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Interdisciplinary orthodontic treatment for a patient with generalized aggressive periodontitis: Assessment of IgG antibodies to identify type of periodontitis and correct timing of treatment
CASE REPORT
Interdisciplinary orthodontic treatment for a patient with generalized aggressive periodontitis: Assessment of IgG antibodies to identify type of periodontitis and correct timing of treatment Yoshihito Ishihara,a Kazuya Tomikawa,b Toru Deguchi,c Tadashi Honjo,d Koji Suzuki,e Takayuki Kono,e Takuo Kuboki,f Hiroshi Kamioka,g Shogo Takashiba,h and Takashi Yamashiroi Okayama, Fukuoka, Yonago, and Suita, Japan, and Columbus, Ohio
Aggressive periodontitis is a great challenge to clinicians when providing orthodontic treatment because of the potential for progression of periodontal disease. In this article, we report the successful comprehensive orthodontic treatment of bimaxillary protrusion and severe crowding in an adult with generalized aggressive periodontitis. A woman, aged 22 years 7 months, with a chief complaint of incisal crowding was diagnosed with a skeletal Class I malocclusion associated with severe anterior crowding, possibly worsened by generalized aggressive periodontitis. In addition to a periodontal examination, a blood IgG antibody titer analysis and microbiologic examination for periodontal pathogens were used to diagnose the type of periodontal disease and determine the proper timing to initiate orthodontic treatment. The total active treatment period was 28 months, followed by periodontal prostheses and regeneration therapy. Consequently, satisfactory facial profile, occlusion, and periodontal health were maintained for at least 36 months. These results indicate that efficient screening is important for providing successful orthodontic treatment in patients with advanced periodontal disease. This report also demonstrates the diagnostic importance of blood IgG antibody titer assays and microbiologic examinations to detect periodontal pathogens. (Am J Orthod Dentofacial Orthop 2015;147:766-80)
a Assistant professor, Department of Orthodontics, Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, Okayama, Japan. b Assistant professor, Division of General Dentistry, Kyushu University Hospital, Fukuoka, Japan. c Associate professor, Division of Orthodontics, College of Dentistry, Ohio State University, Columbus, Ohio. d Assistant professor, Division of Oral and Maxillofacial Biopathological Surgery, Faculty of Medicine, Tottori University, Yonago, Japan. e Assistant professor, Department of Comprehensive Dentistry, Okayama University Hospital, Okayama, Japan. f Professor and chair, Department of Oral Rehabilitation and Regenerative Medicine, Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, Okayama, Japan. g Professor and chair, Department of Orthodontics, Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, Okayama, Japan. h Professor and chair, Department of Pathophysiology-Periodontal Science, Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, Okayama, Japan. i Professor and chair, Department of Orthodontics and Dentofacial Orthopedics, Graduate School of Dentistry, Osaka University, Suita, Japan. All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest, and none were reported. Address correspondence to: Yoshihito Ishihara, Department of Orthodontics, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, 2-5-1 Shikata-Cho, Kita-ku, Okayama 700-8525, Japan; Visiting Assistant Professor, Department of Oral Medicine, Infection and Immunity, Harvard School of Dental Medicine, 188 Longwood Ave, REB313, Boston, MA 02115; e-mail, [email protected]. Submitted, April 2014; revised, August 2014; accepted, September 2014. 0889-5406/$36.00 Copyright Ó 2015 by the American Association of Orthodontists. http://dx.doi.org/10.1016/j.ajodo.2014.09.022
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ggressive periodontitis (AgP), an uncommon and often severe destructive periodontal disease, is primarily characterized by the rapid loss of attachment and bone destruction, usually in relatively young patients.1 With regard to the pathogenesis of periodontitis, oral microorganisms present in biofilms are known to contribute to the onset of the disease. In particular, Aggregatibacter actinomycetemcomitans, a periodontal pathogen, is closely associated with AgP.2-5 Advanced periodontal disease may result in pathologic extrusion, labial inclination of the incisors, or posterior bite collapse, subsequently causing esthetic and functional problems for the patient that often require orthodontic correction. The application of orthodontic treatment in patients with AgP demands special consideration because of the potential for advanced progression of periodontal disease.6 The key to treating affected patients is to ensure close cooperation among the multidisciplinary team, particularly the orthodontist and the periodontist, to address the patient's periodontal status before treatment and to determine the optimal timing of therapy to treat both periodontal and orthodontic problems.
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Fig 1. The patient's initial condition: A, dental radiographs; B, periodontal examinations; C, blood IgG antibody titer values against periodontal pathogens. The following antigens were used: Aggregatibacter actinomycetemcomitans Y4, ATCC29523, SUNY67, Prevotella intermedia ATCC33563, ATCC25611, Porphyromonas gingivalis FDC381, and SU63. All values are expressed as ELISA units, as defined previously.12
Consequently, complete periodontal screening and recording should be carried out before the orthodontic treatment, and conducting a longitudinal evaluation of the patient's periodontal condition is important for providing optimal treatment. This strategy also helps to avoid lawsuits for any periodontal problems that may arise during treatment.7,8 Nevertheless, in spite of increasing recognition regarding the importance of the pathology of AgP and the need to evaluate functional aspects during diagnosis
and treatment, no previous reports have described the clinical assessment of these factors in orthodontic patients with AgP.9,10 Our aim in this case report therefore was to describe the results of comprehensive orthodontic treatment in a patient with generalized AgP, with a longitudinal quantitative evaluation of her periodontal condition and underlying pathogens. We also demonstrate the stomatognathic improvements achieved with successful orthodontic treatment in this patient.
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Fig 2. Preorthodontic treatment facial and intraoral photographs.
Fig 3. Preorthodontic treatment dental casts.
