate
  • Topical steroids: triamcinolone (Kenalog) in orabase 0.1%, betamethasone valerate 0.1% ointment, dexamethasone (Decadron) elixir 0.5 mg/5ml, or fluocinonide (Lidex) gel 0.05%


Candidiasis is the most prevalent mycotic infection in the oral mucosa. It is caused by an overgrowth of a superficial fungus, Candida albicans, opportunistic fungus found in the oral cavity, gastrointestinal tract, and vagina.

  • Topical antifungal agents:
    • Nysatin (Mycostatin) oral suspension 100,000 units/ml or popsicles
    • Clotrimazole (Mycelex) troches or swabs
  • Antimicrobial mouthrinses: 0.12% chlorhexidine gluconate

Angular cheilitis

Angular cheilitis, perleche, is a painful condition beginning as an inflammation of the commissure of the lips, followed by erosion, ulceration, and fissuring. It is known to be associated with Candida albicans and Staphylococcus aureus. The possible predisposing factors may include immunodeficiency, riboflavin (vitamin B2) deficiency, trauma, and loss of vertical dimension.

  • Topical antifungal agents: nystatin or clotrimazole ointment
  • Topical antifungal/steroid agent: nystatin/triamcinolone acetonide (Mucolog II) ointment
  • Topical antifungal/antibacterial/steroid agent: hydrocortisone/iodoquinol (Vytone) cream 1%

Geographic tongue

Geographic tongue is a benign inflammatory condition that is characterized by desquamation of superficial keratin and the filiform papillae

  • Topical anesthetic/analgesic mouth rinse: Ulcer-Ease [OTC]
  • Topical antifungal/steroid agent: triamcinolone acetonide 0.1% in nystatin suspension
  • Alkaline saline mouth rinse
  • Topical anesthetics/coating agents: 1 to 1 mixture of diphenhydramine (Benadryl) elixir & Maalox [OTC]

Conclusion: Periodontal diseases are among the most frequent diseases affecting children and adolescents. Dental clinicians must be aware of the prevalence, diagnostic characteristics, microbiology, host-related factors, and therapeutic management of each of these disease entities. It is well known that the primary etiology of periodontal diseases is bacterial plaque. However, patients affected by early onset periodontitis (or aggressive periodontitis) often present with impaired immune function, mainly neutrophil dysfunction. Therefore, it is important when managing periodontal diseases in young individuals, the dentist should rule out systemic diseases that can affect host defense mechanisms.


Topic: gender- subgingival microbiome

Authors: Kumar PS

Title: Sex and the subgingival microbiome: do female sex steroids affect periodontal bacteria?

Source: Periodontol 2000. 2013 Feb;61(1):103-24

Type: Discussion

Rating: Good

Keywords: microbiota, sex hormones, endocrinology, oral systemic relationship

Purpose: The purpose of this review is to critically examine the evidence in the literature on the effect of female sex steroids on oral bacterial communities


The effect of female sex steroids on the composition of the subgingival biofilm has been examined using in vivo investigations during periods of change in hormonal levels and in vitro investigations using bacterial cultures. Pregnancy, puberty, menstruation and menopause are four physiological conditions that offer a means to examine the changes that occur in the oral microbial community during fluctuations in endogenous hormonal levels.

Fluctuations in the levels of sex steroid hormones begin at menarche and end with menopause in the human female. The association between gingivitis and increases in systemic sex steroids has been extensively reported and the biological mechanisms underlying this florid inflammatory state have been examined over several decades.

Do women have a different bacterial profile to men?

Umeda et al. (113) found that males, not females, have greater odds of carrying Prevotella intermedia in saliva, subgingival and supragingival plaque. Thus, there is very little evidence in the literature to indicate a gender predilection for oral bacterial colonization, suggesting that the elevated sex steroid levels in females do not produce long-term changes in the oral microbiome.

Do sex steroids affect all mucosal ecosystems?

