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ISSN 2637-7764 Review Article

Ortho- Perio Synergy - A Review

Jeevan M Khatri1, Manjusha M Jadhav2* and Gaurav H Tated2
1
Professor & HOD, Department of Orthodontics and Dentofacial Orthopedics, CSMSS Dental College & Hospital, India
2
Post graduate student, Department of Orthodontics and Dentofacial Orthopedics, CSMSS Dental College & Hospital, India

*Corresponding author: Manjusha M Jadhav, Post graduate student, Department of Orthodontics and Dentofacial Orthopedics, CSMSS Dental College &
Hospital, Aurangabad, India
Submission: November 13, 2017; Published: February 13, 2018

Abstract

In this present era, when a significant number of patients seeking orthodontic treatment are adults, importance of interdisciplinary treatment
approach cannot be overemphasized. Higher susceptibility of plaque accumulation in patients undergoing orthodontic treatment makes involvement
of periodontal treatment almost unavoidable.

Orthodontic treatment aims at providing acceptable functional and aesthetic occlusions using appropriate tooth movements. These movements are
specifically related to interactions of the teeth with their supportive periodontal tissues. Periodontic and orthodontic interactions usually deal with the
establishment of an appropriate diagnosis and the treatment planning needed to enable coordinated perio-ortho therapy. 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.

Keywords: Orthodontics; Periodontium; Periodontal disease

Introduction
A multidisciplinary approach including an orthodontist and
The term synergy refers to two or more distinct influences
a periodontist is done in patients with periodontal disease. Both
or agents acting together to create an effect greater than that
specialists should be involved in the treatment planning of such
predicted by knowing only the separate effects of the individual
patients, and care should be taken in evaluation of progress of the
agents. This definition is applicable to the classic relationship
treatment undertaken. Since orthodontic tooth movements are
between orthodontic and periodontics specialties in treating
strongly associated with interactions of teeth and their supporting
patients. Understanding the biologic basis of periodontal surgical
periodontal structures, we can say every orthodontic intervention
procedures, recent advancements in tissue engineering and
has some kind of periodontal dimension. Adult patients opting for
research development can yield more productive clinical endpoints
orthodontic treatment has increased recently and also the patients
than ever before. Making the most of what these two specialties
with periodontal problems faced by the orthodontists. Orthodontics
offer each other begins with the identification of periodontal
may be an option in case of repositioning of periodontally
problems that could become more complicated during orthodontic
compromised teeth. There are osteogenic changes seen in bone
therapy and, conversely, those that could benefit from orthodontic
during orthodontic tooth movement, and there will be alteration of
therapy [1].
bone deformities and contours. The topography of the underlying
A multidisciplinary approach is often required for the correction bone and other intraosseous deformities influences the prognosis
of complex dentoalveolar problems in patients and this can be of periodontal therapy and pockets elimination [1,2].
better explained by ortho-perio integration. The biologic basis of
Kingsley [4] stated in the late 19th century that age is hardly
orthodontic treatment is that bone remodels and tooth moves on
a limiting factor as far as tooth movement is concerned. But since
application of prolonged pressure to the tooth. Removal of bone
then, for a long time, orthodontists limited their services to children
occurs in some areas and addition in others, in a selective manner.
and adolescents. However in the 1960s and 70s, prevention of
In essence, the tooth socket migrates and the tooth moves through
oral diseases like caries and periodontal breakdown became the
the bone carrying its attachment apparatus, i.e., periodontal
primary reason for seeking orthodontic treatment. Since then
ligament with it. This response occurs through mediation by the
orthodontic treatment has been given to adults as well.
periodontal ligament; therefore, orthodontic tooth movement is
basically a periodontal ligament phenomenon [2,3]. Reasons for adults seeking orthodontic treatment were enlisted
by Perregaard [5] According to him, although 50% of adults seeking

