Salient Periodontal Issues for the Modern Biologic Orthodontist

Ortho-Perio Risk Assessment and timing flowchart for lingual orthodontics in an interdisciplinary adult ortho-perio patient: A case report of ``Perio-Guided'' Orthodontic treatment

INTRODUCTION

The treatment of ortho-perio patients is a challenge for the interdisciplinary team. Not only are adult patients with overt perio pathology involved, but any ortho patient, even young ones, can be a perio patient and vice versa. Diagnosis and risk assessment of every ortho-perio patient is essential to establish a correct treatment plan, schedule and prognosis. Orthodontics becomes a ``Perio-Guided" Orthodontic Treatment and Periodontics a "Ortho-Guided Periodontal Treatment".

MATERIAL AND METHODS

This case report presents a man with a very compromised dentition asking for a complete interdisciplinary rehabilitation treated with a combined ortho-perio treatment in lingual mechanics. The periodontal evaluation confirmed the possibility of performing orthodontic treatment after active periodontal treatment. Treatment objectives were the resolution of the crowding, the correction of the levels of the gingival margin, the bone levelling, the preparation for restorative spaces; the objectives of the latter prior to implant placement were: redistribution of space, optimization of the position of adjacent teeth and their parallelism, exploitation of edentulous sites to correct dental class II and placement of the least number of implants possible. After integrating the conventional perio risk assessment with a new Ortho-Perio Risk Assessment (OPRA), a lingual fixed appliance was applied with the help of miniscrews to correct class II division 2 by substituting the upper right first premolar into a canine and retracting the entire upper arch, while correcting the deep bite and optimising the occlusion.

RESULTS

At the end of the treatment, the patient had molar relationships of class II on the right and class I on the left with a class I canine and the 14 in the position of 13. Incisal relationships were corrected, the position of the incisors was optimized, the spaces in the upper arch were fully resolved by orthodontics. During the treatment, orthodontics corrected the uneven gingival margin of the anterior teeth and levelled the bone.

CONCLUSIONS

Correct ortho-perio risk assessment (OPRA) is necessary to plan the risk of expression of the periodontal phenotype in ortho-patient. OPRA and the lingual mechanics allowed an orthodontic resolution of the malocclusion and an enhancement of the perio-implant-restorative contributions. OPRA followed by periodontal therapy and lingual mechanics resolved the malocclusion by improving the restorative peri-implant conditions. Orthodontists and periodontists should be aware of the characteristics of the individual expression of the periodontal phenotype at the beginning of treatment and involve patients in the outcome, sequencing of combined treatments, ortho-perio retention and stability.

A successful management of sever gummy smile using gingivectomy and botulinum toxin injection: A case report

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Botox injections considered as an alternative treatment for sever gummy smile.

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Extensive surgical procedures can be avoided in treatment of gummy smile by using Botox injections.

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The gingivectomy and Botox injections exhibited satisfactory results for the functional and esthetic rehabilitation of the gummy smile

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The combination of crown lengthening procedures and Botox injections give satisfactory results for gummy smile patients.

Introduction

A gummy smile (GS) affects the esthetic and the psychological status as it usually decreases the self-confidence leading to hidden or controlling the smile. A smile with more than 2 mm exposed gingiva is called gummy smile. It may be due to one or more of the following etiologies; altered passive eruption of teeth, dentoalveolar extrusion, vertical maxillary excess, and short or hyperactive lip muscles. The treatment of gummy smile should be planned according to its cause/causes. The purpose of this case report was to highlight the ability of combined treatment of gingivectomy and Botox injection technique in managing a severe gummy smile. Also, techniques, advantages, disadvantages, indication and contraindications of Botulinum toxin (BT) are discussed at the literacy.

Presentation of the case

A 24 year old female patient with a severe gummy smile was refereed to the periodontal clinics of our institution. Clinical examination revealed that she has a GS of an 11–12 mm gingival exposed area that was indicated for orthognathic surgery. The GS was treated by a gingivectomy surgery to increase the clinical crowns of upper anterior teeth and the use of Botox injections. The treatment showed remarkable and satisfactory results instead of doing extensive surgery.

Discussion and conclusion

It is important to assess the patients’ esthetic expectations and show the possible therapeutic solutions that fit him. We revealed that BT is considered as one of the minimally invasive, quick and affordable modalities that can replace extensive surgical procedures for corrections of sever GS.

Combined Periodontal, Orthodontic, and Prosthetic Treatment in an Adult Patient

A 41-year-old man had a significant loss of bone and supporting tissues with pathologic migration of several teeth and several missing teeth. He was treated with an interdisciplinary therapeutic protocol that included nonsurgical periodontal therapy based on strict control of supragingival plaque, subgingival periodontal therapy, orthodontic and endodontic treatment, and replacement of restorations. The orthodontic therapy was performed in a severely reduced bone support and the presence of pathological tooth migration after periodontal disease control. The interdisciplinary treatment protocol was the key to achieve a significant improvement in his facial and dental esthetics, masticatory function, and quality of life.

The adjunct effectiveness of diode laser gingivectomy in maintaining periodontal health during orthodontic treatment

OBJECTIVE

To evaluate the effectiveness of diode laser gingivectomy as an adjunct to nonsurgical periodontal treatment in the management of periodontal health among patients receiving fixed orthodontic appliance therapy (FOAT).

MATERIALS AND METHODS

Thirty patients undergoing FOAT with gingival enlargement were block randomized into two treatment groups. The test group received diode laser gingivectomy (940-nm diode laser, ezlase, Biolase Technology Inc) as an adjunct to nonsurgical periodontal treatment. The control group received nonsurgical periodontal treatment only. For both groups, five periodontal parameters were assessed at baseline, 1 month, 3 months, and 6 months: Plaque Index, Gingival Index, bleeding on probing, probing pocket depth, and Gingival Overgrowth Index. Intra- and intergroup variations in the periodontal parameters were determined over time.

RESULTS

Both groups showed statistically significant improvements in periodontal health over the study period (P < .05). However, significant improvements in periodontal health were evident earlier among the test group subjects (P < .05). The magnitude of improvement in periodontal health compared to baseline was greater in the test group than in the control group for Gingival Overgrowth Index at 1 month (P < .001) and 3 months (P < .05), Gingival Index at 3 months (P < .05) and 6 months (P < .05), and probing pocket depth at 1 month (P < .05).

CONCLUSIONS

Nonsurgical periodontal management with or without the adjunct use of lasers can be effective in the management of gingival health problems among patients receiving FOAT. The adjunctive use of lasers can produce an earlier and greater improvement in gingival health.

Orthodontic-periodontics interdisciplinary approach

In this present era, when a significant number of patients seeking orthodontic treatment are adults, importance of multidisciplinary treatment approach cannot be overemphasized. Higher susceptibility of plaque accumulation in patients undergoing orthodontic treatment makes involvement of periodontist almost unavoidable. Also, orthodontic treatment frequently results in undesirable periodontal changes which require immediate attention. More recently, orthodontics has been used as an adjunct to periodontics to increase connective tissue support and alveolar bone height. The purpose of this article is to review the adverse effects of orthodontic treatment on the periodontal tissues and to discuss the mutually beneficial relationship shared between the two specialties.