Thus, the available data indicate that, although female sex steroids alter mucosal surfaces, an effect on mucosa-associated biofilms is not as readily apparent. Thus, there are divergent opinions on the effect of ovarian hormones on complex microbial ecosystems in the human body

Endogenous sex steroids and the subgingival biofilm:


The predominant subgingival organisms in prepubertal children are reported to be Lactobacillus, Streptococcus, Capnocytophaga, Eikenella, Prevotella and Actinomyces spp., and Peptostreptococcus. Puberty is a time of change in the

subgingival ecosystem. Changes in relative abundance contribute to this compositional shift, and several species belonging to the genera Veillonella, Streptococcus, Capnocytophaga, Fusobacterium, Prevotella and Actinomyces, increase in abundance. Available evidence indicates that in pre-, circum- and postpubertal children, as well as young adults, increases in the detection frequency and proportion of black-pigmented Bacteroides are preceded by, and correlate with, an increase in gingival inflammation. In pubertal children, correlations between an increase in sex steroid levels and the proportions of these organisms have not been demonstrated except in one study. Taken together, these data suggest that the presence of gingival inflammation, rather than the increase in levels of sex steroids, correlates strongly with the prevalence and levels of black-pigmented Bacteroides.

Menstrual cycle

Scant evidence in the literature does not support the hypothesis that hormonal fluctuations during the menstrual cycle affect either the gingiva or the subgingival biofilm. However, the suitability of the menstrual cycle as a model to examine the effects of hormonal changes on subgingival bacteria must be carefully and critically examined, as these hormonal fluctuations are rapid, occur over a relatively short space of time (sometimes only a few hours), and are repeated in periodic cycles. It should be questioned whether these repeated cyclical fluctuations have a long-term effect on a relatively stable, well-established community, and whether studies can be designed to effectively examine any possible effect on the bacterial community over these small intervals of time.


Although early evidence from cultivation-based approaches indicated that hormonal surges during pregnancy may play a role in increasing the subgingival levels of black-pigmented Bacteroides, more recent investigations using molecular methods did not corroborate these findings. As in puberty, the levels of black-pigmented Bacteroides demonstrate a stronger correlation with gingival inflammation during pregnancy than with the levels of circulating hormones. Thus, at present, there is very little evidence linking pregnancy and preferential colonization by certain bacterial species.

Summary and conclusions

Puberty, the menstrual cycle, pregnancy and the perimenopause are periods of significant hormonal surges, while a dramatic decrease occurs after menopause. An increase in gingival inflammation has been associated with these periods of increased hormonal levels, and it was thought that sex steroids play an etiological role by altering the gingival microanatomy as well as the subgingival bacterial community. Early investigations suggested that increases

in female sex steroids led to preferential colonization by black-pigmented Bacteroides, especially P. intermedia. Evidence to support this comes from the following data:

  1. Black-pigmented Bacteroides were found at higher levels in pregnant than non-pregnant women.
  2. Black-pigmented Bacteroides were found at higher levels in women using oral contraceptives.
  3. Estrogen and progesterone substitute for Vitamin K, an important nutrient for black-pigmented Bacteroides.

However, several confounding variables affect these studies, the most important of which is that the subgingival microbiome is affected by several environmental factors, including inflammation. As ovarian hormones exert a predominantly proinflammatory effect on the gingiva, it is difficult to separate the direct effects of female sex steroids from the effects of gingival inflammation on the gingival community. Other factors that need to be considered are that very few studies demonstrate a positive correlation between hormonal and bacterial levels, and positive correlations between gingival inflammation and bacterial profiles are consistent in all studies. Prevotella species are found in periodontal health and disease, and show a higher prevalence at sites with deep probing depths and inflammation. Prevotella species have also been found in all forms of gingivitis, including necrotizing ulcerative gingivitis and HIV-related gingivitis. Further, studies using cultivation-based approaches for bacterial identification diverge significantly in terms of bacterial nomenclature, and are also limited since these methods do not allow for highly discriminatory bacterial identification, and make it difficult to draw definitive conclusions.

BL: At present, there is no definitive evidence linking elevated states of ovarian hormones to preferential enrichment of the subgingival microbiome for selected species.

AAP Position Paper 1996 ARTICLE

P: To represent a brief summary of the current state of knowledge about periodontal diseases in children and adolescents.

