08 PRD GTR Ortho

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Orthodontic treatment of periodontally involved teeth after tissue

regeneration
Article in The International journal of periodontics & restorative dentistry · January 2009

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559
Orthodontic Treatment of Periodontally

Involved Teeth After Tissue
Regeneration
Carlo Ghezzi, DDS1/Silvia Masiero, DDS2/ Patients with periodontal disease can
Maurizio Silvestri, DDS3/Gianfranco Zanotti, DDS4/ present pathologic tooth migration
Giulio Rasperini, DDS5 (PTM), often with severe intrabony
defects. Periodontal bone loss appears
In this consecutive series, 14 patients with severe intrabony defects and pathologic to be a major agent in the etiology of
tooth migration were treated with guided tissue regeneration (GTR) and subse- PTM, along with occlusal changes
quent orthodontic therapy in an attempt to evaluate the validity of this multidisci- caused by several factors.1 The pres-
plinary approach. Probing pocket depths (PPD), clinical attachment levels (CAL), sure produced by inflammatory tissues
and gingival recessions were assessed at baseline, 1 year after GTR, and at the end within periodontal pockets is also con-
of orthodontic therapy. Radiographs were obtained at all time points. Esthetic
sidered important.1 Unfortunately,
parameters were recorded with the papilla presence index (PPI). Statistical analyses
PTM can be associated with esthetic
were carried out to compare the data at each time point. From baseline to 1 year
damage of the smile line, reducing a
after GTR, the mean PPD reduction was 5.57 mm, with a residual mean PPD of 2.71
patient’s self-esteem. To solve both
mm; mean CAL gain was 5.86 mm. Both differences were statistically significant.
There were no statistically significant differences between 1 year after GTR and the issues, therefore, a combination of
end of orthodontic therapy (mean PPD reduction 0.07 mm; mean CAL gain 0.43 orthodontic and periodontic treatment
mm). The reduction in PPI reflected the enhancement of papilla height that was is often needed.
observed in 9 of the 14 patients. Within the limits of this research, this study affirms The movement of teeth with
the possibility of a combined orthodontic-periodontal approach that prevents dam- reduced but healthy periodontium has
aging the regenerated periodontal apparatus and produces esthetic improvements been studied in some animal and clin-
as a result of realignments and enhancement of papilla height. (Int J Periodontics ical reports.2–4 These studies con-
Restorative Dent 2008;28:559–567.) firmed that the attachment is not dam-
aged when inflammation is absent.
However, in the presence of plaque-
1Consultant Professor, Department of Periodontology, School of Dentistry, University of induced inflammation, orthodontic
Milano, Milan, Italy. forces cause uncontrolled periodon-
2Private Practice, Saronno, Italy.
3Consultant Professor, Department of Periodontology, School of Dentistry, University of tal attachment loss.5 In a histologic ani-
Pavia, Pavia, Italy. mal study, Polson et al6 created angu-
4Private Practice, Pessano, Italy.
lar bony defects and treated them with
5Research Professor, Department of Periodontology, School of Dentistry, University of
conventional scaling and root planing;
Milano, Milan, Italy.
no attachment gain was achieved. In
Correspondence to: Dr Carlo Ghezzi, Via S. Pellico, 26/2, I-20019 Settimo Milanese, Italy; another animal experimental study,
fax: +390-2-33514223; e-mail: [email protected].
Volume 28, Number 6, 2008

