- Email: [email protected]
Orthodontic contribution to the periodontal management of a patient with localized aggressive periodontitis (post-juvenile periodontitis)
orthodontic waves 65 (2006) 81–87
available at www.sciencedirect.com
journal homepage: www.elsevier.com/locate/odw
Case report
Orthodontic contribution to the periodontal management of a patient with localized aggressive periodontitis (post-juvenile periodontitis) Tomoko Ogino a,*, Yoshiki Nakamura a, Kazuhiro Gomi b, Ayao Hirashita a a b
Department of Orthodontics, School of Dental Medicine, Tsurumi University, 2-1-3 Tsurumi, Tsurumiku, Yokohama, Japan Department of Periodontics, Tsurumi University, Japan
article info
abstract
Article history:
In aggressive periodontitis, pathological tooth migration and destruction of occlusion often
Received 20 December 2005
occur in patients’ younger age, therefore, it is necessary to give a treatment considering their
Accepted 20 February 2006
quality of life.
Published on line 15 May 2006
A 30-year-old female patient diagnosed as Angle class I upper protrusion associated with post-juvenile periodontitis had diastema of maxillary incisors since she was about 20 years
Keywords:
old. She was treated by multidisciplinary approach of a periodontist and an orthodontist and
Aggressive periodontitis
patients obtained esthetical dental arch and functional occlusion. Periodontal tissue was
Orthodontic treatment
also in good condition and she was very satisfied with the outcome. The patient has
Periodontal treatment
obtained periodontal and orthodontic long favorable stability. Good periodontal condition
Long-term stability
has been maintained for 6 years after active orthodontic treatment.
Quality of life
1.
# 2006 Elsevier Ltd and the Japanese Orthodontic Society. All rights reserved.
Introduction
In advanced periodontal disease, spacing of anterior segments combined with proclination of maxillary incisors and deep bite often occurs [1,2]. Once this malalignment has been occurred, the traumatic occlusion could cause further breakdown [3] of the periodontal tissue and also it would make brushing procedure very difficult and would fail to remove plaque as to maintain oral hygiene, therefore, it seems that this situation fails into the negative spiral in periodontal destruction. As far as juvenile periodontitis is concerned, which is now called localized or generalized aggressive periodontitis [4], progress of lesion is very rapid as it is formally known as the early onset periodontitis [5] and the conditions described above occur in the early stage. Reconstruction of the occlusion and alignment of the malposed teeth with orthodontic
treatment should be necessary not only to prevent the further progress of disease, but also to satisfy the patients’ functional and esthetic demands, especially for young patients. The present article shows the result of treatment using multidisciplinary approach of orthodontic and periodontal management to the patient with destruction of occlusion and malposition of anterior segments caused by post-juvenile periodontitis, who showed the long-term stability of reconstructed occlusion and good periodontal condition.
2.
Case report
A patient was referred from a periodontist to consult about the possibility of orthodontic treatment. The patient was a 30year-old female and her chief complaint was maxillary incisor
* Corresponding author. Tel.: +81 45 581 1001x8383; fax: +81 45 582 8868. E-mail addresses: [email protected], [email protected] (T. Ogino). 1344-0241/$ – see front matter # 2006 Elsevier Ltd and the Japanese Orthodontic Society. All rights reserved. doi:10.1016/j.odw.2006.02.002
82
orthodontic waves 65 (2006) 81–87
first molar, and also both proximal and distal site of a right maxillary first molar (Fig. 4A). Pocket probing also proved the attachment loss for measured 10 mm at the mesiobuccal site of a maxillary left molar as the deepest and 6–7 mm at the proximal sites of maxillary incisors. Mandibular molars also had deep probing depth as 6 mm at the proximal sites of the left first molar and 6 mm at the distolingual site of the right first molar (Table 1). For all of the above, the patient was diagnosed as Angle class I maxillary protrusion associated with post-juvenile periodontitis and treatment plan was decided with consideration of the approach to both periodontitis and malocclusion.
3.
Fig. 1 – Facial photographs: (A) initial (30 years 9 months); (B) post-active treatment (32 years 9 months); and (C) 6 years after active treatment (38 years 9 months).
