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orthodontics
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INTRODUCTION
We need to consider and treat a patient as an
Increased patient awareness Consumer rights Developments in various fields of dentistry and science More and more adults are seeking for orthodontic
treatment Changing treatment objectives Primary motivating factor – Improving dental appearance
INDIVIDUAL
CLASSIFICATICLASSIFICATION ON
PHASES OF IDT
Any type of interdisciplinary therapy(IDT) should have the following steps
PRELIMINARY THERAPY:PRELUDE TO IDT
TREATMENT PLANNING: PHASE II OF IDT
DIAGNOSTICS: PHASE I OF IDT
DEFINITIVE THERAPY:PHASE III OF IDT
MAINTENANCE:PHASE IV OF IDT
ORTHODONTIC PERIODONTIC –
INTERACTIONS Statistically significant periodontal differences
between patients with normal and malaligned teeth has been noticed indicating that irregular teeth are a predisposing factor to periodontal disease
ORTHODONTIC TREATMENT PLANNING
Various studies have shown that -
Alveolar bone height reduced in areas of increased over jet Gingivitis is generally associated with crowding Level of bacteria is higher in areas of crowding compared with normal areas in same patient
BENEFITS OF ORTHODONTICS BENEFITS OF ORTHODONTICS FOR AFOR A PERIODONTAL PATIENT PERIODONTAL PATIENT
1. ALIGNING CROWDED OR MALPOSED TEETH PERMITS THE ADULT
PATIENT BETTER ACCESS TO CLEAN ALL SURFACES OF THEIR TEETH
ADEQUATELY.
2. TREMENDOUS ADVANTAGE FOR PATIENTS WHO ARE SUSCEPTIBLE TO
PERIODONTAL BONE LOSS OR DO NOT HAVE THE DEXTERITY TO
MAINTAIN ORAL HYGIENE
3. VERTICAL ORTHODONTIC TOOTH REPOSITIONING CAN IMPROVE
CERTAIN TYPES OF OSSEOUS DEFECTS IN PERIODONTAL PATIENTS.
OFTEN THE TOOTH MOVEMENT ELIMINATES THE NEED FOR
RESECTIVE OSSEOUS SURGERY
5 ORTHODONTIC TREATMENT ALLOWS OPEN GINGIVAL EMBRASURES TO
BE CORRECTED TO REGAIN LOST PAPILLA. IF THESE OPEN GINGIVAL
EMBRASURES ARE LOCATED IN THE MAXILLARY ANTERIOR REGION
6. ORTHODONTIC TREATMENT COULD IMPROVE ADJACENT TOOTH
POSITION BEFORE IMPLANT PLACEMENT OR TOOTH REPLACEMENT.
THIS IS ESPECIALLY TRUE FOR THE PATIENT WHO HAS BEEN
MISSING TEETH FOR SEVERAL YEARS AND HAS DRIFTING AND
TIPPING OF THE ADJACENT DENTITION.
4. ORTHODONTIC TREATMENT CAN IMPROVE THE ESTHETIC
RELATIONSHIP OF THE MAXILLARY GINGIVAL MARGIN LEVELS
BEFORE RESTORATIVE DENTISTRY.
Age per se is not a contraindication for orthodontic treatment , lighter forces should be used as there is an decreased cellular activity of the PDL(Reitan, Angle Orthod 1985)
Although the world wide prevalence of gingival inflammation is high, advanced periodontal disease affects 8 % - 30% of population . (Papapanou et al, JCP 1989)
A MAGNIFICIENT ORTHODONTIC TREATMENT CAN BE DESTROYED BY POOR PERIODONTAL SUPPORT.
HENCE ,
EVALUATION AND MAINTENANCE OF PERIODONTAL HEALTH BEFORE , DURING AND AFTER TREATMENT IS VERY IMPORTANT
PERIODONTAL RISK ASSESSMENT BEFORE ORTHODONTIC
TREATMENT This includes special emphasis on the following HISTORY Previous periodontal disease Drug history Systemic diseases
CLINICAL EXAMINATION Check for the following : Bleeding on probing Tooth mobility Thin fragile gingiva Pockets
Psychosocial stress Lifestyle factors such as
diet, alcohol use and especially smoking
Deficiencies in the immune
system The presence of specific
bacteria
Sex (disease is more common
in women than in men) Age Diabetes mellitus Osteoporosis Polymorphonuclear
leukocyte count
MICROBIOLOGY ASSOCIATED WITH ORTHODONTIC
MATERIALS
Orthodontic band placement causes an overall increase in salivary bacterial counts especially
lactobacillus , prevotella intermedia , porphyromonous gingivalis , bacteroids
EFFECTS OF ORTHODONTIC TREATMENT ON THE
PERIODONTIUM
FORCE
TISSUE RESPONSE
STRONG/ HEAVY FORCE (Forces far exceeding capillary blood pressure)
PDL on pressure side ischemia & degeneration of PDL = hyalinization = more delay in tooth movement
MODERATE FORCE (Force exceeding capillary blood pressure)
PDL strangulation resulting in delay in bone resorption
LIGHT FORCE (Force less than capillary blood pressure )
PDL ischemia with simultaneous bone resorption and formation = more continuous tooth movement
EQULIBRIUM CONCEPT
It is not only the forces of the musculature that help in maintaining tooth position.