560
Diedrich et al 7 treated intrabony aim of the present study was to evalu- study. Intraoral radiographs, PPD, CAL,
defects using enamel matrix deriva- ate the stability of this combined treat- and gingival recession were recorded
tive plus polylactic resorbable mem- ment in re-creating the periodontal after calibration to the nearest mil-
branes in the test sites. The authors attachment in 14 periodontal patients limeter using a manual pressure-
found that the test procedure resulted with severe intrabony defects. Esthetic sensitive probe (UNC 15, Hu-Friedy)
in regeneration of the periodontal evaluations were carried out using the (Figs 1 and 2).
apparatus with minimal epithelial Papilla Presence Index (PPI) proposed All patients received a regenera-
downgrowth. by Cardaropoli and coworkers.25 tive procedure appropriate to their soft
Data from two other animal histo- and hard tissue morphology. The mod-
logic studies suggest that formation of ified papilla preservation technique
new periodontal attachment is achiev- Method and materials (Fig 3) was selected when the inter-
able with OFD plus orthodontic treat- dental space was wider than 2 mm; the
ment.8,9 In one of these studies, Geraci In this study, 14 consecutive patients simplified papilla preservation tech-
et al8 created three-wall defects and presenting the following criteria were nique was performed when the space
treated them with OFD; they showed enrolled: (1) age of at least 21 years; (2) was less than 2 mm.27,28 A full-thick-
that it is possible to rebuild lost peri- good general health, with women not ness flap was elevated to allow ade-
odontal support in conjunction with pregnant or lactating; (3) nonsmoking quate visualization at the treatment
bodily tooth movement. Moreover, status; (4) presence of severe peri- site. An apical horizontal periosteal
Melsen et al9 confirmed the capacity of odontitis treated with scaling, root incision was performed to achieve ten-
OFD associated with orthodontic planing, and oral hygiene instructions; sion-free primary closure of the flap.
movement to result in new connective (5) good oral hygiene with full-mouth Clinical decision-making on the treat-
fiber formation over the deepest point plaque score (FMPS)26 and full-mouth ment of the infrabony defect was
of root instrumentation when intrusive bleeding score (FMBS) < 25% at base- made according to the protocol
tooth movement was performed. line; (6) presence of a deep infrabony described by Cortellini and Tonetti.29
However, no histologic evidence defect with a probing pocket depth Three-wall infrabony defects were
of regeneration in association with (PPD) ≥ 6 mm; ( 7 ) migration and treated with enamel matrix derivative
OFD in humans has been demon- diastema between two teeth subse- alone, whereas two-wall and one-wall
strated to date, whereas several stud- quent to periodontal disease; (8) need defects were treated with a resorbable
ies have shown the histologic benefits for orthodontic treatment. collagen membrane plus bone graft
of treatment with guided tissue regen- (Fig 4). In each case, a combination of
eration (GTR).10–13 In addition, recent internal mattress sutures and single
reviews showed that GTR procedures Treatment sutures was performed to obtain com-
produce better results than open flap plete primary closure.
debridement in terms of probing All patients received cause-related Patients received antibiotic ther-
pocket depth (PPD) reduction and clin- therapy in the presurgical phase. This apy (Augmentin, SmithKline Beecham;
ical attachment level (CAL) gain, and consisted of a complete periodontal 3 g/d for 6 d) and rinsed twice a day for
result in only slight gingival loss after examination and multiple scaling and 15 days with chlorhexidine 0.2% and
surgery.14–18 root planing sessions in addition to with chlorhexidine 0.12% for another
The clinical point of view of ortho- oral hygiene instructions. Re-evalua- 2 weeks. Sutures were removed after
dontic movement in patients with tion was performed 1 month after the 8 days, and patients were enrolled in
severe intrabony defects has not been completion of the initial phase. All a recall system that included profes-
analyzed in a randomized clinical con- patients who showed a FMPS and sional tooth cleaning and remotivation
trolled study; only limited reports with FMBS below 25% at the re-evaluation during orthodontic treatment. One
conflicting results are available.19–24 The visit were consecutively enrolled in this year after surgery, clinical and radio-

561
Fig 1 (left) Migration of the maxillary right

lateral incisor with loss of the interdental
papilla and a PPD of 8 mm. A PPI score of 4
with diastema was assigned.
Fig 2 (right) Bone defect before the initial

phase of treatment.
Fig 3 (left) Flap design with the modified

papilla preservation technique.
Fig 4 (right) Intrasurgical view exhibiting

an intraosseous component of 6 mm.
graphic measurements were per- with the goal to obtain movement that appointments. The clinician selected
formed as at baseline. would not impair the newly regener- an appropriate fixed retention device
Orthodontic treatment started 1 ated attachment.4,30,31 after active therapy.32 This long-term
year after surgery. Patients underwent Straight-wire preadjusted brack- retention was used to prevent relapse,
different types of movement according ets with thermoactive nickel archwire to decrease tooth mobility, and to
to the clinical need to realign the den- (3M MBT 0.22-inch Victory system) improve chewing comfort. At the end
tal arch: intrusion and bodily move- were used to achieve well-controlled of the orthodontic therapy, clinical and
ment that included movement away repositioning (Figs 5 and 6). During radiographic measurements were per-
from the defect (tension side) and the treatment period, patients were formed as at baseline (Figs 7 and 8).
movement into the defect (pressure enrolled in an oral hygiene mainte-
side). Orthodontics was performed nance program with monthly recall