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 Mod Res Dent Copyright © Manjusha M Jadhav

orthodontic treatment report with the chief complaint of untreated bleeding on probing. Since bleeding swollen gingiva is ubiquitous in
malocclusion, a significant percentage of patients (12%) seek the orthodontic population, universal caution should be employed
orthodontic treatment to prevent occurrence or progression of and supportive periodontal care recommended routinely as an
periodontal diseases. Better compliance offered by adult patients integral part of orthodontic therapy. Studies have pointed out the
compensate for the slower tissue response. importance of a full-mouth examination, six sites per tooth, for a
comprehensive description of periodontal status in orthodontic
Orthodontic patients can be classified into three categories:
patients [1,3].
a) Patients with good oral health;
The conclusion that seems most logical is that some periodontal
b) Patients with periodontal disease and/or loss of permanent damage may occur, particularly in those patients who exhibit poor
teeth; and oral hygiene during fixed appliance therapy, but the contribution
of orthodontic care is generally minor, occasionally severe
c) Patients with severe skeletal discrepancies.
enough to justify periodontal therapy and prevalent enough to
A multidisciplinary approach involving an orthodontist and a indicate concomitant supportive periodontal therapy as a routine
periodontist is required to treat patients belonging to the second preventive tactic during fixed appliance therapy. It is advisable
category. While treating such patients, both specialists should be that professional scaling and root planning, where indicated, be
involved in treatment planning, and the treatment progress should performed by a periodontist [9,10].
be evaluated.
Mucogingival Changes During Orthodontic Treatment
Mechanisms of Tissue Damage
It has been widely believed that appropriately applied
Unfestooned orthodontic bands are particularly suspects orthodontic forces do not damage the periodontium. However,
as possibly complicating factors jeopardizing interproximal insufficient width of attached gingival is widely believed to be a
periodontal support, and at the present time “special periodontally predisposing factor for recession. Lang & Loe [11] concluded from
friendly bands” are being designed in research and design their study that 2mm of keratinized gingiva is adequate to maintain
laboratories. These challenging effects of band impingement gingival health.
may directly compromise local resistance related to subgingival
It is believed that alveolar bone dehiscence is a predisposing
pathogens in susceptible patients and result in damage to both
factor for the development of gingival recession. So as long as
interproximal gingival tissues and alveolar crestal bone in a manner
a tooth is housed within the alveolar bone, orthodontic tooth
similar to that produced by faulty crown margins. Periodontal
movement (OTM) will not result in recession. Batenhorst concluded
support might also be damaged during tooth intrusion where
from his experiment on monkeys that facial tipping, extrusion, and
patients have active periodontitis or gingival infection significant
bodily movements of incisors results in apical shift of labial gingival
enough to convert to periodontal disease. In these kinds of
margin and loss of attachment. However a study done on humans
susceptible patients a screening examination for the interleukin
failed to prove the same.
(IL) family of inflammatory mediators may be wise. The details
of genetic screening involve studying the genetic potential of Steiner [12] suggested that tension in the marginal tissue
exaggerated immunologic reactions of host response to bacterial created by the orthodontic forces could be an important factor in
challenge such as those that recruit IL-1β [5,6]. causing gingival recession. This means, the thickness of the gingival
tissue at the pressure side and not its apico-coronal width, is an
The etiology of periodontal problems may not simply rely on
indicator of possible recession. An experimental study was done
exaggerated host immunologic reactions. Mattingly et al. [7] and
on monkeys to confirm this hypothesis. Following extensive bodily
others [6-8] reflect the view that long-term fixed appliances can
movement of incisors in a labial direction, most teeth showed
contribute to unfortunate but predictable qualitative alterations
clinically some apical displacement of the gingival margin as well
in the subgingival bacterial biofilms that become progressively
as loss of probing attachment, but no loss of connective tissue
periodontopathic with time.
attachment when evaluated histologically.
On a practical level it seems that an absence of bleeding on
probing is a better forecasting parameter of health than bleeding Periodontal Tissue Response and Different Orthodontic
on probing is a predictor of progressive disease. In other words, Forces
an absence of bleeding on probing, despite the pocket depth Tooth movement induced by orthodontic force is the result
can justifiably be used as a test of “healthy gums.” The best test of placing controlled forces on teeth. The applied force causes
is “bleeding on probing” elicited by stroking the sulci with a remodeling changes in the dental and periodontal tissues.
flexible plastic periodontal probe at a comfortable range of force Orthodontic force application results in compression of the
between 10 and 20g. Those orthodontic patients who present with alveolar bone and the periodontal ligament on one side while the
persistent bleeding on such probing should be notified that they periodontal ligament is stretched on the opposite side. The bone is
are “at risk” and that prudence dictates a more intensive regimen selectively resorbed on the compressed side and deposited on the
of periodontal therapy than those who present with little or no tension side [4].