Disc: Gingivitis is a universal finding of children and adolescents. Loss of periodontal support found 1-9% in 5-11 years old and 1-46% in 12-15 years old. Clinical distinct periodontal infections that can affect young children include:

  • Chronic Gingivitis: Presence of gingival inflammation without detectable loss of bone or clinical attachment. Little is known about the microbiology, increased sub-g levels of Actinomyces sp. or black- pigmented anaerobic rods may be important. Usually responds through removal of bacterial deposits and improved OH.
  • Early Onset (Aggressive): Distinct types of periodontitis that affect young individuals who are otherwise healthy. Localized form is found in teenagers and young adults and incidence between 0.1-15%. Most reports suggest 0.2% except African Americans 2.5%. Patients have little local deposits; A. A found as etiologic factor. A variety of functional defects have been reported in neutrophils from patients with LJP. These included anomalies of chemotaxis, phagocytosis, bactericidal activity etc.

May respond to meticulous mechanical therapy with antibiotics. Generalized form is considered a disease of young adults but can begin around puberty. Patients have heavy accumulations of plaque and calculus. Prevalence in US 0.13%. Subgingival sites have P. Gingivalis and some patients exhibit suppressed chemotaxis. Tx : may not respond to mechanical therapy in combination with antibiotics. May require other antibiotics based on characteristics of flora.

  • NUG/P: Found more in children in underdeveloped areas of Africa, Asia or South America. The two most significant findings used in the diagnosis of NUG/P are the presence of interproximal necrosis and ulceration and the rapid onset of gingival pain. High spirochete and P. Intermedia found. Some factors that predispose children are viral infections, malnutrition, emotional stress, sleep deprivation and systemic illnesses. Tx: local therapy with AB and careful follow-up.
  • Perio associated with systemic illnesses: Papillon-Lefevre, cyclic neutropenia, agranulocytosis, Down syndrome, Type I diabetes and Leukocyte adherence deficiency syndrome (LAD). It is probable that defects in neutrophil and immune cell function associated with these diseases play an important role in increased susceptibility to periodontitis and other infections. Studies suggested diabetic children have more inflammation despite similar plaque scores. 10% of diabetics 11-18years old were found to have periodontitis. A.a, Capnocytophaga and anaerobic Vibrios found. Local debridement and antimicrobial therapy may be useful. LAD-begins between time of eruption of primary teeth up to age 4 or 5. Termed prepubertal periodontitis. Both generalized and localized. Neutrophils from some patients with prepubertal periodontitis have abnormalities in a cell surface glycoprotein that mediates adherence to surfaces. Patients may present like LAD if they have underlying hypophosphatasia or agranulocytosis. Pathogens involved A. A, P. Intermedia, E. Corrodens and Capnocytophaga.

BL: Children and adolescents are subject to a wide variety of periodontal infections. Diagnosis more difficult but early diagnosis is most important for success. A medical evaluation is warranted in cases with systemic illness if extremely resistant to therapy.

Clerehugh 2001 ARTICLE

P: To review the diagnosis and management procedures in the treatment of periodontal diseases in children and adolescents.

Hx and exam: Most important aspect for diagnosing these diseases in children. Even though periodontal disease is primarily bacterial etiology, look for host susceptibility. All children should be periodically monitored for perio involvement. If the child develops pocketing, has poor OH on multiple visits, has other periodontal conditions, Perio screening (full charting) and appropriate radiographs (avoid excess radiation) should be utilized and the condition monitored. Dentists should probe #3, 8, 14, 19, 24, 30 and if they find a 4mm or greater pocket, then further perio evaluation should be performed (full charting).

Systemic Risk Factors associated with gingival diseases in children: Hormones (puberty, birth control, pregnancy), Drugs (anticonvulsants, Ca channel blockers and chemotherapeutics), HIV/AIDS generally manifests as linear gingival erythema and NUG/NUP, Leukemia (Acute myeloblastic leukemia and acute lymphoblastic leukemia very common and have gingival manifestations like gingival swelling, bleeding, and ulcers), Vit C deficiency (gingival swelling, bleeding, sponginess and ulceration), diabetes.

Other Local Risk Factors: Smoking in adolescents (earlier onset common, increases as children get further into adolescence), Subgingival restorations or calculus, mouth breathing, lack of lip competence, ortho treatment, developmental dental features like enamel pearls and radicular grooves.

Genetic diseases: neutropenia, papillon-lefevre, chediak higashi, LAD syndromes, Down’s syndrome, hypophospatasia, Ehlers-Danlos syndrome.

They recommend following a basic perio index, scoring the dentition, then treating based on this.

