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Orthodontic treatment of periodontal defects. Part II: a systematic review on human and animal studies
progress in orthodontics 1 2 ( 2 0 1 1 ) 45–52
available at www.sciencedirect.com
journal homepage: www.elsevier.com/locate/pio
Review
Orthodontic treatment of periodontal defects. Part II: a systematic review on human and animal studies Roberto Rotundo a,∗ , Turi Bassarelli b , Elettra Pace a , Gloria Iachetti a , Jana Mervelt a , Giovanpaolo Pini Prato a a b
Department of Periodontology, University of Florence, Italy Private Practice, Prato, Italy
a r t i c l e
i n f o
a b s t r a c t
Article history:
Several studies have been published focusing on the possibility to treat patients affected by
Received 30 January 2011
periodontal defects by means of orthodontic treatment. The aim of this systematic review is
Accepted 4 February 2011
to evaluate the efficacy of the orthodontic treatment applied to the therapy of infraosseous defects, gingival recessions, and furcation lesions. An electronic and a manual search were
Keywords:
performed based on a PICO assessment worksheet. Both human and animal studies were
Furcation defect
selected for this review. The electronic search (from January 1966 to December 2009) and
Gingival recession
the hand search (from January 1988 to December 2009) were conducted by 3 independent
Infrabony/intrabony/angular defect
reviewers.
Orthodontics
A total of 197 articles were found and only 29 were considered eligible for this review. In
Systematic review
particular, 22 studies dealing with infrabony defects, 1 gingival recession, and 6 furcation
Therapy
defect treatments. Due to the weak evidence and the controversial and unclear results, it appears important to encourage the researchers to produce Randomized Controlled clinical Trials aimed to investigate the efficacy of the orthodontic treatment for the correction of periodontal defects. © 2011 Società Italiana di Ortodonzia SIDO. Published by Elsevier Srl. All rights reserved.
1.
Introduction
It has been clearly observed that periodontitis determines defects that involve alveolar bone and soft tissues, such as infrabony / suprabony defects, furcation lesions, and gingival recessions.1 Several non-surgical and surgical periodontal techniques have been developed showing optimal clinical outcomes based on the reconstruction of the infrabony defects, the stability of the surrounding treated area in correspondence of furcation defects, and the reconstruction of the mucogingival tissues around gingival recessions.2–5
∗
On the other hand, some case report studies6–9 and personal opinions made by specialist leaders have reported the possibility to treat periodontal defects using orthodontic therapy in combination with periodontal therapy in patients with tooth malpositions. It is well known that in totally healthy or reduced periodontium orthodontic tooth movement does not produce detrimental effects.10–13 The osteogenic potential of the orthodontic tooth movement results in the development of pressure and tension zones within the marginal and apical parts of the periodontium, with a consequent bone resorption and bone apposition. This biological process might positively influence the healing of the periodontal defects. However, a
Corresponding author. Via Vasco De’ Gama 33/3 - 50127, Florence, Italy. E-mail address: roberto.rotundo@unifi.it (R. Rotundo). 1723-7785/$ – see front matter © 2011 Società Italiana di Ortodonzia SIDO. Published by Elsevier Srl. All rights reserved. doi:10.1016/j.pio.2011.02.008
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Table 1 – Results from electronic and manual search (total number of studies) detailed for each periodontal defect DEFECTS (total number)
ELECTRONIC SEARCH
MANUAL SEARCH
INFRABONY DEFECTS (33) GINGIVAL RECESSION (144) FURCATION DEFECTS (20)
20 143 19
13 1 1
recent systematic review14 reported that, based on a reduced number of eligible studies, orthodontic therapy results in any case in small detrimental effects to the healthy periodontium. On the contrary, orthodontic tooth movements might cause further loss of connective attachment in sites with periodontal inflammation. In fact, the position of the plaque-induced lesion is shifted from a suprabony to an infrabony position when orthodontic forces produce tipping or intrusion of a tooth into the alveolar bone. Under these conditions, an enhanced rate of periodontal destruction is observed.10 A recent systematic review by Rotundo et al.15 carried out on clinical trials dealing with orthodontic treatment of periodontal defects reported that no systematic reviews, randomized or not-randomized controlled trials were identified and, as a consequence, no meta-analysis was possible to be performed. Therefore, to verify if the beneficial effect of the orthodontic therapy to treat infraosseous defects, gingival recessions, and furcation lesions was observed in other studies with different methodologies (case series or case reports) and / or different experimental units (animals or humans), a broader systematic review of the literature following the PRISMA statement was performed.
2.
Materials and methods
2.1.
Inclusion Criteria and Outcome Measures
This review was accomplished following the PRISMA (Preferred Reporting Items for Systematic reviews and Metaanalysis) statement aimed to help authors report a wide array of systematic reviews to assess the benefits and harms of health care interventions.16,17 However, for this systematic review of the literature, the types of studies included were not only Systematic Reviews (SR), Randomized Controlled Trials (RCTs), Controlled Clinical Trials (CCT), but also Case Series (CS), Case Reports (CR) and Animal Studies (AS). The comparative interventions considered eligible for this review were Orthodontic Treatment versus Periodontal Therapy; Orthodontic Treatment plus Periodontal Therapy versus Periodontal Therapy alone; Orthodontic Treatment versus Orthodontic Treatment; Orthodontic Treatment alone.
2.2.
Search strategy
Two searching strategies were adopted for this review: electronic and hand-search. The electronic search utilized were Medline (Pubmed) and all the Cochrane Library databases that include Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of effects, Cochrane Central Register of Controlled Trials, Cochrane Methodology Register, Health
Technology Assessment Database, NHS Economic Evaluation Database, all the Cochrane Groups. There was no language restriction. The period investigated was from January 1966 to December 2009 and the following terms were searched: • “Orthodontics”[MeSH] AND “therapy”[Subheading] AND “Gingival Recession”[MeSH] • “Orthodontics”[MeSH] AND “therapy”[Subheading] AND “Furcation Defects”[MeSH] • “Orthodontics”[MeSH] AND “therapy”[Subheading] AND “Intrabony Defect” “[All Fields] • “Orthodontics”[MeSH] AND “therapy”[Subheading] AND “Infrabony Defect” “[All Fields] • “Orthodontics”[MeSH] AND “therapy”[Subheading] AND “Infraosseous Defect” “[All Fields] • “Orthodontics”[MeSH] AND “therapy”[Subheading] AND “Intraosseous Defect” “[All Fields] • “Orthodontics”[MeSH] AND “therapy”[Subheading] AND “Angular Defect” “[All Fields] For the period from January 1988 to December 2009, the following journals were manually searched: Journal of Periodontology, Journal of Clinical Periodontology, International Journal of Periodontics and Restorative Dentistry, American Journal of Orthodontics and Dentofacial Orthopedics, The Angle Orthodontist, European Journal of Orthodontics. Other studies could be collected reviewing the reference lists of each article. The titles and abstracts (when available) of articles searched manually were scanned independently by three blinded examiners (G.I., J.M., E.P.) by means of a cross-over method. The titles and abstracts (when available) of articles searched electronically were scanned independently by a third examiner (R.R.).
3.