562
Fig 5 (left) Clinical view after 6 months of

orthodontic therapy.
Fig 6 (right) Clinical view at the end of

orthodontic therapy. Notice the esthetic
improvement, which has improved the PPI
score from 4 to 3.
Fig 7 (left) The final PPD.
Fig 8 (right) Final radiograph shows com-

plete defect fill 20 months after surgery.
Statistical analysis Results (P > .81) and mean CAL gain was 0.57
mm (P > .29). Statistical analyses are
Statistical analysis was performed to From T.0 to T.360 the mean PPD reduc- reported in Tables 1 and 2. The reduc-
compare the data from baseline (T.0) to tion was 5.57 ± 1.55 mm, with a resid- tion in PPI reflected an enhancement
1 year after GTR (T.360) and from T.360 ual mean PPD of 2.71 ± 0.82 mm; of the papilla height, which was
to the end of orthodontic treatment mean CAL gain was 5.86 ± 1.74 mm, observed in 9 of 14 patients (Table 3).
(T.END). Preoperative and postopera- with a residual mean CAL of 4.28 ±
tive means and standard deviations 1.68 mm. Both differences were sta-
were calculated. Differences were ana- tistically significant (P < .001). There
lyzed by means of the Student t test for were no statistically significant differ-
paired observations. The level of sig- ences between T.360 and T.END:
nificance was set at 5%. mean PPD reduction was 0.07 mm

563
Table 1 Mean probing pocket depths (PPD) Table 2 Periodontal parameters before and
and clinical attachment levels (CAL) after orthodontic treatment
before and after periodontal
Parameter Mean SD P
regenerative procedures
PPD
Parameter Mean SD P Start 2.7 0.8
PPD End 2.6 0.7
Baseline 8.2 1.7 Reduction 0.07 0.2 > .81*
1y 2.7 0.8 .001* CAL
Gain 5.5 1.5 Start 4.2 1.6
CAL End 3.7 1
Baseline 10.1 3 Gain 0.43 0.7 > .29*
1y 4.2 1.6 .001* PPD = probing pocket depth; CAL = clinical attachment level.
Gain 5.8 1.7 *No significant difference (t test for coupled data).
*Significant difference (t test for coupled data).
Table 3 Frequency of various papilla

presence index scores at beginning
and end of orthodontic treatment
Patient Start End
1 4 2
2 4 3
3 4 3
4 3 4
5 2 1
6 1 1
7 3 3
8 4 4
9 4 4
10 3 2
11 4 3
12 2 1
13 2 1
14 2 1
Discussion treatment is typically carried out in the ing in intrabony pocket formation in
preorthodontic phase to eliminate peri- cases of uncontrolled periodontal
Currently, periodontal clinicians con- odontal infection, with nonsurgical inflammation or in the absence of
sider treatment planning to be treatment5,33 followed by a surgical good patient compliance.2–5 In the
satisfactory only when inflammatory regenerative procedure. presence of deep infrabony defects,
periodontal control, esthetic consider- Several studies have demon- periodontal regeneration seems to be
ations, and full-time supportive pro- strated that teeth with reduced but the only way to re-create periodontal
fessional care are thoroughly taken into healthy periodontium can be moved support, as shown by clinical,14–18 his-
account. Advanced chronic periodon- without attachment loss, whereas both tologic,6,7,10–13 and long-term survival
titis may lead to the formation of intra- intrusion and bodily movement may studies.34 However, histologic findings
bony pockets, with flaring of the ante- cause conversion of supragingival by Melsen et al9 and Geraci et al8 have
rior teeth.1 Systematic periodontal plaque into subgingival plaque, result- shown the possibility to rebuild lost

564
Fig 9 Clinical documentation of patient x.
Fig 9a (left) At baseline, the PPI score is 4.

An interdental diastema is present.
Fig 9b (right) At the end of the orthodon-

tic-periodontal treatment, the PPI score is 2.
attachment only with OFD and earlier correct application of biomechanical

