INTRODUCTION:

The term consortium refers to a group made up of two or more entities that work together to achieve a common objective. A well-co-ordinated multidisciplinary approach between the various dental specialties is necessary to tackle complex dental problems.

The primary objective of periodontal therapy is to establish and create an oral environment that is conducive to maintaining the patient's dentition in a healthy, comfortable, functional and aesthetic state and when feasible to regenerate and preserve the periodontal attachment¹. Orthodontic therapy aims at proper alignment of the teeth and thus improves the occlusal and jaw relationship and facilitates better mastication, speech and improves the overall quality of life. Orthodontic treatment is based on the principle that when prolonged, intermittent force and pressure is applied to a tooth, it will move as the surrounding bone remodels². Bone is selectively resorbed in some areas and deposited in others and this response is mediated by the cells within the periodontal ligament. thus, the periodontal- orthodontic consortium is mutually beneficial and the inter-disciplinary approach of both periodontal and orthodontic therapy can benefit the final outcome of the dental treatment.

Cellular and Molecular Changes During Orthodontic Tooth Movement:

During orthodontic tooth movement, the two main interlinked processes that occur are bending of the alveolar bone and remodelling of the periodontal tissues including the periodontal ligament, alveolar bone and gingiva³. Mechanical loading results in alterations in vascularity and blood flow of periodontal tissues. This results in local synthesis and release of several neurotransmitters, cytokines, growth factors, colony-stimulating factors and arachidonic acid metabolites and these molecules produce various cellular responses within the cellsof the periodontium and alveolar bone creating a conducive microenvironment for tissue deposition or resorption³. Several pathways for cell-signalling are thus activated, which leads to turnover of cells within periodontal ligament and also localised bone resorption and bone deposition^3,4.

Alveolar bone response to orthodontic forces

Impact of Orthodontic Treatment on Periodontium:

The presence of braces and other orthodontic attachments may hamper the complete removal of dental plaque by various mechanical plaque control aids. Orthodontic therapy may eventually lead to several periodontal complications like gingivitis, periodontitis, alveolar bone loss, gingival recession, tooth mobility, black triangles, periodontal pocket, fenestration and dehiscence⁵. Also improper oral hygiene may lead to accumulation of pathogenic flora of bacteria in the dental plaque of the patients undergoing orthodontic treatment which includes Porphyromonas gingivalis, Tannerella forsythia, Eubacterium nodatum, Campylobacter rectus, Parvimonas micra, and Actinomyces odontolyticus⁶.

Adjunctive periodontal treatment for orthodontic patients:

Orthodontic forces when properly planned and delivered do not cause any damage to the periodontal ligament. Orthodontic treatment aims at correcting malaligned teeth and facilitates better mastication and speech. Optimal periodontal health is an important prerequisite for the success and long term stability of an orthodontic treatment. There are several periodontal procedures that are performed as an adjunct to orthodontic therapy⁷. The width of attached gingiva is an important factor to facilitate the maintenance of adequate plaque control and gingival health. Insufficient width of keratinised tissue can predispose to the development of gingival recession. Lang and Loe reported that a minimum 2mm of gingiva with atleast 1mm zone of attached gingiva, was necessary for the maintenance of gingival health⁸. However other researchers reported that minimal zone of gingiva can be healthily maintained without progressive gingival recession provided traumatic toothbrushing and inflammation are controlled⁹. Mucogingival surgeries such as Free gingival graft, Sub epithelial connective tissue graft and Apically repositioned graft can be utilized for augmenting the width of attached gingiva. Most often, gingival recession during orthodontic treatment was reported in the maxillary and mandibular anterior teeth^10,11. Kurol et al reported gingival invaginations after orthodontic closure of extraction spaces in 35% of cases¹². These invaginations may vary from slight fissures in the keratinized gingiva to deep spaces or gaps across the interdental papilla buccally or lingually running deeply to the alveolar bone. Gingival invaginations can act as good sites for plaque retention which may eventually lead to breakdown of the periodontium¹³. Surgical elimination of these invaginations should be performed to eliminate plaque retention. Adjunctive mouth rinses are also recommended in patients undergoing orthodontic therapy¹⁴.

Aberrant frenal attachment is considered to be an etiological agent for midline diastema. The labial frenum when positioned near the gingival margin may also lead to gingival recession due to the tension exerted on the gingival margin by the frenal pull. Hypertrophic frenal attachment can also increase the tendency for relapse after orthodontic space closure¹⁵. Abnormal frenum can be eliminated by frenectomy and the ideal time for performing this procedure is after the completion of fixed orthodontic treatment and about 6 weeks before the appliances are removed¹⁵, unless the frenum prevents closure of space.

