A simple presentation of some of the benefits of orthodontics on periodontal health.

2. Objectives
Discuss the diagnostic tools which are
pertinent for orthodontics
Discuss the importance of orthodontics and
periodontal therapy

3. (Dr L. Andrews, AJO-DO 1972)
A cornerstone article on optimum static occlusion

4. Super class I molar: Optimum occlusion
• The distal surface of the permanent upper first
molar should be in contact with the mesial surface of
the lower second permanent molar
– This gives the best interdigitation of the premolars
– Class I canine
– Adequate overbite and overjet
1

5. Angulation (tip)
• The part of the tooth
gingival to the crown is
distal to the part which is
incisal or occlusal to the
gingival margin
• This concept is very
important in esthetic
dentistry
2

6. This angulation is incorporated in most
bonded brackets

7. Improvement in the angulation of the
upper incisors

8. Proper angulation of the tooth…..
…..influences
– The emergence of the
teeth
– The position of the
contact points
– The creation of black
triangles
– Gingival contours
– The closure of
diastemas

9. …. At the smile level

10. Each tooth has it’s own
inclination (torque)
…. torque influences
– Lip support
– Gingival contours
– The size of the arches
– The shape of the arches
– Emergence profile of the
teeth
– The smile line
3

11. 2006: Gingival recession, dentist sends for a gingival graft
Periodontal response to occlusal
trauma and poor inclination

12. 2011: recall visit
Patient refused comprehensive
orthodontics

13. Pre-ortho Impacted canines upper arch
Periodontal response (adult)

14. Some lingual root torque and better
hygiene. Still needs a graft

15. Torque and periodontics
• 28 year old patient with
‘’hopeless’’ lower
incisors.
• 36 months of agressive
ortho for correction of
Cl III relationship
• « Nothing to lose »
2007

16. Torquing roots back into bone

17. Finished case post perio-ortho
Tooth mobility 1 to 2 but periodontist
confident we can keep the teeth
2011 after gingival grafts
placed on 41 31 only

18. In this case we also improved the
incisor coupling

19. Other occlusal considerations:
Comments?

20. Optimal Interdigiation
• Maximal interdigitation ,a functional
occlusion with cuspid guidance , respecting
the dictates of the temporo-mandibular joints,
are imporant goals in all orthodontic
treatments
• Form follows function: a well balanced
functional occlusion usually results in better
periodontal health.

21. Contact points marginal Ridges
• Points or surface contacts have a great influence on
the morphology of the gingiva. An example is
comprimised interproximal papillae

22. The gingival line

23. Teeth are aligned respecting the
gingival line
(especiallly in patients who have a gummy smile)

24. It is important to maximize the esthetics by
aligning the gingival margins

25. To enhance periodontal health

26. Orthodontics
Periodontics
Restorative
Dentistry
Patient needing
rehabilitation
Interdisciplinary Treatment

27. Single tooth restorations

28. Factors to consider in the preservation of a
tooth
Possible role of orthodontics
It’s importance as part of the occlusion
Restorability
Periodontics
Endodontics

29. Here is the case:
The patient was a 50 year old male
Good general health
He had # 11,21,22 restored six month previously
He was concerned about the deepbite ,The dentist reassured him that
the occlusion would improve by itself…. now #21 was fractured…..

30. Sequence of treatment is very
important!
Normally, we begin by establishing posterior support
Implants
placed but not
restored

31. Diagnosis
• #21 fractured at gingival
margin
• Occlusal trauma on anterior
teeth
• Loss of posterior support
• Violation of the biologic
width

32. Initial investigation: Temporisation of
crowns at #11,21,22

33. It was decided to extrude #21 to re-
establish biologic width

34. The gingival line became uneven
Orthodontic extrusion results in an uneven gingival line. Some times fibrotomies can
be performed to decrease the extent of the lowering of the gingival crest
One of the advantages of orthodontic extrusion is that it significantly
reduces the amount of lengthening of the crown preparation

35. Lengthening of the clinical crown was
limited to t eth #12,22

36. Healing phase with excellent
temporary crowns

37. Multiple restorations

38. Orthodontic treatment and multiple
restorations
• 40 year old mother
• Consults because she
breaks her lower
anterior teeth
• Second opinion:
• Patient refused
orthognathic surgery

41. Observations
• Cl II malocclusion –Bimaxillary retrusion
• Overbite: 80% -100%
• Retrusive upper and lower incisors
• Heavily restored dentition
• Severe curve of Spee
• 36 absent, 37 decayed

42. Treatment Objectives
• Open the bite
• Correct curve of Spee
• Improve Class II relationship (compensation)
• Optimum positioning of crowns and roots for
future rehabilitation
• Replace bridge.

