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Interdisciplinary treatment of a patient with severe pathologic tooth migration caused by localized aggressive periodontitis
CASE REPORT
Interdisciplinary treatment of a patient with severe pathologic tooth migration caused by localized aggressive periodontitis Sachiko Maeda,a Yoshinobu Maeda,b Yoshihiro Ono,a Kimio Nakamura,a and Takeshi Sasakia Osaka, Japan An interdisciplinary approach was used to treat a patient with pathologic migration of teeth, with severe anterior proclination and molar mesial inclination due to localized aggressive periodontitis. The combination of regenerative periodontal therapy, prosthodontic rehabilitation, and orthodontic treatment greatly improved function and esthetics. (Am J Orthod Dentofacial Orthop 2005;127:374-84)
L
ocalized, aggressive periodontitis was formerly called localized juvenile periodontitis or localized early-onset periodontitis. This disease causes localized breakdown of the periodontal attachment in particular parts of the dental arch early in life.1 The common symptom is rapid attachment loss in the first molar and incisor area. However, the pathologic manifestations of this disease are varied, and it is quite difficult to differentiate the generalized type from adult periodontitis or the transient type in young adult patients.2 The attachment loss can result in pathologic extrusion or labial inclination of the incisors, producing esthetic and functional problems for the patient.3-5 Orthodontic treatment of this disease not only improves esthetics and function but also helps prevent inflammation and the recurrence of periodontal breakdown.6-9 It is impossible to treat this disease with orthodontic therapy alone, and it is inevitable that periodontal therapy, prosthodontic tooth replacement, and splinting of mobile teeth will be required. Periodontal therapy could include regeneration techniques in conjunction with orthodontic treatment.10,11 In this case report, we describe an interdisciplinary approach, including regenerative periodontal therapy, prosthodontic rehabilitation and maintenance, and orthodontic treatment, to address pathologic tooth migration due to localized aggressive periodontitis. a
Private practice, Osaka, Japan. Professor and division head, Division for Interdisciplinary Dentistry, Osaka University Faculty of Dentistry, Osaka, Japan. Reprint requests to: Dr Sachiko Maeda, Fukoku Building Dental Clinic, 2-4 Komatsubara-cho, Kita-ku, Osaka, Japan; e-mail, [email protected]. Submitted, October 2003; revised and accepted, January 2004. 0889-5406/$30.00 Copyright © 2005 by the American Association of Orthodontists. doi:10.1016/j.ajodo.2004.01.019
b
374
DIAGNOSIS AND ETIOLOGY
The patient was a woman aged 27 years 4 months with a chief complaint of rapid extrusion of the maxillary incisors due to localized aggressive periodontitis. She had no systemic problems. At the initial examination (Figs 1-5), significant recession of attached gingiva was noted in both the maxillary and mandibular anterior segments. Periodontal probing showed deep pockets in almost the entire arch, as well as bleeding. The pockets were deepest around the maxillary and mandibular incisors and first molars (Table I). The central incisors in both arches had class 3 mobility. Radiographically, bone loss extended to the root apex of the right maxillary central incisor, and vertical bone defects were found on both maxillary first molars and the left lateral incisor. A furcation defect was present on the left maxillary first molar. A diagnosis of localized aggressive periodontitis was made. The patient had maxillary dentoalveolar protrusion, a Class II molar relationship, 2 mm of overbite, and 6 mm of overjet. The prognosis for the right maxillary central incisor was hopeless, so it was extracted and replaced with a Maryland bridge pontic. The mandibular anterior teeth were severely crowded. Cephalometric analysis showed an ANB angle of ⫹3.0° and skeletal values that were normal, albeit large for both mandibular length and facial height. Severe labial proclination of both the maxillary and mandibular incisors was present (Table II). The panoramic radiograph showed that significant bone loss had occurred in both the maxillary and mandibular anterior regions and in the molar area. An osteosclerotic region was also found at the extraction site of the maxillary right central incisor. The maxillary
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Fig 1. Pretreatment facial photographs.
Fig 2. Pretreatment intraoral photographs.
and mandibular molars and premolars were inclined mesially (Fig 5). TREATMENT OBJECTIVES
The orthodontic objectives for this patient were to improve masticatory function and esthetics and to enhance periodontal health by removing inflammatory and occlusal disease, as follows: (1) correct the labial inclination and crowding of both the maxillary and mandibular anterior teeth to allow the lips to close easily and protect the labial gingiva from xerostomia; (2) correct the mesial inclination of the maxillary and
mandibular molars to improve masticatory function and eliminate excessive lateral forces; and (3) relieve crowding to facilitate oral hygiene. TREATMENT ALTERNATIVES
Two options for achieving the treatment objectives were considered. The first was to upright the molars to allow lingual retraction and relieve anterior crowding. This option could restore the original angulation of the molars, and the treatment time would be relatively short, but achieving proper anchorage would be difficult.
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Fig 3. Pretreatment dental casts.
Fig 5. Panoramic radiograph just before start of treatment. Note anterior bone loss and osteosclerotic region at central incisor extraction site.
Fig 4. Initial panoramic and dental radiographs.
The second option was to extract both maxillary and mandibular premolars. This option would permit lingual retraction of the anterior teeth to resolve crowding, but the treatment time would be relatively long, and this could negatively affect periodontal health. The treatment options were presented to the patient and discussed. For the maxillary arch, the decision was made to upright the molars to improve tooth angulation and permit lingual movement of the anterior teeth. For
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Table I.