spacing and protrusion. Gingival inflammation had occurred in her earlier age and incisor spacing has been present since she was about 20 years old. The patient displayed a profile of convexity (Fig. 1A). Dental examination showed 5.0 mm of overbite and 8.0 mm of overjet combined with 4 mm of diastema in maxillary incisors and slight crowding of mandibular incisors (Figs. 2A and 3A). There were non-appropriate contacts because of slight rotations at right mandibular premolars. The molar relationship was Angle class I. Lateral cephalometric analysis showed the proclination of both maxillary and mandibular incisors (U-1 to FH = 116.08, L-1 to MP = 108.08) and SNA–SNB difference was 10.08. Radiographic examination revealed sever bone loss at both maxillary and mandibular incisors, at proximal sites of maxillary right and left first molars and a left mandibular
Treatment planning and progress
Prior to starting orthodontic treatment, the patient received periodontal treatment to aim at complete exclusion of the infection source and reduce the deep periodontal pockets to the depth of less than 3 mm. The treatment included scaling and root planing, flap surgery at the site with more than 6 mm of pocket depth and instruction in oral hygiene. After 8 months from first inspection of periodontal treatment, tissue condition was greatly improved as the maxillary incisor pocket depth showed a decrease, from 7 to 1 mm, and at the maxillary left first molar, from 10 to 2 mm, which had been with the most sever attachment loss (Figs. 2B and 3B, Table 2). No bleeding was observed at probing. After periodontal treatment the orthodontic treatment was planned to aim at (1) alignment of the maxillary and mandibular arches to close the space in maxillary incisors and correct the excessive curve of Spee (4.7 mm) and discrepancies in the height of marginal ridges; (2) intrusion of maxillary and mandibular incisors to reduce the overbite; and (3) lingual movement of the maxillary incisors to reduce the overjet. At the patient’s age of 31 years and 2 months, and 6 months after the flap operation, the orthodontic treatment started using multi bracket appliance with .022 slot standard brackets. The sequence of archwires is provided in Table 3. The first molars were continuously ligated with those adjacent second molars and premolars so that the force would not act on the first molars only, and the light depressive forces were applied carefully when intruding the anterior teeth. Anterior teeth also were placed altogether with continuous ligation when retracted, for distributing the force acting on the central incisors with bone loss. During the orthodontic treatment, the patients were given periodontal management including professional mechanical tooth cleaning performed at 3months intervals [6] and when decided necessary. Orthodontic treatment was finished at the age of 32 years and 9 months, and Begg-type retainer for the maxillary arch and fixed-type retainer for the mandibular were applied. Active orthodontic treatment period was 1 year and 7 months.
4.
Treatment results
Post-treatment facial photographs are shown in Fig. 1B. Examination of intraoral photographs (Figs. 2C and 3C) and the cast model showed continuous dental arches, which were
orthodontic waves 65 (2006) 81–87
83
Fig. 2 – Oral photographs (frontal and lateral views): (A) initial (30 years and 9 months); (B) after flap operation (31 years and 2 months); (C) post-active treatment (32 years and 9 months); and (D) 6 years after active treatment (38 years 9 months).
Fig. 3 – Oral photographs (occlusal views of upper and lower dental arch): (A) initial (30 years and 9 months); (B) after flap operation (31 years and 2 months); (C) post-active treatment (32 years and 9 months); and (D) 6 years after active treatment (38 years 9 months).
84
orthodontic waves 65 (2006) 81–87
Fig. 4 – Intraoral radiographs: (A) initial (30 years 9 months); (B) post-active treatment (32 years 9 months); and (C) 6 years after active treatment (38 years 9 months).
functionally, and esthetically adequate, and flat occlusal plane was obtained. Both of the maxillary and mandibular central incisors and first molars remained the pocket depth of 1–2 mm when measured by the same periodontist as the beginning of treatment (Table 4). The super imposition of the lateral cephalometric analysis showed lingual inclination of maxillary incisors and intrusion of mandibular incisors (Fig. 5), and consequently we could obtain the appropriate overbite of 2.0 mm and overjet of 2.5 mm (Table 5). Periodontal tissues together with alveolar bone were in good condition when studying intraoral X-rays, which revealed no further bone destruction (Fig. 4B). It has been 6 years passed since orthodontic treatment was finished. The patient has been under the observation and
periodontal management has been performed every 36 months. Mandibular fixed retainer is still stable and maxillary retainer was worn 24 h for first 2 years and is now voluntarily used as twice a week during night. The patient has good oral condition without any relapse of periodontitis, dental arches and occlusion (Figs. 1C, 2D and 3D). The intraoral X-rays showed no progression of the alveolar bone resorption (Fig. 4C).
5.
Discussion
Periodontitis affected patients in younger age as shown in this case need an improvement of life quality with esthetic and functional management lasting long years [7,8]. Orthodontic
85
orthodontic waves 65 (2006) 81–87
Table 1 – A periodontal chart at the initial examination
CAL means clinical attachment level, and PD means pocket depth. Measuring were done at the mesial, central, and distal site of the buccal and lingual or palatal pocket, respectively. Bleeding was observed on probing the boxed teeth.