orthodontic movement, probably as a apparatus that is appropriate for each
consequence of the mitotic activity on patient and the monitoring of oral
the ligament cells.35 Unfortunately, hygiene. The correct sequence of bio-
other studies have not been able to mechanics is intended to reduce the
replicate this result. However, some risk of root resorption, gingival reces-
clinical studies in which nonregenera- sion, and further bone loss. In the post-
tive surgical therapy was performed in orthodontic phase, permanent
association with orthodontic move- retention is performed so that rem-
ment, presented the possibility to cor- ineralization can be completed without
rect pathologic tooth migration after the risk of relapse and to eliminate sec-
severe periodontal attachment ondary occlusal trauma, thereby
loss.36,37 The true goal of this therapy improving patient comfort.
should be to stop disease progression Realignment of flaring teeth with
and regenerate the lost periodontium, a combined orthodontic-periodontal
thereby changing the long-term prog- approach is an essential contribution to
nosis of the teeth. The choice of regen- esthetic dentistry. In fact, the presence
erative surgery for periodontal ther- of interdental papillae is one of the
apy seems to be safer and more most important factors in a harmo-
predictable. nious smile. The management of hard
Two issues seem to be very deli- and soft tissue is a major concern for
cate during the orthodontic phase: the clinicians today, with issues such as the

565
Fig 10 Radiographic documentation of

patient x.
Fig 10a (left) Bone defect at baseline.
Fig 10b (right) Bone regeneration follow-

ing GTR surgery and orthodontic therapy.
presence of a “black triangle” causing point by stripping and subsequent

esthetic impairment. Some studies orthodontic space closure are
have presented procedures to re- needed.43 In addition to this, reduction
create missing papillae, with unpre- of the distance between the two adja-
dictable results.38–41 A combined cent roots appears to be another influ-
orthodontic-periodontal approach can ential factor.44, 45
help to modify the height of the papil- Although the ability to draw con-
lae36 (Figs 9 and 10). The first aim is to clusions from the present study is lim-
reduce the distance between the bone ited because of the small number of
crest and the contact point, following cases, this study presents one way to
the findings of Tarnow et al.42 If this dis- combine orthodontic and periodon-
tance is 5 mm, 98% of the embrasure tal therapy effectively and safely. This
papilla space can be completely filled; therapy resulted in improved probing
when the distance is 6 mm, only 56% pocket depths and clinical attachment
is completely filled, and when it is near levels provided by guided tissue
7 mm, the percentage goes down to regeneration, and no detrimental
27%. When the distance is about 10 effect to the new apparatus was seen
mm, the space cannot be reduced. In during the orthodontic phase, in which
such cases, to obtain the missing general improvement of the esthetic
papilla,the augmentation of bone sup- parameters took place, including
port by regeneration procedures and realignment of migrated teeth and
apical repositioning of the contact increased papilla height.

566
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Farronato of the University of Milan for his con- 145–151. 198–207.
tributions to this article. 11. Camelo M, Nevins ML, Lynch SE, Schenk 20. Re S, Corrente G, Abundo R, Cardaropoli D.
RK, Simion M, Nevins M. Periodontal regen- The use of orthodontic intrusive movement
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composite graft and a Bio-Gide membrane. odontal patients: A case report. Int J
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Orthodontic treatment of periodontally involved teeth after tissue

Article in The International journal of periodontics & restorative dentistry · January 2009

Maurizio Silvestri Gianfranco Zanotti

Palatal soft tissue harvesting View project

The user has requested enhancement of the downloaded file.

The International Journal of Periodontics & Restorative Dentistry

Orthodontic Treatment of Periodontally

Volume 28, Number 6, 2008

The International Journal of Periodontics & Restorative Dentistry

Fig 1 (left) Migration of the maxillary right

Fig 2 (right) Bone defect before the initial

Fig 3 (left) Flap design with the modified

Fig 4 (right) Intrasurgical view exhibiting

Volume 28, Number 6, 2008

Fig 5 (left) Clinical view after 6 months of

Fig 6 (right) Clinical view at the end of

Fig 7 (left) The final PPD.

Fig 8 (right) Final radiograph shows com-

The International Journal of Periodontics & Restorative Dentistry

*Significant difference (t test for coupled data).

Table 3 Frequency of various papilla

Volume 28, Number 6, 2008

Fig 9 Clinical documentation of patient x.

Fig 9a (left) At baseline, the PPI score is 4.

Fig 9b (right) At the end of the orthodon-

attachment only with OFD and earlier correct application of biomechanical

The International Journal of Periodontics & Restorative Dentistry

Fig 10 Radiographic documentation of

Fig 10a (left) Bone defect at baseline.

Fig 10b (right) Bone regeneration follow-

presence of a “black triangle” causing point by stripping and subsequent

Volume 28, Number 6, 2008

The International Journal of Periodontics & Restorative Dentistry

Volume 28, Number 6, 2008

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