Diagnosis: Classification: Gingivitis, NUG, incipient adult periodontitis, EOP (divided in 4 subgroups), NUP (these three forms of perio are a classif published by Kinane 2001 for children), Mucogingival problems

Tx Plan: Initial: cause related (plaque control/OHI, smoking cessation, SRP, phase I caries control)

Corrective: sx or non-sx, ortho, mucogingival procedures, definitive restorations

Supportive: SPT, with appropriate re-education and retreatment if needed

Recall: Appropriate Interval

If pt is under 7 years of age, the parent is responsible for plaque control.

BL: Plaque is the key component of periodontal disease, but children and adolescents require different management than adults, including age appropriate screening, instruction and intervention.

Comment: Very thorough review of periodontal disease in children and adolescents. Excellent charts with the different etiologies.

Mombelli 1989 ARTICLE

P: To follow the development of the gingival conditions during puberty and to correlate oral clinical parameters with chronological age as well as with parameters used for the determination of the pubertal development.

M&M: A 4-year longitudinal study was performed on 22 boys and 20 girls (avg 11 yrs old). Pubertal, skeletal parameters, PII, GI were assessed every year. Papillary bleeding index was measured 10 times in all interdental spaces of the dentition. Determination of skeletal maturity was obtained by evaluating hand wrist radiographs.

R: The bleeding tendency, represented by whole mouth mean PBI values, as well as the % of bleeding interdental sites, was found to increase significantly with the start of the pubertal phase. A significant trend of decrease was noted after the age of 14 years in boys and girls. In boys, mean PBI and the % of interdental sites with bleeding were correlated with testicular growth, and in girls with the Tanner index for sex characteristics (pubic hair & breast development). PII and GI showed no trend.

D: Since no differences in mean PI throughout the study, the increasing gingivitis trends may be explained at least in part by host-dependent factors.

BL: Bleeding tendency is related to pubertal changes.

Mombelli 1995 ARTICLE

Purpose: To assess the oral clinical and microbiological status of young adults 6 years after puberty and to compare these findings with the conditions observed during puberty.

Materials and methods:

33 subjects (19 male, 14 female)of those that participated in the 4 year longitudinal study and were re-examined at a mean age of 20.8 years old. PI was measured at 4 sites/tooth and microbiological samples were obtained from the mesial aspect of both upper 1st molars. Papillary bleeding index was measured for all interdental spaces and PD, AL decayed, missing and filed teeth (DMFT) were recorded.

Participants were divided in 3 groups according to the amount of gingivitis developed during puberty. Group A included subjects demonstrating marked and sustained increase in full mouth mean PBI scores during puberty, Group B subjects demonstrated clearly visible but less pronounced puberty gingivitis and Group C those no exceeding 1.5 in PBI scores at any time during puberty.

Results: 8/33 had taken antibiotics in the last 6 months, 11 were smokers and 15 had orthodontic therapy. 8 females were taking oral contraceptives. Interdental caries was detected in 13 subjects radiographically. No clinical or radiographic evidence was observed. One 7mm pseudopocket was found, no sites with PD more than 5mm and 3% had PDs of more than 4mm. AL was not exceeding 4mm in any case.

Male subjects had significantly higher mean PI, Slightly increase PDs and higher DMFT score.

Subjects in Group A showed more sites with pronounced bleeding and the more sites with AL more than 3mm.

PBI was significantly higher in individuals with a history of orthodontic therapy and lower in smokers.

Subjects with history of orthodontic Tx had more sites with a AL of more than 3mm.

Mean PD was correlated to the history of pubery gingivitis, orthodontic Tx and smoking.

No significant influence or antibiotic therapy in the past 6 months and oral contraceptives.

All microbiologic samples contained cocci and most of them nonmotile rods. Motile and fusiform organisms were detected in 1/3 of samples and spirochetes were infrequently found. Black pigmented anaerobes found in 33% and P. Intermedia in 27%. P. gingivalis has not been detected in none of the two studies. Individuals with no pronounced puberty gingivitis showed the lowest anaerobic total counts. Spirochetes and A.a. were found exclusively in Group A subjects.

Significant correlation was found between the number of positive samples during puberty and presence 6 years later for P. intermedia and spirochetes.

