PERIODONTAL INTERVENTION IN ORTHODONTICS

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1 University Journal of Dental Sciences PERIODONTAL INTERVENTION IN ORTHODONTICS Interdisciplinary Dentistry Amitabh Srivastava, Pratima Srivastava, Vishu Aggarwal, Shubham Kumar 1 Professor& Head, Department of Periodontology and Implantology, Sardar Patel Post-Graduate Institute of Dental and Medical Sciences. Lucknow 2,4 Post-Graduate Student, Department of Periodontology and Implantology, Sardar Patel Post-Graduate Institute of Dental and Medical Sciences. Lucknow 3 Post-Graduate Student, Department of Orthodontics, Sardar Patel Post-Graduate Institute of Dental and Medical Sciences. Lucknow ABSTRACT : Orthodontic treatment in adult patient with periodontally compromised tooth is challenging. A multidisciplinary approach is required for proper intervention of treatment planning and treatment procedure to be carried out. This case series entitles about the interdisciplinary approach between two specialities in managing a patients which requires orthodontic treatment and having periodontally compromised tooth or vice-versa. Keywords : Perio-Ortho Intervention, Gingival Overgrowth, PAOO, Periodontally Compromised Tooth, Photo Dynamic Therapy(PDT). Source of support : Nil Conflict of interest: None INTRODUCTION : Periodontal health is an important factor that may influence thesuccess of orthodontic therapy. One of the most common side effects linked to orthodontic treatment are reported to be the periodontal complications[1].orthodontic therapy induces periodontal complications which mainly includes gingivitis, periodontitis, gingival recession, gingival overgrowth, alveolar bone loss, dehiscence, fenestration, interdental fold, and dark triangles[2]. The reasons whichinfluence periodontal complications involve oral hygiene status of the patient and the technique used in the treatment of periodontally compromised teeth1.the application of orthodontic force brings about a biomechanical change in the cells of Periodontal Ligament and alveolar bone. The deformation of bone crystalline structure generates a bioelectric potential. Neurotransmitters released by paradental tissues under the influence of peripheral forces result in a cascade of events that can be outlined as[2]: Movement of PDL fluids from areas of compression into areas of tension A gradual development of strain in cells and ECM in the paradental tissues involved Release of phospholipase A2 and cleavage of phospholipids leading to release of PGE2 and leukotrienes ECM remodelling and signal transduction through integrin trans-membrane channels Cytoplasmic alterations and release of second messengers of tooth movement - camp and cgmp, ionositol phosphates, calcium and tyrosine kinases Release of kinases such as protein kinase A, kinase C and Mitigen activated protein MAP kinases Direct transduction of mechanical forces to the nucleus of strained cells through the cytoskeleton, leading to activation University Journal of Dental Sciences, An Official Publication of Aligarh Muslim University, Aligarh. India 25

2 of specific genes Release of neuropeptides (nociceptive and vasoactive) from paradental afferent nerve endings Interaction of vasoactive neuropeptides with endothelial cells in strained paradental tissue Adhesion of circulated leukocytes to activated endothelial cells Migration by diapedesis of leukocytes into the extravascular space Synthesis and release of signalling molecules by leukocytes that have migrated into the strained paradental tissues Interaction of various types of paradental cells with the signal molecules released by the migratory leukocytes Activation of the cells to participate in the modelling and remodelling of the paradental tissues. The goal of periodontal therapy is to restore and maintain the health and integrity of periodontal tissues. In periodontally compromised patients, the loss of teeth or periodontal support results in pathological migration of teeth involving single or a group of teeth. It may results in the development of a midline diastema, spacing between the teeth with or without incisalproclination, rotation or tipping of bicuspids and molars with the collapse of the posterior occlusion and decreasing vertical dimension. Orthodontic treatment either helps to correct these problems, or it helps to prevent them from progressing further. The main reasons for the provision of orthodontic treatment are the improvement of facial and dental aesthetics with health and function. However, association between bothconditions is still controversial.