aesthetic recovery [9]. Orthodontic treatment also contributed to the promotion of oral health of the patient. The patient was satisfied with this successful outcome of esthetic and functional improvement, which has motivated her to pay careful attention to her oral hygiene. The patient’s high motivation could be the tremendous advantage for the maintenance of good oral condition and also has eased orthodontic and periodontal post-treatment management at regular intervals, which has enabled to remain almost the same good condition during the
treatment of the patient with post-juvenile periodontitis in the present article showed exceptional ability to enhance tooth retention and lead to improved oral hygiene. Reconstruction of occlusion is helpful to maintain the good tissue condition by avoiding traumatic occlusion, which leads to further more bone loss, and by recovering the adequate tight contact. Alignment of crowded or malposed teeth should be a tremendous advantage to clean up all surfaces of the teeth, which is essential care for the periodontitis, and patients, moreover, could also have
Table 2 – A periodontal chart after the flap operation CAL PD Maxilla PD CAL
2 2 7 2 3
CAL PD Mandibula PD CAL
21 22 22 22 3 2 7 2 2
2 2 6 2 3
23 23
22 22 12 13 2 2 6 2 2
21 31
2 2 5 1 1
22 22
12 12 11 12 2 2 5 2 3
12 12
3 2 4 1 1
21 21
12 12 11 11 2 2 4 2 3
11 12
1 1 3 1 1
12 12
11 11 22 23 2 2 3 2 2
12 12
1 1 2 1 1
12 12
12 11 11 13 2 2 2 2 3
12 12
3 1 1 1 1
14 12
13 11 11 13 2 2 1 1 2
12 15
3 1 1 1 3
12 12
11 11 11 11 2 2 1 2 2
12 13
12 12 12 12
1 1 2 1 1
11 11 12 12
3 2 2 2 3
12 12 12 13
2 2 3 2 2
11 11 22 12
2 2 3 2 2
11 11 12 12
1 1 4 2 2 2 1 4 2 2
11 11 12 12 11 11 13 15
1 1 5 2 2
12 11
1 1 5 1 2
11 11
11 11
11 22
2 2 6 1 1
22 21
1 1 6 1 1
11 11
12 12
11 12
3 2 7 2 2
22 22
1 1 7 2 3
23 22
22 22
22 33
CAL means clinical attachment level, and PD means pocket depth. Measuring were done at the mesial, central, and distal site of the buccal and lingual or palatal pocket, respectively. No bleeding was observed.
Table 3 – A periodontal chart after orthodontic treatment CAL PD Maxilla PD CAL CAL PD Mandibula PD CAL
2 2 7 2 3
12 12 21 21 3 3 7 2 3
21 22 21 21
2 2 6 2 3
12 12 11 22 2 2 6 1 1
21 22 11 11
1 1 5 1 2
11 11 11 12 1 1 5 1 2
11 11 12 13
2 2 4 1 3
11 11 11 11 2 2 4 2 2
12 12 12 12
1 1 3 1 1
11 11 11 11 2 2 3 1 1
11 11 12 12
1 1 2 1 1
12 11 11 13 1 1 2 1 1
12 11 11 15
3 1 1 1 1
13 11 11 13 1 1 1 1 2
11 11 11 12
3 1 1 1 5
11 11 11 11 2 2 1 1 1
11 11 11 11
1 1 2 1 3
11 11 11 11
1 1 2 1 3
12 12 11 23
1 1 3 1 1
11 11 11 11
2 1 3 1 2
12 11 12 12
2 1 4 2 3 3 2 4 2 3
12 12 12 12 12 12 11 13
3 2 5 1 1
12 12
2 2 5 1 2
12 12
11 11
12 23
1 1 6 1 1
14 12
2 2 6 1 2
22 22
11 11
11 22
3 1 7 2 2
12 12
2 2 7 2 3
23 23
22 22
23 34
CAL means clinical attachment level, and PD means pocket depth. Measuring were done at the mesial, central, and distal site of the buccal and lingual or palatal pocket, respectively. No bleeding was observed.
86
orthodontic waves 65 (2006) 81–87
Table 4 – Archwire sequence Maxillary Leveling
Intrusion of the incisors Canine retraction Anterior retraction Finishing Mandibular Leveling
Intrusion of the incisors Finishing
.0175 respond .014 Niti .016 SS .018 SS and .016 .022 utility .018 SS .017 .025 SS .018 .025 SS
.0175 respond .014 Niti .016 SS .016 SS and .016 .022 utility .018 SS and .016 .022 utility .018 .025 SS
long observation period. Orthodontic treatment is a potent alternative modality after periodontal treatment instead of the other modalities such as temporary or permanent fixation and prosthodontic treatment. In the treatment of patients with periodontitis, there have been indicated several considerations. Several reports have suggested that orthodontic force can have negative effects such as accurate loss of attachment and further bone destruction when periodontal inflammation is present [10,11]. An experimental study has also shown that regeneration of the periodontal ligament does not occur in the tissue with inflammation and [12] that degenerated tissues produced in the pressure side of tooth movement are defenseless to the bacterial infection [13]. On the other hand, force acting on tooth causes no further breakdown with absence of inflammation [14]. Therefore, it is essential to eliminate inflammation of periodontal tissues prior to orthodontic treatment. In this case, an intensive care was
Fig. 5 – Superimposition of pretreatment (30 years and 9 months; black line), post-active treatment (32 years and 9 months; dashed line) and 6 years after active treatment (38 years and 9 months: long dashed line): (A) superimposed on the SN plane at S; (B) superimposed on the Palatal Plane at PNS; and (C) superimposed on the Mandibular Plane at Me. Little difference was seen between post-active treatment and after 6 years of the treatment.