Fiberotomy is a method to reduce the relapse of orthodontically treated teeth, especially rotated teeth. The supracrestal gingival fibres contribute to relapse of rotation and hence the technique of “circumferential supracrestal fiberotomy” can be performed to prevent relapse and to achieve proper rearrangement and remodelling of the supporting tissues¹⁶. The transseptal fibers are cut interdentally by entering the periodontal ligament space. This procedure is performed before the removal of orthodontic appliances towards the end of active tooth movement and is contraindicated in the presence of gingival inflammation¹⁷.

Crown lengthening is a surgical procedure performed to increase the clinical tooth structure for aesthetic or restorative purposes either by gingivectomy or an apically repositioned flap in combination with ostectomy prior to orthodontic bonding procedures. Crown lengthening facilitates easy placement of orthodontic attachment on teeth with short clinical crowns¹⁸. Careful oral hygiene procedures with uni-tufted brushes should be advised for 2 months after the procedure for complete healing to occur.

Pre-orthodontic osseous surgery is usually indicated for various alveolar bone defects such as hemiseptum, three-walled defect, osseous crater and furcation involvement. Shallow craters (4-5mm pockets) can be maintained non-surgically during orthodontic therapy. However large craters need to be eliminated by reshaping the defect so that the patient can maintain these interproximal areas during orthodontic treatment. Intrabony defects have to be managed by regenerative therapy using bone grafts to achieve defect fill and periodontal regeneration. Orthodontic treatment can be initiated 3-6 months after periodontal regenerative surgery, if the results of periodontal therapy are stable¹⁹.

A concept of “Periodontal Ligament Distraction” is proposed where the canines can be rapidly distracted distally in premolar extraction space within three weeks. This concept and technique is best used on those cases whose anterior teeth are severely crowded or protruded. In addition to orthodontic tooth movement, this technique can be used to regenerate new bone and keratinized gingival tissue for treating periodontal disease²⁰.

Adjunctive orthodontic treatment for periodontally compromised patients:

The correction of malaligned teeth can remove deleterious occlusal interferences and also prevent plaque accumulation thus facilitating better oral hygiene maintenance. Patients using fixed orthodontic appliance are more susceptible to calculus formation than patient without orthodontic treatment^21,22.Orthodontic movements like uprighting, extrusion, intrusion and rotation can correct pathologic migration of teeth and prevent further breakdown of the periodontal structures. Orthodontic uprighting maintains arch integrity and improves the periodontal status. Reduction of bony defects and improved gingival contour were reported on uprighted teeth. G.Corrente et al reported that combined orthodontic and periodontal therapy resulted in the realignment of extruded teeth with infrabony defects, obtaining a significant probing depth reduction, clinical attachment gain, and radiological bone fill²³. Orthodontic extrusion of teeth with advanced periodontal disease was evaluated in beagle dogs by R. Yukna et al²⁴. The results showed that the extruded teeth had an intact attachment apparatus with all components in the same relative position on the teeth as in the controls. Also, a shallower sulcus and less gingival inflammation were noted in the extruded teeth.

Arias ANE et al reported bone increase in a vertical defect through orthodontic intrusion in an adult patient with reduced periodontium²⁵. The authors reported that orthodontic intrusion with light and continuous forces generated new periodontal tissue formation, increased alveolar bone and gingival insertion by eliminating the depth of periodontal pockets²⁵. Intrusion of migrated incisors with intrabony defects in adult periodontitis patients have shown the efficacy of a combined orthodontic-periodontal approach. Intrusive movement, after proper periodontal surgical therapy, can positively modify both the alveolar bone and the soft periodontal tissues.

Furcation involvement requires special attention during orthodontic treatment. The molars will require bands with tubes and other attachments that will hinder the patient's access to the buccal furcation for oral hygiene practice and instrumentation at the time of recall. When hemisection is indicated in Class III furcation involved mandibular molars, it may be advantageous to push the roots apart by orthodontic treatment if the hemisected molar will be used as an abutment for a bridge after orthodontic treatment²⁶. The key to treating periodontally compromised patients is proper communication and diagnosis before initiating orthodontic therapy as well as continued dialogue during orthodontic treatment²⁷.