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Fig 4. Preorthodontic treatment radiographs: A, lateral cephalogram; B, posteroanterior cephalogram; C, panoramic radiograph; D, dental radiograph; E, periodontal examinations, probing, and bleeding on probing. DIAGNOSIS AND ETIOLOGY
A 21-year-old woman was referred by her general dentist to the outpatient dental clinic of Okayama University Hospital in Japan for treatment of AgP. Her medical history was unremarkable. However, a full-mouth series of periapical radiographs showed severe vertical bone loss, and preserving her maxillary left central
incisor was considered to be impossible because of the deep infrabony defects (Fig 1, A). The initial periodontal examination showed a deep probing pocket depth with sulcus bleeding (Fig 1, B). In addition to the periodontal examination, a blood IgG antibody titer assay for periodontal pathogens with an enzyme-linked immunosorbent assay (ELISA), as previously described, was used to assess the degree of periodontal disease based on the
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Table I. Summary of the cephalometric findings Variables Angular measurements ( ) ANB SNA SNB FMA U1-SN IMPA FMIA Interincisal angle Occlusal plane to Frankfort horizontal Gonial angle Linear measurements (mm) S-N N-Me Me/PP Overjet Overbite U1/PP U6/PP L1/Mp L6/Mp L1/AP E-line to upper lip E-line to lower lip
Japanese norms (adult female)
SD
Pretreatment
Posttreatment
Postretention
2.8 80.8 77.9 30.5 105.9 93.4 56.0 123.6 16.9 122.2
2.44 3.61 4.54 3.60 8.79 6.77 8.09 10.64 4.40 5.29
3.0 81.0 78.0 29.5 117.0 101.0 49.5 102.5 17.0 126.5
3.0 81.0 78.0 29.5 106.5 82.0 68.5 132.0 14.5 126.0
3.0 81.0 78.0 29.5 108.5 84.0 66.5 128.5 14.5 126.0
67.9 125.8 68.6 3.1 3.3 31.0 24.6 44.2 32.9 5.5 2.5 0.9
3.65 5.04 3.71 1.07 1.89 2.34 2.00 2.68 2.50 3.00 1.90 1.90
70.0 130.5 71.5 0.5 1.0 25.5 23.0 49.5 36.5 10.5 4.0 7.0
70.0 131.0 71.5 3.5 3.0 26.5 23.5 49.0 37.5 3.0 1.0 4.0
70.0 131.0 71.5 3.5 2.5 26.0 23.5 49.0 37.5 3.5 0.5 4.0
detection of humoral immunologic responses accompanying the elevation in the serum IgG antibody titers against periodontal pathogens.11,12 The results showed that the IgG antibody titer against A actinomycetemcomitans Y4, the B strain of A actinomycetemcomitans, which is frequently associated with AgP, was 4.85 times higher than the mean of 2 SD of the values observed in the healthy controls in a previous report (Fig 1, C).12 The patient was therefore diagnosed with generalized AgP, possibly caused by A actinomycetemcomitans Y4. The patient was referred to our orthodontic department 1 year later at 22 years 7 months of age to discuss the possibility of orthodontic treatment. Her chief complaint was crooked teeth and difficulty in controlling dental plaque. Her facial photographs showed a symmetrical face, a convex profile, and an acute nasolabial angle (Fig 2). Severe crowding was observed in both sets of incisors, and an anterior crossbite in both lateral incisors with Class II canine and Angle Class I molar relationships on both sides were also noted (Figs 2 and 3). The maxillary dental midline was deviated 2.0 mm to the left on the facial side relative to the mandibular dental midline. The patient was instructed regarding oral hygiene techniques and received initial periodontal debridement therapy to assess her periodontal tissue response. The initial periodontal preparation included instructions in oral hygiene, supragingival scaling, and root planning with professional
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tooth cleaning and antibiotic therapy. Periodontal pocket irrigation was also performed after those procedures. At the 6-month reevaluation visit, the radiographs and measurements demonstrated distinct clinical improvements and a reduction in bleeding on probing (Fig 4), although significant areas of vertical bone loss in the mandibular first molars remained evident (Fig 4, D). In comparison with Japanese norms, the results of the cephalometric analysis showed a skeletal Class I jaw relationship (ANB, 3.0 ) and an average mandibular plane angle (FMA, 29.5 ).13 In addition, the maxillary and mandibular incisors were labially inclined (U1-SN, 117.0 ; IMPA, 101.0 ), and the patient exhibited a decreased overjet of 0.5 mm and an overbite of 1.0 mm (Table I). TREATMENT OBJECTIVES
Based on these findings, the patient was diagnosed with a Class I malocclusion with lip protrusion, severe incisor crowding, and advanced bone loss, possibly caused by A actinomycetemcomitans. The treatment objectives were to treat the malocclusion, provide better periodontal health, reduce the probing depths, improve the osseous topography, and establish better occlusal contacts, anterior guidance, and esthetics by leveling and retracting the incisors. We planned to extract, for orthodontic reasons, the patient's maxillary right lateral incisor,
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Fig 5. Treatment results after the periodontal flap surgery: A, intraoral photographs of the periodontal flap surgery; B, dental radiographs after the periodontal flap surgery; C, periodontal examinations after the periodontal flap surgery, probing, and bleeding on probing.
mandibular left first premolar, and the distal root of the mandibular right first molar (hemisectioning) because of the extensive periodontal damage. We also designed interdisciplinary treatments involving orthodontic therapy, periodontal therapy with regenerative techniques, periodontal plastic surgery, prosthodontic rehabilitation, and a strictly supervised oral hygiene program. Screening of the periodontal pocket depth, bleeding on probing, blood IgG antibody titer, and microbiologic findings for periodontal disease with real-time polymerase chain reaction assays were performed by periodontists in the transition phase of each active treatment step.14
TREATMENT ALTERNATIVES
One alternative therapeutic method proposed for this patient involved solely restorative or prosthodontic treatment. However, such treatment would have required the extraction of teeth with severe bone loss followed by restoration of the occlusion with partial dentures and endodontic treatment for the intact teeth before prosthetic tooth preparation. Although the patient understood the need for tooth removal, she preferred to avoid further extractions and selected the orthodontic treatment plan. Since AgP tends to
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Fig 6. Measurements from the periodontal disease screening during treatment: A, blood IgG antibody titers against A actinomycetemcomitans, with the values expressed as ELISA units, as defined previously; B, the results of the quantitative evaluation of the microbiota of the patient by real-time polymerase chain reaction; the vertical axis indicates the numbers of bacteria in the subgingival plaque samples, as defined previously.14
reach a peak at approximately 20 years of age, it is important to save the patient's teeth and to place him or her on an excellent periodontal maintenance program. TREATMENT PROGRESS
Before the start of the active orthodontic treatment, professional periodontal therapy was performed, including periodontal flap surgery, by a periodontist (Fig 5, A). During the periodontal therapy, the patient showed decreased probing pocket depths and sulcus bleeding, with an increased attachment level, compared with the initial data (Fig 5, B and C). Both the IgG antibody titer against A actinomycetemcomitans Y4 and the total microbiologic count significantly decreased after periodontal flap surgery (Fig 6). In addition, the titers of A actinomycetemcomitans and Prevotella intermedia were found to be decreased in
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the preorthodontic treatment period but not after the surgery (Fig 6, B). Based on the improvements after the periodontal therapy, we decided that the patient's periodontal condition was well controlled and initiated the orthodontic treatment. She subsequently underwent a maintenance program with visits once a month, more frequently than in normal periodontal treatment programs, because orthodontic treatment greatly affects the periodontal status. A lingual arch was placed in the maxillary arch to correct the crossbite of the maxillary left lateral incisor. After correcting the anterior crossbite, a 0.022in preadjusted edgewise appliance was placed for all self-ligating brackets on the maxillary arch. The initial alignment was achieved with a 0.012-in nickeltitanium wire. Five months after leveling and alignment, a 0.016 3 0.016-in titanium-molybdenum wire was installed to induce closure of the extraction spaces in the maxillary arch. A 0.022-in preadjusted edgewise
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Fig 7. Posttreatment facial and intraoral photographs.