Results
The manual and electronic search retrieved initially a total of 197 articles: 33 articles for infrabony defects (20 electronic and 13 manual), 144 articles for gingival recessions (143 electronic and 1 manual), and 20 articles for furcation defects (19 electronic and 1 manual) (Table 1). After examining the titles, abstracts, and full text and eliminating the editorials, opinion based articles / interviews and case reports without numeric results only 29 studies were chosen for this review (Fig. 1). In particular, 22 studies (7 on animal models and 15 on humans) dealing with infrabony defects therapies were selected while only 1 (on humans) out of 144 articles and 6 (4 on humans and 2 on animal models) out of 21 articles were selected dealing with gingival recession and furcation defect treatments, respectively. From a methodological point of view, the found articles were 4 Case Series, 16 Case Reports and 9 Animal Studies (Table 2).
47
182 records identified through database searching
15 additional records identified through manual searching
197 after duplicates removed
Screening
Identification
progress in orthodontics 1 2 ( 2 0 1 1 ) 45–52
Eligibility
197 records screened
166 records excluded
Included
31 full-text articles assessed for eligibility
2 full-text articles excluded (treatment of different periodontal defects)
29 studies included in qualitative synthesis
0 studies included in quantitative synthesis (metaanalysis due to the lacking of SR and RCT)
Figure 1 – PRISMA flow diagram. Table 2 – Methodology of the studies included in the final qualitative analysis DEFECTS INFRABONY DEFECTS GINGIVAL RECESSION FURCATION DEFECTS
4.
SR 0 0 0
RCT 0 0 0
Discussion
The results will be discussed in relation to the single type of defect.
4.1.
Infrabony defects
Infrabony defects are defined when the bottom of the pocket results more apical than the alveolar bone crest. During the orthodontic treatment and after the resolution of inflammation, the theoretical changes in osseous topography may be accomplished by moving teeth into an infraosseous defect, teeth extrusion or uprighting and teeth intrusion.
4.1.1.
Animal studies
The effect of the bodily movement of teeth into infrabony periodontal defects has been evaluated in experimental animal studies. Polson et al.12 observed in 4 monkeys that if
CCT
CS
CR
ANIMAL STUDY
0 0 0
2 1 1
13 0 3
7 0 2
periodontal treatment was performed before the orthodontic tooth movement was started, and the monkeys were subjected to plaque control measures during the entire course of the experiment, the angular bony defects were eliminated and no deleterious effect was detected on the level of the connective tissue attachment. However, no regeneration of the supporting apparatus was observed. Similar conclusions were reported in other animal model studies on rats and dogs.18,19 On contrary, Geraci and coworkers20 demonstrated the formation of a new connective tissue attachment to a root surface previously exposed to periodontal disease when moving a tooth into an artificially produced infrabony lesion in two monkeys. In case where inflamed infrabony pockets were orthodontically treated, Wennström and coworkers21 reported in a study on dogs that orthodontic therapy involving bodily tooth movement may enhance the rate of destruction of the connective tissue attachment.
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Orthodontic elimination of an infrabony pocket by tooth extrusion has shown a maintained relationship between the cemento-enamel junction and the bone crest in a study performed on 5 beagle dogs.22 In fact, the bone followed the tooth during the extrusion movement because of the elongation of the periodontal fiber bundles. In contrast, teeth subjected to extrusion with concomitant fiberotomy, the crestal part of the alveolar bone did not follow the root during the extrusion. Consequently, the root movement resulted in an increased distance between the cemento-enamel junction and the alveolar bone crest with an improvement in the crown-to-root ratio. On the same animal model, VanVenrooy and coworkers23 evaluated the orthodontic extrusion of teeth with advanced periodontal disease. Results showed that control teeth (with periodontal disease alone) maintained their position with evident signs of advanced periodontitis. Experimental teeth (with periodontal lesions and orthodontic extrusive forces) had shallower pocket depths, less gingival inflammation, and no bleeding on probing. The improved periodontal condition resulting from orthodontic extrusion may have been due to both physiologic and microbiologic changes in the local environment of the teeth. The shallower sulcus depth may reflect a peeling away of the sulcular and junctional epithelium as proposed by Atherton and Kerr.24 In addition, the subgingival microbial plaque may have been converted to a supragingival plaque by the extrusive tooth movement, thereby lessening its pathogenicity and effect on the gingival tissue. Intrusion has been regarded as a very controversial topic in the orthodontic literature and no studies were identified dealing with treatment of infrabony defects. However, Melsen25 in an animal study conducted on 3 Macaca fascicularis analyzed the reaction of the periodontal tissues to intrusion of teeth and evaluated the influence of oral hygiene on the observed reactions using a split-mouth design. Histological analyses showed a significant difference of the marginal bone in the two experimental sides. On the hygiene side, clear signs of bone deposited during forced eruption were still present. This was not observed on the non-hygiene side. The extension of bone resorption was also different on the two sides. On the hygiene side, only the periodontal side of the alveolar bone was subject to resorption, whereas on the other group of teeth, the gingival margin was also destroyed. Based on these results, it can be concluded that intrusion of teeth does not result in a decrease of the marginal bone level provided the gingival inflammation is kept to a minimum. The same investigating group by Melsen and coworkers26 performed another animal study to investigate the tissue reaction related to orthodontic intrusion of teeth with a reduced periodontium and further to evaluate the influence of oral hygiene on this reaction. The histological analysis showed that new cementum formation and new collagen attachment were observed following the surgical procedure if the oral hygiene was maintained. In addition, it was also demonstrated that the intrusion improved the quantity of new attachment if it was carried out under healthy conditions and an optimal plaque control, ranged from 0.7 to 2.3 mm. In case of intrusion without an appropriate plaque control, the results varied from moderate new attachment to an evident periodontal bone loss.
4.1.2.
Human studies
Clinicians often encounter osseous defects that are best treated by conventional surgical techniques, including bone grafting and guided tissue regeneration, with the goal of establishing a new periodontal attachment. On occasion, the recognition of an infrabony defect proximal to single-rooted elongated, tilted and migrated teeth may present an opportunity to consider resolution by orthodontic tooth movement. In case of teeth treated by bodily movement into infrabony periodontal defects, the results of case report/series studies7,27,28 showed significant differences not only clinically but also radiographycally. At the end of the treatment, most patients showed a reduced pocket depth (up to 3 mm), gain of clinical attachment level (up to 5 mm) and a gingival recession reduction (up to 2 mm). However, in some cases a narrowing and remodeling of the infrabony defect was associated with an increased probing pocket depth and gingival recessions.7,27 In his clinical and histological study, Brown29 reported the reduction of deep pockets and the related infrabony defects in teeth tilted mesially in five patients. Later, Ingber30 showed in another case report the favourable clinical and histological results of the treatment of 1- or 2-wall infrabony defects using extrusive tooth movement, based on the fact that the orthodontic tension created within the periodontal ligament stimulates the bone formation. It has been also reported that periodontal disease and traumatic occlusion may cause or enhance an isolated vertical infrabony defect. In such cases, the resolution of the inflammation (before) and the traumatic occlusion (after) are necessary to treat the defect. Iino et al.31 discussed in a case-report study the successful orthodontic treatment of an adult patient with one- and two-wall wide isolated vertical infrabony defects of the maxillary right lateral incisor, left canine, and mandibular left incisor associated with an anterior crossbite. After a non-surgical periodontal treatment, the inflammation was reduced, even though the vertical infrabony defects still remained and the orthodontic treatment was performed. At the end of tooth extrusion, the clinical and radiological data showed the improvement of the vertical infrabony defects, the patient’s anterior crossbite, the traumatic occlusion and the gingival aesthetics. In the treatment of adult patients with a previous history of periodontal disease, intrusion of elongated and migrated incisors is suggested to close anterior diastema and to realign the malposed teeth. In several studies,8,9,32,33 at the end of a combined treatment with periodontal therapy and intrusive movement, there was a significant decrease in the probing depth values, with a radiographic remarkable reduction of the infrabony defect volume. New supracrestal and periodontal ligament collagen fibers may be gained on the tension side, which can transfer the orthodontic force stimulus to the alveolar bone.34 Other clinical observations from case-report and case series studies confirmed that different regenerative procedures may enrich the therapeutic spectrum in combined periodontal/orthodontic approaches, showing satisfactory clinical results in terms of pocket depth reduction and CAL gain, with a radiographic defect resolution.35–41 However, the adjunctive benefit of the orthodontic therapy for the resolution of the infrabony defects where, perhaps, the main effect is the realignment of malposed teeth affected
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49
by an infrabony defect treated by means of the periodontal therapy still remains unclear.
or in combination with periodontal techniques of teeth with furcation involvement.
