CHAPTER 56

Orthodontics: Interdisciplinary Periodontal and

Implant Therapy

CHAPTER 56A
Adjunctive Role of Orthodontic Therapy
†
Vincent G. Kokich

CHAPTER OUTLINE
Benefits of Orthodontic Therapy Orthodontic Treatment of Gingival Discrepancies
Preorthodontic Osseous Surgery (e-only) (e-only)
Orthodontic Treatment of Osseous Defects (e-only) Conclusion

For discussions of preorthodontic osseous surgery, orthodontic treatment of osseous defects, the orthodontic treatment of
gingival discrepancies, and implant interactions in orthodontics, please go to the companion website at www.expertconsult.com.

Orthodontic tooth movement may be of substantial beneit to the adult surfaces of their teeth. This could be a tremendous advantage for
periorestorative patient. Many adults who seek routine restorative patients who are susceptible to periodontal disease or do not have
dentistry have problems with tooth malposition, which compromises the dexterity to maintain oral hygiene.
their ability to clean and maintain their dentition. If these individuals 2. Vertical orthodontic tooth repositioning can improve certain types
also are susceptible to periodontal disease, tooth malposition may be of osseous defects in periodontal patients. Often, moving the
an exacerbating factor that could cause premature loss of speciic teeth. tooth eliminates the need for resective osseous surgery.
Orthodontic appliances have become smaller, less noticeable, 3. Orthodontic treatment can improve the aesthetic relationship of
and easier to maintain during orthodontic therapy. Many adults are the maxillary gingival margins before restorative dentistry. Aligning
taking advantage of the opportunity to have their teeth aligned to the gingival margins orthodontically avoids gingival recontouring,
improve the aesthetics of their smile. Underlying gingival or osseous which could also entail bone removal and exposure of the roots
periodontal defects often can be improved during orthodontic therapy of the teeth (eFig. 56A.1).
if the orthodontist is aware of the situation and designs the appropriate 4. Orthodontic therapy also beneits the patient with a severe fracture
tooth movement. In addition, implants have become a major part of of a maxillary anterior tooth that requires forced eruption to
the treatment plan for many adults with missing teeth. If adjacent permit adequate restoration of the root. Erupting the root allows
teeth have drifted into edentulous spaces, orthodontic therapy is the crown preparation to have suficient resistance form and
often helpful to provide the ideal amount of space for implants and retention for the inal restoration.
subsequent restorations. This chapter shows the ways in which 5. Orthodontic treatment allows open gingival embrasures to be
adjunctive orthodontic therapy can enhance the periodontal health corrected to regain lost papillae. If open gingival embrasures are
and restorability of teeth and presents the role of implant dentistry located in the maxillary anterior region, this can present an aesthetic
in both periodontics and orthodontics. problem. In most patients, these areas can be corrected with a
combination of orthodontic root movement, tooth reshaping, and
restoration.
Benefits of Orthodontic Therapy 6. Orthodontic treatment could improve adjacent tooth position-
Orthodontic therapy can provide several beneits to adult periodontal ing before implant placement or tooth replacement. This is
patients. The following seven factors should be considered: especially true for the patient who has been missing teeth
1. Aligning crowded or malpositioned maxillary or mandibular for several years and has drifting and tipping of the adjacent
anterior teeth permits adult patients better access to clean all dentition.
7. A common tooth malalignment problem that results in peri-
†
Deceased. odontal pockets is the mesially tipped molar. Orthodontic

582
 CHAPTER 56 Orthodontics 582.e1

Abstract
Orthodontic tooth movement may be of substantial beneit to the
adult periorestorative patient. Many adults who seek routine restorative
dentistry have problems with tooth malposition, which compromises
their ability to clean and maintain their dentition. If these individuals
also are susceptible to periodontal disease, tooth malposition may
be an exacerbating factor that could cause premature loss of speciic
teeth.

Keywords
orthodontic appliance
malposed teeth
tooth malposition
osseous defect
gingival embrasure
forced eruption
gingival discrepancies
edentulous spaces
582.e2 PART 3 CLINICAL PERIODONTICS

A B C

D E F
eFig. 56A.1 This patient initially had overlapped maxillary central incisors (A), and after initial orthodontic
alignment of the teeth, an open gingival embrasure appeared between the centrals (B). Radiography showed
that the open embrasure was caused by divergence of the central incisor roots (C). To correct the problem, the
central incisor brackets were repositioned (D), and the roots were moved together. This required restoration of
the incisal edges after orthodontic therapy (E) because these teeth had worn unevenly before therapy. As the
roots were paralleled (F), the tooth contact moved gingivally and the papilla moved incisally, resulting in elimination
of the open gingival embrasure.