Fig 8. Posttreatment dental casts.
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Fig 9. Posttreatment radiographs: A, lateral cephalogram; B, posteroanterior cephalogram; C, panoramic radiograph; D, dental radiographs; E, periodontal examinations.
appliance was then placed in the mandibular posterior segment with a 0.016-in heat-activated nickel-titanium wire in the mandibular arch. After leveling and alignment, a 0.022-in preadjusted edgewise appliance was placed in the mandibular anterior segment with a continuous 0.016-in heat-activated nickel-titanium wire in the mandibular arch. After subsequent leveling and alignment of the mandibular arch, a 0.016 3 0.022-in titanium-molybdenum wire with a
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T-loop was installed for mandibular anterior tooth retraction. Stainless steel wires were positioned to coordinate both arch forms, and a stainless steel 0.016 3 0.022in wire was placed for detailing. The total active orthodontic treatment period was 28 months. After removing the appliances, both incisors were stabilized using lingual bonded retainers. Wrap-around retainers were also placed.
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Fig 10. Superimposed cephalometric tracings showing the changes from pretreatment to posttreatment: A, sella-nasion plane at sella; B, palatal plane at ANS; C, mandibular plane at menton.
TREATMENT RESULTS
The orthodontic treatment resulted in improvements in the patient's facial profile, with decreased lip protrusion, allowing for natural lip closure (Fig 7). Acceptable occlusion was also obtained, with normal overjet (3.5 mm) and overbite (3.0 mm), although a small amount of midline deviation persisted (Figs 7 and 8; Table I). The posttreatment casts showed good interdigitation of the teeth (Fig 8). Acceptable root parallelism was also achieved, and neither undue root resorption nor marginal bone loss was observed (Fig 9). Although the numbers of Porphyromonas gingivalis increased, the IgG antibody titer against A actinomycetemcomitans Y4, as well as the patient's microbiologic data and periodontal condition, remained generally well controlled during active orthodontic treatment because of the supportive periodontal therapy once a month (Fig 6). The posttreatment cephalometric assessment showed no marked skeletal changes, and the maxillary and mandibular incisors were lingually inclined by 10.5 and 19.0 , respectively (Fig 10; Table I). In an evaluation of the jaw movement with a jawmovement recording system with 6 degrees of freedom (Gnatho-Hexagraph system, version 1.31; Ono Sokki, Kanagawa, Japan), a smooth and stable incisal path was observed during both protrusive and lateral
excursions. Moreover, condylar movement increased on both sides after the orthodontic treatment (Fig 11). Acceptable occlusion, facial esthetics, and periodontal disease screening values were maintained over the 36-month postretention period (Figs 6, and 12-14). Periodontal prosthetic treatment was subsequently applied to the maxillary anterior segment to stabilize the mobile teeth. Periodontal regeneration therapy and plastic surgery were also performed. The cephalometric analysis showed a slight labial inclination of both incisors (Fig 15). Furthermore, although the occlusal force and occlusal contact area slightly decreased during the posttreatment period, overall improvements were noted in the postretention period (Table II). We continue to provide supportive periodontal treatment for this patient more frequently than in normal recall patients. Currently, the recall interval is 2 to 3 months because the patient's periodontal condition remains stable. Importantly, she reported satisfaction with the treatment results. DISCUSSION
There have been various reports of successful morphologic and esthetic changes after orthodontic treatment in patients with localized AgP15-17; however, few reports have described the outcomes of patients
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Fig 11. The condylar movement and the incisal paths detected using a 6 degrees of freedom jawmovement recording system. The red line indicates the opening phase, and the blue line shows the closing phase: A, pretreatment; B, posttreatment.
with generalized AgP. In this patient, the periodontists diagnosed her with generalized AgP possibly caused by A actinomycetemcomitans Y4. Generalized AgP is
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characterized by the onset of interproximal attachment loss affecting at least 3 permanent teeth other than the first molars and the incisors.18 Although most
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Fig 12. Postretention facial and intraoral photographs.
Fig 13. Postretention dental casts.
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Fig 14. Postretention radiographs: A, lateral cephalogram; B, posteroanterior cephalogram; C, panoramic radiograph; D, dental radiograph; E, periodontal examinations, probing, and bleeding on probing.
clinicians would agree that aggressive forms of periodontitis are distinctive, the features marking the clinical distinction between chronic periodontitis and generalized AgP remain obscure.19 This type of periodontal disease thus is a great challenge to clinicians providing orthodontic treatment because poorly controlled periodontal health can result in the rapid and irreversible breakdown of the periodontal support apparatus.20
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The general approach to determining the orthodontic diagnosis and treatment plan in adults with periodontitis requires an examination of the patient's periodontal status, such as the prevalence of periodontal pockets, the degree of tooth mobility, the extent of tooth loss, and behavioral factors. In our patient, in addition to conventional periodontal disease screening, we conducted a blood IgG antibody titer test as well as microbiologic
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Fig 15. Superimposed cephalometric tracings showing the changes from posttreatment to postretention: A, sella-nasion plane at sella; B, palatal plane at ANS; and C, mandibular plane at menton.
monitoring of periodontal pathogens to quantitatively evaluate her periodontitis. As a result, the levels of periodontal pathogens were significantly decreased by the intensive periodontal treatment, including periodontal surgery (Fig 5), and remained well controlled during the orthodontic treatment (Fig 6). Most importantly, the orthodontic treatment did not cause any irreversible periodontal destruction. Although not all patients with periodontitis, such as those with chronic periodontitis, require bacteriologic testing, our results indicate that conducting efficient quantitative screening is crucial for providing successful orthodontic treatment in patients with severe periodontitis. Orthodontic treatment with extractions was planned for this patient in light of the significant periodontal damage to improve her facial profile and achieve an acceptable occlusion. Furthermore, eliminating the incisor crowding helped to improve the bone support and secure access for plaque control. The orthodontic alteration of tooth inclinations may also help to increase the flat bone topography in such cases, thus permitting better oral hygiene. In addition, this patient's deep periodontal pockets and bony defects were managed with orthodontic extrusion to level the alveolar crestal bone between the teeth by increasing the height and volume of the vertical bone; this resulted in a more
favorable periodontal status. By focusing on orthodontic mechanics when applying orthodontic forces to the patient's teeth, we were able to apply a lighter orthodontic force to the teeth with compromised bone support because those teeth move easily, and greater forces can negatively affect the periodontal tissues. Previous studies have clearly demonstrated that fixed orthodontic appliances and elastomeric rings increase plaque accumulation and bacterial colonization, which can impede the patient's ability to provide oral hygiene.21-23 Therefore, we limited the application of elastomeric ligation in this patient as much as possible and primarily used loop mechanics for space closure. Moreover, treatment with self-ligating brackets was considered in the hope of achieving better oral hygiene.24 To the best of our knowledge, this is the first report of a quantitative evaluation of the jaw movement and occlusal function obtained after orthodontic treatment in an adult with generalized AgP. Although the posttreatment measurements of functional issues were reduced, these values were higher than the initial measurements (Table II). We speculated that the patient's functional recovery may be attributed to the effects of the periodontal prosthetic treatments, although the exact reasons are not clear. The interdisciplinary
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Table II. Changes in occlusal function during ortho-
dontic treatment Pretreatment Posttreatment Postretention
Occlusal force (N) 731 651 804
5. Occlusal contact area (mm2) 17.9 14.2 19.1
6. 7. 8.