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How to cite this article: Jeevan M K, Manjusha M J, Gaurav H T. Ortho- Perio Synergy - A Review. Mod Res Dent. 1(4). MRD.000518. 2018. 66
DOI: 10.31031/MRD.2018.01.000518
 Mod Res Dent Copyright © Manjusha M Jadhav

i. Light orthodontic force, i.e., force less than capillary blood disease accelerator is eliminated in the absence of crowding of teeth
pressure, causes periodontal ligament ischemia with simultaneous
b) It orients vertical occlusal forces and makes it parallel to
bone resorption and deposition resulting in continuous tooth
the long axis of the tooth. Therefore, it uniformly distributes muscle
movement.
force to the dental arch
ii. Moderate orthodontic forces, i.e., forces exceeding capillary
c) It helps in achieving an adequate crown-root ratio in some
blood pressure lead to periodontal ligament strangulation resulting
cases by orthodontic extrusion, with no loss of surrounding bone
in delayed bone resorption.
d) It positions prosthetic pillars for the placement of fixed
iii. Strong/heavy orthodontic forces, i.e., forces far exceeding
prostheses
capillary blood pressure, cause ischemia and degeneration of
the periodontal ligament on the compressed side resulting in e) It reduces bruxism during the mechanotherapy
hyalinization with more delay in tooth movement [5].
f) It allows the use of light, precise, and continuous tooth
Greenbaum studied the effects of slow and rapid maxillary movements.
expansion on the periodontium. They concluded that patients
The whole periodontal apparatus involving bone, periodontal
subjected to rapid maxillary expansion showed significantly lesser
ligament, and supporting tissues remodels with orthodontic
bone relative to the cemento-enamel junction when compared
therapy [11]. Resorption of alveolar bone seen on the pressure
to patients treated with slow expansion and the control group.
side and deposition on the tension side and periodontal ligament
However, they did not find any significant difference in probing
compresses and the blood vessels squeezes out which decreases
depth and width of attached gingival between the groups.
blood supply [11,12]. Hydrostatic pressure in the periodontal
Siew Han Chay has shown that gingival margin can be moved ligament decreases on application of excessive pressure, and if it is
incisally by as much as 9mm using orthodontic extrusion. Erkan localized to a specific region, potential of root resorption increases
observed that gingival margin and mucogingival junction moved in [15]. Apart from that, periodontal tissues having different types of
the same direction along with teeth by 79 and 62%, respectively, orthodontic tooth movement show variation in their response.
when mandibular incisor was intruded orthodontically. Extrusion of
Prevention of Periodontal Breakdown during
mandibular incisor produces gingival margin and the mucogingival
junction movement in the same direction as the extruded teeth by
Orthodontic Treatment
80 and 52.5%, respectively. This also results in reduction of the Orthodontic bands, brackets and wires not only test the patient’s
sulcus depth without significant reduction in the width of attached ability to maintain good oral hygiene, but also compromises the
gingival. Also, no attachment loss was observed [13]. self-cleansing property of the dentition. Orthodontic attachments
have the potential to cause plaque accumulation and increase the
A longitudinal study conducted by Alstad on patients
pathogenicity of the microbes. This tendency is often dealt with
undergoing orthodontic treatment did not report any significant
by thorough professional prophylaxis. Repeating the oral hygiene
loss of attachment. They concluded that if a professional preventive
instructions on each visit and rubber cup prophylaxis are effective
program is pursued throughout the course of orthodontic
measures to prevent plaque accumulation and gingival enlargement.
treatment, loss of attachment can be limited to less than 0.1mm per
Costa et al. compared the efficacy of manual, electric and ultrasonic
surface.
toothbrushes in patients undergoing fixed orthodontic therapy.
Orthodontic Treatment in Periodontally Susceptible They concluded that plaque scores on the buccal surfaces of teeth
Patient were lowered in patients using ultrasonic toothbrush. Also, S.
mutans count reduction was seen in patients using ultrasonic and
Patients who have susceptibility to periodontal disease can
electric toothbrushes. According to Hannah, oral hygiene can be
be subjected to orthodontic treatment under severe control.
improved in orthodontic patients by using a sanguinaria-containing
This is undertaken to prevent biofilm formation and to eliminate
toothpaste along with a sanguinaria-containing oral rinse [4].
periodontal pockets. Furthermore, the stable periodontal status is
maintained by the orthodontics [7-10]. Orthodontic Treatment as an Adjunct to Periodontal
Although there is no clear relationship between malocclusion Therapy
and periodontitis or between the effects of orthodontic tooth In many situations, orthodontic treatment can serve as an
movement and periodontal status, the literature explains clear adjunct to periodontal therapy. Various orthodontic treatments
interaction between orthodontist and periodontist [14]. such as uprighting, intrusion, and rotation are performed to correct
the pathologically migrated teeth that control further periodontal
Notable contributions of orthodontist in the field of periodontics
breakdown, improve oral function, and provide acceptable
are as follows:
aesthetics. These procedures should be performed only after
a) It provides well-shaped dental arches and helps in controlling the periodontal disease.
maintaining good oral hygiene. Malocclusion as a periodontal