A B

C D

E F
eFig. 56A.2 Before orthodontic treatment, this patient had significant mesial tipping of the maxillary right
first and second molars, causing marginal ridge discrepancies and deep periodontal pockets (A). The tipping
produced root proximity between the molars as well as a disruption of the normal gingival anatomy (B). To
eliminate the root proximity, the brackets were placed perpendicular to the long axes of the teeth (C). This
method of bracket placement facilitated root alignment and elimination of the root proximity, as well as leveling
of the marginal ridge discrepancies (D through F).
 CHAPTER 56 Orthodontics 583

uprighting of tipped molars corrects the deep gingival contours

and eliminates or reduces the mesial periodontal pocket
Conclusion
(eFig. 56A.2). There are many beneits to integrating orthodontics and periodontics
in the management of adult patients with underlying periodontal
defects. The key to treating these patients is communication and
LEARNING BOX 56A.1 proper diagnosis before orthodontic therapy, as well as continued
dialog during treatment. Not all periodontal problems are treated in
Orthodontic therapy can contribute in many ways to help patients with
the same way. This chapter provides a framework for the integration
periodontal problems. In selected cases, vertical orthodontic tooth reposition-
of orthodontics to solve periodontal problems.
ing can improve certain types of osseous defects to eliminate the need
for resective periodontal surgery. Many patients have crowded, malaligned, Case Scenarios are found on the companion website
and malpositioned maxillary or mandibular anterior teeth, presenting a www.expertconsult.com.
difficult biofilm control problem. Aligning the crowded teeth orthodontically
will help patients maintain improved biofilm control. The incorporation of References
orthodontic therapy in the treatment of these clinical periodontal problems
References can be found on the companion Expert
is a great aid to the clinician and the patient. Consult website at www.expertconsult.com.

CHAPTER 56B
Orthodontics, Implants, and Periodontal Interactions
Frank Celenza

CHAPTER OUTLINE
Introduction
Implant Interactions in Orthodontics (e-only)
Conclusion

one can utilize the body’s reparative and remodeling capacities to

Introduction effect periodontal alterations as a result of tooth movement. Further,
Whereas the interrelationships between the disciplines of orthodontics as implant modalities are called upon, a greater demand for accurate
and implantology might not seem close to the casual observer, in tooth position arises. Moreover, as more adult patients are seeking
fact they are quite intimate. In addition, the integration of periodontics orthodontic and implant treatment, an understanding of the need
with orthodontics and implants presents an even more interesting for and methods of ensuring periodontal health before and during
and important combination. Although the conventional orthodontic orthodontic and implant care becomes paramount. Consequently, the
patient might be quite different in nature from the periodontal patient, intimate relationships among these three distinct dental disciplines
there are many useful and interesting interactions between the dis- become apparent in both the treatment planning and treatment execution
ciplines that can and should be harnessed for the best treatment phases of therapy. We can truly address this topic as interdisciplinary
outcomes. This is especially true in current treatment planning in dentistry.
which implants are used as anchors to move teeth.
The conventional orthodontic patient might be characterized as
an adolescent or young adult, usually with a healthy, although not Conclusion
always complete, dentition. This patient most often does not present Signiicant and fascinating interplays exist between the practices of
with a signiicant medical or dental history. Conversely, the periodontal orthodontics and periodontics, which also includes implantology.
patient often does present with a signiicant and contributory medical Reciprocal relationships can be harnessed through proper sequencing
history and a long list of dental problems, which often includes of treatments to enhance outcomes. Utilization of various implants
restorative considerations. Further, the periodontium will be com- can facilitate orthodontic mechanotherapy, streamline treatment,
promised and in need of treatment, usually preparatory to orthodontic eliminate compliance dependency, improve predictability and even
intervention. Also, there will often be tooth replacement considerations introduce new treatment options. Conversely, orthodontic preparation
to be sequenced into the therapy. It is in this situation that implant prior to implant placement can yield a more favorable environment
therapy may be part of the treatment scenario. How, then, are these through orthodontically induced site development in which both
two divergent patient types to be managed by combining treatment hard and soft tissue can be augmented and remodeled. Further, spatial
modalities from these three disciplines? management of implant sites and neighboring tooth positions is often
This section delineates some of the interrelationships that can be essential to ideal implant location.
utilized for better therapeutic outcomes. When the clinician gains Periodontal treatment preparatory to orthodontic treatment is often
an appreciation for the periodontal apparatus that supports a tooth required to eliminate inlammation and bolster the investing tooth
and applies an understanding of the physiology of tooth movement, structures, thereby permitting successful tooth movement without
 CHAPTER 56 Orthodontics 583.e1