Initial pocket depth and bleeding on probing
Maxillary teeth Pocket depth (labial) Bleeding on probing Pocket depth (lingual) Bleeding on probing Mandibular teeth Pocket depth (labial) Bleeding on probing Pocket depth (lingual) Bleeding on probing
7 223 333 * 7 533 *** 422
6 439 ** 326 *** 6 136 *** 226
5 525 *** 323 *** 5 326 *** 216 *
4 563 *** 313 * 4 325 *** 326 **
3 326 * 325 *** 3 623 *** 423 ***
2 526 *** 334 *** 2 433 *** 743 ***
1 888 *** 628 *** 1 322 *** 333 ***
1 625 ** 635 *** 1 334 *** 653 ***
2 668 *** 626 ** 2 322 *** 535 ***
3 423 ** 323 ** 3 333 *** 523 ***
4 823 * 823 * 4 445 *** 323
5 323 *** 323 5 434 *** 422
6 768 *** 623 ** 6 433
7 323 ** 335
334 *
333
7 333
Bleeding observed at *mesial, **middle, and ***distal probing points during 6-point probing methods.
Table II. Pretreatment and posttreatment cephalometric measurements
Skeletal pattern SNA (°) SNB (°) ANB (°) MP/SN (°) Gonial angle (°) OP/SN (°) SN (mm) N-Me (mm) A-Ptm/NF (mm) Ar-Me (mm) Denture pattern Interincisal angle (°) U1-SN (°) L1-MP (°) FMIA (°) L1-AP (°)
Mean
SD
Pretreatment
Posttreatment
80.8 77.9 2.8 37.1 122.1 16.9 67.9 125.8 47.9 106.6
3.61 4.54 2.44 4.64 5.29 4.4 3.65 5.04 2.8 5.74
78.2 75.2 3 36.1 122.5 16.8 71 139.5 47 115.5
79.5 75.9 3.6 36.4 122 16.6 71 140 46.5 114
123.6 10.64
107.4
123.4
105.9 93.4 56 5.5
111 105.5 44.6 10
105.5 94.8 55.5 5
8.79 6.77 8.09 3
MP, Mandibular plane; OP, occlusal plane; Me, menton; Ptm, pterygomaxillary fissure; NF, nasal floor; Ar, articulare; U1, maxillary incisor; L1, mandibular incisor; FMIA, Frankfort-mandibular incisor angle; AP, subpinale-pogonion.
the mandible, the decision was made to upright the molars and to resolve crowding by extracting the left central incisor, which had experienced severe bone loss and gingival recession. Because the maxillary incisors would eventually be restored, the Bolton discrepancy would be resolved. The patient agreed to proceed with this plan. TREATMENT PROGRESS
At age 27 years 6 months, the maxillary right central incisor was extracted, and guided bone regeneration performed (Fig 6). Open-flap curettage was completed by age 27 years 11 months (Fig 7). The mandibular left central incisor was extracted at age 28 years 3 months. After periodontal reevaluation to ensure that most of the pockets were less than 3 mm
(Table III), a preadjusted edgewise appliance with an .018-in slot was placed at age 28 years 5 months. The leveling process started with a .012-in nickel-titanium archwire after cervical pull-type headgear was applied to the maxillary first molars. Mandibular central incisor crowding was relieved, and the mesial inclination of the mandibular molar was improved after 11 months of leveling. A .017 ⫻ .025-in stainless steel archwire was placed in the mandibular arch, and a .016 ⫻ .022-in multiloop edgewise archwire was placed in the maxillary arch. Class II elastics were used to encourage distal movement of the maxillary dentition (Fig 8). After 7 months of uprighting and 3 months of detailing, the orthodontic appliances were removed. A maxillary removable circumferential retainer was used in the maxillary arch, and a canine-to-canine bonded retainer was placed in the mandibular arch. The overall active orthodontic treatment duration was 21 months. Two months after the initiation of the retention phase, a provisional bridge was placed in the maxillary anterior region. A nightguard was prescribed for the maxillary arch instead of the retainer. Six months after the start of the retention phase, guided tissue regeneration with a connective tissue graft was performed with an enamel matrix derivative (Emdogain; Biora, Malmo, Sweden) and a decalcified, freeze-dried bone allograft in the maxillary left lateral incisor. The buccal roots of the maxillary left first molar were sectioned and removed. Recontouring of the bone was performed in the mandibular molar region. Ten months after the periodontal surgeries, a porcelain fused metal bridge was cemented in the maxillary region. Crowns were also placed on the maxillary and mandibular left molars. Maintenance was continuous, with professional mechanical teeth cleaning every 2 months. TREATMENT RESULTS
Treatment for this patient led to improved facial esthetics due to the decrease in lip protrusion; this
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Fig 6. A, Extraction of maxillary right central incisor. B, Guided bone regeneration.
Fig 7. A, Open flap curettage of maxillary right molar. B, Open flap curettage of maxillary left molar.
Fig 8. Uprighting of maxillary dentition. Table III.