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How to cite this article: Jeevan M K, Manjusha M J, Gaurav H T. Ortho- Perio Synergy - A Review. Mod Res Dent. 1(4). MRD.000518. 2018. 67
DOI: 10.31031/MRD.2018.01.000518
 Mod Res Dent Copyright © Manjusha M Jadhav

Although there is no consistent relation between malocclusion Patient’s compliance, motivation, and oral hygiene maintenance
and periodontal disease, certain characteristics of malocclusion will help determine the best time to start adjunctive orthodontic
can promote a pathologic environment and hinder periodontal treatment. It is suggested that tooth movement can be undertaken
therapy. [3] Correction of crowded or malposed teeth permit the 6 months after completion of active periodontal treatment if there
patient better access to clean all the surfaces of his/her teeth. Food is sufficient evidence of complete resolution of inflammation.
impactions are also reduced or eliminated by the creation of proper
Sanders has recommended a three-step comprehensive
arch form and proximal contact [6].
protocol to be followed before, during, and after adjunctive
Orthodontic uprighting of the tilted molars has several orthodontic therapy.
advantages: The distal movement tooth allows the deposition of
Periodontics as an Adjunct to Orthodontic Treatment
alveolar bone on the mesial defect. This also eliminates the gingival
folding and plaque retentive area on the mesial side [7]. On many occasions, a stable and esthetically acceptable
outcome cannot be achieved with orthodontics without adjunctive
Orthodontic extrusion of teeth may be indicated for shallowing
periodontal procedures. For instance, a high labial frenum
out intraosseous defects and for increasing the clinical crown
attachment is considered to be a causative factor of midline
length of single teeth. Extrusion results in coronal positioning of
diastema. Frenectomy is recommended in such cases as the fibres
intact connective tissue attachment along the tooth and also the
are thought to prevent the mesial migration of the central incisors.
bone deposition [8]. Orthodontic intrusion has been recommended
However, the timing of periodontal intervention has been a topic of
for teeth with horizontal bone defect or infrabony pockets, and
much debate.
for increasing the crown length of a single tooth. The intrusion
of plaque-infected teeth may lead to apical displacement of According to Vanarsdall, surgical removal of a maxillary
supragingival plaque, which results in periodontal destruction [9]. labial frenum should be delayed until after orthodontic treatment
Professional supragingival and subgingival scalings are important unless the tissue prevents space closure or becomes painful and
during the active phase of intrusion. traumatized. Forced eruption of a labially or palatally impacted
tooth is now a common orthodontic treatment procedure. Careful
Furcation defects require special attention during orthodontic
exposure of the impacted tooth while preserving keratinized tissue
treatment. They are difficult to maintain and can worsen during
requires the expertise of a periodontist. Preservation of keratinized
orthodontic treatment. In Class III furcation cases, a possible
tissue is important to prevent loss of attachment. The preferred
method for treating the furcation is by hemisecting the crown and
surgical procedure is primarily an apically or laterally positioned
root and pushing the roots apart may be advantageous [3]. The
pedicle graft [2,4].
hemiseptal defects can be eliminated using uprighting, extrusion,
and leveling of the bone defect [10]. Bodily movement of the tooth Retention of orthodontically achieved tooth rotation is a
into an intrabony defect has been believed to “carry the bone,” problem that has always plagued the orthodontist. Circumferential
along with the tooth, that results in improvement of the defect. supracrestal fiberotomy (CSF) is a procedure that is frequently
This could improve adjacent tooth position before placement of used to enhance post-treatment stability. Edwards concluded
implant or tooth replacement [6]. If the tooth is supraerupted with from his long-term prospective study that CSF is more successful
osseous defect, intrusion and leveling of the bone defect can help to in preventing relapse in the maxillary arch. According to him, CSF
eliminate these problems. does not affect the periodontium adversely [2].

Tullochis of the opinion that fixed appliance therapy is more Mucogingival surgeries may be needed during the course of
preferable if a patient is suffering from periodontitis. Fixed orthodontic treatment to maintain sufficient width of attached
appliance allows easy splinting of teeth to achieve stable anchorage. gingival. Also, crown lengthening procedures can facilitate easy
He also highlights the importance of reducing the force magnitude placement of orthodontic attachments on teeth with short clinical
and applying counteracting moments to reduce the stress on crowns. This procedure can also be used for smile designing.
periodontal ligament fibres. Alveolar ridge augmentation and placements of dental implants are
the other adjunctive periodontal treatment procedures undertaken
Lijian has enlisted the various precautions to be taken when
to facilitate achievement of orthodontic treatment goals [7,8].
attempting tooth movement in height-reduced periodontium, which
includes achieving stable anchorage and long-term periodontal There is an ever increasing concern for dentofacial esthetics
maintenance care. in adult population. The primary motivating factor for seeking
orthodontic treatment is dental appearance. Pathologic migration of
Deepa reported the use of orthodontic soft aligners in
anterior teeth is a common cause of esthetic concern among adults.
repositioning a periodontally involved tooth. Light and intermittent
The disruption of equilibrium in tooth position may be caused by
forces generated by the soft aligner allow regeneration of tissue
several etiologic factors. These include periodontal attachment loss,
during tooth movement. Along with periodontal procedures,
pressure from inflamed tissues, occlusal factors, oral habits such as
orthodontically assisted occlusal improvement may be required
tongue thrusting and bruxism, loss of teeth without replacement,
in treatment of patients with severely attrited lower anterior teeth
gingival enlargement and iatrogenic factors. However, according
[4].