A B

C D

E F
eFig. 56A.3 This patient had a 6-mm probing defect distal to the maxillary right first molar (A). When this
area was flapped (B), a cratering defect was apparent. Osseous surgery was performed to alter the bony
architecture of the buccal and lingual surfaces to eliminate the defect (C and D). After 6 weeks, the probing
pocket defect had been reduced to 3 mm and orthodontic appliances were placed on the teeth (E). Because
the crater was eliminated before orthodontic therapy, the patient could maintain the area during and after
orthodontic treatment (F).

membranes, have been successful in regenerating three-wall defects.14

Preorthodontic Osseous Surgery If the result of periodontal therapy is stable 3 to 6 months after
The extent of periodontal osseous surgery depends on the type of periodontal surgery (eFig. 56A.4), orthodontic treatment may be
defect (e.g., crater, hemiseptal defect, three-wall defect, or furcation initiated.
lesion). The prudent clinician understands which defects can be
improved with orthodontic treatment and which will require pre-
orthodontic periodontal surgical intervention.
Orthodontic Treatment of Osseous Defects
Osseous Craters Hemiseptal Defects
An osseous crater is an interproximal, two-wall defect that does not Hemiseptal defects are one- or two-wall osseous defects that often
improve with orthodontic treatment. Some shallow craters (4 to are found around mesially tipped teeth (eFig. 56A.5) or teeth that
5 mm pocket) may be maintained nonsurgically during orthodontic have supererupted (eFig. 56A.6). Usually, these defects can be
treatment. However, if surgical correction is necessary, this type of eliminated with the appropriate orthodontic treatment. In the case
osseous lesion can easily be eliminated by reshaping the defect12,15 of the tipped tooth, uprighting2,5 and eruption of the tooth levels the
and reducing the pocket depth (eFig. 56A.3; see Chapter 62). This bony defect. If the tooth is supererupted, intrusion and leveling of
in turn enhances the ability to maintain these interproximal areas the adjacent cementoenamel junctions (CEJs) can help level the
during orthodontic treatment. The need for surgery is based on the osseous defect.
patient’s response to initial root planing, the patient’s periodontal It is imperative that periodontal inlammation be controlled before
resistance, the location of the defect, and the predictability of orthodontic treatment. This usually can be achieved with patient
maintaining defects nonsurgically while the patient is wearing education regarding bioilm control, initial debridement, and scaling
orthodontic appliances. and root planing. After the completion of orthodontic treatment,
these teeth should be stabilized for at least 6 months and reassessed
Three-Wall Intrabony Defects periodontally. Often, the pocket has been reduced or eliminated and
Three-wall osseous defects are amenable to pocket reduction with no further periodontal treatment is needed. It would be injudicious
regenerative periodontal therapy.1 Bone grafts using either autogenous to perform preorthodontic osseous corrective surgery on such lesions
bone from the surgical site or allografts, along with resorbable if orthodontics is part of the overall treatment plan.
583.e2 PART 3 CLINICAL PERIODONTICS

A B
eFig. 56A.4 This patient had a significant periodontal
pocket (A) distal to the mandibular right first molar.
Periapical radiograph (B) confirmed the osseous defect.
A flap was elevated (C), revealing a deep, three-wall
osseous defect. Freeze-dried bone (D) was placed in
the defect. Six months after the bone graft, orthodontic
treatment was initiated (E). The final periapical radiograph
shows that the preorthodontic bone graft helped regener-
ate bone and eliminate the defect distal to the molar
(F). C D

E F

A B
eFig. 56A.5 This patient was missing the mandibular
left second premolar, and the first molar had tipped
mesially (A). Pretreatment periapical radiograph (B)
revealed a significant hemiseptal osseous defect on the
mesial side of the molar. To eliminate the defect, the
molar was erupted, and the occlusal surface was
equilibrated (C). The eruption was stopped after the
bone defect was leveled (D). The posttreatment intraoral
photograph (E) and periapical radiograph (F) show that
the periodontal health was improved by orthodontic C D
correction of the hemiseptal defect.