Preorthodontic treatment pocket depth and bleeding on probing (in millimeters)
Maxillary teeth Pocket depth (labial) Bleeding on probing Pocket depth (lingual) Bleeding on probing Mandibular teeth Pocket depth (labial) Bleeding on probing Pocket depth (lingual) Bleeding on probing
7 333
6 323
333
325 ** 6 436 ** 326 ***
7 433 * 422 *
5 322 ** 212 ** 5 326
4 323 * 123 * 4 323
3 212 * 223
223 **
223 **
222 *
3 222
2 211 ** 222 * 2 411 * 322
1
1 112
1 212
1 222
2 336 ** 422 * 2 322
222
223
222
122
3 212
212
222 3 222
4 212 * 222 4 323 * 212
5 223 * 322 * 5 433 ** 322
6 534 * 222 * 6 333 *** 323
7 333 ** 333 * 7 333 323
Bleeding observed at *mesial, **middle, and ***distal probing points during 6-point probing methods.
allowed the lips to close naturally (Figs 9-13). A Class I molar relationship was obtained with normal overjet and overbite, although a small amount of midline deviation still existed. The amount of gingival recession of the mandibular anterior teeth did not
change after orthodontic treatment. Posttreatment cephalometric analysis showed little change in the skeletal pattern but significant improvement in the angulation of the anterior teeth (Table II). Cephalometric superimposition showed that inclination of
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Fig 9. Posttreatment facial photographs.
Fig 10. Posttreatment intraoral photographs.
Table IV.
Postorthodontic treatment pocket depth and bleeding on probing (in millimeters)
Maxillary teeth Pocket depth (labial) Bleeding on probing Pocket depth (lingual) Bleeding on probing Mandibular teeth Pocket depth (labial) Bleeding on probing Pocket depth (lingual) Bleeding on probing
7 112 * 332 * 7 222 * 211 *
6 223
5 311
4 312
3 212
112
212
6 222 * 121
5 111
222 * 4 111 * 111
222 * 3 111
111
112
2 222 *** 112 ** 2 111 * 212
1
1 212 ** 211
1 211
2 112
322 1
4 312 * 222 * 4 212
5 212
6 123
7 211
222 *** 2 112
3 212 * 222 * 3 212
222 * 5 123
222
212
212
212
112
122 * 6 223 * 223 *
Bleeding observed at *mesial, **middle, and ***distal probing points during 6-point probing methods.
7 222 * 222
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Fig 11. Posttreatment dental casts.
Fig 12. Superimposed pretreatment and posttreatment tracings.
Fig 13. Posttreatment panoramic and dental radiographs.
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Fig 14. Facial photographs 3 years after treatment.
Fig 15. Intraoral photographs 3 years after treatment.
both the maxillary and mandibular anterior teeth had improved, as had retraction of the maxillary incisors. Pocket depths had decreased significantly (Table IV). Panoramic and periapical radiographs confirmed flattening of the interproximal bone topography. New bone was also found in the extraction site of the maxillary right central incisor. Good root parallelism was obtained after the uprighting procedure. Bone levels did not change at the alveolar bone crest. Three years after the active orthodontic treatment,
the periodontal and occlusal findings had not changed (Figs 14-17). DISCUSSION
According to Hart et al,2 the diagnosis of localized aggressive periodontitis is based on attachment loss of at least 4 mm on at least 2 permanent first molars and incisors (1 of which must be a first permanent molar). No more than 2 other permanent teeth, not first permanent molars or incisors, should be affected. Subjects must be systemically healthy and less than 35 years of
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Fig 16. Dental casts 3 years after treatment.
Fig 17. Panoramic radiograph 3 years after treatment.
age. The case presented here included severe attachment loss not only in the first molar and incisor region but also in the canine and premolar region. However, localized aggressive periodontitis was diagnosed because it was regarded as the transient phase from localized aggressive periodontitis to generalized aggressive periodontitis. Pathologic migration is defined as a change in tooth position resulting from disruption of the forces that maintain the teeth in a normal position, with reference
to the skull.12 The clinical manifestations of pathologic migration, such as proclination, diastema, rotation, extrusion, and drifting have been found in 30% to 50% of patients with moderate to severe periodontal disease.3,5 Because pathologic migration affects esthetics, this is frequently a chief complaint of periodontally involved patients.13 The etiology of pathologic migration has not yet been clarified, but it is thought to be related to attachment loss and bone resorption, according to clinical reports or observations. In this patient, proclination and extrusion of both the maxillary and mandibular incisors and mesial inclination of the molars were significant. These symptoms became worse within 2 to 3 years, according to the patient. Because of the excessive proclination of the anterior teeth, it was difficult for her to close her lips, leading to dryness in the oral cavity. The effectiveness of orthodontic treatment for patients with periodontal disease is enhanced by eliminating inflammatory factors, creating access for oral hygiene, and altering occlusal factors during tooth alignment.9 It has also been reported that gingiva or alveolar bone topography can be improved by altering the tooth inclination or extrusion.8,14