Table 5 – Cephalometric measurements
SNA (8) SNB (8) ANB (8) Go A (8) Mp-FH (8) U1 to FH (8) L1 to Mp (8) Interincisal (8) A’-Ptm’ (mm) Gn-Cd (mm) Is-Is’ (mm) Ii-Ii’ (mm) Overjet (mm) Overbite (mm) Curve of Spee (mm)
Pre-treatment (30 years 9 months)
Post-treatment (32 years 9 months)
Six years after (38 years 9 months)
82.7 72.7 10.0 122.0 33.0 116.0 108.0 102.5 52.5 112.0 36.0 51.0 8.0 5.0 4.7
82.0 72.5 9.5 122.0 31.5 100.5 108.0 120.0 51.5 112.0 36.0 48.0 2.0 2.5 0.9
82.6 72.7 9.3 121.8 32.0 100.0 108.9 121.0 51.4 112.0 36.0 48.0 2.0 2.5 1.0
orthodontic waves 65 (2006) 81–87
made to recover the periodontal environment with no inflammation before the orthodontic treatment, closely to its normal circumstance so that the tissue response could be the same as that in normal periodontal tissues free from infections. In order to eliminate the source of the infection, excluding deep pockets to the extent of 3 mm by scaling, root planing and flap operation, were performed prior to the orthodontic treatment, and also elimination of subgingival calculus and plaque were performed throughout the orthodontic treatment. As a result, healthy periodontal condition was maintained during orthodontic treatment in cooperation with the periodontist, suggesting that the multidisciplinary management of orthodontists and periodontists should be an ideal approach. As a result, there was no bone loss in the areas of first molars during the orthodontic treatment. It is also very essential to continuously eliminate subgingival calculus and plaque, the source of the infection throughout the treatment. The patient has obtained long favorable stability both in periodontics and orthodontics. Good periodontal condition with healthy gingival tissue and continuous dental arch with normal overbite and overjet have been maintained for 6 years since the orthodontic treatment was completed. The cephalometric analysis showed little changes in dental arch. This long-term stability is due to not only the improvement of periodontal tissues, occlusion and arches, but also patient’s motivation of oral hygiene and possibly, patient’s compliance to use the retainer. The mandibular fixed retainer prevents the relapse of mandibular curve of spee and it may restrain the maxillary incisors from the excessive occlusal pressure. This may also be the reason for this long-term stability. In this case, we planned to intrude maxillary incisors for improving the deep bite and applied the light depressive forces carefully, because large forces could negatively affect the periodontal membrane [15]. The appropriate overbite, however, was obtained due to the intrusion of mandibular incisors. This indicates that intruding the maxillary incisors with alveolar bone loss may be difficult and we should consider the skeletal anchorage in such cases. In summary, orthodontic treatment with systematic approach, is a very helpful mean to prevent the recurrence of periodontitis by means of not only acquiring good oral environment, but also winning of patient’s high motivation to oral health by recovering the esthetics and it provides better quality of life.
Acknowledgement We thank Prof. Takashi Arai, Department of Periodontics, School of Dental Medicine, Tsurumi University for his review of our manuscript.