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How to cite this article: Jeevan M K, Manjusha M J, Gaurav H T. Ortho- Perio Synergy - A Review. Mod Res Dent. 1(4). MRD.000518. 2018. 68
DOI: 10.31031/MRD.2018.01.000518
 Mod Res Dent Copyright © Manjusha M Jadhav

to the literature, destruction of tooth supporting structures is Later, the force might be increased up to 50-80g in bodily movement
the most relevant factor. The periodontal disease and its sequela and 30-50g in tipping, corresponding to a distance of movement of
such as diastema, pathological migration, labial tipping or missing 0.5-1.0mm per month, depending on the amount of the remaining
teeth often lead to functional and esthetic problems either alone alveolar bone and the degree of marginal bone loss [15].
or with restorative problems. Advanced periodontal disease is
Tooth Movement and Implant Aesthetics
characterized by severe attachment loss, reduced alveolar bone
support, tooth mobility and gingival recession. Orthodontic There are mainly three areas where orthodontics plays a role in
treatment is initiated only after periodontal disease is brought implant rehabilitation. The lack of adequate space for implant can
under control. This communication highlights good treatment be managed by orthodontic movement of the neighboring teeth to
outcome achieved in a patient with impaired dentofacial aesthetics an optimal position, which will allow redistribution of the available
and advanced periodontal disease [3]. space in the dental arch and provide space for implant placement
[8].
Lt. Col. M. Panwar et al. in 2010 presented a case report on
combined periodontal and orthodontic treatment of pathologic Selective orthodontic extrusion of a hopeless incisor or molar
migration of anterior teeth. Comprehensive orthodontics was may be useful to improve the placement of a single tooth implant
initiated with pre-adjusted edgewise appliances using very light by vertically increasing the height of the ridge upon extrusion. Both
force, which resulted in optimal biological response. Since there the alveolar bone and periodontal tissues follow the extruded tooth,
was trauma from lower anterior teeth, anterior bite plane allowed leading to bone formation in the direction of tooth movement.
posterior eruption of teeth, which resulted in the opening of the
The reduced buccolingual ridge thickness associated with
bite. The periodontal health improved the moment trauma was
extraction space shows difficulty in implant placement. It can
relieved. Periodontal treatment and the patient’s co-operation in
be managed by orthodontic movement of the adjacent tooth to
oral hygiene were also continued as supportive therapy [1,2].
the edentulous space, which results in bone deposition along
Michael et al. in 2009 provided the treatment options for the the tension side and the implant can be placed at the site of the
significant dental midline diastema. After the required prosthetic orthodontically moved tooth. This is an alternative to surgical
intervention, periodontal tissues were altered by gingivoplasty horizontal ridge augmentation [8].
and crown lengthening and provided optimal result with favorable
esthetic, functional, and biologic consequences [4].
Corticotomy-Assisted Orthodontics
Corticotomy-assisted orthodontics has been employed in
Orthodontic Treatment in Adults
various forms to accelerate orthodontic treatment. Rapid tooth
In the recent era, there is a raising influx of adult patients movement associated with corticotomy was first introduced by
seeking orthodontic treatment. Adult orthodontics need Henry Kole [11]. The cortical plates of the bone are believed to be
special consideration in several aspects such as psychosocial, the main resistance to orthodontic tooth movement. In corticotomy-
biological, mechanical, and age-related considerations such as assisted orthodontics, rapid tooth movement is achieved by
the aging of tissues, lack of growth potential, vulnerability to disrupting the continuity of the cortical bone by a selective cut and
temporomandibular joint (TMJ) disorder, and root resorption [7]. preserving the vitality of the teeth and marginal periodontium.

Age per se is not a contraindication to orthodontic treatment. The biology behind corticotomy-assisted orthodontics is the
Compared to children and teenagers, the tissue response to regional acceleratory phenomenon (RAP). It is a local response of
orthodontic force, especially cell mobilization and conversion the tissue to noxious stimuli, through which the tissue regenerates
of collagen fibers, is much slower in adults. The hyalinized zones at a faster rate than normal (without corticotomy). The areas
are easily formed on the pressure side of orthodontically moved around the cuts are associated with intensified bone response, i.e.,
teeth and it temporarily prevents tooth movement in the intended increased osteoblastic-osteoclastic activity and increased level of
direction. Once the hyalinized zone is eliminated, tooth movement inflammatory mediators, which accelerate the bone turnover and
can occur [1]. facilitate rapid orthodontic tooth movement [16].