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For this patient, esthetics were improved by retracting the anterior teeth. In addition, protection of the gingiva and mucosa was established by the normal lip closure, which prevents dryness in the oral cavity. Eliminating mandibular anterior crowding helped to improve bone support and secure access for plaque control. The orthodontic alteration of tooth inclination in the molar region helped gain flat bone topography for better oral hygiene. However, the orthodontist should be cautious when applying orthodontic forces to teeth with severe periodontal disease and bone resorption. Lighter orthodontic forces should be applied to teeth with compromised bone support because they can move easily, and larger forces can negatively affect the periodontal membrane.9,15 The interval of orthodontic force activation should also be longer, because remodeling the periodontal tissues will take longer than in patients with healthy periodontal tissues.6,13,17,18 Tooth movement mainly involved uprighting the tipped molars. We tried to avoid significant movement of the mandibular anterior teeth by extracting a central incisor that had a poor prognosis. We spent twice as long as usual on each step of the orthodontic treatment, and no further bone or attachment loss occurred. Scaling, root planing, resective therapy of gingiva or bone, and forced extrusion have all been used as treatment options for periodontal disease with bone loss. The efficacy of bone grafting or regeneration therapy with Emdogain has recently been proved. Basdra et al19 and Nemcovsky et al10 reported a decrease in pocket depth or bone defects on radiographs by applying orthodontic treatment after the guided tissue regeneration procedure in patients with bone defects. In our patient, bone loss at the maxillary right central incisor extraction site was minimized by the guided tissue regeneration procedure. Furthermore, the guided tissue regeneration therapy was applied after the orthodontic treatment to the maxillary left lateral incisor, where half the supporting bone was missing. This allowed us to restore the maxillary anterior teeth with greater predictability and improved esthetics. Definitive periodontal treatment was performed in the molar region after the orthodontic treatment. The buccal roots of the maxillary left first molar were resected and extracted, with bone recontouring to achieve a flat topography. This tooth was prosthodontically splinted to the neighboring teeth. With these interdisciplinary procedures, it was possible to distribute occlusal stress broadly and create an environment conducive to good oral hygiene, even in a severely periodontally compromised situation. Some authors have reported that orthodontic tooth
movement is possible without further bone or attachment loss if the active treatment is delayed until the inflammation is under control.13,16,20 In contrast, the lack of special oral hygiene instructions or professional cleaning results in bone resorption.6 Open flap curettage, root planing, and regenerative periodontal therapy were applied, along with a strict oral hygiene program, including brushing and rinsing plus professional cleaning every 2 weeks during the treatment period. With this oral hygiene program, orthodontic treatment was completed without further attachment loss. CONCLUSIONS
We have described an interdisciplinary approach for treating pathologic tooth migration with severe proclination of the anterior teeth and mesial inclination of the molars. Treatments included orthodontic therapy, periodontal therapy with regenerative techniques, prosthodontic rehabilitation, and a strictly supervised oral hygiene program. As a result, significant improvements in function, esthetics, and periodontal health were achieved.
REFERENCES 1. 1999 workshop for a Classification of Periodontal Disease and Conditions. Ann Periodontal 1999;4:1-112. 2. Hart TC, Marazita ML, Schenkein HA, Gunsolley JG, Diehl SR. No female preponderance in juvenile periodontitis after correction for ascertainment bias. J Periodontol 1991;62:745-9. 3. Towfighi PP, Brunsvold MA, Storey AT, Arnold RM, Willman DE, McMahan CA. Pathologic migration of anterior teeth in patients with moderate to severe periodontitis. J Periodontol 1997;68:967-72. 4. Goldman HM, Cohen DW. Periodontal therapy. 6th ed. Saint Louis: C.V. Mosby; 1980. 5. Martinez-Canut P, Carrasquer A, Magan R, Lorca A. A study on factors associated with pathologic tooth migration. J Clin Periodontol 1997;24:492-7. 6. Årtun J, Urbye KS. The effect of orthodontic treatment on periodontal bone support in patients with advanced loss of marginal periodontium. Am J Orthod Dentofacial Orthop 1988; 93:143-8. 7. Reiten K. Effects of force, magnitude and direction of tooth movement on different alveolar bone types. Angle Orthod 1964;34:244-55. 8. Brown S. The effect of orthodontic therapy on certain types of periodontal defects (I). J Periodontol 1973;44:742-56. 9. Melsen B, Agerbak N, Eriksen J, Terp S. New attachment through periodontal treatment and orthodontic intrusion. Am J Orthod Dentofacial Orthop 1988;94:104-16. 10. Nemcovsky C, Zubery Y, Artzi Z, Lieberman MA. Orthodontic tooth movement following guided tissue regeneration: report of three cases. Int J Adult Orthod Orthognath Surg 1996;11:347-55. 11. Stelzel MJ, Flores-de-Jacoby L. Guided tissue regeneration in a combined periodontal and orthodontic treatment: a case report. Int J Period Rest Dent 1998;18:189-95.
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12. Chasens AI. Periodontal disease, pathologic tooth migration and adult orthodontics. N Y J Dent 1979;49:40-3. 13. Eliasson LÅ, Hugoson A, Kurol J, Siwe H. The effects of orthodontic treatment on periodontal tissues in patients with reduced periodontal support. Eur J Orthod 1982;4:1-9. 14. Ingber JS. Forced eruption. Part I. A method of treating isolated one and two wall infrabony osseous defects—rationale and case report. J Periodontol 1974;45:199-206. 15. Williams S, Melsen B, Agerbaek N, Asboe V. The orthodontic treatment of malocclusion in patients with previous periodontal disease. Br J Orthod 1982;9:178-84. 16. Ericsson I, Thilander B. Orthodontic forces and recurrence of periodontal disease. Am J Orthod 1978;74:41-50.
American Journal of Orthodontics and Dentofacial Orthopedics March 2005
17. Mathews DP, Kokich VG. Managing treatment for the orthodontic patient with periodontal problems. Semin Orthod 1997;3:2138. 18. Boyd RL, Leggott PJ, Quinn RS, Eakle WS, Chambers D. Periodontal implications of orthodontic treatment in adults with reduced or normal periodontal tissues versus those of adolescents. Am J Orthod Dentofacial Orthop 1989;96:191-9. 19. Basdra EK, Mayer T, Komposch G. Guided tissue regeneration precedes tooth movement and crossbite correction. Angle Orthod 1995;65:307-10. 20. Polson AM, Caton J, Polson A, Nyman S, Novak J, Reed B. Periodontal response after tooth movement into intrabony defects. J Periodontol 1984;55:197-202.