87
references
[1] Ong MMA, Wang H-L. Periodontal and orthodontic treatment in adults. Am J Orthod Dentofacial Orthop 2002;122:420–8. [2] Towfighi PP, Brunsvold MA, Storey AT, Arnold RM, William DE, McMahan CA. Pathologic migration of anterior teeth in patients with moderate to severe periodontitis. J Periodontol 1997;68:967–72. [3] Kaufman H, Carranza Jr FA, Endres B, Newman MG, Murphy N. The influence of trauma from occlusion on the bacterial repopulation of periodontal pockets in dogs. J Periodontol 1984;55:86–92. [4] Armitage GC. Development of a classification system for periodontal diseases and conditions. Ann Periodontol 1999;4:1–6. [5] Nagy RJ, Carranza FA, Newman MG. Aggressive periodontitis. In: Newman MG, Takei HH, Carranza FA, editors. Carranza’s clinical periodontology. 9th ed., Philadelphia, London: W.B. Saunders; 2002. p. 409–13. [6] Boyd RL. Mucogingival considerations and their relationship to orthodontics. J Periodontol 1978;49: 67–76. [7] Needleman I, McGrath C, Floyd P, Biddle A. Impact of oral health on the life quality of periodontal patients. J Clin Periodontol 2004;31:454–7. [8] Klages U, Bruckner A, Zentner A. Dental aesthetics, selfawareness, and oral health-related quality of life in young adults. Eur J Orthod 2004;26:507–14. [9] Re S, Corrente G, Abundo R, Cardaropoli D. Orthodontic treatment in periodontally compromised patients: 12-year report. Int J Periodontics Restoractive Dent 2000;20: 31–9. [10] Lindhe J, Svanberg G. Influence of trauma from occlusion on progression of experimental periodontitis in the beagle dog. J Clin Periodontol 1974;1:3–14. [11] Wennstrom JL, Stokland BL, Nyman S, Thilander B. Periodontal tissue response to orthodontic movement of teeth with infrabony pockets. Am J Orthod Dentofacial Orthop 1993;103:313–9. [12] Ericsson I, Thilander B, Lindhe J, Okamoto H. The effect of orthodontic tilting movements on the periodontal tissues of infected and non-infected dentitions in dogs. J Clin Periodontol 1977;4:278–93. [13] Nakamura Y, Tanaka T, Noda K, Shimpo S, Oikawa T, Hirashita A, et al. Calcification of degenerating tissues in the periodontal ligament during tooth movement. J Periodont Res 2003;38:343–50. [14] Polson A, Caton J, Polson AP, Nyman S, Novak J, Reed B. Periodontal response after tooth movement into infrabony defects. J Periodontol 1984;55:197–202. [15] 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.
available at www.sciencedirect.com
journal homepage: www.elsevier.com/locate/odw
Case report
Orthodontic contribution to the periodontal management of a patient with localized aggressive periodontitis (post-juvenile periodontitis) Tomoko Ogino a,*, Yoshiki Nakamura a, Kazuhiro Gomi b, Ayao Hirashita a a b
Department of Orthodontics, School of Dental Medicine, Tsurumi University, 2-1-3 Tsurumi, Tsurumiku, Yokohama, Japan Department of Periodontics, Tsurumi University, Japan
article info
abstract
Article history:
In aggressive periodontitis, pathological tooth migration and destruction of occlusion often
Received 20 December 2005
occur in patients’ younger age, therefore, it is necessary to give a treatment considering their
Accepted 20 February 2006
quality of life.
Published on line 15 May 2006
A 30-year-old female patient diagnosed as Angle class I upper protrusion associated with post-juvenile periodontitis had diastema of maxillary incisors since she was about 20 years
Keywords:
old. She was treated by multidisciplinary approach of a periodontist and an orthodontist and
Aggressive periodontitis
patients obtained esthetical dental arch and functional occlusion. Periodontal tissue was
Orthodontic treatment
also in good condition and she was very satisfied with the outcome. The patient has
Periodontal treatment
obtained periodontal and orthodontic long favorable stability. Good periodontal condition
Long-term stability
has been maintained for 6 years after active orthodontic treatment.
Quality of life
1.
# 2006 Elsevier Ltd and the Japanese Orthodontic Society. All rights reserved.
Introduction
In advanced periodontal disease, spacing of anterior segments combined with proclination of maxillary incisors and deep bite often occurs [1,2]. Once this malalignment has been occurred, the traumatic occlusion could cause further breakdown [3] of the periodontal tissue and also it would make brushing procedure very difficult and would fail to remove plaque as to maintain oral hygiene, therefore, it seems that this situation fails into the negative spiral in periodontal destruction. As far as juvenile periodontitis is concerned, which is now called localized or generalized aggressive periodontitis [4], progress of lesion is very rapid as it is formally known as the early onset periodontitis [5] and the conditions described above occur in the early stage. Reconstruction of the occlusion and alignment of the malposed teeth with orthodontic
treatment should be necessary not only to prevent the further progress of disease, but also to satisfy the patients’ functional and esthetic demands, especially for young patients. The present article shows the result of treatment using multidisciplinary approach of orthodontic and periodontal management to the patient with destruction of occlusion and malposition of anterior segments caused by post-juvenile periodontitis, who showed the long-term stability of reconstructed occlusion and good periodontal condition.
2.
Case report
A patient was referred from a periodontist to consult about the possibility of orthodontic treatment. The patient was a 30year-old female and her chief complaint was maxillary incisor
* Corresponding author. Tel.: +81 45 581 1001x8383; fax: +81 45 582 8868. E-mail addresses: [email protected], [email protected] (T. Ogino). 1344-0241/$ – see front matter # 2006 Elsevier Ltd and the Japanese Orthodontic Society. All rights reserved. doi:10.1016/j.odw.2006.02.002
82
orthodontic waves 65 (2006) 81–87
first molar, and also both proximal and distal site of a right maxillary first molar (Fig. 4A). Pocket probing also proved the attachment loss for measured 10 mm at the mesiobuccal site of a maxillary left molar as the deepest and 6–7 mm at the proximal sites of maxillary incisors. Mandibular molars also had deep probing depth as 6 mm at the proximal sites of the left first molar and 6 mm at the distolingual site of the right first molar (Table 1). For all of the above, the patient was diagnosed as Angle class I maxillary protrusion associated with post-juvenile periodontitis and treatment plan was decided with consideration of the approach to both periodontitis and malocclusion.