Conclusion: Significant relationship between the severity of puberty gingivitis and periodontal and microbiological conditions 6 years after puberty was found. It is to be investigated if these signs indicate an increased risk for periodontal disease.

Bimstein 1996 ARTICLE

Purpose: To assess, in the primary molar area, the relationships between microbial composition of the sub-gingival plaque, contact loss cause by caries, and alveolar bone loss (ABL).

Materials and methods:

  • 20 children divided into

    • A) Contact loss due to proximal caries with at least 1 site having ABL and 1 site without it (2 mm radiographic bone loss as cut off)

    • B) No ABL with and without contact loss

  • The microbial samples were taken from each site, and analyzed by dark-field microscopy and cultures of total anaerobic bacteria. The total colony forming units (CFU) was identified.


A. Contact loss

B. No bone loss



Contact loss

CEJ-Bone crest

2.7 mm

1.5 mm

1.5 mm

Anaerobic CFU

2.06 x 106

3.49 x 106

13.41 x 106

Pg CFU proportion




Sum of pathogenic (spirochetes and motile rods)




Sum of Nonpathogenic (filaments, cocci, rods)





  • Contact loss with ABL showed SS greater distance from CEJ-Alveolar bone crest

  • Spirochetes and motile rods may be part of the indigenous flora of the oral cavity in children. However, their proportions are SS higher in the sub-gingival plaque of sites in children with ABL than in those without ABL.

  • In sites where Aa was found, higher proportions of spirochetes, lower proportions of cocci, and more CFU of Pg were obtained.

  • Both Aa and Pg were found in sites in children without marginal ABL and could not be related to marginal ABL.

Kargul 1998 NO ARTICLE

P: To investigate the effect on plaque pH and saliva pH of Flixotide (F) (inhaler corticosteroid) and Ventoline (V) (inhaler salbutamol), as well as the effect of chewing gum on pH after inhaler use.

M&M: 30 children, males and females, ages 6-14, suffering from chronic asthma, use of inhaler for 1 year, and no other med problems. Pts instructed not to eat 1 hr prior to appt. Baseline plaque and saliva index taken at IP PM sites in all 4 quads. Pts used Flixotide (F) and pH taken at 1, 5, 10, 20, 30 minutes after inhaler use. This was followed by chew gum for 1 minute and pH taken again. Use of (F) again and rinse with water following the use of (F) and pH taken. Pts followed the same protocol for the Ventoline (V) inhaler.

R: At baseline, the plaque and saliva values were comparable in all pts. In Flixotide (F) and Ventoline(V) the pH values decreased in all 4 quads during 30 minutes as well as after rinse with water. Thirty min pH values increased in all 4 plaque sites with chewing gum after inhaler use.

C: SS decrease in pH of saliva and plaque was found after medication with inhaler forms in asthmatic children. It is suggested that they receive special caries prevention attention and chew sugar free gum after using the inhaler.

  1. How effective are tooth transplants? What factors govern the success of tooth transplants?

Proye and Polson 1982 ARTICLE

Purpose: To determine the healing sequence in the transeptal region and PDL after teeth re-implantation.

M&M: Mechanical plaque removal was performed 3 times a weeks for 6 weeks prior to extraction of 12 teeth (4 squirrel monkeys). Teeth were extracted, examined & reimplanted within 3 minutes. Teeth were soaked in saliva or placed in the socket during that time. Animals were maintained on a soft diet and Vit-C. Oral hygiene was maintained 3 times a week and CHX 2% rinse. Animals were sacrificed at 1, 3, 7, 21 days & 3 teeth were examined histologically and radiographically.

Results: Clinical observations: Prior to extraction no mobility or gingival inflammation was present. After re-implantation teeth had slight MD-BL mobility that remained. No teeth were exfoliated.

Histologic analysis:

  • Day 1: Severe disruption of coronal PDL and transeptal fibers & marked acellularity.
  • Day 3: Cell repopulation in the transeptal region, the area adjacent to the root surface was acellular.
  • Day 7: the transeptal fiber region was cellular with areas of fiber continuity; the coronal PDL had localized areas of acellularity and lack of fiber continuity.
  • Day 21: Normal fibers density & orientation in the transeptal area; coronal PDL was cellular but normal orientation was absent. Root resorption involving cementum & dentin was present on every surface. Ankylosis was present in 1/6 PDLs.