4.2.
4.3.1.
Gingival recession
The main etiologic factors for a gingival recession onset are periodontal disease (plaque-related factor) and toothbrushing trauma.42 In addition, gingival recession may be also a consequence of periodontal therapy. In fact, since it occurs primarily as a result of resolution of the inflammation, it may be seen following both non-surgical and surgical therapy, too. The main indications for the treatment of gingival recession are aesthetic / cosmetic demands and root hypersensitivity.42 The control of plaque accumulation and traumatic toothbrushing are able per se to prevent / arrest further progression of these lesions. However, in many cases, appropriate periodontal surgical procedures may be performed to treat gingival recessions.4 At the same time, some authors have proposed the use of orthodontic forces to reduce/solve the gingival recession defects.
4.2.1.
Animal studies
From this literature review, no animal studies dealing with orthodontic treatment of gingival recession were found.
4.2.2.
Human studies
The two studies found (1 case series and 1 case reports) dealing with treatment of gingival recession due to periodontal disease or tootbrushing trauma described an overall improvement of the clinical condition in terms of recession reduction.43,44 A case series study by Re and coworkers44 was aimed to evaluate the combined effect of periodontal surgery with orthodontic intrusion to reduce the gingival recession around the maxillary central incisors and secondly to see if a thin or a thick gingival biotype responded differently. Twenty-eight adult patients, suffering from severe chronic periodontitis were treated consecutively. At baseline, all patients presented a gingival recession on the buccal and mesial aspects of the treated teeth. The periodontal treatment consisted of open flap surgery. Orthodontic treatment started 7-10 days after surgery. The results reported that all variables showed a statistically significant improvement between baseline and 1-year follow-up. In particular, the mean recession reduction was 0.96 mm on the buccal sites and 1.71 mm on the mesial sites. No statistical difference was recorded in terms of gingival recession values between thin and thick biotypes.
4.3.
Furcation defects
The treatment of furcation lesions remains one of the most difficult clinical problems in terms of cost/benefit ratio. Different periodontal therapies have been proposed pending on the severity of the lesion, such as scaling and root planing only with or without furcationplasty, tunnel preparation, root resection or tooth extraction, regenerative techniques with or without bone graft or, in the worst condition, tooth extraction.45,46 However, aim of the present review was also to search papers that dealt with orthodontic treatment alone
Animal studies
The electronic and hand search resulted in 2 studies dealing with orthodontic treatment of furcation defects in animal models.47,48 For both studies, the main purpose was to evaluate the effect of orthodontic tooth movement on the periodontal tissues after regenerative treatment, considering the biological principle that an orthodontic movement could stimulate hard and soft tissue healing. The results were different as regard the type of lesion and the therapy used. In the first study,47 class II furcations were created in four mongrel dogs and treated with regenerative therapy. After 2 months of a strict regimen of plaque control, each dog’s furcation of the premolars was randomly assigned to a test or a control group. In the test group, bodily orthodontic movement of the second premolars was performed in the mesial direction, while the control premolars remained unmoved. The results showed that there were no statistically significant differences between the two groups in terms of total bone or linear extension of periodontal regeneration on the radicular surfaces. Later, the same research group48 was projected to assess orthodontic intrusion effects on periodontal tissues in dog premolars with Class III furcations treated with open flap debridement (OFD) or guided tissue regeneration (GTR) associated to bone autograft (BA). The results showed that all Class III furcations were closed or reduced to class II or I in the intrusion groups, while 50% of the lesions in non-moved teeth remained unchanged.
4.3.2.
Human studies
Frank and coworkers49 treated advanced Class II and Class III furcation defects in three patients with passive or active eruption before periodontal surgery in order to improve its crown-to-root ratio and minimize any compromise to the periodontium of adjacent teeth, preventing the exposure of sensitive, caries-susceptible root surfaces of the furcation of adjacent teeth. The difficult oral hygiene procedures in upper molars with Class III furcation defects was discussed by Mayer and Basdra50 in their case report, suggesting a combined surgical and orthodontic treatment consisting in root resection orthodontic alignment of the separated roots. Afterwards, the affected anatomic situation of the upper molars can be changed into a situation comparable to the single-rooted anterior teeth, with better conditions for plaque control and, therefore, a better long-term prognosis. A case report by Ogihara and Marks36 reported a combined orthodontic-regenerative therapy of a right maxillary first premolar furcation defect treated at first with regenerative therapy. Eight weeks later, orthodontic extrusion was initiated. At the end of treatment, radiographic and reentry documentation reported successful outcomes. In the only case series study by Burch et al.,51 it was reviewed in a retrospective way the changes of 20 furcated mandibular molars after orthodontic uprighting 16 months after the periodontal treatment. On the buccal surface, 9
50
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furcation lesions worsened, 1 improved and 10 remained unchanged; on the lingual aspect, 9 furcated molars worsened, and 11 remained unchanged. The reasons of these results given by the authors were based on the periodontal inflammation since no periodontal non-surgical and surgical therapy was performed before the orthodontic treatment.
5.
Conclusions
This systematic review aimed to verify the beneficial effect of orthodontic treatment of infrabony defects, gingival recessions, and furcation defects is based on only 4 case series, 16 case reports an 9 animal studies. Hence, a sound conclusion cannot be drawn. As a consequence, the clinicians must perform these therapies only after the resolution of the periodontal inflammation paying particular attention to each clinical case. For this reason, it appears important to encourage the researchers to produce randomized controlled clinical trials on the efficacy of the orthodontic treatment in combination with the periodontal therapy in the treatment of these common periodontal defects.
Conflict of interest The authors have reported no conflict of interest.
Riassunto Obiettivo: Sono stati pubblicati numerosi studi che hanno analizzato la possibilità di trattare pazienti affetti da problemi parodontali per mezzo del trattamento ortodontico. Lo scopo di questa revisione sistematica è stato quello di valutare l’efficacia del trattamento ortodontico per la terapia dei difetti infraossei, delle recessioni gengivali e delle lesioni della forcazione. Materiali e metodi: È stata eseguita una ricerca elettronica e manuale basata sul foglio di lavoro PICO. In questa revisione sono stati selezionati sia studi su animali che sull’uomo. La ricerca elettronica (dal gennaio 1966 al dicembre 2009) e la ricerca manuale (dal gennaio 1988 al dicembre 2009) sono state effettuate da 3 revisori indipendenti. Risultati: Su un totale di 197 articoli solo 29 sono risultati utilizzabili per la presente revisione. In particolare 22 studi sul trattamento dei difetti infraossei, 1 studio sul trattamento delle recessioni gengivali e 6 studi sul trattamento dei difetti della forcazione. Conclusioni: Il riscontro di un basso grado di evidenza scientifica e di risultati controversi e non chiari rafforza l’importanza di incoraggiare i ricercatori ad intraprendere studi clinici controllati randomizzati per valutare l’efficacia del trattamento ortodontico per la correzione dei difetti parodontali.