approach used for this patient made it possible to distribute the occlusal stress broadly and improve the stomatognathic function, even under severely compromised periodontal conditions. These results indicate that providing a better environment is conducive for obtaining long-term occlusal stability and good periodontal health. Further observation of the patient's occlusal stability with supportive periodontal treatment is required because her long-term prognosis will depend on her ability to maintain her periodontal health. Furthermore, special care and attention must be paid to her occlusal condition to prevent progression of the periodontal disease. We will continue to perform blood IgG antibody titer tests and microbiologic examinations regularly, as well as obtain regular periapical radiographs, to carefully monitor her periodontal condition because AgP has a high risk of recurrence. We also suggest that blood IgG antibody titer assays and microbiologic examinations should be part of the supportive periodontal treatment in patients with AgP.
9.
10.
11.
12.
13.
14.
15.
CONCLUSIONS
We treated an adult with bimaxillary protrusion and severe crowding possibly associated with generalized AgP. The comprehensive orthodontic treatment resulted in a significant improvement in the patient's periodontal condition, functional occlusion, and esthetic balance; these treatment results remained stable for 36 months. Longitudinal quantitative screenings of her periodontal status and any underlying pathogens are therefore an effective approach to maintaining periodontal health during orthodontic treatment in patients with severe periodontitis.
17.
18. 19. 20.
21.
REFERENCES 1. American Academy of Periodontology. Parameter on aggressive periodontitis. J Periodontol 2000;71(5 Suppl):867-9. 2. Newman MG, Socransky SS, Savitt ED, Propas DA, Crawford A. Studies of the microbiology of periodontosis. J Periodontol 1976;47:373-9. 3. Mandell RL, Socransky SS. A selective medium for Actinobacillus actinomycetemcomitans and the incidence of the organism in juvenile periodontitis. J Periodontol 1981;52:593-8. 4. Bragd L, Dahlen G, Wikstr€om M, Slots J. The capability of Actinobacillus actinomycetemcomitans, Bacteroides gingivalis and
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16.
22.
23.
24.
Bacteroides intermedius to indicate progressive periodontitis: a retrospective study. J Clin Periodontol 1987;14:95-9. Tonetti MS, Mombelli A. Early-onset periodontitis. Ann Periodontol 1999;4:39-53. Brunsvold MA. Pathologic tooth migration. J Periodontol 2005; 76:859-66. Mathews DP, Kokich VG. Managing treatment for the orthodontic patient with periodontal problems. Semin Orthod 1997;3:21-38. Kokich VG. Don't start without the charting. Am J Orthod Dentofacial Orthop 2011;139(Suppl):S14. Ishihara Y, Kuroda S, Nishiyama A, Sasaki A, Takano-Yamamoto T, Yamashiro T. Functional improvements after orthodontic-surgical reconstruction in a patient with multiple maxillofacial fractures. Am J Orthod Dentofacial Orthop 2012;142:534-45. Ishihara Y, Kuroda S, Sumiyoshi K, Takano-Yamamoto T, Yamashiro T. Extraction of the lateral incisors to treat maxillary protrusion: quantitative evaluation of the stomatognathic functions. Angle Orthod 2013;83:341-54. Murayama Y, Nagai A, Okamura K, Kurihara H, Nomura Y, Kokeguchi S, et al. Serum immunoglobulin G antibody to periodontal bacteria. Adv Dent Res 1988;2:339-45. Kudo C, Naruishi K, Maeda H, Abiko Y, Hino T, Iwata M, et al. Assessment of the plasma/serum IgG test to screen for periodontitis. J Dent Res 2012;91:1190-5. Wada K, Matsushima K, Shimazaki S, Miwa Y, Hasuike Y, Sunami R. An evaluation of a new case analysis of a lateral cephalometric roentgenogram. J Kanazawa Med Univ 1981;6:60-70. Maeda H, Fujimoto C, Haruki Y, Maeda T, Kokeguchi S, Petelin M, et al. Quantitative real-time PCR using TaqMan and SYBR green for Actinobacillus actinomycetemcomitans, Porphyromonas gingivalis, Prevotella intermedia, tetQ gene and total bacteria. FEMS Immunol Med Microbiol 2003;39:81-6. Okada K, Yamashiro T, Tenshin S, Takano-Yamamoto T. Orthodontic treatment for a patient with Pierre-Robin sequence complicated by juvenile periodontitis. Cleft Palate Craniofac J 2000;37: 318-24. Maeda S, Maeda Y, Ono Y, Nakamura K, Sasaki T. Interdisciplinary treatment of a patient with severe pathologic tooth migration caused by localized aggressive periodontitis. Am J Orthod Dentofacial Orthop 2005;127:374-84. Passanezi E, Janson M, Janson G, Sant’Anna AP, de Freitas MR, Henriques JF. Interdisciplinary treatment of localized juvenile periodontitis: a new perspective to an old problem. Am J Orthod Dentofacial Orthop 2007;131:268-76. Armitage GC. Periodontal diagnoses and classification of periodontal diseases. Periodontol 2000 2004;34:9-21. Armitage GC. Development of a classification system for periodontal diseases and conditions. Ann Periodontol 1999;4:1-6. Thilander B. Infrabony pockets and reduced alveolar bone height in relation to orthodontic therapy. Semin Orthod 1996; 2:55-61. Balenseifen JW, Madonia JV. Study of dental plaque in orthodontic patients. J Dent Res 1970;49:320-4. Sinclair PM, Berry CW, Bennett CL, Israelson H. Changes in gingiva and gingival flora with bonding and banding. Angle Orthod 1987; 57:271-8. T€ urkkahraman H, Sayin MO, Bozkurt FY, Yetkin Z, Kaya S, Onal S. Archwire ligation techniques, microbial colonization, and periodontal status in orthodontically treated patients. Angle Orthod 2005;75:231-6. Nalc¸acı R, Ozat Y, Cokako glu S, T€ urkkahraman H, Onal S, Kaya S. Effect of bracket type on halitosis, periodontal status, and microbial colonization. Angle Orthod 2014;84:479-85.