3.
Fig. 1 – Facial photographs: (A) initial (30 years 9 months); (B) post-active treatment (32 years 9 months); and (C) 6 years after active treatment (38 years 9 months).
spacing and protrusion. Gingival inflammation had occurred in her earlier age and incisor spacing has been present since she was about 20 years old. The patient displayed a profile of convexity (Fig. 1A). Dental examination showed 5.0 mm of overbite and 8.0 mm of overjet combined with 4 mm of diastema in maxillary incisors and slight crowding of mandibular incisors (Figs. 2A and 3A). There were non-appropriate contacts because of slight rotations at right mandibular premolars. The molar relationship was Angle class I. Lateral cephalometric analysis showed the proclination of both maxillary and mandibular incisors (U-1 to FH = 116.08, L-1 to MP = 108.08) and SNA–SNB difference was 10.08. Radiographic examination revealed sever bone loss at both maxillary and mandibular incisors, at proximal sites of maxillary right and left first molars and a left mandibular
Treatment planning and progress
Prior to starting orthodontic treatment, the patient received periodontal treatment to aim at complete exclusion of the infection source and reduce the deep periodontal pockets to the depth of less than 3 mm. The treatment included scaling and root planing, flap surgery at the site with more than 6 mm of pocket depth and instruction in oral hygiene. After 8 months from first inspection of periodontal treatment, tissue condition was greatly improved as the maxillary incisor pocket depth showed a decrease, from 7 to 1 mm, and at the maxillary left first molar, from 10 to 2 mm, which had been with the most sever attachment loss (Figs. 2B and 3B, Table 2). No bleeding was observed at probing. After periodontal treatment the orthodontic treatment was planned to aim at (1) alignment of the maxillary and mandibular arches to close the space in maxillary incisors and correct the excessive curve of Spee (4.7 mm) and discrepancies in the height of marginal ridges; (2) intrusion of maxillary and mandibular incisors to reduce the overbite; and (3) lingual movement of the maxillary incisors to reduce the overjet. At the patient’s age of 31 years and 2 months, and 6 months after the flap operation, the orthodontic treatment started using multi bracket appliance with .022 slot standard brackets. The sequence of archwires is provided in Table 3. The first molars were continuously ligated with those adjacent second molars and premolars so that the force would not act on the first molars only, and the light depressive forces were applied carefully when intruding the anterior teeth. Anterior teeth also were placed altogether with continuous ligation when retracted, for distributing the force acting on the central incisors with bone loss. During the orthodontic treatment, the patients were given periodontal management including professional mechanical tooth cleaning performed at 3months intervals [6] and when decided necessary. Orthodontic treatment was finished at the age of 32 years and 9 months, and Begg-type retainer for the maxillary arch and fixed-type retainer for the mandibular were applied. Active orthodontic treatment period was 1 year and 7 months.
4.
Treatment results
Post-treatment facial photographs are shown in Fig. 1B. Examination of intraoral photographs (Figs. 2C and 3C) and the cast model showed continuous dental arches, which were
orthodontic waves 65 (2006) 81–87
83
Fig. 2 – Oral photographs (frontal and lateral views): (A) initial (30 years and 9 months); (B) after flap operation (31 years and 2 months); (C) post-active treatment (32 years and 9 months); and (D) 6 years after active treatment (38 years 9 months).
Fig. 3 – Oral photographs (occlusal views of upper and lower dental arch): (A) initial (30 years and 9 months); (B) after flap operation (31 years and 2 months); (C) post-active treatment (32 years and 9 months); and (D) 6 years after active treatment (38 years 9 months).
84
orthodontic waves 65 (2006) 81–87
Fig. 4 – Intraoral radiographs: (A) initial (30 years 9 months); (B) post-active treatment (32 years 9 months); and (C) 6 years after active treatment (38 years 9 months).
functionally, and esthetically adequate, and flat occlusal plane was obtained. Both of the maxillary and mandibular central incisors and first molars remained the pocket depth of 1–2 mm when measured by the same periodontist as the beginning of treatment (Table 4). The super imposition of the lateral cephalometric analysis showed lingual inclination of maxillary incisors and intrusion of mandibular incisors (Fig. 5), and consequently we could obtain the appropriate overbite of 2.0 mm and overjet of 2.5 mm (Table 5). Periodontal tissues together with alveolar bone were in good condition when studying intraoral X-rays, which revealed no further bone destruction (Fig. 4B). It has been 6 years passed since orthodontic treatment was finished. The patient has been under the observation and
periodontal management has been performed every 36 months. Mandibular fixed retainer is still stable and maxillary retainer was worn 24 h for first 2 years and is now voluntarily used as twice a week during night. The patient has good oral condition without any relapse of periodontitis, dental arches and occlusion (Figs. 1C, 2D and 3D). The intraoral X-rays showed no progression of the alveolar bone resorption (Fig. 4C).