Résumé Objectif: De nombreuses études ont été publiées concernant la possibilité de traiter des patients souffrant de défauts parodontaux à l’aide de l’orthodontie. Le but de cette révision systématique est évaluer l’efficacité du traitement d’orthodontie pour ce qui est des défauts infraosseux, des récessions gingivales et des lésions de furcation. Matériels et méthodes: On a effectué deux recherches, l’une électronique et l’autre manuelle, fondées sur un worksheet d’évaluation PICO. Pour cette révision on a sélectionné aussi bien des recherches
sur les êtres humains que sur les animaux. L’étude électronique (du mois de janvier 1966 au mois de décembre 2009) et l’étude manuelle (du mois de janvier 1988 au mois de décembre 2009) ont été menées par 3 reviewers indépendants. Résultats: Au total, on a trouvé 197 articles et seulement 29 ont été retenus pour cette révision. 22 études concernaient les défauts infraosseux, 1 récession gingivale, et 6 traitements de défaut de furcation. Conclusions: Suite à l’évidence trop limitée et aux résultats controversés et pas tellement clairs, il semble important d’encourager les chercheurs à mener des essais cliniques contrôlés pour bien identifier l’efficacité du traitement d’orthodontie pouvant corriger les défauts parodontaux.
Resumen Objetivo: Se han publicado numerosos estudios acerca de la posibilidad de tratar a pacientes afectados por defectos periodontales por medio de la ortodoncia. El objeto de esta revisión sistemática es valorar la eficacia del tratamiento ortodóncico aplicado a la terapia de los defectos infraóseos, las recesiones gingivales, las lesiones de furcación. Materiales y métodos: Se llevó a cabo una doble investigación, manual y electrónica, fundamentada en una hoja de trabajo de valoración de PICO. Para esta revisión se seleccionaron investigaciones tanto en animales como en seres humanos. La búsqueda electrónica (de enero de 1966 a diciembre de 2009) y la búsqueda manual (de enero de 1988 a diciembre de 2009) fueron realizadas por tres reviewers independientes. Resultados: Se encontró un total de 197 artículos y sólo 29 fueron considerados elegibles para esta revisión. De manera particular, 22 ˜ estudios atanen a los defectos infraoseos, 1 recesión gingival, y 6 tratamientos de defecto de furcación. Conclusiones: Por la debil evidencia y los resultados no claros y controvertidos, parece importante estimular a los investigadores a que realicen ensayos clínicos controlados que apunten a profundizar en la eficacia del tratamiento ortodóncico para corregir los defectos periodontales.
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7. Nevins M, Wise RJ. Use of orthodontic therapy to alter infrabony pockets. 2. Int J Periodontics Restorative Dent 1990;10:198–207. 8. Re S, Corrente G, Abundo R, Cardaropoli D. Orthodontic treatment in periodontally compromised patients: 12-year report. Int J Periodontics Restorative Dent 2000;20:31–9. 9. Re S, Corrente G, Abundo R, Cardaropoli D. The use of orthodontic intrusive movement to reduce infrabony pockets in adult periodontal patients: a case report. Int J Periodontics Restorative Dent 2002;22:365–71. 10. 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. 11. Ericsson I, Thilander B, Lindhe J. Periodontal conditions after orthodontic tooth movements in the dog. Angle Orthod 1978;48:210–8. 12. Polson A, Caton J, Polson AP, Nyman S, Novak J, Reed B. Periodontal response after tooth movement into intrabony defects. J Periodontol 1984;55:197–202. 13. Lindhe J, Ericsson I. The influence of trauma from occlusion on reduced but healthy periodontal tissues in dogs. J Clin Periodontol 1976;3:110–22. 14. Bollen AM, Cunha-Cruz J, Bakko DW, Huang GJ, Hujoel PP. The effects of orthodontic therapy on periodontal health. A systematic review of controlled evidence. J Am Dent Assoc 2008;139:413–22. 15. Rotundo R, Nieri M, Iachetti G, Mervelt J, Cairo F, Baccetti T, et al. Orthodontic treatment of periodontal defects. A systematic review. Prog Orthod 2010;11:41–4. 16. Moher D, Liberati A, Tetzlaff J, Altman DG, The PRISMA Group. Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement. Br Med J 2009;339:b2535. 17. Liberati A, Altman DG, Tetzlaff J, Mulrow C, Gøtzsche PC, Ioannidis JP, et al. The PRISMA Statement for Reporting Systematic Reviews and Meta-Analyses of Studies That Evaluate Health Care Interventions: Explanation and Elaboration. Br Med J 2009;339:b2700. 18. Diedrich P, Fritz U, Kinzinger G, Angelakis J. Movement of periodontally affected teeth after guided tissue regeneration (GTR) - an experimental pilot study in animals. J Orofac Orthop 2003;64:214–27. 19. Nemcovsky CE, Sasson M, Beny L, Weinreb M, Vardimon AD. Periodontal healing following orthodontic movement of rat molars with intact versus damaged periodontia towards a bony defect. Eur J Orthod 2007;29:338–44. 20. Geraci TF, Nevins M, Crossetti HW, Drizen K, Ruben MP. Reattachment of the periodontium after tooth movement into an osseous defect in a monkey. 1. Int J Periodontics Restorative Dent 1990;10:184–97. 21. Wennström 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. 22. Berglundh T, Marinello CP, Lindhe J, Thilander B, Liljenberg B. Periodontal tissue reactions to orthodontic extrusion. An experimental study in the dog. J Clin Periodontol 1991;18:330–6. 23. Van Venrooy JR, Yukna RA. Orthodontic extrusion of single-rooted teeth affected with advanced periodontal disease. Am J Orthod 1985;87:67–74. 24. Atherton JD, Kerr NW. Effect of orthodontic tooth movement upon the gingivae. An investigation. Br Dent J 1968;18: 555–60. 25. Melsen B. Tissue reaction following application of extrusive and intrusive forces to teeth in adult monkeys. Am J Orthod 1986;89:469–75.