In certain areas of the dentition like the mandibular anteriors the pressure from the tongue within is more than the pressure from the extroral muscles. Here the metabolic activity of the periodontal ligament helps in maintaining tooth position
Tooth movement and the periodontium
Cardinal Rule – Before doing any tooth movement there should be no inflammation in the periodontal attachment.
Periodontal response to various kinds of tooth movement in periodontally compromised patients1. Extrusion
2. Intrusion
3. Tipping – Uncontrolled
- Controlled
4. Bodily movement
CONTROLLED TIPPING also produces high forces in the periodontal ligament as the fulcrum shifts more and more apically with increasing amounts of bone loss
Infact cases have been documented where a gingival lesion has been converted into a periodontal lesion by the injudicious use of tipping moments.
Mild gingival changes associated with orthodontic appliances are transitory. These cause no periodontal damage and resolve on their own.
BODILY MOVEMENT
Moving a tooth bodily into a periodontal defect has been believed to ‘carry the bone’ along with the tooth resulting in improvement of the defect.
However recent studies have shown that this only an illusion because it causes only an improved connective tissue attachment and infact worsens the bony defect. Hence until new evidence surfaces this is contraindicated.
ADULT ORTHODONTICS
How is adult orthodontics different???
1. Response to orthodontic force is relatively slower
2. Lack of growth – Restraint
3. Motivations differ from other age groups, so do psychological reactions
4. Heightened susceptibility to periodontal disease.
5. High % of pts. Esp. Indian scenario – Preexisting periodontal disease
SPECIAL CONSIDERATIONS IN ADULTS
Always defer treatment till active lesions gingival/periodontal are arrested.
Infact applying force in the presence of inflammation could convert a gingival lesion into a periodontal one in adults because of lesser resistance and tissue turnover.
In adults do a thorough periodontal phase involving scaling, flaps and soft tissue grafts in cases with extremely reduced width of attached gingiva.
After preorthodontic treatment there should be a phase of maintenance allowing the tissues to recover as well as evaluate patient co-operation.
These cases require routine scaling and other hygeine aids like electric toothbrushes, interdental brushes, water piks , chemical aids like chlorhexidine etc depending on the degree of periodontal ligament
SPECIAL CONSIDERATIONS IN SPECIAL CONSIDERATIONS IN ADULTSADULTS
CLASSIFICATION BASED ON THE DEGREE OF
INVOVEMENT
CLASSIFICATION BASED ON THE DEGREE OF INVOVEMENT
MODERATE PERIODONATL INVOLVEMENT Disease control Preliminary periodontal therapy here includes all but
osseous surgeries Important to remove all irritants, flap surgeries are
especially recommended for complete calculus removal.
Use bonding, self ligating brackets, steel ligatures Routine scaling at 2-4month interval. Mechanical and chemical adjuvants for oral hygeine
CLASSIFICATION BASED ON THE DEGREE OF INVOVEMENT
SEVERE PERIODONTAL INVOLVEMENT
All other measures additional do the following
1. Periodontal maintenance scheduling as frequent as orthodontic appointments.
2. Treatment goals & mechanics modified to keep force levels to a minimum & lessen the span of tooth movement.
CLASSIFICATION BASED ON THE DEGREE OF INVOVEMENT
Disease control, hygiene maintenance Use bonded rather than banded attachments Use self ligating brackets/steel ligatures. Schedule periodontal maintenance visits in
addition to orthodontic visits. Advise mechanical aids such as powered
toothbrushes, interdental brushes etc. Advise chemical aids such as chlorhexidine
OPG reveals generalized bone resorption with increased severity in anterior segment
PRE & POST TREATMENT COMPARISON
Comparison of pre and post treatment OPG note the amount of bone is maintained if not reduced and significant amount of bone formation in upper anterior segment due to tooth Moving closer to each other
RETENTION & STABILTY
MILD & MODERATE COMPROMISE
1. Stability of the achieved results is usually fair.
2. However other than the mild cases most of them require permanent retention in the form of removable wrap around retainers.
3.Fixed retention in terms of bonded retainers is usually not recommended because of the difficulty in maintaining adequate hygiene
Circumferential Supracrestal Fibrotomy The retention period should continue
part time for at least 12 months to allow time for remodelling
CSF reduces the mean relapse by 30 %(Edwards AJO 1970)
Should be performed towards the end of finishing phase
SEVERELY COMPROMISED CASES
1.These require immediate splinting after debonding.
2.Splinting is provided by vaccum formed retainers to be worn for a period of 4-6 weeks.
3.Following this permanent retention using removable retainers is mandatory.
4.Routine followup visits at regular intervals for periodontal maintainence/evaluation of patient hygeine measures are recommended.
Minimal amount of tooth movement was carried out since bone was not very conducive , hence surgery was opted
Intraoral photographs with severe overjet and periodontally compromised Status
Permanent retention is mandatory for adult patients
Molar protraction Molar protraction
Note the amount of bone formation
ORTHO - PERIO IDT PHASES PRELIMINARY THERAPY:
Control of active pd disease –Main objective All except definite osseous surgery & repositioned flaps
TREATMENT PLANNING : Decide on types of tooth movement, force levels
DIAGNOSTICS: Evaluate the degree of compromise, Identify sites of active periodontal destruction
DEFINITVE THERAPY: Use bonded appliances whenever possible, Self ligating brackets, avoid O-rings, Plan periodontal maintenance schedules.
MAINTAINENCE: Use of vacuum formed retainer immediately after debonding. Concept of permanent retention