[2] Orthodontic patients can be classified into various categories: firstly, Patients with good oral health; secondly, Patients with periodontal disease and/or loss of permanent teeth; and lastly, Patients with severe skeletal discrepancies. For the patients belonging to second category a multidisciplinary approach is needed involving an Orthodontist and aperiodontist for treatment planning and treatment progress[3]. This clinical series of cases describes an interdisciplinary approach for the treatment of periodontally compromised patients with malaligned teeth. Periodontal therapies include non-surgical and surgical therapy with regenerative procedures to stabilize the periodontal condition. Case Series The cases described below are of patients who reported to Department Of Orthodontics at Sardar Patel Post Graduate Institute of Dental and Medical Sciences (SPPGIDMS), Lucknow, Uttar Pradesh, India with the chief complain of malaligned teeth. During the mid-phase of treatment they developed periodontal complications and were referred to the Department of Periodontology and Implantology, SPPGIDMS for treatment of periodontally compromised teeth or impacted teeth. The treatment plan was discussed interdepartmentally and informed consent was received from all the patients before starting with treatment. All the patients were subjected to Phase-I Therapy before starting with further intervention. CASE-1: Interdisciplinary Approach for Crown exposure A patient aged 14 years was referred to Department of Periodontology and Implantology for crown exposure in maxillary 25. On clinicalexamination chronic generalised gingival inflammation was noticed and soft tissue coverage on tooth was present in the maxillary left posterior region of tooth (i.r.t 25)where exposure of crown was required. Treatment; 1. Local infiltration of anesthesia 2% lignocaine (with 1:100,000 adrenaline) given. 2. Bleeding points marked with the help of Hu-Friedy pocket marker. 3. External bevel incisions were given by Kirkland Knife and interdental tissues were released using Orban's Knife. 4. Adequate haemostasis was achieved using 810 nm Picasso diode laser in non-continous mode; at 2.5watt; 30ms duration. 5. No dressing was applied after the surgery. 6. Postoperatively, a vitamin E gel was prescribed for local application 3-4 times a day for 2 days and recalled after 7 days. Fig-1 Preoperative View Fig-2Removal of Soft Tissue University Journal of Dental Sciences, An Official Publication of Aligarh Muslim University, Aligarh. India 26

3 University J Dent Scie 2016; No. 2, Vol. 1 Fig-6 External Bevel Gingivectomy Fig-3 Excised Tissue Fig-4 Post- Operative View Fig-7Post-Operative after 15 Days CASE-3:Approach for Periodontaly Accelerated Osteogenic Orthodontics (PAOO) CASE-2: Approach for Gingivectomy and Gingivoplasty On clinical examination patient's oral hygiene was compromised with generalised gingival overgrowth present in maxillary and mandibular anterior. A 5mm periodontal pocket depth measured with UNC15 probe was present with severe gingival inflammation. A patient aged 20 years referred to Department of Periodontology and Implantology for corticotomy in relation to maxillary 13, 14 and 23, 24 for Accelerated Ostegenic Orthodontics. On clinical examination patients oral hygiene was compromised with the presence of plaque and mild inflammation was present. TREATMENT: 1. Local anesthesia 2% lignocaine (with 1:100,000 adrenaline) given in the area. 2. Bleeding point marked with the help of Hu-Friedy Pocket Marker before excision. 3. External bevel gingivectomy performed in the region with the help of Kirkland and Orban's knife. 4. No dressing was applied after the surgery. TREATMENT : 1. Bilateral Local anesthesia 2% lignocaine (with 1:100,000 adrenaline) given in the area (maxilla i.r.t 13, 14 and 23, 24). 