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26. Melsen B, Agerbaek N, Eriksen J, Terp S. New attachment through periodontal treatment and orthodontic intrusion. Am J Orthod Dentofacial Orthop 1988;94:104–16. 27. Kazandjian G, Scopp IW, Stahl S. Combined orthodontic-periodontal treatment of an infrabony defect. A case report. J Periodontol 1979;50:479–82. 28. Cirelli JA, Cirelli CC, Holzhausen M, Martins LP, Brandão CH. Combined periodontal, orthodontic, and restorative treatment of pathologic migration of anterior teeth: a case report. Int J Periodontics Restorative Dent 2006;26: 501–6. 29. Brown IS. The effect of orthodontic therapy on certain types of periodontal defects. I. Clinical findings. J Periodontol 1973;44:742–56. 30. Ingber JS. Forced eruption. I. A method of treating isolated one and two wall infrabony osseous defects-rationale and case report. J Periodontol 1974;45:199–206. 31. Iino S, Taira K, Machigashira M, Miyawaki S. Isolated vertical infrabony defects treated by orthodontic tooth extrusion. Angle Orthod 2008;78:728–36. 32. Cardaropoli D, Re S, Corrente G, Abundo R. Intrusion of migrated incisors with infrabony defects in adult periodontal patients. Am J Orthod Dentofacial Orthop 2001;120:671–5. 33. Steffensen B, Storey AT. Effects of orthodontic intrusive forces in treatment of periodontally compromised incisors. Case Report. Int J Periodontics Restorative Dent 1993;13: 433–41. 34. Diedrich PR. Guided tissue regeneration associated with orthodontic therapy. Semin Orthod 1996;2:39–45. 35. Nemcovsky CE, Zubery Y, Artzi Z, Lieberman MA. Orthodontic tooth movement following guided tissue regeneration: report of three cases. Int J Adult Orthodon Orthognath Surg 1996;11:347–55. 36. Ogihara S, Marks MH. Enhancing the regenerative potential of guided tissue regeneration to treat an intrabony defect and adjacent ridge deformity by orthodontic extrusive force. J Periodontol 2006;77:2093–100. 37. Stelzel MJ, Flores-de-Jacoby L. 1998 Guided tissue regeneration in a combined periodontal and orthodontic treatment: a case report. Int J Periodontics Restorative Dent 1998;8:189–95. 38. Cardaropoli D, Re S. Interdental papilla augmentation procedure following orthodontic treatment in a periodontal patient. J Periodontol 2005;76:655–61. 39. Cardaropoli D, Re S, Manuzzi W, Gaveglio L, Cardaropoli G. Bio-Oss collagen and orthodontic movement for the treatment of infrabony defects in the esthetic zone. Int J Periodontics Restorative Dent 2006;26:553–9. 40. Ghezzi C, Masiero S, Silvestri M, Zanotti G, Rasperini G. Orthodontic treatment of periodontally involved teeth after tissue regeneration. Int J Periodontics Restorative Dent 2008;28:559–67. 41. Sam K, Rabie AB, King NM. Orthodontic intrusion of periodontally involved teeth. J Clin Orthod 2001;35: 325–30. 42. Wennström JL. Mucogingival therapy. Ann Periodontol 1996;1:671–701. 43. Tzur B, Brezniak N, Ben-Yehuda A. Controlled tooth eruption for restoration of a local gingival defect. J Clin Orthod 1992;26:645–7. 44. Re S, Cardaropoli D, Abundo R, Corrente G. Reduction of gingival recession following orthodontic intrusion in periodontally compromised patients. Orthod Craniofac Res 2004;7:35–9. 45. Schallhorn RG, McClain PK. Periodontal regeneration using combined techniques. Periodontol 2000 1993;1: 109–17.
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46. De Sanctis M, Murphy KG. The role of resective periodontal surgery in the treatment of furcation defects. Periodontol 2000 2000;22:154–68. 47. da Silva VC, Cirelli CC, Ribeiro FS, Costa MR, Comelli Lia RC, Cirelli JA. Orthodontic movement after periodontal regeneration of class II furcation: a pilot study in dogs. J Clin Periodontol 2006;33:440–8. 48. da Silva VC, Cirelli CC, Ribeiro FS, Leite FR, Benatti Neto C, Marcantonio RA, et al. Intrusion of teeth with class III furcation: a clinical, histologic and histometric study in dogs. J Clin Periodontol 2008;35:807–16.
49. Frank CA, Pearson BS, Booker BW. Orthodontic eruption of furca-involved molars. Compend Contin Educ Dent 1995;16:664–8. 50. Mayer T, Basdra EK. A combined surgical and orthodontic treatment of Class III furcations. Report of a case. J Clin Periodontol 1997;24:233–6. 51. Burch JG, Bagci B, Sabulski D, Landrum C. Periodontal changes in furcations resulting from orthodontic uprighting of mandibular molars. Quintessence Int 1992;23:509–13.
available at www.sciencedirect.com
journal homepage: www.elsevier.com/locate/pio
Review
Orthodontic treatment of periodontal defects. Part II: a systematic review on human and animal studies Roberto Rotundo a,∗ , Turi Bassarelli b , Elettra Pace a , Gloria Iachetti a , Jana Mervelt a , Giovanpaolo Pini Prato a a b
Department of Periodontology, University of Florence, Italy Private Practice, Prato, Italy
a r t i c l e
i n f o
a b s t r a c t
Article history:
Several studies have been published focusing on the possibility to treat patients affected by
Received 30 January 2011
periodontal defects by means of orthodontic treatment. The aim of this systematic review is
Accepted 4 February 2011
to evaluate the efficacy of the orthodontic treatment applied to the therapy of infraosseous defects, gingival recessions, and furcation lesions. An electronic and a manual search were
Keywords:
performed based on a PICO assessment worksheet. Both human and animal studies were
Furcation defect
selected for this review. The electronic search (from January 1966 to December 2009) and
Gingival recession
the hand search (from January 1988 to December 2009) were conducted by 3 independent
Infrabony/intrabony/angular defect
reviewers.
Orthodontics
A total of 197 articles were found and only 29 were considered eligible for this review. In
Systematic review
particular, 22 studies dealing with infrabony defects, 1 gingival recession, and 6 furcation
Therapy
defect treatments. Due to the weak evidence and the controversial and unclear results, it appears important to encourage the researchers to produce Randomized Controlled clinical Trials aimed to investigate the efficacy of the orthodontic treatment for the correction of periodontal defects. © 2011 Società Italiana di Ortodonzia SIDO. Published by Elsevier Srl. All rights reserved.
1.
Introduction
It has been clearly observed that periodontitis determines defects that involve alveolar bone and soft tissues, such as infrabony / suprabony defects, furcation lesions, and gingival recessions.1 Several non-surgical and surgical periodontal techniques have been developed showing optimal clinical outcomes based on the reconstruction of the infrabony defects, the stability of the surrounding treated area in correspondence of furcation defects, and the reconstruction of the mucogingival tissues around gingival recessions.2–5
∗
On the other hand, some case report studies6–9 and personal opinions made by specialist leaders have reported the possibility to treat periodontal defects using orthodontic therapy in combination with periodontal therapy in patients with tooth malpositions. It is well known that in totally healthy or reduced periodontium orthodontic tooth movement does not produce detrimental effects.10–13 The osteogenic potential of the orthodontic tooth movement results in the development of pressure and tension zones within the marginal and apical parts of the periodontium, with a consequent bone resorption and bone apposition. This biological process might positively influence the healing of the periodontal defects. However, a
Corresponding author. Via Vasco De’ Gama 33/3 - 50127, Florence, Italy. E-mail address: roberto.rotundo@unifi.it (R. Rotundo). 1723-7785/$ – see front matter © 2011 Società Italiana di Ortodonzia SIDO. Published by Elsevier Srl. All rights reserved. doi:10.1016/j.pio.2011.02.008
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progress in orthodontics 1 2 ( 2 0 1 1 ) 45–52
Table 1 – Results from electronic and manual search (total number of studies) detailed for each periodontal defect DEFECTS (total number)
ELECTRONIC SEARCH
MANUAL SEARCH
INFRABONY DEFECTS (33) GINGIVAL RECESSION (144) FURCATION DEFECTS (20)
20 143 19
13 1 1
recent systematic review14 reported that, based on a reduced number of eligible studies, orthodontic therapy results in any case in small detrimental effects to the healthy periodontium. On the contrary, orthodontic tooth movements might cause further loss of connective attachment in sites with periodontal inflammation. In fact, the position of the plaque-induced lesion is shifted from a suprabony to an infrabony position when orthodontic forces produce tipping or intrusion of a tooth into the alveolar bone. Under these conditions, an enhanced rate of periodontal destruction is observed.10 A recent systematic review by Rotundo et al.15 carried out on clinical trials dealing with orthodontic treatment of periodontal defects reported that no systematic reviews, randomized or not-randomized controlled trials were identified and, as a consequence, no meta-analysis was possible to be performed. Therefore, to verify if the beneficial effect of the orthodontic therapy to treat infraosseous defects, gingival recessions, and furcation lesions was observed in other studies with different methodologies (case series or case reports) and / or different experimental units (animals or humans), a broader systematic review of the literature following the PRISMA statement was performed.