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Interdisciplinary orthodontic treatment for a patient with generalized aggressive periodontitis: Assessment of IgG antibodies to identify type of periodontitis and correct timing of treatment Yoshihito Ishihara,a Kazuya Tomikawa,b Toru Deguchi,c Tadashi Honjo,d Koji Suzuki,e Takayuki Kono,e Takuo Kuboki,f Hiroshi Kamioka,g Shogo Takashiba,h and Takashi Yamashiroi Okayama, Fukuoka, Yonago, and Suita, Japan, and Columbus, Ohio
Aggressive periodontitis is a great challenge to clinicians when providing orthodontic treatment because of the potential for progression of periodontal disease. In this article, we report the successful comprehensive orthodontic treatment of bimaxillary protrusion and severe crowding in an adult with generalized aggressive periodontitis. A woman, aged 22 years 7 months, with a chief complaint of incisal crowding was diagnosed with a skeletal Class I malocclusion associated with severe anterior crowding, possibly worsened by generalized aggressive periodontitis. In addition to a periodontal examination, a blood IgG antibody titer analysis and microbiologic examination for periodontal pathogens were used to diagnose the type of periodontal disease and determine the proper timing to initiate orthodontic treatment. The total active treatment period was 28 months, followed by periodontal prostheses and regeneration therapy. Consequently, satisfactory facial profile, occlusion, and periodontal health were maintained for at least 36 months. These results indicate that efficient screening is important for providing successful orthodontic treatment in patients with advanced periodontal disease. This report also demonstrates the diagnostic importance of blood IgG antibody titer assays and microbiologic examinations to detect periodontal pathogens. (Am J Orthod Dentofacial Orthop 2015;147:766-80)
a Assistant professor, Department of Orthodontics, Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, Okayama, Japan. b Assistant professor, Division of General Dentistry, Kyushu University Hospital, Fukuoka, Japan. c Associate professor, Division of Orthodontics, College of Dentistry, Ohio State University, Columbus, Ohio. d Assistant professor, Division of Oral and Maxillofacial Biopathological Surgery, Faculty of Medicine, Tottori University, Yonago, Japan. e Assistant professor, Department of Comprehensive Dentistry, Okayama University Hospital, Okayama, Japan. f Professor and chair, Department of Oral Rehabilitation and Regenerative Medicine, Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, Okayama, Japan. g Professor and chair, Department of Orthodontics, Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, Okayama, Japan. h Professor and chair, Department of Pathophysiology-Periodontal Science, Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, Okayama, Japan. i Professor and chair, Department of Orthodontics and Dentofacial Orthopedics, Graduate School of Dentistry, Osaka University, Suita, Japan. All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest, and none were reported. Address correspondence to: Yoshihito Ishihara, Department of Orthodontics, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, 2-5-1 Shikata-Cho, Kita-ku, Okayama 700-8525, Japan; Visiting Assistant Professor, Department of Oral Medicine, Infection and Immunity, Harvard School of Dental Medicine, 188 Longwood Ave, REB313, Boston, MA 02115; e-mail, [email protected]. Submitted, April 2014; revised, August 2014; accepted, September 2014. 0889-5406/$36.00 Copyright Ó 2015 by the American Association of Orthodontists. http://dx.doi.org/10.1016/j.ajodo.2014.09.022
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ggressive periodontitis (AgP), an uncommon and often severe destructive periodontal disease, is primarily characterized by the rapid loss of attachment and bone destruction, usually in relatively young patients.1 With regard to the pathogenesis of periodontitis, oral microorganisms present in biofilms are known to contribute to the onset of the disease. In particular, Aggregatibacter actinomycetemcomitans, a periodontal pathogen, is closely associated with AgP.2-5 Advanced periodontal disease may result in pathologic extrusion, labial inclination of the incisors, or posterior bite collapse, subsequently causing esthetic and functional problems for the patient that often require orthodontic correction. The application of orthodontic treatment in patients with AgP demands special consideration because of the potential for advanced progression of periodontal disease.6 The key to treating affected patients is to ensure close cooperation among the multidisciplinary team, particularly the orthodontist and the periodontist, to address the patient's periodontal status before treatment and to determine the optimal timing of therapy to treat both periodontal and orthodontic problems.
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Fig 1. The patient's initial condition: A, dental radiographs; B, periodontal examinations; C, blood IgG antibody titer values against periodontal pathogens. The following antigens were used: Aggregatibacter actinomycetemcomitans Y4, ATCC29523, SUNY67, Prevotella intermedia ATCC33563, ATCC25611, Porphyromonas gingivalis FDC381, and SU63. All values are expressed as ELISA units, as defined previously.12
Consequently, complete periodontal screening and recording should be carried out before the orthodontic treatment, and conducting a longitudinal evaluation of the patient's periodontal condition is important for providing optimal treatment. This strategy also helps to avoid lawsuits for any periodontal problems that may arise during treatment.7,8 Nevertheless, in spite of increasing recognition regarding the importance of the pathology of AgP and the need to evaluate functional aspects during diagnosis
and treatment, no previous reports have described the clinical assessment of these factors in orthodontic patients with AgP.9,10 Our aim in this case report therefore was to describe the results of comprehensive orthodontic treatment in a patient with generalized AgP, with a longitudinal quantitative evaluation of her periodontal condition and underlying pathogens. We also demonstrate the stomatognathic improvements achieved with successful orthodontic treatment in this patient.
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Fig 2. Preorthodontic treatment facial and intraoral photographs.
Fig 3. Preorthodontic treatment dental casts.