5.
Discussion
Periodontitis affected patients in younger age as shown in this case need an improvement of life quality with esthetic and functional management lasting long years [7,8]. Orthodontic
85
orthodontic waves 65 (2006) 81–87
Table 1 – A periodontal chart at the initial examination
CAL means clinical attachment level, and PD means pocket depth. Measuring were done at the mesial, central, and distal site of the buccal and lingual or palatal pocket, respectively. Bleeding was observed on probing the boxed teeth.
aesthetic recovery [9]. Orthodontic treatment also contributed to the promotion of oral health of the patient. The patient was satisfied with this successful outcome of esthetic and functional improvement, which has motivated her to pay careful attention to her oral hygiene. The patient’s high motivation could be the tremendous advantage for the maintenance of good oral condition and also has eased orthodontic and periodontal post-treatment management at regular intervals, which has enabled to remain almost the same good condition during the
treatment of the patient with post-juvenile periodontitis in the present article showed exceptional ability to enhance tooth retention and lead to improved oral hygiene. Reconstruction of occlusion is helpful to maintain the good tissue condition by avoiding traumatic occlusion, which leads to further more bone loss, and by recovering the adequate tight contact. Alignment of crowded or malposed teeth should be a tremendous advantage to clean up all surfaces of the teeth, which is essential care for the periodontitis, and patients, moreover, could also have
Table 2 – A periodontal chart after the flap operation CAL PD Maxilla PD CAL
2 2 7 2 3
CAL PD Mandibula PD CAL
21 22 22 22 3 2 7 2 2
2 2 6 2 3
23 23
22 22 12 13 2 2 6 2 2
21 31
2 2 5 1 1
22 22
12 12 11 12 2 2 5 2 3
12 12
3 2 4 1 1
21 21
12 12 11 11 2 2 4 2 3
11 12
1 1 3 1 1
12 12
11 11 22 23 2 2 3 2 2
12 12
1 1 2 1 1
12 12
12 11 11 13 2 2 2 2 3
12 12
3 1 1 1 1
14 12
13 11 11 13 2 2 1 1 2
12 15
3 1 1 1 3
12 12
11 11 11 11 2 2 1 2 2
12 13
12 12 12 12
1 1 2 1 1
11 11 12 12
3 2 2 2 3
12 12 12 13
2 2 3 2 2
11 11 22 12
2 2 3 2 2
11 11 12 12
1 1 4 2 2 2 1 4 2 2
11 11 12 12 11 11 13 15
1 1 5 2 2
12 11
1 1 5 1 2
11 11
11 11
11 22
2 2 6 1 1
22 21
1 1 6 1 1
11 11
12 12
11 12
3 2 7 2 2
22 22
1 1 7 2 3
23 22
22 22
22 33
CAL means clinical attachment level, and PD means pocket depth. Measuring were done at the mesial, central, and distal site of the buccal and lingual or palatal pocket, respectively. No bleeding was observed.
Table 3 – A periodontal chart after orthodontic treatment CAL PD Maxilla PD CAL CAL PD Mandibula PD CAL
2 2 7 2 3
12 12 21 21 3 3 7 2 3
21 22 21 21
2 2 6 2 3
12 12 11 22 2 2 6 1 1
21 22 11 11
1 1 5 1 2
11 11 11 12 1 1 5 1 2
11 11 12 13
2 2 4 1 3
11 11 11 11 2 2 4 2 2
12 12 12 12
1 1 3 1 1
11 11 11 11 2 2 3 1 1
11 11 12 12
1 1 2 1 1
12 11 11 13 1 1 2 1 1
12 11 11 15
3 1 1 1 1
13 11 11 13 1 1 1 1 2
11 11 11 12
3 1 1 1 5
11 11 11 11 2 2 1 1 1
11 11 11 11
1 1 2 1 3
11 11 11 11
1 1 2 1 3
12 12 11 23
1 1 3 1 1
11 11 11 11
2 1 3 1 2
12 11 12 12
2 1 4 2 3 3 2 4 2 3
12 12 12 12 12 12 11 13
3 2 5 1 1
12 12
2 2 5 1 2
12 12
11 11
12 23
1 1 6 1 1
14 12
2 2 6 1 2
22 22
11 11
11 22
3 1 7 2 2
12 12
2 2 7 2 3
23 23
22 22
23 34
CAL means clinical attachment level, and PD means pocket depth. Measuring were done at the mesial, central, and distal site of the buccal and lingual or palatal pocket, respectively. No bleeding was observed.