2.
Materials and methods
2.1.
Inclusion Criteria and Outcome Measures
This review was accomplished following the PRISMA (Preferred Reporting Items for Systematic reviews and Metaanalysis) statement aimed to help authors report a wide array of systematic reviews to assess the benefits and harms of health care interventions.16,17 However, for this systematic review of the literature, the types of studies included were not only Systematic Reviews (SR), Randomized Controlled Trials (RCTs), Controlled Clinical Trials (CCT), but also Case Series (CS), Case Reports (CR) and Animal Studies (AS). The comparative interventions considered eligible for this review were Orthodontic Treatment versus Periodontal Therapy; Orthodontic Treatment plus Periodontal Therapy versus Periodontal Therapy alone; Orthodontic Treatment versus Orthodontic Treatment; Orthodontic Treatment alone.
2.2.
Search strategy
Two searching strategies were adopted for this review: electronic and hand-search. The electronic search utilized were Medline (Pubmed) and all the Cochrane Library databases that include Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of effects, Cochrane Central Register of Controlled Trials, Cochrane Methodology Register, Health
Technology Assessment Database, NHS Economic Evaluation Database, all the Cochrane Groups. There was no language restriction. The period investigated was from January 1966 to December 2009 and the following terms were searched: • “Orthodontics”[MeSH] AND “therapy”[Subheading] AND “Gingival Recession”[MeSH] • “Orthodontics”[MeSH] AND “therapy”[Subheading] AND “Furcation Defects”[MeSH] • “Orthodontics”[MeSH] AND “therapy”[Subheading] AND “Intrabony Defect” “[All Fields] • “Orthodontics”[MeSH] AND “therapy”[Subheading] AND “Infrabony Defect” “[All Fields] • “Orthodontics”[MeSH] AND “therapy”[Subheading] AND “Infraosseous Defect” “[All Fields] • “Orthodontics”[MeSH] AND “therapy”[Subheading] AND “Intraosseous Defect” “[All Fields] • “Orthodontics”[MeSH] AND “therapy”[Subheading] AND “Angular Defect” “[All Fields] For the period from January 1988 to December 2009, the following journals were manually searched: Journal of Periodontology, Journal of Clinical Periodontology, International Journal of Periodontics and Restorative Dentistry, American Journal of Orthodontics and Dentofacial Orthopedics, The Angle Orthodontist, European Journal of Orthodontics. Other studies could be collected reviewing the reference lists of each article. The titles and abstracts (when available) of articles searched manually were scanned independently by three blinded examiners (G.I., J.M., E.P.) by means of a cross-over method. The titles and abstracts (when available) of articles searched electronically were scanned independently by a third examiner (R.R.).
3.
Results
The manual and electronic search retrieved initially a total of 197 articles: 33 articles for infrabony defects (20 electronic and 13 manual), 144 articles for gingival recessions (143 electronic and 1 manual), and 20 articles for furcation defects (19 electronic and 1 manual) (Table 1). After examining the titles, abstracts, and full text and eliminating the editorials, opinion based articles / interviews and case reports without numeric results only 29 studies were chosen for this review (Fig. 1). In particular, 22 studies (7 on animal models and 15 on humans) dealing with infrabony defects therapies were selected while only 1 (on humans) out of 144 articles and 6 (4 on humans and 2 on animal models) out of 21 articles were selected dealing with gingival recession and furcation defect treatments, respectively. From a methodological point of view, the found articles were 4 Case Series, 16 Case Reports and 9 Animal Studies (Table 2).
47
182 records identified through database searching
15 additional records identified through manual searching
197 after duplicates removed
Screening
Identification
progress in orthodontics 1 2 ( 2 0 1 1 ) 45–52
Eligibility
197 records screened
166 records excluded
Included
31 full-text articles assessed for eligibility
2 full-text articles excluded (treatment of different periodontal defects)
29 studies included in qualitative synthesis
0 studies included in quantitative synthesis (metaanalysis due to the lacking of SR and RCT)
Figure 1 – PRISMA flow diagram. Table 2 – Methodology of the studies included in the final qualitative analysis DEFECTS INFRABONY DEFECTS GINGIVAL RECESSION FURCATION DEFECTS
4.
SR 0 0 0
RCT 0 0 0
Discussion
The results will be discussed in relation to the single type of defect.
4.1.
Infrabony defects
Infrabony defects are defined when the bottom of the pocket results more apical than the alveolar bone crest. During the orthodontic treatment and after the resolution of inflammation, the theoretical changes in osseous topography may be accomplished by moving teeth into an infraosseous defect, teeth extrusion or uprighting and teeth intrusion.
4.1.1.
Animal studies
The effect of the bodily movement of teeth into infrabony periodontal defects has been evaluated in experimental animal studies. Polson et al.12 observed in 4 monkeys that if
CCT
CS
CR
ANIMAL STUDY
0 0 0
2 1 1
13 0 3
7 0 2
periodontal treatment was performed before the orthodontic tooth movement was started, and the monkeys were subjected to plaque control measures during the entire course of the experiment, the angular bony defects were eliminated and no deleterious effect was detected on the level of the connective tissue attachment. However, no regeneration of the supporting apparatus was observed. Similar conclusions were reported in other animal model studies on rats and dogs.18,19 On contrary, Geraci and coworkers20 demonstrated the formation of a new connective tissue attachment to a root surface previously exposed to periodontal disease when moving a tooth into an artificially produced infrabony lesion in two monkeys. In case where inflamed infrabony pockets were orthodontically treated, Wennström and coworkers21 reported in a study on dogs that orthodontic therapy involving bodily tooth movement may enhance the rate of destruction of the connective tissue attachment.