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Fig 4. Preorthodontic treatment radiographs: A, lateral cephalogram; B, posteroanterior cephalogram; C, panoramic radiograph; D, dental radiograph; E, periodontal examinations, probing, and bleeding on probing. DIAGNOSIS AND ETIOLOGY
A 21-year-old woman was referred by her general dentist to the outpatient dental clinic of Okayama University Hospital in Japan for treatment of AgP. Her medical history was unremarkable. However, a full-mouth series of periapical radiographs showed severe vertical bone loss, and preserving her maxillary left central
incisor was considered to be impossible because of the deep infrabony defects (Fig 1, A). The initial periodontal examination showed a deep probing pocket depth with sulcus bleeding (Fig 1, B). In addition to the periodontal examination, a blood IgG antibody titer assay for periodontal pathogens with an enzyme-linked immunosorbent assay (ELISA), as previously described, was used to assess the degree of periodontal disease based on the
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Table I. Summary of the cephalometric findings Variables Angular measurements ( ) ANB SNA SNB FMA U1-SN IMPA FMIA Interincisal angle Occlusal plane to Frankfort horizontal Gonial angle Linear measurements (mm) S-N N-Me Me/PP Overjet Overbite U1/PP U6/PP L1/Mp L6/Mp L1/AP E-line to upper lip E-line to lower lip
Japanese norms (adult female)
SD
Pretreatment
Posttreatment
Postretention
2.8 80.8 77.9 30.5 105.9 93.4 56.0 123.6 16.9 122.2
2.44 3.61 4.54 3.60 8.79 6.77 8.09 10.64 4.40 5.29
3.0 81.0 78.0 29.5 117.0 101.0 49.5 102.5 17.0 126.5
3.0 81.0 78.0 29.5 106.5 82.0 68.5 132.0 14.5 126.0
3.0 81.0 78.0 29.5 108.5 84.0 66.5 128.5 14.5 126.0
67.9 125.8 68.6 3.1 3.3 31.0 24.6 44.2 32.9 5.5 2.5 0.9
3.65 5.04 3.71 1.07 1.89 2.34 2.00 2.68 2.50 3.00 1.90 1.90
70.0 130.5 71.5 0.5 1.0 25.5 23.0 49.5 36.5 10.5 4.0 7.0
70.0 131.0 71.5 3.5 3.0 26.5 23.5 49.0 37.5 3.0 1.0 4.0
70.0 131.0 71.5 3.5 2.5 26.0 23.5 49.0 37.5 3.5 0.5 4.0
detection of humoral immunologic responses accompanying the elevation in the serum IgG antibody titers against periodontal pathogens.11,12 The results showed that the IgG antibody titer against A actinomycetemcomitans Y4, the B strain of A actinomycetemcomitans, which is frequently associated with AgP, was 4.85 times higher than the mean of 2 SD of the values observed in the healthy controls in a previous report (Fig 1, C).12 The patient was therefore diagnosed with generalized AgP, possibly caused by A actinomycetemcomitans Y4. The patient was referred to our orthodontic department 1 year later at 22 years 7 months of age to discuss the possibility of orthodontic treatment. Her chief complaint was crooked teeth and difficulty in controlling dental plaque. Her facial photographs showed a symmetrical face, a convex profile, and an acute nasolabial angle (Fig 2). Severe crowding was observed in both sets of incisors, and an anterior crossbite in both lateral incisors with Class II canine and Angle Class I molar relationships on both sides were also noted (Figs 2 and 3). The maxillary dental midline was deviated 2.0 mm to the left on the facial side relative to the mandibular dental midline. The patient was instructed regarding oral hygiene techniques and received initial periodontal debridement therapy to assess her periodontal tissue response. The initial periodontal preparation included instructions in oral hygiene, supragingival scaling, and root planning with professional
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tooth cleaning and antibiotic therapy. Periodontal pocket irrigation was also performed after those procedures. At the 6-month reevaluation visit, the radiographs and measurements demonstrated distinct clinical improvements and a reduction in bleeding on probing (Fig 4), although significant areas of vertical bone loss in the mandibular first molars remained evident (Fig 4, D). In comparison with Japanese norms, the results of the cephalometric analysis showed a skeletal Class I jaw relationship (ANB, 3.0 ) and an average mandibular plane angle (FMA, 29.5 ).13 In addition, the maxillary and mandibular incisors were labially inclined (U1-SN, 117.0 ; IMPA, 101.0 ), and the patient exhibited a decreased overjet of 0.5 mm and an overbite of 1.0 mm (Table I). TREATMENT OBJECTIVES
Based on these findings, the patient was diagnosed with a Class I malocclusion with lip protrusion, severe incisor crowding, and advanced bone loss, possibly caused by A actinomycetemcomitans. The treatment objectives were to treat the malocclusion, provide better periodontal health, reduce the probing depths, improve the osseous topography, and establish better occlusal contacts, anterior guidance, and esthetics by leveling and retracting the incisors. We planned to extract, for orthodontic reasons, the patient's maxillary right lateral incisor,
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Fig 5. Treatment results after the periodontal flap surgery: A, intraoral photographs of the periodontal flap surgery; B, dental radiographs after the periodontal flap surgery; C, periodontal examinations after the periodontal flap surgery, probing, and bleeding on probing.
mandibular left first premolar, and the distal root of the mandibular right first molar (hemisectioning) because of the extensive periodontal damage. We also designed interdisciplinary treatments involving orthodontic therapy, periodontal therapy with regenerative techniques, periodontal plastic surgery, prosthodontic rehabilitation, and a strictly supervised oral hygiene program. Screening of the periodontal pocket depth, bleeding on probing, blood IgG antibody titer, and microbiologic findings for periodontal disease with real-time polymerase chain reaction assays were performed by periodontists in the transition phase of each active treatment step.14
TREATMENT ALTERNATIVES
One alternative therapeutic method proposed for this patient involved solely restorative or prosthodontic treatment. However, such treatment would have required the extraction of teeth with severe bone loss followed by restoration of the occlusion with partial dentures and endodontic treatment for the intact teeth before prosthetic tooth preparation. Although the patient understood the need for tooth removal, she preferred to avoid further extractions and selected the orthodontic treatment plan. Since AgP tends to
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Fig 6. Measurements from the periodontal disease screening during treatment: A, blood IgG antibody titers against A actinomycetemcomitans, with the values expressed as ELISA units, as defined previously; B, the results of the quantitative evaluation of the microbiota of the patient by real-time polymerase chain reaction; the vertical axis indicates the numbers of bacteria in the subgingival plaque samples, as defined previously.14
reach a peak at approximately 20 years of age, it is important to save the patient's teeth and to place him or her on an excellent periodontal maintenance program. TREATMENT PROGRESS
Before the start of the active orthodontic treatment, professional periodontal therapy was performed, including periodontal flap surgery, by a periodontist (Fig 5, A). During the periodontal therapy, the patient showed decreased probing pocket depths and sulcus bleeding, with an increased attachment level, compared with the initial data (Fig 5, B and C). Both the IgG antibody titer against A actinomycetemcomitans Y4 and the total microbiologic count significantly decreased after periodontal flap surgery (Fig 6). In addition, the titers of A actinomycetemcomitans and Prevotella intermedia were found to be decreased in
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the preorthodontic treatment period but not after the surgery (Fig 6, B). Based on the improvements after the periodontal therapy, we decided that the patient's periodontal condition was well controlled and initiated the orthodontic treatment. She subsequently underwent a maintenance program with visits once a month, more frequently than in normal periodontal treatment programs, because orthodontic treatment greatly affects the periodontal status. A lingual arch was placed in the maxillary arch to correct the crossbite of the maxillary left lateral incisor. After correcting the anterior crossbite, a 0.022in preadjusted edgewise appliance was placed for all self-ligating brackets on the maxillary arch. The initial alignment was achieved with a 0.012-in nickeltitanium wire. Five months after leveling and alignment, a 0.016 3 0.016-in titanium-molybdenum wire was installed to induce closure of the extraction spaces in the maxillary arch. A 0.022-in preadjusted edgewise
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Fig 7. Posttreatment facial and intraoral photographs.