Interdisciplinary treatment of a patient with severe pathologic tooth migration caused by localized aggressive periodontitis Sachiko Maeda,a Yoshinobu Maeda,b Yoshihiro Ono,a Kimio Nakamura,a and Takeshi Sasakia Osaka, Japan An interdisciplinary approach was used to treat a patient with pathologic migration of teeth, with severe anterior proclination and molar mesial inclination due to localized aggressive periodontitis. The combination of regenerative periodontal therapy, prosthodontic rehabilitation, and orthodontic treatment greatly improved function and esthetics. (Am J Orthod Dentofacial Orthop 2005;127:374-84)
L
ocalized, aggressive periodontitis was formerly called localized juvenile periodontitis or localized early-onset periodontitis. This disease causes localized breakdown of the periodontal attachment in particular parts of the dental arch early in life.1 The common symptom is rapid attachment loss in the first molar and incisor area. However, the pathologic manifestations of this disease are varied, and it is quite difficult to differentiate the generalized type from adult periodontitis or the transient type in young adult patients.2 The attachment loss can result in pathologic extrusion or labial inclination of the incisors, producing esthetic and functional problems for the patient.3-5 Orthodontic treatment of this disease not only improves esthetics and function but also helps prevent inflammation and the recurrence of periodontal breakdown.6-9 It is impossible to treat this disease with orthodontic therapy alone, and it is inevitable that periodontal therapy, prosthodontic tooth replacement, and splinting of mobile teeth will be required. Periodontal therapy could include regeneration techniques in conjunction with orthodontic treatment.10,11 In this case report, we describe an interdisciplinary approach, including regenerative periodontal therapy, prosthodontic rehabilitation and maintenance, and orthodontic treatment, to address pathologic tooth migration due to localized aggressive periodontitis. a
Private practice, Osaka, Japan. Professor and division head, Division for Interdisciplinary Dentistry, Osaka University Faculty of Dentistry, Osaka, Japan. Reprint requests to: Dr Sachiko Maeda, Fukoku Building Dental Clinic, 2-4 Komatsubara-cho, Kita-ku, Osaka, Japan; e-mail, [email protected]. Submitted, October 2003; revised and accepted, January 2004. 0889-5406/$30.00 Copyright © 2005 by the American Association of Orthodontists. doi:10.1016/j.ajodo.2004.01.019
b
374
DIAGNOSIS AND ETIOLOGY
The patient was a woman aged 27 years 4 months with a chief complaint of rapid extrusion of the maxillary incisors due to localized aggressive periodontitis. She had no systemic problems. At the initial examination (Figs 1-5), significant recession of attached gingiva was noted in both the maxillary and mandibular anterior segments. Periodontal probing showed deep pockets in almost the entire arch, as well as bleeding. The pockets were deepest around the maxillary and mandibular incisors and first molars (Table I). The central incisors in both arches had class 3 mobility. Radiographically, bone loss extended to the root apex of the right maxillary central incisor, and vertical bone defects were found on both maxillary first molars and the left lateral incisor. A furcation defect was present on the left maxillary first molar. A diagnosis of localized aggressive periodontitis was made. The patient had maxillary dentoalveolar protrusion, a Class II molar relationship, 2 mm of overbite, and 6 mm of overjet. The prognosis for the right maxillary central incisor was hopeless, so it was extracted and replaced with a Maryland bridge pontic. The mandibular anterior teeth were severely crowded. Cephalometric analysis showed an ANB angle of ⫹3.0° and skeletal values that were normal, albeit large for both mandibular length and facial height. Severe labial proclination of both the maxillary and mandibular incisors was present (Table II). The panoramic radiograph showed that significant bone loss had occurred in both the maxillary and mandibular anterior regions and in the molar area. An osteosclerotic region was also found at the extraction site of the maxillary right central incisor. The maxillary
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Fig 1. Pretreatment facial photographs.
Fig 2. Pretreatment intraoral photographs.
and mandibular molars and premolars were inclined mesially (Fig 5). TREATMENT OBJECTIVES
The orthodontic objectives for this patient were to improve masticatory function and esthetics and to enhance periodontal health by removing inflammatory and occlusal disease, as follows: (1) correct the labial inclination and crowding of both the maxillary and mandibular anterior teeth to allow the lips to close easily and protect the labial gingiva from xerostomia; (2) correct the mesial inclination of the maxillary and
mandibular molars to improve masticatory function and eliminate excessive lateral forces; and (3) relieve crowding to facilitate oral hygiene. TREATMENT ALTERNATIVES
Two options for achieving the treatment objectives were considered. The first was to upright the molars to allow lingual retraction and relieve anterior crowding. This option could restore the original angulation of the molars, and the treatment time would be relatively short, but achieving proper anchorage would be difficult.
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Fig 3. Pretreatment dental casts.
Fig 5. Panoramic radiograph just before start of treatment. Note anterior bone loss and osteosclerotic region at central incisor extraction site.
Fig 4. Initial panoramic and dental radiographs.
The second option was to extract both maxillary and mandibular premolars. This option would permit lingual retraction of the anterior teeth to resolve crowding, but the treatment time would be relatively long, and this could negatively affect periodontal health. The treatment options were presented to the patient and discussed. For the maxillary arch, the decision was made to upright the molars to improve tooth angulation and permit lingual movement of the anterior teeth. For
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Table I.