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progress in orthodontics 1 2 ( 2 0 1 1 ) 45–52
Orthodontic elimination of an infrabony pocket by tooth extrusion has shown a maintained relationship between the cemento-enamel junction and the bone crest in a study performed on 5 beagle dogs.22 In fact, the bone followed the tooth during the extrusion movement because of the elongation of the periodontal fiber bundles. In contrast, teeth subjected to extrusion with concomitant fiberotomy, the crestal part of the alveolar bone did not follow the root during the extrusion. Consequently, the root movement resulted in an increased distance between the cemento-enamel junction and the alveolar bone crest with an improvement in the crown-to-root ratio. On the same animal model, VanVenrooy and coworkers23 evaluated the orthodontic extrusion of teeth with advanced periodontal disease. Results showed that control teeth (with periodontal disease alone) maintained their position with evident signs of advanced periodontitis. Experimental teeth (with periodontal lesions and orthodontic extrusive forces) had shallower pocket depths, less gingival inflammation, and no bleeding on probing. The improved periodontal condition resulting from orthodontic extrusion may have been due to both physiologic and microbiologic changes in the local environment of the teeth. The shallower sulcus depth may reflect a peeling away of the sulcular and junctional epithelium as proposed by Atherton and Kerr.24 In addition, the subgingival microbial plaque may have been converted to a supragingival plaque by the extrusive tooth movement, thereby lessening its pathogenicity and effect on the gingival tissue. Intrusion has been regarded as a very controversial topic in the orthodontic literature and no studies were identified dealing with treatment of infrabony defects. However, Melsen25 in an animal study conducted on 3 Macaca fascicularis analyzed the reaction of the periodontal tissues to intrusion of teeth and evaluated the influence of oral hygiene on the observed reactions using a split-mouth design. Histological analyses showed a significant difference of the marginal bone in the two experimental sides. On the hygiene side, clear signs of bone deposited during forced eruption were still present. This was not observed on the non-hygiene side. The extension of bone resorption was also different on the two sides. On the hygiene side, only the periodontal side of the alveolar bone was subject to resorption, whereas on the other group of teeth, the gingival margin was also destroyed. Based on these results, it can be concluded that intrusion of teeth does not result in a decrease of the marginal bone level provided the gingival inflammation is kept to a minimum. The same investigating group by Melsen and coworkers26 performed another animal study to investigate the tissue reaction related to orthodontic intrusion of teeth with a reduced periodontium and further to evaluate the influence of oral hygiene on this reaction. The histological analysis showed that new cementum formation and new collagen attachment were observed following the surgical procedure if the oral hygiene was maintained. In addition, it was also demonstrated that the intrusion improved the quantity of new attachment if it was carried out under healthy conditions and an optimal plaque control, ranged from 0.7 to 2.3 mm. In case of intrusion without an appropriate plaque control, the results varied from moderate new attachment to an evident periodontal bone loss.
4.1.2.
Human studies
Clinicians often encounter osseous defects that are best treated by conventional surgical techniques, including bone grafting and guided tissue regeneration, with the goal of establishing a new periodontal attachment. On occasion, the recognition of an infrabony defect proximal to single-rooted elongated, tilted and migrated teeth may present an opportunity to consider resolution by orthodontic tooth movement. In case of teeth treated by bodily movement into infrabony periodontal defects, the results of case report/series studies7,27,28 showed significant differences not only clinically but also radiographycally. At the end of the treatment, most patients showed a reduced pocket depth (up to 3 mm), gain of clinical attachment level (up to 5 mm) and a gingival recession reduction (up to 2 mm). However, in some cases a narrowing and remodeling of the infrabony defect was associated with an increased probing pocket depth and gingival recessions.7,27 In his clinical and histological study, Brown29 reported the reduction of deep pockets and the related infrabony defects in teeth tilted mesially in five patients. Later, Ingber30 showed in another case report the favourable clinical and histological results of the treatment of 1- or 2-wall infrabony defects using extrusive tooth movement, based on the fact that the orthodontic tension created within the periodontal ligament stimulates the bone formation. It has been also reported that periodontal disease and traumatic occlusion may cause or enhance an isolated vertical infrabony defect. In such cases, the resolution of the inflammation (before) and the traumatic occlusion (after) are necessary to treat the defect. Iino et al.31 discussed in a case-report study the successful orthodontic treatment of an adult patient with one- and two-wall wide isolated vertical infrabony defects of the maxillary right lateral incisor, left canine, and mandibular left incisor associated with an anterior crossbite. After a non-surgical periodontal treatment, the inflammation was reduced, even though the vertical infrabony defects still remained and the orthodontic treatment was performed. At the end of tooth extrusion, the clinical and radiological data showed the improvement of the vertical infrabony defects, the patient’s anterior crossbite, the traumatic occlusion and the gingival aesthetics. In the treatment of adult patients with a previous history of periodontal disease, intrusion of elongated and migrated incisors is suggested to close anterior diastema and to realign the malposed teeth. In several studies,8,9,32,33 at the end of a combined treatment with periodontal therapy and intrusive movement, there was a significant decrease in the probing depth values, with a radiographic remarkable reduction of the infrabony defect volume. New supracrestal and periodontal ligament collagen fibers may be gained on the tension side, which can transfer the orthodontic force stimulus to the alveolar bone.34 Other clinical observations from case-report and case series studies confirmed that different regenerative procedures may enrich the therapeutic spectrum in combined periodontal/orthodontic approaches, showing satisfactory clinical results in terms of pocket depth reduction and CAL gain, with a radiographic defect resolution.35–41 However, the adjunctive benefit of the orthodontic therapy for the resolution of the infrabony defects where, perhaps, the main effect is the realignment of malposed teeth affected
progress in orthodontics 1 2 ( 2 0 1 1 ) 45–52
49
by an infrabony defect treated by means of the periodontal therapy still remains unclear.
or in combination with periodontal techniques of teeth with furcation involvement.
4.2.
4.3.1.
Gingival recession
The main etiologic factors for a gingival recession onset are periodontal disease (plaque-related factor) and toothbrushing trauma.42 In addition, gingival recession may be also a consequence of periodontal therapy. In fact, since it occurs primarily as a result of resolution of the inflammation, it may be seen following both non-surgical and surgical therapy, too. The main indications for the treatment of gingival recession are aesthetic / cosmetic demands and root hypersensitivity.42 The control of plaque accumulation and traumatic toothbrushing are able per se to prevent / arrest further progression of these lesions. However, in many cases, appropriate periodontal surgical procedures may be performed to treat gingival recessions.4 At the same time, some authors have proposed the use of orthodontic forces to reduce/solve the gingival recession defects.
4.2.1.
Animal studies
From this literature review, no animal studies dealing with orthodontic treatment of gingival recession were found.
4.2.2.
Human studies
The two studies found (1 case series and 1 case reports) dealing with treatment of gingival recession due to periodontal disease or tootbrushing trauma described an overall improvement of the clinical condition in terms of recession reduction.43,44 A case series study by Re and coworkers44 was aimed to evaluate the combined effect of periodontal surgery with orthodontic intrusion to reduce the gingival recession around the maxillary central incisors and secondly to see if a thin or a thick gingival biotype responded differently. Twenty-eight adult patients, suffering from severe chronic periodontitis were treated consecutively. At baseline, all patients presented a gingival recession on the buccal and mesial aspects of the treated teeth. The periodontal treatment consisted of open flap surgery. Orthodontic treatment started 7-10 days after surgery. The results reported that all variables showed a statistically significant improvement between baseline and 1-year follow-up. In particular, the mean recession reduction was 0.96 mm on the buccal sites and 1.71 mm on the mesial sites. No statistical difference was recorded in terms of gingival recession values between thin and thick biotypes.
4.3.
