ORTHODONTICS
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 J. Relationship between malalignment of the teeth and periodontal disease. Scand J Dent Res. 80:104-110, 1972.
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.
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
Brown IA. The effect of orthodontic therapy on certain types of periodontal defects. I. Clinical findings. J. Periodontol. 44:742-756, 1973.
Kraal JH, et al. Periodontal conditions in patients after molar uprighting. J Prosthet Dent 43:156 - 1980.
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, Wang H-L, Smith FN. Interrelationship between periodontics and adult orthodontics. J Clin Perio 25:271-277,1998. (Review)
Ericsson I : The combined effects of plaque and physical stress on periodontal tissues. J. Clin. Periodontol. 13:918 -, 1986. (Review)
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.
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
Polson A, et al. Periodontal response after tooth movement into intrabony defects. J. Periodontol. 55:197-202, 1984.
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.
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.
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
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.
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 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.
Ingber J. Forced eruption. Part II. A method of treating nonrestorable teeth -periodontal and restorative considerations. J. Periodontol 47:203-216, 1976.
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.
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
Carvalho et al: Orthodontic extrusion with or without circumferential fiberotomy and root planing. Int J Periodontics Restorative Dent 2006; 26:87-93
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.
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?
Reed B, Polson AM, Subtelny JD. Long-term periodontal status of teeth moved into extraction sites. Am J Orthod Dent Orthoped. 88:205-, 1985.
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
Liou E, Huang CS. Rapid canine retraction through distraction of the periodontal ligament. Am J Orthod Dentofac Orthop 1998; 114: 372-380.
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.
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.
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?
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.
Edwards JG. The diastema, the frenum, the frenectomy: A clinical study. Amer J Orthod Dent Orthoped. 71: 489-508, 1977.
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
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
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
Karring T, et al. Bone regeneration in orthodontically produced alveolar bone dehiscences. J. Periodontal Res. 17:309-315, 1982.
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?
Kokich V: Surgical and orthodontic management of impacted maxillary canines. Am J Orthod Dentofac Orthoped 2004; 126: 278-283
Artun J, Osterberg SK, Joondeph DR. Long-term periodontal status of labially erupted canines following orthodontic treatment. J Clin Periodontol. 13:856-861, 1986.
Burden D, Mullally B, Robinson S. Palatally ectopic canines: Closed eruption versus open eruption. Am J Ortho Dento Orthop 115:640-644, 1999.
Quiryen M, Op Heij DG, et al. Periodontal health of orthodontically extruded impacted teeth. J Periodontol 71:1708-1714, 2000.
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
How are implants utilized in ortho therapy? Do TADs have the same healing pattern as other titanium based implants?
McGuire M et al: Temporary anchorage devices for tooth movement: A review and case reports. J Periodontol, 2006;Oct:77(10)1613-24
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
Celenza F. Implant interactions with orthodontics. J Evid Based Dent Pract. 2012 Sep;12(3 Suppl):192-201.
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?
Maynard GJ, Oschenbein C. Mucogingival problems, prevalence and therapy in children. J. Periodontol. 46:543-552, 1975.
Powell RN, McEniery TM : A longitudinal study of isolated gingival recession in the mandibular central incisor region of children aged 6-8 years. J. Clin. Periodontol. 9:357-364, 1982.
Person M, Linnartsson B : Improvement potential of isolated gingival recession in children. Swed. Dent. J. 10:45-51, 1986.
Bimstein E, Eidelman E : Morphological changes in the attached and keratinized gingiva and gingival sulcus in the mixed dentition period. A 5-year longitudinal study. J. Clin. Periodontol. 15:175, 1988
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.
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.
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?
Position Paper. Periodontal diseases of children and adolescents. J Periodontol 67:57-62, 1996.
Clerehugh V, Tugnait A. Diagnosis and management of periodontal diseases in children and adolescents. Perio 2000 26:146-168, 2001
Mombelli A, et al. Gingival health and gingivitis development during puberty. A 4 - year longitudinal study. J. Clin. Periodontol. 16:451-456, 1989.
Mombelli A, Rutar A, Lang NP. Correlation of the periodontal status 6 years after puberty with clinical and microbiological conditions during puberty. J Clin Periodontol 22:300-305,1995.
Bimstein E, Ram D, Naor R, Sela MN. The composition of subgingival microflora in two groups of children with and without primary dentition alveolar bone loss. Pediatric Dent 18:42-47, 1996.
Kargul B, Tanboga I, Ergeneli S, Karakoc F, Dagli E. Inhaler medication effects on saliva and plaque pH in asthmatic children. J Clin Pediatric Dent 22:137-140, 1998.
How effective are tooth transplants? What factors govern the success of tooth transplants?
Proye MP, Polson AM. Repair in different zones of the periodontium after tooth reimplantation. J. Periodontol. 53:379-389, 1982.
Pogrel MA. Evaluation of over 400 autogenous tooth transplants. J. Oral Maxillofac. Surg. 45:205-211, 1987
ORTHODONTICS
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?
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.
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) ARTICLE
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 ARTICLE
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 ARTICLE
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.
Resutls:
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.
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?
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 ARTICLE
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 ARTICLE
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 ARTICLE
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 ARTICLE
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 ARTICLE
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 ARTICLE
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 ARTICLE
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:
Zone A: bone tissue within the distal portion of the previous 4th premolar site, 4x6mm
Zone B: distal aspect of the distal root of the 3rd premolar, pressure side and a 300μm wide area adjacent to it
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 ARTICLE
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.
Results:
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.
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 ARTICLE
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 ARTICLE
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 ARTICLE
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 ARTICLE
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 ARTICLE
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 ARTICLE
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.
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?
Reed 1985 ARTICLE
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 ARTICLE
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 ARTICLE
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.
Results:
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 ARTICLE
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-grafted 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.
Wilcko 2009 ARTICLE
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.
Advantages:
Enhanced scope of malocclusion treatment
Decreased treatment times
Increased alveolar volume and more structurally complete periodontuim
Alveolar reshaping for the subtle enhancement of a pt’s profile
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.
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?
Coatoam 1981 ARTICLE
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.
Disc:
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 ARTICLE
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 ARTICLE
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 ARTICLE
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 ARTICLE
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 ARTICLE
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.
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?
Kokich 2004 ARTICLE
Purpose: Discussion article on impacted maxillary canines.
Discussion
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 ARTICLE
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 ARTICLE
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 ARTICLE
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 ARTICLE
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.
How are implants utilized in ortho therapy? Do TADs have the same healing pattern as other titanium based implants?
McGuire 2006 ARTICLE
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.
D:
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 ARTICLE
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 ARTICLE
P: To delineate some interactions between orthodontics and dental implants.
D:
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.
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?
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).
Materials&Methods:
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).
Results:
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.
Conclusion:
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.
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.
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?
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.
R:
|
|
A. Contact loss |
B. No bone loss |
|
|
ABL |
No ABL |
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 |
1.8% |
0.9% |
9.0% |
|
Sum of pathogenic (spirochetes and motile rods) |
34.4% |
15.9% |
9.7% |
|
Sum of Nonpathogenic (filaments, cocci, rods) |
65.1% |
84.8% |
90.3% |
BL:
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.
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.
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.
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%
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