Initial pocket depth and bleeding on probing
Maxillary teeth Pocket depth (labial) Bleeding on probing Pocket depth (lingual) Bleeding on probing Mandibular teeth Pocket depth (labial) Bleeding on probing Pocket depth (lingual) Bleeding on probing
7 223 333 * 7 533 *** 422
6 439 ** 326 *** 6 136 *** 226
5 525 *** 323 *** 5 326 *** 216 *
4 563 *** 313 * 4 325 *** 326 **
3 326 * 325 *** 3 623 *** 423 ***
2 526 *** 334 *** 2 433 *** 743 ***
1 888 *** 628 *** 1 322 *** 333 ***
1 625 ** 635 *** 1 334 *** 653 ***
2 668 *** 626 ** 2 322 *** 535 ***
3 423 ** 323 ** 3 333 *** 523 ***
4 823 * 823 * 4 445 *** 323
5 323 *** 323 5 434 *** 422
6 768 *** 623 ** 6 433
7 323 ** 335
334 *
333
7 333
Bleeding observed at *mesial, **middle, and ***distal probing points during 6-point probing methods.
Table II. Pretreatment and posttreatment cephalometric measurements
Skeletal pattern SNA (°) SNB (°) ANB (°) MP/SN (°) Gonial angle (°) OP/SN (°) SN (mm) N-Me (mm) A-Ptm/NF (mm) Ar-Me (mm) Denture pattern Interincisal angle (°) U1-SN (°) L1-MP (°) FMIA (°) L1-AP (°)
Mean
SD
Pretreatment
Posttreatment
80.8 77.9 2.8 37.1 122.1 16.9 67.9 125.8 47.9 106.6
3.61 4.54 2.44 4.64 5.29 4.4 3.65 5.04 2.8 5.74
78.2 75.2 3 36.1 122.5 16.8 71 139.5 47 115.5
79.5 75.9 3.6 36.4 122 16.6 71 140 46.5 114
123.6 10.64
107.4
123.4
105.9 93.4 56 5.5
111 105.5 44.6 10
105.5 94.8 55.5 5
8.79 6.77 8.09 3
MP, Mandibular plane; OP, occlusal plane; Me, menton; Ptm, pterygomaxillary fissure; NF, nasal floor; Ar, articulare; U1, maxillary incisor; L1, mandibular incisor; FMIA, Frankfort-mandibular incisor angle; AP, subpinale-pogonion.
the mandible, the decision was made to upright the molars and to resolve crowding by extracting the left central incisor, which had experienced severe bone loss and gingival recession. Because the maxillary incisors would eventually be restored, the Bolton discrepancy would be resolved. The patient agreed to proceed with this plan. TREATMENT PROGRESS
At age 27 years 6 months, the maxillary right central incisor was extracted, and guided bone regeneration performed (Fig 6). Open-flap curettage was completed by age 27 years 11 months (Fig 7). The mandibular left central incisor was extracted at age 28 years 3 months. After periodontal reevaluation to ensure that most of the pockets were less than 3 mm
(Table III), a preadjusted edgewise appliance with an .018-in slot was placed at age 28 years 5 months. The leveling process started with a .012-in nickel-titanium archwire after cervical pull-type headgear was applied to the maxillary first molars. Mandibular central incisor crowding was relieved, and the mesial inclination of the mandibular molar was improved after 11 months of leveling. A .017 ⫻ .025-in stainless steel archwire was placed in the mandibular arch, and a .016 ⫻ .022-in multiloop edgewise archwire was placed in the maxillary arch. Class II elastics were used to encourage distal movement of the maxillary dentition (Fig 8). After 7 months of uprighting and 3 months of detailing, the orthodontic appliances were removed. A maxillary removable circumferential retainer was used in the maxillary arch, and a canine-to-canine bonded retainer was placed in the mandibular arch. The overall active orthodontic treatment duration was 21 months. Two months after the initiation of the retention phase, a provisional bridge was placed in the maxillary anterior region. A nightguard was prescribed for the maxillary arch instead of the retainer. Six months after the start of the retention phase, guided tissue regeneration with a connective tissue graft was performed with an enamel matrix derivative (Emdogain; Biora, Malmo, Sweden) and a decalcified, freeze-dried bone allograft in the maxillary left lateral incisor. The buccal roots of the maxillary left first molar were sectioned and removed. Recontouring of the bone was performed in the mandibular molar region. Ten months after the periodontal surgeries, a porcelain fused metal bridge was cemented in the maxillary region. Crowns were also placed on the maxillary and mandibular left molars. Maintenance was continuous, with professional mechanical teeth cleaning every 2 months. TREATMENT RESULTS
Treatment for this patient led to improved facial esthetics due to the decrease in lip protrusion; this
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Fig 6. A, Extraction of maxillary right central incisor. B, Guided bone regeneration.
Fig 7. A, Open flap curettage of maxillary right molar. B, Open flap curettage of maxillary left molar.
Fig 8. Uprighting of maxillary dentition. Table III.