Furcation defects
The treatment of furcation lesions remains one of the most difficult clinical problems in terms of cost/benefit ratio. Different periodontal therapies have been proposed pending on the severity of the lesion, such as scaling and root planing only with or without furcationplasty, tunnel preparation, root resection or tooth extraction, regenerative techniques with or without bone graft or, in the worst condition, tooth extraction.45,46 However, aim of the present review was also to search papers that dealt with orthodontic treatment alone
Animal studies
The electronic and hand search resulted in 2 studies dealing with orthodontic treatment of furcation defects in animal models.47,48 For both studies, the main purpose was to evaluate the effect of orthodontic tooth movement on the periodontal tissues after regenerative treatment, considering the biological principle that an orthodontic movement could stimulate hard and soft tissue healing. The results were different as regard the type of lesion and the therapy used. In the first study,47 class II furcations were created in four mongrel dogs and treated with regenerative therapy. After 2 months of a strict regimen of plaque control, each dog’s furcation of the premolars was randomly assigned to a test or a control group. In the test group, bodily orthodontic movement of the second premolars was performed in the mesial direction, while the control premolars remained unmoved. The results showed that there were no statistically significant differences between the two groups in terms of total bone or linear extension of periodontal regeneration on the radicular surfaces. Later, the same research group48 was projected to assess orthodontic intrusion effects on periodontal tissues in dog premolars with Class III furcations treated with open flap debridement (OFD) or guided tissue regeneration (GTR) associated to bone autograft (BA). The results showed that all Class III furcations were closed or reduced to class II or I in the intrusion groups, while 50% of the lesions in non-moved teeth remained unchanged.
4.3.2.
Human studies
Frank and coworkers49 treated advanced Class II and Class III furcation defects in three patients with passive or active eruption before periodontal surgery in order to improve its crown-to-root ratio and minimize any compromise to the periodontium of adjacent teeth, preventing the exposure of sensitive, caries-susceptible root surfaces of the furcation of adjacent teeth. The difficult oral hygiene procedures in upper molars with Class III furcation defects was discussed by Mayer and Basdra50 in their case report, suggesting a combined surgical and orthodontic treatment consisting in root resection orthodontic alignment of the separated roots. Afterwards, the affected anatomic situation of the upper molars can be changed into a situation comparable to the single-rooted anterior teeth, with better conditions for plaque control and, therefore, a better long-term prognosis. A case report by Ogihara and Marks36 reported a combined orthodontic-regenerative therapy of a right maxillary first premolar furcation defect treated at first with regenerative therapy. Eight weeks later, orthodontic extrusion was initiated. At the end of treatment, radiographic and reentry documentation reported successful outcomes. In the only case series study by Burch et al.,51 it was reviewed in a retrospective way the changes of 20 furcated mandibular molars after orthodontic uprighting 16 months after the periodontal treatment. On the buccal surface, 9
50
progress in orthodontics 1 2 ( 2 0 1 1 ) 45–52
furcation lesions worsened, 1 improved and 10 remained unchanged; on the lingual aspect, 9 furcated molars worsened, and 11 remained unchanged. The reasons of these results given by the authors were based on the periodontal inflammation since no periodontal non-surgical and surgical therapy was performed before the orthodontic treatment.
5.
Conclusions
This systematic review aimed to verify the beneficial effect of orthodontic treatment of infrabony defects, gingival recessions, and furcation defects is based on only 4 case series, 16 case reports an 9 animal studies. Hence, a sound conclusion cannot be drawn. As a consequence, the clinicians must perform these therapies only after the resolution of the periodontal inflammation paying particular attention to each clinical case. For this reason, it appears important to encourage the researchers to produce randomized controlled clinical trials on the efficacy of the orthodontic treatment in combination with the periodontal therapy in the treatment of these common periodontal defects.
Conflict of interest The authors have reported no conflict of interest.
Riassunto Obiettivo: Sono stati pubblicati numerosi studi che hanno analizzato la possibilità di trattare pazienti affetti da problemi parodontali per mezzo del trattamento ortodontico. Lo scopo di questa revisione sistematica è stato quello di valutare l’efficacia del trattamento ortodontico per la terapia dei difetti infraossei, delle recessioni gengivali e delle lesioni della forcazione. Materiali e metodi: È stata eseguita una ricerca elettronica e manuale basata sul foglio di lavoro PICO. In questa revisione sono stati selezionati sia studi su animali che sull’uomo. La ricerca elettronica (dal gennaio 1966 al dicembre 2009) e la ricerca manuale (dal gennaio 1988 al dicembre 2009) sono state effettuate da 3 revisori indipendenti. Risultati: Su un totale di 197 articoli solo 29 sono risultati utilizzabili per la presente revisione. In particolare 22 studi sul trattamento dei difetti infraossei, 1 studio sul trattamento delle recessioni gengivali e 6 studi sul trattamento dei difetti della forcazione. Conclusioni: Il riscontro di un basso grado di evidenza scientifica e di risultati controversi e non chiari rafforza l’importanza di incoraggiare i ricercatori ad intraprendere studi clinici controllati randomizzati per valutare l’efficacia del trattamento ortodontico per la correzione dei difetti parodontali.
Résumé Objectif: De nombreuses études ont été publiées concernant la possibilité de traiter des patients souffrant de défauts parodontaux à l’aide de l’orthodontie. Le but de cette révision systématique est évaluer l’efficacité du traitement d’orthodontie pour ce qui est des défauts infraosseux, des récessions gingivales et des lésions de furcation. Matériels et méthodes: On a effectué deux recherches, l’une électronique et l’autre manuelle, fondées sur un worksheet d’évaluation PICO. Pour cette révision on a sélectionné aussi bien des recherches
sur les êtres humains que sur les animaux. L’étude électronique (du mois de janvier 1966 au mois de décembre 2009) et l’étude manuelle (du mois de janvier 1988 au mois de décembre 2009) ont été menées par 3 reviewers indépendants. Résultats: Au total, on a trouvé 197 articles et seulement 29 ont été retenus pour cette révision. 22 études concernaient les défauts infraosseux, 1 récession gingivale, et 6 traitements de défaut de furcation. Conclusions: Suite à l’évidence trop limitée et aux résultats controversés et pas tellement clairs, il semble important d’encourager les chercheurs à mener des essais cliniques contrôlés pour bien identifier l’efficacité du traitement d’orthodontie pouvant corriger les défauts parodontaux.
Resumen Objetivo: Se han publicado numerosos estudios acerca de la posibilidad de tratar a pacientes afectados por defectos periodontales por medio de la ortodoncia. El objeto de esta revisión sistemática es valorar la eficacia del tratamiento ortodóncico aplicado a la terapia de los defectos infraóseos, las recesiones gingivales, las lesiones de furcación. Materiales y métodos: Se llevó a cabo una doble investigación, manual y electrónica, fundamentada en una hoja de trabajo de valoración de PICO. Para esta revisión se seleccionaron investigaciones tanto en animales como en seres humanos. La búsqueda electrónica (de enero de 1966 a diciembre de 2009) y la búsqueda manual (de enero de 1988 a diciembre de 2009) fueron realizadas por tres reviewers independientes. Resultados: Se encontró un total de 197 artículos y sólo 29 fueron considerados elegibles para esta revisión. De manera particular, 22 ˜ estudios atanen a los defectos infraoseos, 1 recesión gingival, y 6 tratamientos de defecto de furcación. Conclusiones: Por la debil evidencia y los resultados no claros y controvertidos, parece importante estimular a los investigadores a que realicen ensayos clínicos controlados que apunten a profundizar en la eficacia del tratamiento ortodóncico para corregir los defectos periodontales.
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