Adult bone is less reactive to orthodontic force. Compared to Corticotomy-assisted orthodontics has several advantages
the elderly, there is a greater risk of marginal bone loss and loss such as this procedure reduces the treatment time and facilitates
of attachment with mild gingival infection. Loss of attachment expansion of the dental arch and produces less root resorption
results in apical shift of the center of resistance, thereby increasing rate compared to normal tooth movement due to decreased
the distance from the point of force application to the center of resistance from the cortical bone [2,3]. It also provides improved
resistance, which in turn increases the tipping moment produced postorthodontic stability and slower relapse tendency [14].
by the given force than that of the healthy tooth. Hence, the absolute
Periodontally Accelerated Osteogenic Orthodontics
magnitude of force should be reduced [7].
Periodontally accelerated osteogenic orthodontics (PAOO), also
Lindhe (1989) recommended the use of an interrupted force of termed Wilckodontics, was introduced by Wilcko et al. in 2001.
20-30g in adults during the initial stage of orthodontic treatment.

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How to cite this article: Jeevan M K, Manjusha M J, Gaurav H T. Ortho- Perio Synergy - A Review. Mod Res Dent. 1(4). MRD.000518. 2018. 69
DOI: 10.31031/MRD.2018.01.000518
 Mod Res Dent Copyright © Manjusha M Jadhav