Fig 8. Posttreatment dental casts.
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Fig 9. Posttreatment radiographs: A, lateral cephalogram; B, posteroanterior cephalogram; C, panoramic radiograph; D, dental radiographs; E, periodontal examinations.
appliance was then placed in the mandibular posterior segment with a 0.016-in heat-activated nickel-titanium wire in the mandibular arch. After leveling and alignment, a 0.022-in preadjusted edgewise appliance was placed in the mandibular anterior segment with a continuous 0.016-in heat-activated nickel-titanium wire in the mandibular arch. After subsequent leveling and alignment of the mandibular arch, a 0.016 3 0.022-in titanium-molybdenum wire with a
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T-loop was installed for mandibular anterior tooth retraction. Stainless steel wires were positioned to coordinate both arch forms, and a stainless steel 0.016 3 0.022in wire was placed for detailing. The total active orthodontic treatment period was 28 months. After removing the appliances, both incisors were stabilized using lingual bonded retainers. Wrap-around retainers were also placed.
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Fig 10. Superimposed cephalometric tracings showing the changes from pretreatment to posttreatment: A, sella-nasion plane at sella; B, palatal plane at ANS; C, mandibular plane at menton.
TREATMENT RESULTS
The orthodontic treatment resulted in improvements in the patient's facial profile, with decreased lip protrusion, allowing for natural lip closure (Fig 7). Acceptable occlusion was also obtained, with normal overjet (3.5 mm) and overbite (3.0 mm), although a small amount of midline deviation persisted (Figs 7 and 8; Table I). The posttreatment casts showed good interdigitation of the teeth (Fig 8). Acceptable root parallelism was also achieved, and neither undue root resorption nor marginal bone loss was observed (Fig 9). Although the numbers of Porphyromonas gingivalis increased, the IgG antibody titer against A actinomycetemcomitans Y4, as well as the patient's microbiologic data and periodontal condition, remained generally well controlled during active orthodontic treatment because of the supportive periodontal therapy once a month (Fig 6). The posttreatment cephalometric assessment showed no marked skeletal changes, and the maxillary and mandibular incisors were lingually inclined by 10.5 and 19.0 , respectively (Fig 10; Table I). In an evaluation of the jaw movement with a jawmovement recording system with 6 degrees of freedom (Gnatho-Hexagraph system, version 1.31; Ono Sokki, Kanagawa, Japan), a smooth and stable incisal path was observed during both protrusive and lateral
excursions. Moreover, condylar movement increased on both sides after the orthodontic treatment (Fig 11). Acceptable occlusion, facial esthetics, and periodontal disease screening values were maintained over the 36-month postretention period (Figs 6, and 12-14). Periodontal prosthetic treatment was subsequently applied to the maxillary anterior segment to stabilize the mobile teeth. Periodontal regeneration therapy and plastic surgery were also performed. The cephalometric analysis showed a slight labial inclination of both incisors (Fig 15). Furthermore, although the occlusal force and occlusal contact area slightly decreased during the posttreatment period, overall improvements were noted in the postretention period (Table II). We continue to provide supportive periodontal treatment for this patient more frequently than in normal recall patients. Currently, the recall interval is 2 to 3 months because the patient's periodontal condition remains stable. Importantly, she reported satisfaction with the treatment results. DISCUSSION
There have been various reports of successful morphologic and esthetic changes after orthodontic treatment in patients with localized AgP15-17; however, few reports have described the outcomes of patients
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Fig 11. The condylar movement and the incisal paths detected using a 6 degrees of freedom jawmovement recording system. The red line indicates the opening phase, and the blue line shows the closing phase: A, pretreatment; B, posttreatment.
with generalized AgP. In this patient, the periodontists diagnosed her with generalized AgP possibly caused by A actinomycetemcomitans Y4. Generalized AgP is
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characterized by the onset of interproximal attachment loss affecting at least 3 permanent teeth other than the first molars and the incisors.18 Although most
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Fig 12. Postretention facial and intraoral photographs.
Fig 13. Postretention dental casts.
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Fig 14. Postretention radiographs: A, lateral cephalogram; B, posteroanterior cephalogram; C, panoramic radiograph; D, dental radiograph; E, periodontal examinations, probing, and bleeding on probing.
clinicians would agree that aggressive forms of periodontitis are distinctive, the features marking the clinical distinction between chronic periodontitis and generalized AgP remain obscure.19 This type of periodontal disease thus is a great challenge to clinicians providing orthodontic treatment because poorly controlled periodontal health can result in the rapid and irreversible breakdown of the periodontal support apparatus.20
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The general approach to determining the orthodontic diagnosis and treatment plan in adults with periodontitis requires an examination of the patient's periodontal status, such as the prevalence of periodontal pockets, the degree of tooth mobility, the extent of tooth loss, and behavioral factors. In our patient, in addition to conventional periodontal disease screening, we conducted a blood IgG antibody titer test as well as microbiologic
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Fig 15. Superimposed cephalometric tracings showing the changes from posttreatment to postretention: A, sella-nasion plane at sella; B, palatal plane at ANS; and C, mandibular plane at menton.
monitoring of periodontal pathogens to quantitatively evaluate her periodontitis. As a result, the levels of periodontal pathogens were significantly decreased by the intensive periodontal treatment, including periodontal surgery (Fig 5), and remained well controlled during the orthodontic treatment (Fig 6). Most importantly, the orthodontic treatment did not cause any irreversible periodontal destruction. Although not all patients with periodontitis, such as those with chronic periodontitis, require bacteriologic testing, our results indicate that conducting efficient quantitative screening is crucial for providing successful orthodontic treatment in patients with severe periodontitis. Orthodontic treatment with extractions was planned for this patient in light of the significant periodontal damage to improve her facial profile and achieve an acceptable occlusion. Furthermore, eliminating the incisor crowding helped to improve the bone support and secure access for plaque control. The orthodontic alteration of tooth inclinations may also help to increase the flat bone topography in such cases, thus permitting better oral hygiene. In addition, this patient's deep periodontal pockets and bony defects were managed with orthodontic extrusion to level the alveolar crestal bone between the teeth by increasing the height and volume of the vertical bone; this resulted in a more
favorable periodontal status. By focusing on orthodontic mechanics when applying orthodontic forces to the patient's teeth, we were able to apply a lighter orthodontic force to the teeth with compromised bone support because those teeth move easily, and greater forces can negatively affect the periodontal tissues. Previous studies have clearly demonstrated that fixed orthodontic appliances and elastomeric rings increase plaque accumulation and bacterial colonization, which can impede the patient's ability to provide oral hygiene.21-23 Therefore, we limited the application of elastomeric ligation in this patient as much as possible and primarily used loop mechanics for space closure. Moreover, treatment with self-ligating brackets was considered in the hope of achieving better oral hygiene.24 To the best of our knowledge, this is the first report of a quantitative evaluation of the jaw movement and occlusal function obtained after orthodontic treatment in an adult with generalized AgP. Although the posttreatment measurements of functional issues were reduced, these values were higher than the initial measurements (Table II). We speculated that the patient's functional recovery may be attributed to the effects of the periodontal prosthetic treatments, although the exact reasons are not clear. The interdisciplinary
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Table II. Changes in occlusal function during ortho-
dontic treatment Pretreatment Posttreatment Postretention
Occlusal force (N) 731 651 804
5. Occlusal contact area (mm2) 17.9 14.2 19.1
6. 7. 8.