Autoradiographic analysis: NSD in the densities between the transeptal and PDL fibers at 1 & 3 days. At day 7 transeptal fiber density was significantly greater & at day 21 the PDL density was greater.

BL: Reattachment between teeth and periodontium can occur after re-implantation. Healing seems to be more rapid within the transeptal region.

Pogrel 1987 NO ARTICLE

P: To evaluate the success rate of extracted teeth transplanted into prepared recipient sites.

M&M: 416 teeth were transplanted in 368 pts (14-38y). The teeth were 162 max canines, 124 mand 3rd molars, 63 max 3rd molars, and 67 other types of transplants. Oral PCN was given starting 24 hrs pre-op and ended 3 days postop. Teeth were transplanted according to Thonner’s technique. Donor teeth were extracted atraumatically then the recipient site was prepared by extensive drilling and possibly creating a labial osteoplastic flap to create buccolingual width, then the tooth was transplanted. Most teeth were splinted with vacuform splints, however some had wire or silver splint fixation. The vacuform splints were discarded when mobility was < 1 mm. Pulp tests and RAs were performed q 6mos for 2 yrs.

R: 302 teeth (72%) were successful a/f 2 yrs. 14% were vital to EPT. No teeth that were successful for at least 2 yrs have developed problems related to the procedure. Of 47 teeth transplanted into sockets with periapical radiolucencies before transplantation, 25 (53%) were successful, significantly lower than non-infected (75%). Radiographic obliteration of the pulp chamber indicated a successful result; no narrowing of the pulp chamber indicated a non-vital pulp. In 58 cases, the teeth were lost due to external and internal resorption. The success rate was 62% of upper canine transplants, 81% for mand 3rd molar transplants, 76% for max 3rd molar transplants and 76% for others.

Disc: Teeth removed atraumatically (most imp factor is to maintain vitality of periodontal ligament) and transplanted w/in 3 minutes to a well-fitted socket had a success rate of 94%. Endo Tx is indicated only when symptoms develop. Ca(OH)2 may arrest or slow external resorption, but once developed, transplant was headed for failure. Ideal time for transplantation is when root development is 50-75% of final length. Tth with wide open apices had a higher chance of revitalization.

BL: overall success rate was 72%


How effective are tooth transplants? What factors govern the success of tooth transplants?


Topic: Autotransplantation

Authors: Atala-Acevedo C, Abarca J, Martínez-Zapata MJ, Díaz J, Olate S, Zaror C.

Title: Success Rate of Autotransplantation of Teeth With an Open Apex: Systematic Review and Meta-Analysis.

Source: J Oral Maxillofac Surg. 2017 Jan;75(1):35-50.

Type: Systematic Review and Meta-Analysis.

Rating: Good

PURPOSE: To determine the success rate of autotransplanted permanent teeth with an open apex and to identify the most influential prognostic factors.

METHODS: A systematic search of the MEDLINE, EMBASE, LILACS, and SciELO databases was conducted for January 1990 to August 2015. The study eligibility criteria were primary studies that had evaluated patients with autotransplantation with an open apex, with or without preparation of the socket, and a minimum of 12 months of follow-up. The principal outcome was the success rate of autotransplanted teeth with an open apex. Two of us independently performed the selection process and data extraction. The Effective Public Health Practice Project’s Quality Assessment Tool was used for the quality assessment of the studies. The odds ratio (OR) was calculated, with the 95% confidence interval (CI).

RESULTS: A total of 21 studies were included in the present analysis. Of the 21 studies, 10 were retrospective and 11 were prospective. All the studies were of weak methodologic quality. The overall success rate was 89.68%, the survival rate was 98.21%, and the mean follow-up period was 6 years, 3 months (standard deviation 5.81 years). Among the prognostic factors analyzed, the premolars had a lower failure risk than did the molars (OR, 0.46; 95% CI, 0.25 to 0.84). The stage of development of the root and the autotransplantation receptor site showed no statistically significant differences.

The success rate of the studies was 89.68% (95% CI 86.77 to 92.59%). The success rate was high, although the heterogeneity of 64.6% was substantial

CONCLUSIONS: The overall success rate and survival were high, despite the methodologic limitations of the included studies. Further study is needed of the prognostic factors that influence the success of autotransplantation with an open apex