Adjunctive orthodontic applications in dental implantology:

Orthodontic treatment has been proposed as a useful method for augmenting the resorbed alveolar bone and reforming aesthetically appealing gingival margin, prior to implant placement. Orthodontic treatment strategies can be used as an adjunct in selected cases for bone volume augmentation to aid future implant placement and maintain space for the prosthetic rehabilitation of the implant. These include orthodontic extrusion of compromised teeth to generate vertical bone volume and improve gingival architecture,tooth preservation and postponing orthodontic space opening to maintain bone volume in future implant site, orthodontic implant site switching to eliminate the deficient bone volume and the provision of a rigid fixed-bonded retainer to maintain the implant site²⁸. Mini implants are temporary anchorage devices that are small titanium bone screw or stainless steel bone screw which are either placed in buccal alveolar bone or palatal side for active space closure²⁹.

Corticotomy assisted orthodontic treatment:

This technique involves selective alveolar corticotomy in the form of decortication lines and dots performed surrounding the teeth to be moved. It induces a state of increased tissue turnover and a transient osteopenia, which is later followed by accelerated rate of tooth movement. The several advantages of this technique involves faster tooth movement, shorter treatment time, safer expansion of constricted arches, better stability post-orthodontic treatment. Corticotomy-assisted accelerated orthodontic treatment has shown to fasten the treatment duration by 2.2–3 folds compared to conventional orthodontic treatment³⁰. The mechanism behind corticotomy-assisted orthodontics is the regional acceleratory phenomenon (RAP). It is a local response of the tissues to noxious stimuli, through which the tissue regenerates at a faster rate than normal. The areas around the corticotomy are associated with enhanced osteoblastic-osteoclastic activity and increased level of inflammatory mediators, which accelerates the bone remodelling and facilitate rapid orthodontic tooth movement.

Sequential Piezocision Accelerated Orthodontic treatment:

Piezocision-assisted orthodontic treatment is a minimally invasive surgical technique to achieve rapid orthodontic tooth movement. Microsurgical openings are made interproximally in the buccal gingivae to let the piezoelectric knife create injury to the alveolar bone that will lead to transient demineralization and facilitate accelerated tooth movement³¹. Piezocision gives orthodontist the tools to control the anchorage value of teeth by selectively altering the bone density around them, using the piezoelectric knife at key time intervals, in an effort to successfully solve orthodontic challenges. Over the years, this technique has evolved to a more staged and sequential approach, with selected segments of the arch demineralized at various times during orthodontic treatment to aid in the achievement of specific results³².

Periodontally accelerated osteogenic orthodontics (PAOO)

Periodontally accelerated osteogenic orthodontics is a clinical procedure that combines selective alveolar corticotomy based on the bone healing pattern of regional acceleratory phenomenon. Tooth movement can be enhanced and completed with increased alveolar bone volume providing an intact periodontium, reduced need for extractions and increased bone support for teeth and overlying soft tissues, thereby improving gingival and facial esthetics. With this technique, teeth can be moved 2 to 3 times further in 1/3rd to 1/4th the time required for traditional orthodontic therapy³³. The surgical technique for PAOO consists of 5 steps, that is, reflecting a flap, decortication of bone adjacent to the malpositioned teeth by using low-speed round burs, particulate grafting using deproteinized bovine bone, autogenous bone, decalcified freeze-dried bone allograft, flap closure using non resorbable interrupted sutures and orthodontic force application. The placement of orthodontic brackets and activation of the arch wires are typically done the week before the surgical aspect of PAOO is performed. After flap repositioning, an immediate heavy orthodontic force can be applied to the teeth and in all cases initiation of orthodontic force should not be delayed more than 2 weeks after surgery³³.

MAPA-cision:

MAPA-cision is a novel regenerative technique for periodontally facilitated orthodontic treatment that is named after those who first reported the procedure³⁴. It is a minimally invasive piezoelectric surgical procedure that facilitates orthodontic tooth movement and simultaneously increases bone thickness following the principle of guided bone regeneration. A ‘bone bundle’ or ‘small sausage’ which is a new regenerative device containing resorbable collagen membrane with filling materials, is inserted through a tunnelling technique to increase the bone width by allowing the teeth to move within an enhanced periodontal support. This technique is versatile and can be customized according to specific clinical conditions³⁴.

CONCLUSION:

Owing to the higher number of adult patients seeking orthodontic treatment, orthodontists frequently encounter patients with periodontal disease in their practice. A combined periodontal- orthodontic management may become beneficial in these scenarios. The introduction of various newer techniques like PAOO and MAPA-cision has reduced the orthodontic treatment time significantly along with improving treatment outcomes. Adult orthodontic tooth movement can be performed on both healthy and diseased periodontium provided optimal forces are used, gingival inflammation is controlled and thorough oral hygiene is maintained throughout the active phase of treatment.

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Received on 11.05.2021 Modified on 03.10.2021

Research J. Pharm. and Tech. 2022; 15(5):2371-2375.

DOI: 10.52711/0974-360X.2022.00394