It is a revised corticotomy-facilitated technique, which involves are the most commonly used material for band cementation. This
a full-thickness labial and lingual flap elevation accompanied by material exhibits a continuous release and uptake of fluoride, which
selective surgical scarring of the labial and lingual cortical bones has certain antibacterial activities. However, their antibacterial
(corticotomy) followed by placement of the graft material, surgical effect is limited to a relatively narrow spectrum of bacteria. Recent
closure, and orthodontic force application. studies have shown that the addition of chlorhexidine (CHD) to
resin composites and glass ionomer cements for cementation
Rapid tooth movement associated with PAOO is substantially
significantly improves the antibacterial effect. GICs with the
different from periodontal ligament cell-mediated tooth movement.
addition of 18% CHD showed significant inhibition of bacteria in
Recent evidence suggests that RAP is a localized osteoporosis
comparison with the control groups without compromising on the
state, which occurs as a part of healing and may be responsible for
mechanical properties [3,5].
rapid tooth movement associated with PAOO. The placement of
orthodontic appliance and its activation are typically done in the Accelerated Osteogenic Orthodontics and Periodontal
week before surgical procedure. However, in complex mucogingival Implications
procedures, the absence of orthodontic appliance may enable
In an attempt to reduce the treatment duration, procedures like
easier soft tissue manipulation and suturing. A heavy orthodontic
accelerated osteogenic orthodontics (AOOs) are being popularized.
force immediately after surgery is usually recommended in this
Kim et al. [9] reported rapid tooth movement when temporary
condition. The initiation of orthodontic force should not be delayed
anchorage devices were used in combination with AOO. However,
more than 2 weeks after surgery. The time period for RAP usually
this procedure involves decortications and subsequent placement
lasts for 4-6 months. A delay in activation of the orthodontic
of graft material. Hence, continuous periodontal monitoring is
appliance will fail to take full advantage of the regional acceleratory
required when this technique is employed. With the increasing
phenomenon [2].
popularity of these invasive procedures, partnership with a
Piezocision-Assisted Orthodontics periodontist will become indispensible for orthodontists in the
near future.
Piezosurgery assisted orthodontics is a new minimally invasive
surgical procedure introduced by Dibart et al. [8]. In this technique Esthetic Finishing of Treatment Results
microincision is performed on the buccal gingiva that allows the
Orthodontists experience different challenges in treating adults
piezoelectric knife to give osseous cuts to the buccal cortical plates
with a reduced periodontal support as compared to adolescents.
and initiate RAP. This procedure provides rapid tooth movement
Worn out tooth, abrasion, eroded teeth, missing papillae, and
without an extensive traumatic surgical approach. This procedure
unequal crown lengths are common problems, and an esthetic
also maintains the clinical benefit of the bone or soft tissue grafting,
appearance of the teeth and gingiva after bracket removal is
along with tunnel approach.
difficult to obtain. Many incisors in adults with malocclusions have
Piezosurgery works only on mineralized tissues, sparing soft more or less worn incisal edges. This represents an adaptation