44. Improvement of Class II

45. Post orthodontics. Left side needs more prosthodontic work.

46. Periodontics- Orthodontics

47. Improvement of the periodontium
• Orthodontic treatment could improve a
controlled periodontal condition by:
– Re-establishment of adequate contact points and
optimal inter-radicular distances
– Alignment of the teeth to allow better oral
hygiene
– Re-establishment of a stable occlusion
– Optimize « anterior coupling »

48. Be careful!
• It is contraindicated to
begin orthodontic
treatment (Invisalign
included) in the
presence of active
periodontal disease.
• A curettage is minimal
treatment

49. Look for periodontal,
endodontic, caries cystic and
any other problems

50. Free gingival graft or not pre-
orthodontic therapy?

53. Orthodontic Preparation DEC 2008
Opening space for surgical cut RPE inserted and cemented

54. MARCH 2009

55. SEPT 2009

56. ESTABLISHING PROPER OCCLUSION

57. Gingival grafts????

58. APRIL 2010: IMPROVED OCCLUSION.
MUCH IMPROVED PERIODONTAL
CONDITION
Will need gingival graft on 14 and lower incisors but other teeth are now under control

59. Orthodontics in collaboration with
periodontics
• Improve the oral hygiene
• Make contact points
adequate
• Establish functional
occlusion
• Optimize the position of
the teeth to accept
occlusal forces in the long
axes of the teeth
• Perform selective
extrusion –intrusion
• Improve esthetics

60. Post curettage , orthodontic and
prosthodontic therapy:
Noticeable improvement in gingival margins

61. Simple orthodontic treatment

62. Treatment post periodontal treatment
(Photos Dr Benhamou)
Thirty five year old patient whose complaint was night time
bleeding.
Dentist told her it was due to her pregnancy
Had a consultation with a periodontist on the
recommendation of a friend.
With only digital pressure!
Pus and bleeding….Purple and edematous gingiva

63. General horizontal bone loss
(moderate to severe)

64. Periodontics was instituted
pre-orthodontics
• Debridement and curettage to be performed
• Reshape the inadequate contours of the crown
of #11
• Bleeding of gums to be addressed
• Gingival grafts to be made where necessary

65. After debridement

66. Intrusion and interproximal reduction
of incisors

67. Hhowever, there were still food traps.

68. Orthodontic treatment:
Interproximal reduction (IPR) is essential in this case
• The interproximal
reduction was limited
to the anterior
segments.
• The posterior segments
improved without IPR
Zachrisson showed greater stability
post orthodontics if we could avoid the
proclination of the lower incisors

69. • Ultra light forces
• Upper and lower
incisor intrusion
2 onces
elastics.

70. • Controlled periodontal condition
• Active phase of orthodontics is finished

74. • Female 17years old
• Chief Complaint:
– I do not like my smile and my gums
bleed when i brush
• Medical Historye:
– Good general health
– No allergies
– No smoking
• Dental history:
– Poor oral hygiene
– Brushes only once a day
– No flossing
– Noticed upper teeth separatingsince
last year
Data Collection

75. Clinical Evaluation
• Extra oral
– Gummy smile
– Narrow smile
• Intra oralClasse I molaire
– Overbite 100%
– PSR IV maxilla
– Gingival redness and swelling
– Mobility: 2 on 11, 21 ,24
– Exsudât 11 et 24
– Diastema 11 and 21: 2.5 mm

76. • Localized bone loss 11, 24
• Generalized horizontal bone loss (10-20%) with 40% between11 and 21
• 18, 28, 38, 48 impacted
• Low caries rate
Radiologic Evaluation

77. 1. Periodontics
• Diagnostic: Aggressive localized periodontitis
• Treatment:
– Debridement (antibiotics)
– Hygiene instructions
– Bone grafting 24
– Open curettage 11-21
– 3 months recall

78. 2. Orthodontie

79. Overeruption of the upper incisors

80. Goals of treatment (limited)
• Intrusion of upper incisors
• Maintain posterior occlusion
• Reshape upper arch
• Close anterior diastema
• Reposition upper laterals for veneers or
composite restorations (Bolton discrepancy)

81. Intrusion arch . Light forces
Favorable gingival
response

82. Creation of a more favorable occlusal plane

86. Orthodontic Extraction
• Limit bone resorption
• Better control of bony levels
• Atraumatic extraction
• Better gingival contour

87. Extrusion pre-implant
Immediate implant
Atraumatic extractionaction atraumatique de reste de la racine
Very light orthdontic wire ( NiTi) to bring bone with the root
Orthodontic bracketing
Temporize
Calcium Hydroxyde (Coronal reduction )