Preorthodontic treatment pocket depth and bleeding on probing (in millimeters)
Maxillary teeth Pocket depth (labial) Bleeding on probing Pocket depth (lingual) Bleeding on probing Mandibular teeth Pocket depth (labial) Bleeding on probing Pocket depth (lingual) Bleeding on probing
7 333
6 323
333
325 ** 6 436 ** 326 ***
7 433 * 422 *
5 322 ** 212 ** 5 326
4 323 * 123 * 4 323
3 212 * 223
223 **
223 **
222 *
3 222
2 211 ** 222 * 2 411 * 322
1
1 112
1 212
1 222
2 336 ** 422 * 2 322
222
223
222
122
3 212
212
222 3 222
4 212 * 222 4 323 * 212
5 223 * 322 * 5 433 ** 322
6 534 * 222 * 6 333 *** 323
7 333 ** 333 * 7 333 323
Bleeding observed at *mesial, **middle, and ***distal probing points during 6-point probing methods.
allowed the lips to close naturally (Figs 9-13). A Class I molar relationship was obtained with normal overjet and overbite, although a small amount of midline deviation still existed. The amount of gingival recession of the mandibular anterior teeth did not
change after orthodontic treatment. Posttreatment cephalometric analysis showed little change in the skeletal pattern but significant improvement in the angulation of the anterior teeth (Table II). Cephalometric superimposition showed that inclination of
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Fig 9. Posttreatment facial photographs.
Fig 10. Posttreatment intraoral photographs.
Table IV.
Postorthodontic treatment pocket depth and bleeding on probing (in millimeters)
Maxillary teeth Pocket depth (labial) Bleeding on probing Pocket depth (lingual) Bleeding on probing Mandibular teeth Pocket depth (labial) Bleeding on probing Pocket depth (lingual) Bleeding on probing
7 112 * 332 * 7 222 * 211 *
6 223
5 311
4 312
3 212
112
212
6 222 * 121
5 111
222 * 4 111 * 111
222 * 3 111
111
112
2 222 *** 112 ** 2 111 * 212
1
1 212 ** 211
1 211
2 112
322 1
4 312 * 222 * 4 212
5 212
6 123
7 211
222 *** 2 112
3 212 * 222 * 3 212
222 * 5 123
222
212
212
212
112
122 * 6 223 * 223 *
Bleeding observed at *mesial, **middle, and ***distal probing points during 6-point probing methods.
7 222 * 222
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Fig 11. Posttreatment dental casts.
Fig 12. Superimposed pretreatment and posttreatment tracings.
Fig 13. Posttreatment panoramic and dental radiographs.
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Fig 14. Facial photographs 3 years after treatment.
Fig 15. Intraoral photographs 3 years after treatment.
both the maxillary and mandibular anterior teeth had improved, as had retraction of the maxillary incisors. Pocket depths had decreased significantly (Table IV). Panoramic and periapical radiographs confirmed flattening of the interproximal bone topography. New bone was also found in the extraction site of the maxillary right central incisor. Good root parallelism was obtained after the uprighting procedure. Bone levels did not change at the alveolar bone crest. Three years after the active orthodontic treatment,
the periodontal and occlusal findings had not changed (Figs 14-17). DISCUSSION
According to Hart et al,2 the diagnosis of localized aggressive periodontitis is based on attachment loss of at least 4 mm on at least 2 permanent first molars and incisors (1 of which must be a first permanent molar). No more than 2 other permanent teeth, not first permanent molars or incisors, should be affected. Subjects must be systemically healthy and less than 35 years of
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Fig 16. Dental casts 3 years after treatment.
Fig 17. Panoramic radiograph 3 years after treatment.
age. The case presented here included severe attachment loss not only in the first molar and incisor region but also in the canine and premolar region. However, localized aggressive periodontitis was diagnosed because it was regarded as the transient phase from localized aggressive periodontitis to generalized aggressive periodontitis. Pathologic migration is defined as a change in tooth position resulting from disruption of the forces that maintain the teeth in a normal position, with reference
to the skull.12 The clinical manifestations of pathologic migration, such as proclination, diastema, rotation, extrusion, and drifting have been found in 30% to 50% of patients with moderate to severe periodontal disease.3,5 Because pathologic migration affects esthetics, this is frequently a chief complaint of periodontally involved patients.13 The etiology of pathologic migration has not yet been clarified, but it is thought to be related to attachment loss and bone resorption, according to clinical reports or observations. In this patient, proclination and extrusion of both the maxillary and mandibular incisors and mesial inclination of the molars were significant. These symptoms became worse within 2 to 3 years, according to the patient. Because of the excessive proclination of the anterior teeth, it was difficult for her to close her lips, leading to dryness in the oral cavity. The effectiveness of orthodontic treatment for patients with periodontal disease is enhanced by eliminating inflammatory factors, creating access for oral hygiene, and altering occlusal factors during tooth alignment.9 It has also been reported that gingiva or alveolar bone topography can be improved by altering the tooth inclination or extrusion.8,14