approach used for this patient made it possible to distribute the occlusal stress broadly and improve the stomatognathic function, even under severely compromised periodontal conditions. These results indicate that providing a better environment is conducive for obtaining long-term occlusal stability and good periodontal health. Further observation of the patient's occlusal stability with supportive periodontal treatment is required because her long-term prognosis will depend on her ability to maintain her periodontal health. Furthermore, special care and attention must be paid to her occlusal condition to prevent progression of the periodontal disease. We will continue to perform blood IgG antibody titer tests and microbiologic examinations regularly, as well as obtain regular periapical radiographs, to carefully monitor her periodontal condition because AgP has a high risk of recurrence. We also suggest that blood IgG antibody titer assays and microbiologic examinations should be part of the supportive periodontal treatment in patients with AgP.
9.
10.
11.
12.
13.
14.
15.
CONCLUSIONS
We treated an adult with bimaxillary protrusion and severe crowding possibly associated with generalized AgP. The comprehensive orthodontic treatment resulted in a significant improvement in the patient's periodontal condition, functional occlusion, and esthetic balance; these treatment results remained stable for 36 months. Longitudinal quantitative screenings of her periodontal status and any underlying pathogens are therefore an effective approach to maintaining periodontal health during orthodontic treatment in patients with severe periodontitis.
17.
18. 19. 20.
21.
REFERENCES 1. American Academy of Periodontology. Parameter on aggressive periodontitis. J Periodontol 2000;71(5 Suppl):867-9. 2. Newman MG, Socransky SS, Savitt ED, Propas DA, Crawford A. Studies of the microbiology of periodontosis. J Periodontol 1976;47:373-9. 3. Mandell RL, Socransky SS. A selective medium for Actinobacillus actinomycetemcomitans and the incidence of the organism in juvenile periodontitis. J Periodontol 1981;52:593-8. 4. Bragd L, Dahlen G, Wikstr€om M, Slots J. The capability of Actinobacillus actinomycetemcomitans, Bacteroides gingivalis and
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16.
22.
23.
24.
Bacteroides intermedius to indicate progressive periodontitis: a retrospective study. J Clin Periodontol 1987;14:95-9. Tonetti MS, Mombelli A. Early-onset periodontitis. Ann Periodontol 1999;4:39-53. Brunsvold MA. Pathologic tooth migration. J Periodontol 2005; 76:859-66. Mathews DP, Kokich VG. Managing treatment for the orthodontic patient with periodontal problems. Semin Orthod 1997;3:21-38. Kokich VG. Don't start without the charting. Am J Orthod Dentofacial Orthop 2011;139(Suppl):S14. Ishihara Y, Kuroda S, Nishiyama A, Sasaki A, Takano-Yamamoto T, Yamashiro T. Functional improvements after orthodontic-surgical reconstruction in a patient with multiple maxillofacial fractures. Am J Orthod Dentofacial Orthop 2012;142:534-45. Ishihara Y, Kuroda S, Sumiyoshi K, Takano-Yamamoto T, Yamashiro T. Extraction of the lateral incisors to treat maxillary protrusion: quantitative evaluation of the stomatognathic functions. Angle Orthod 2013;83:341-54. Murayama Y, Nagai A, Okamura K, Kurihara H, Nomura Y, Kokeguchi S, et al. Serum immunoglobulin G antibody to periodontal bacteria. Adv Dent Res 1988;2:339-45. Kudo C, Naruishi K, Maeda H, Abiko Y, Hino T, Iwata M, et al. Assessment of the plasma/serum IgG test to screen for periodontitis. J Dent Res 2012;91:1190-5. Wada K, Matsushima K, Shimazaki S, Miwa Y, Hasuike Y, Sunami R. An evaluation of a new case analysis of a lateral cephalometric roentgenogram. J Kanazawa Med Univ 1981;6:60-70. Maeda H, Fujimoto C, Haruki Y, Maeda T, Kokeguchi S, Petelin M, et al. Quantitative real-time PCR using TaqMan and SYBR green for Actinobacillus actinomycetemcomitans, Porphyromonas gingivalis, Prevotella intermedia, tetQ gene and total bacteria. FEMS Immunol Med Microbiol 2003;39:81-6. Okada K, Yamashiro T, Tenshin S, Takano-Yamamoto T. Orthodontic treatment for a patient with Pierre-Robin sequence complicated by juvenile periodontitis. Cleft Palate Craniofac J 2000;37: 318-24. Maeda S, Maeda Y, Ono Y, Nakamura K, Sasaki T. Interdisciplinary treatment of a patient with severe pathologic tooth migration caused by localized aggressive periodontitis. Am J Orthod Dentofacial Orthop 2005;127:374-84. Passanezi E, Janson M, Janson G, Sant’Anna AP, de Freitas MR, Henriques JF. Interdisciplinary treatment of localized juvenile periodontitis: a new perspective to an old problem. Am J Orthod Dentofacial Orthop 2007;131:268-76. Armitage GC. Periodontal diagnoses and classification of periodontal diseases. Periodontol 2000 2004;34:9-21. Armitage GC. Development of a classification system for periodontal diseases and conditions. Ann Periodontol 1999;4:1-6. Thilander B. Infrabony pockets and reduced alveolar bone height in relation to orthodontic therapy. Semin Orthod 1996; 2:55-61. Balenseifen JW, Madonia JV. Study of dental plaque in orthodontic patients. J Dent Res 1970;49:320-4. Sinclair PM, Berry CW, Bennett CL, Israelson H. Changes in gingiva and gingival flora with bonding and banding. Angle Orthod 1987; 57:271-8. T€ urkkahraman H, Sayin MO, Bozkurt FY, Yetkin Z, Kaya S, Onal S. Archwire ligation techniques, microbial colonization, and periodontal status in orthodontically treated patients. Angle Orthod 2005;75:231-6. Nalc¸acı R, Ozat Y, Cokako glu S, T€ urkkahraman H, Onal S, Kaya S. Effect of bracket type on halitosis, periodontal status, and microbial colonization. Angle Orthod 2014;84:479-85.
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