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orthodontic waves 65 (2006) 81–87
Table 4 – Archwire sequence Maxillary Leveling
Intrusion of the incisors Canine retraction Anterior retraction Finishing Mandibular Leveling
Intrusion of the incisors Finishing
.0175 respond .014 Niti .016 SS .018 SS and .016 .022 utility .018 SS .017 .025 SS .018 .025 SS
.0175 respond .014 Niti .016 SS .016 SS and .016 .022 utility .018 SS and .016 .022 utility .018 .025 SS
long observation period. Orthodontic treatment is a potent alternative modality after periodontal treatment instead of the other modalities such as temporary or permanent fixation and prosthodontic treatment. In the treatment of patients with periodontitis, there have been indicated several considerations. Several reports have suggested that orthodontic force can have negative effects such as accurate loss of attachment and further bone destruction when periodontal inflammation is present [10,11]. An experimental study has also shown that regeneration of the periodontal ligament does not occur in the tissue with inflammation and [12] that degenerated tissues produced in the pressure side of tooth movement are defenseless to the bacterial infection [13]. On the other hand, force acting on tooth causes no further breakdown with absence of inflammation [14]. Therefore, it is essential to eliminate inflammation of periodontal tissues prior to orthodontic treatment. In this case, an intensive care was
Fig. 5 – Superimposition of pretreatment (30 years and 9 months; black line), post-active treatment (32 years and 9 months; dashed line) and 6 years after active treatment (38 years and 9 months: long dashed line): (A) superimposed on the SN plane at S; (B) superimposed on the Palatal Plane at PNS; and (C) superimposed on the Mandibular Plane at Me. Little difference was seen between post-active treatment and after 6 years of the treatment.
Table 5 – Cephalometric measurements
SNA (8) SNB (8) ANB (8) Go A (8) Mp-FH (8) U1 to FH (8) L1 to Mp (8) Interincisal (8) A’-Ptm’ (mm) Gn-Cd (mm) Is-Is’ (mm) Ii-Ii’ (mm) Overjet (mm) Overbite (mm) Curve of Spee (mm)
Pre-treatment (30 years 9 months)
Post-treatment (32 years 9 months)
Six years after (38 years 9 months)
82.7 72.7 10.0 122.0 33.0 116.0 108.0 102.5 52.5 112.0 36.0 51.0 8.0 5.0 4.7
82.0 72.5 9.5 122.0 31.5 100.5 108.0 120.0 51.5 112.0 36.0 48.0 2.0 2.5 0.9
82.6 72.7 9.3 121.8 32.0 100.0 108.9 121.0 51.4 112.0 36.0 48.0 2.0 2.5 1.0
orthodontic waves 65 (2006) 81–87
made to recover the periodontal environment with no inflammation before the orthodontic treatment, closely to its normal circumstance so that the tissue response could be the same as that in normal periodontal tissues free from infections. In order to eliminate the source of the infection, excluding deep pockets to the extent of 3 mm by scaling, root planing and flap operation, were performed prior to the orthodontic treatment, and also elimination of subgingival calculus and plaque were performed throughout the orthodontic treatment. As a result, healthy periodontal condition was maintained during orthodontic treatment in cooperation with the periodontist, suggesting that the multidisciplinary management of orthodontists and periodontists should be an ideal approach. As a result, there was no bone loss in the areas of first molars during the orthodontic treatment. It is also very essential to continuously eliminate subgingival calculus and plaque, the source of the infection throughout the treatment. The patient has obtained long favorable stability both in periodontics and orthodontics. Good periodontal condition with healthy gingival tissue and continuous dental arch with normal overbite and overjet have been maintained for 6 years since the orthodontic treatment was completed. The cephalometric analysis showed little changes in dental arch. This long-term stability is due to not only the improvement of periodontal tissues, occlusion and arches, but also patient’s motivation of oral hygiene and possibly, patient’s compliance to use the retainer. The mandibular fixed retainer prevents the relapse of mandibular curve of spee and it may restrain the maxillary incisors from the excessive occlusal pressure. This may also be the reason for this long-term stability. In this case, we planned to intrude maxillary incisors for improving the deep bite and applied the light depressive forces carefully, because large forces could negatively affect the periodontal membrane [15]. The appropriate overbite, however, was obtained due to the intrusion of mandibular incisors. This indicates that intruding the maxillary incisors with alveolar bone loss may be difficult and we should consider the skeletal anchorage in such cases. In summary, orthodontic treatment with systematic approach, is a very helpful mean to prevent the recurrence of periodontitis by means of not only acquiring good oral environment, but also winning of patient’s high motivation to oral health by recovering the esthetics and it provides better quality of life.
Acknowledgement We thank Prof. Takashi Arai, Department of Periodontics, School of Dental Medicine, Tsurumi University for his review of our manuscript.
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