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For this patient, esthetics were improved by retracting the anterior teeth. In addition, protection of the gingiva and mucosa was established by the normal lip closure, which prevents dryness in the oral cavity. Eliminating mandibular anterior crowding helped to improve bone support and secure access for plaque control. The orthodontic alteration of tooth inclination in the molar region helped gain flat bone topography for better oral hygiene. However, the orthodontist should be cautious when applying orthodontic forces to teeth with severe periodontal disease and bone resorption. Lighter orthodontic forces should be applied to teeth with compromised bone support because they can move easily, and larger forces can negatively affect the periodontal membrane.9,15 The interval of orthodontic force activation should also be longer, because remodeling the periodontal tissues will take longer than in patients with healthy periodontal tissues.6,13,17,18 Tooth movement mainly involved uprighting the tipped molars. We tried to avoid significant movement of the mandibular anterior teeth by extracting a central incisor that had a poor prognosis. We spent twice as long as usual on each step of the orthodontic treatment, and no further bone or attachment loss occurred. Scaling, root planing, resective therapy of gingiva or bone, and forced extrusion have all been used as treatment options for periodontal disease with bone loss. The efficacy of bone grafting or regeneration therapy with Emdogain has recently been proved. Basdra et al19 and Nemcovsky et al10 reported a decrease in pocket depth or bone defects on radiographs by applying orthodontic treatment after the guided tissue regeneration procedure in patients with bone defects. In our patient, bone loss at the maxillary right central incisor extraction site was minimized by the guided tissue regeneration procedure. Furthermore, the guided tissue regeneration therapy was applied after the orthodontic treatment to the maxillary left lateral incisor, where half the supporting bone was missing. This allowed us to restore the maxillary anterior teeth with greater predictability and improved esthetics. Definitive periodontal treatment was performed in the molar region after the orthodontic treatment. The buccal roots of the maxillary left first molar were resected and extracted, with bone recontouring to achieve a flat topography. This tooth was prosthodontically splinted to the neighboring teeth. With these interdisciplinary procedures, it was possible to distribute occlusal stress broadly and create an environment conducive to good oral hygiene, even in a severely periodontally compromised situation. Some authors have reported that orthodontic tooth
movement is possible without further bone or attachment loss if the active treatment is delayed until the inflammation is under control.13,16,20 In contrast, the lack of special oral hygiene instructions or professional cleaning results in bone resorption.6 Open flap curettage, root planing, and regenerative periodontal therapy were applied, along with a strict oral hygiene program, including brushing and rinsing plus professional cleaning every 2 weeks during the treatment period. With this oral hygiene program, orthodontic treatment was completed without further attachment loss. CONCLUSIONS
We have described an interdisciplinary approach for treating pathologic tooth migration with severe proclination of the anterior teeth and mesial inclination of the molars. Treatments included orthodontic therapy, periodontal therapy with regenerative techniques, prosthodontic rehabilitation, and a strictly supervised oral hygiene program. As a result, significant improvements in function, esthetics, and periodontal health were achieved.
REFERENCES 1. 1999 workshop for a Classification of Periodontal Disease and Conditions. Ann Periodontal 1999;4:1-112. 2. Hart TC, Marazita ML, Schenkein HA, Gunsolley JG, Diehl SR. No female preponderance in juvenile periodontitis after correction for ascertainment bias. J Periodontol 1991;62:745-9. 3. Towfighi PP, Brunsvold MA, Storey AT, Arnold RM, Willman DE, McMahan CA. Pathologic migration of anterior teeth in patients with moderate to severe periodontitis. J Periodontol 1997;68:967-72. 4. Goldman HM, Cohen DW. Periodontal therapy. 6th ed. Saint Louis: C.V. Mosby; 1980. 5. Martinez-Canut P, Carrasquer A, Magan R, Lorca A. A study on factors associated with pathologic tooth migration. J Clin Periodontol 1997;24:492-7. 6. Årtun J, Urbye KS. The effect of orthodontic treatment on periodontal bone support in patients with advanced loss of marginal periodontium. Am J Orthod Dentofacial Orthop 1988; 93:143-8. 7. Reiten K. Effects of force, magnitude and direction of tooth movement on different alveolar bone types. Angle Orthod 1964;34:244-55. 8. Brown S. The effect of orthodontic therapy on certain types of periodontal defects (I). J Periodontol 1973;44:742-56. 9. Melsen B, Agerbak N, Eriksen J, Terp S. New attachment through periodontal treatment and orthodontic intrusion. Am J Orthod Dentofacial Orthop 1988;94:104-16. 10. Nemcovsky C, Zubery Y, Artzi Z, Lieberman MA. Orthodontic tooth movement following guided tissue regeneration: report of three cases. Int J Adult Orthod Orthognath Surg 1996;11:347-55. 11. Stelzel MJ, Flores-de-Jacoby L. Guided tissue regeneration in a combined periodontal and orthodontic treatment: a case report. Int J Period Rest Dent 1998;18:189-95.
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12. Chasens AI. Periodontal disease, pathologic tooth migration and adult orthodontics. N Y J Dent 1979;49:40-3. 13. Eliasson LÅ, Hugoson A, Kurol J, Siwe H. The effects of orthodontic treatment on periodontal tissues in patients with reduced periodontal support. Eur J Orthod 1982;4:1-9. 14. Ingber JS. Forced eruption. Part I. A method of treating isolated one and two wall infrabony osseous defects—rationale and case report. J Periodontol 1974;45:199-206. 15. Williams S, Melsen B, Agerbaek N, Asboe V. The orthodontic treatment of malocclusion in patients with previous periodontal disease. Br J Orthod 1982;9:178-84. 16. Ericsson I, Thilander B. Orthodontic forces and recurrence of periodontal disease. Am J Orthod 1978;74:41-50.
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17. Mathews DP, Kokich VG. Managing treatment for the orthodontic patient with periodontal problems. Semin Orthod 1997;3:2138. 18. Boyd RL, Leggott PJ, Quinn RS, Eakle WS, Chambers D. Periodontal implications of orthodontic treatment in adults with reduced or normal periodontal tissues versus those of adolescents. Am J Orthod Dentofacial Orthop 1989;96:191-9. 19. Basdra EK, Mayer T, Komposch G. Guided tissue regeneration precedes tooth movement and crossbite correction. Angle Orthod 1995;65:307-10. 20. Polson AM, Caton J, Polson A, Nyman S, Novak J, Reed B. Periodontal response after tooth movement into intrabony defects. J Periodontol 1984;55:197-202.