2. Vertical releasing incision followed with intracrevicular incision given covering the base of mucogingival junction with the help of scalpel 15c blade.vertical releasing incision should be positioned at least one tooth away from the bone activation". 3. Mucoperiosteal flap have been raised till the apices of teeth. 4. Selective alveolar decortication is performed in the form of decortication cuts and at points up to 0.5 mm in depth, combined with selective medullary penetration to enhance bleeding. 5. Adequate bio-absorbable grafting material is placed over the decortication site. Flap are then repositioned and sutured into place. 6. Patient discharged with Post-operative instructions. 7. Patient has given an antibiotic coverage with analgesics for 5 days and advised to report for follow-up till the orthodontic treatment continues. Tooth movement should start one or two weeks after surgery. The orthodontic appliance should be activated every two Patient was discharged with all post-surgical instructions and medications for 5 days which included analgesic (ibuprofen 600 mg TDS daily), antibiotic (amoxicillin 500 mg BD). Fig-5 Pre-Operative View University Journal of Dental Sciences, An Official Publication of Aligarh Muslim University, Aligarh. India 27

4 University J Dent Scie 2016; No. 2, Vol. 1 weeks until the end of treatment after PAOO. It accelerates the movement 3-4 times greater than the normal treatment Light was applied in six sites of each tooth. Each site was irradiated for 30 seconds at 0.8 watt4. PDT was repeated after 2, 7, and 14 days Patient was instructed to maintain oral hygiene and tooth brushing technique was demonstrated to patient. Patient was recalled for monthly follow-ups visit till the orthodontic treatment carried out. Fig-8 Pre-Operative View Fig-12 pre-operative view Fig-9 Decortication Done Fig-13 pocket depth measured UNC-15 probe Fig-10 Bone Graft placed & suture done Fig-14 Indocyanine green dye applied Fig-11 Post-Operative View A patient aged 27 years referred to Department of Periodontology and Implantology for periodontal check-up before start of the treatment. On clinical examination patient oral hygiene was compromised with probing pocket depth of 5mm in mandibular anterior region measured with UNC-15 probe. Fig-15 Irradiation Performed TREATMENT: 1. Non-surgical treatment regime photo dynamic therapy (PDT) has been carried out. 2. Photosensitizer (Indocyanine green dye) was applied from the bottom of the periodontal pockets in a coronal direction. After 1 minute, the pockets were rinsed. 3. The Picasso soft tissue diode laser light with a wavelength of 810 nm and a maximum power of 25 mw was used subgingivally. The irradiation was performed using an optical fiber tip from apical to coronal direction. Fig-16 Post-Operative View University Journal of Dental Sciences, An Official Publication of Aligarh Muslim University, Aligarh. India 28

5 also has increased the scope of treatment with reduced side-effects such as root alveolar bone, relapse, inadequate alveolar bone and bacterial factors like caries and infection. The movement brought about by PAOO technique is dentoalveolar in nature and the surrounding periodontium maintains healthy[7]. Fig-17 Post-Operative view after 1 month DISCUSSION : Orthodontic treatment is no longer a contraindicationin the therapy of severe adult periodontal disease for maintenance of a healthy periodontal status after orthodontic treatment. In such cases, orthodontic treatment might enhance the possibilities of saving and restoring a deteriorated dentition. It is important to identify patients who are susceptible to the more severe manifestation of periodontal disease and to control an existing disease before starting a treatment plan involving comprehensive orthodontics[5]. In the present clinical case reports periodontal status before and after the treatment of orthodontic been evaluated. Nasir et al.