tissues and producing micrometric and selective osteotomy cuts to the functional demands such as mastication, swallowing, and
without any osteonecrosis. Compared to the classic decortication respiration. Need for incisal grinding arises to correct rotations and
procedure, piezosurgery has added advantages such as being axial inclination of incisors; however, association with a therapeutic
minimally invasive, safe, and less traumatic to the patients. dentist is necessary. The papillae may be absent in patients with
Piezocision can also be combined with Invisalign in selected cases advanced periodontitis and also in cases of loss of the crestal bone
to produce outcomes that are less time-consuming as well as satisfy between the incisors, hence producing unaesthetic gaps between
the patient’s desire of aesthetic appliance. the teeth after orthodontic tooth movement. Recontouring of the
mesiodistal surfaces of the incisors during the orthodontic finishing
Biocompatible Orthodontic Materials
stage is the best method for correction of this problem [3,4].
It is a well known fact that orthodontic appliances provide a
good environment for oral microbes to thrive and cause diseases Retention Problems and Solutions
like dental caries or even periodontitis. It is thus natural for Adults and children show different tissue reactions with adult
clinicians to try out more biocompatible materials and reduce the being need a longer duration of retention than an adolescent
chances for microbial colonization. Chun et al. suggested surface as adults undergo extensive fixed appliance therapy. According
modification of orthodontic wires with photocatalytic TiO2 as to Proffit [17], resting pressures of lip, cheek, tongue, and forces
a method to prevent the development of dental plaque during produced by metabolic activity within the PDL are major factors
orthodontic treatment. From their experiment, they concluded that that decide the final teeth positioning. In an intact periodontium,
bacterial mass bound to the TiO2-coated orthodontic wires during forces from periodontal membrane counteract unbalanced tongue-
treatment was significantly lower than that of the uncoated wires. lip forces. Its stabilizing function fails when the periodontium
They also demonstrated the bactericidal effect of TiO2-coated breaks down and the incisors movement begins. Hence, permanent
orthodontic wires on S. mutans and P. gingivalis [14]. retention after the orthodontic correction is essential in persons
Since the last two decades or so, glass ionomer cements (GICs) with advanced periodontal disease.

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How to cite this article: Jeevan M K, Manjusha M J, Gaurav H T. Ortho- Perio Synergy - A Review. Mod Res Dent. 1(4). MRD.000518. 2018. 70
DOI: 10.31031/MRD.2018.01.000518
 Mod Res Dent Copyright © Manjusha M Jadhav

“Normal” retention may be sufficient for patients with minimum- 4. Kingsley NW (1880) Treatise on oral deformities as a branch of mechan-
to-moderate loss of periodontal tissue support. Flexible spiral wire ical surgery. D. Appleton and Company, New York, USA.

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Volume 1 - Issue - 4

How to cite this article: Jeevan M K, Manjusha M J, Gaurav H T. Ortho- Perio Synergy - A Review. Mod Res Dent. 1(4). MRD.000518. 2018. 71
DOI: 10.31031/MRD.2018.01.000518
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Volume 1 - Issue - 4

How to cite this article: Jeevan M K, Manjusha M J, Gaurav H T. Ortho- Perio Synergy - A Review. Mod Res Dent. 1(4). MRD.000518. 2018. 72
DOI: 10.31031/MRD.2018.01.000518