[1] in year 2011hypothesied, in the study that there is a change in the periodontal status of the patients receiving fixed orthodontic treatment and results supported the hypothesis and showed a significant change in periodontal status of the patients. Patients referred from orthodontic treatment mostly provides an area for retention of plaque which further leads to gingival inflammation leading to gingivitis and progressing to periodontitis in severe condition[1]. The correction of mal positioned teeth permits the patient for better maintenance of oral hygiene and also improves the morphology of soft and hard tissue. Most of the time gingival overgrowth in orthodontic patients is iatrogenic because of the long-time of treatment protocol and patient is inevitable to maintain oral status. Gingival overgrowth temporize the treatment until it is removed surgically, especially when its size and inflammatory symptoms are important. Removal of gingival overgrowth by clinical crown lengthening included both gingivectomy and gingivoplasty procedures, results in satisfactory results with the maintainance of oral hygiene by patient[6]. Periodontally accelerated osteogenic orthodontic (PAOO), also known as alveolar osteogenic orthodontics or Wilckodontics. Its goal is to enhance the manner of treatment in which the periodontium responds to applied forces and provides more intact periodontium and increases the alveolarbone volume to support the teeth and overlying soft tissues duringretention. It shortened the treatment times and Periodontal disease results from inflammation of the supporting structure of the teeth and results in chronic infection caused by various periodontopathic bacteria. Photodynamic therapy (PDT) has emerged as a non-invasive therapeutic modality for the treatment of various infections by bacteria, fungi, and viruses. PDT can be considered as an adjunctive to conventional mechanical therapy. Photo sensitizer placed directly in the periodontal pocket activated by the laser light through an optical fibertip placed directly in the pocket. PDT kills the bacteria, and also leads to the detoxification of endotoxins such as lipopolysaccharide by decreasing biological activity[4]. A combined orthodontic-periodontal approach can help to modify the treatment of soft tissue impacted tooth exposure, Gingival Overgrowth, PAOO, Periodontal compromised tooth, as an essential component to maintain esthetic in dentistry. CONCLUSION: With increasing demand to improve aesthetics' patients with compromised periodontal support also seek highly esthetic and functional improvements. Dental treatments in periodontally compromised patients are challenging. However, inter-disciplinary approach can help in maintaining adjunctive periodontal procedures to achieve more stable, good and esthetically acceptable results. REFERENCES: 1. AlfurijiSamah, Alhazmi Nora, AlhamlanNasir, E h a i d e b A l i A, A l r u w a i t h i M o a t a z b e l l a h, AlkatheeriNasser, GeevargheseAmrita.The Effect of Orthodontic Therapy on Periodontal Health: A Review of t h e L i t e r a t u r e I n t J o f Dent2014http://dx.doi.org/ /2014/ Patil AK, Shetty AS, Setty S, Thakur S. Understanding the advances in biology of orthodontic tooth movement for improved ortho-perio interdisciplinary approach. J Indian SocPeriodontol 2013;17: Vinod K, Reddy YG, Reddy VP, Nandan H, Sharma M. Orthodontic-periodontics interdisciplinary approach. J Indian SocPeriodontol 2012;16: RautChetan, SethiKunal. Photodynamic therapy as an adjunct to scaling and root planing in treatment of chronic periodontitis patients: A clinical study. IOSR J Dent and Medical Scien 2015;14:10-4 University Journal of Dental Sciences, An Official Publication of Aligarh Muslim University, Aligarh. India 29

6 5. F e n g a X i n g m e i, O b a b T o m o k o, ObacYasuo,MoriyamadKeiji. An Interdisciplinary Approach for Improved Functional and Esthetic Results in a Periodontally Compromised Adult Patient.Angle Orthodontis 2005;75;No.6 6. PrabhuManavi, Ramesh Amitha,ThomasBiju. Treatment of Orthodontically Induced Gingival Hyperplasia by Diode Laser - Case Report.NUJHS 2015;5;No.2 7. Adusumilli S, Yalamanchi L, Yalamanchili PS. Periodontally accelerated osteogenic orthodontics: An interdisciplinary approach for faster orthodontic therapy. J Pharm BioallSci 2014;6:S2-5. CORRESPONDINGAUTHOR: Dr. Amitabh Srivastava Department of Periodontology and Implantology, Sardar Patel Post-Graduate Inst. of Dental & Medical Sciences, Lucknow, UP, India. docamitabh74@gmail.com University Journal of Dental Sciences, An Official Publication of Aligarh Muslim University, Aligarh. India 30