E F
 CHAPTER 56 Orthodontics 583.e3

A B

C D

E F
eFig. 56A.6 This patient showed overeruption of the maxillary right first molar and a marginal ridge defect
between the second premolar and first molar (A). The pretreatment periapical radiograph (B) showed that the
interproximal bone was flat. To avoid creating a hemiseptal defect, the occlusal surface of the first molar was
equilibrated (C and D), and the malocclusion was corrected orthodontically (E and F).

may require endodontic therapy and restoration of the tooth because

LEARNING BOX 56A.2
of the required amount of reduction of the length of the crown. This
Excellent biofilm control before, during, and after orthodontic therapy is approach is acceptable if the treatment results in a more favorable
of utmost importance to prevent and control periodontal inflammation. bone contour between the teeth.
This is especially important during orthodontic therapy because biofilm Some patients have discrepancies between both the marginal
control is very difficult with the numerous appliances and brackets that ridges and the bony levels between two teeth. However, these dis-
are placed on the dentition. crepancies may not be of equal magnitude; orthodontic leveling of
the bone may still leave a discrepancy in the marginal ridges (see
eFig. 56A.2). In these patients, the crowns of the teeth should not
In the periodontally healthy patient, orthodontic brackets are be used as a guide for completing orthodontic therapy. The bone
positioned on the posterior teeth relative to the marginal ridges and should be leveled orthodontically, and any remaining discrepancy
cusps. However, some adult patients may have marginal ridge dis- between the marginal ridges should be equilibrated. This method
crepancies caused by uneven tooth eruption. When marginal ridge produces the best occlusal result and improves the patient’s periodontal
discrepancies are encountered, the decision as to where to place the health.
bracket or band is not determined by the anatomy of the tooth. In During orthodontic treatment, when teeth are being extruded to
these patients, it is important to assess these teeth radiographically level hemiseptal defects, the patient should be monitored regularly.
to determine the interproximal bone level. Initially, the hemiseptal defect has a greater sulcular depth and is
If the bone level is oriented in the same direction as the marginal more dificult for the patient to clean. As the defect is ameliorated
ridge discrepancy, leveling of the marginal ridges will level the bone. through tooth extrusion, interproximal cleaning becomes easier. The
However, if the bone level is lat between adjacent teeth (see eFig. patient should be recalled every 2 to 3 months during the leveling
56A.6) and the marginal ridges are at signiicantly different levels, process to control inlammation in the interproximal region.
orthodontic correction of the marginal ridge discrepancy produces
a hemiseptal defect in the bone. This could cause a periodontal Advanced Horizontal Bone Loss
pocket between the two teeth. After orthodontic treatment has been planned, one of the most
If the bone is lat and a marginal ridge discrepancy is present, important factors that determine the outcome of therapy is the location
the orthodontist should not level the marginal ridges orthodontically. of the bands and brackets on the teeth. In a periodontally healthy
In these situations, it may be necessary to equilibrate the crown of individual, the position of the brackets is usually determined by the
the tooth (see eFig. 56A.6). For some patients, the latter technique anatomy of the crowns of the teeth. Anterior brackets should be
583.e4 PART 3 CLINICAL PERIODONTICS

A B C

D E F
eFig. 56A.7 Before orthodontic treatment, this patient had a significant class III malocclusion (A). The maxillary
central incisors had overerupted (B) relative to the occlusal plane. Pretreatment periapical radiography (C)
showed that significant horizontal bone loss had occurred. To avoid creating a vertical periodontal defect by
intruding the central incisors, the brackets were placed to maintain bone height (D). The incisal edges of the
centrals were equilibrated (E), and the orthodontic treatment was completed without intruding the incisors (F).

positioned relative to the incisal edges. Posterior bands or brackets Furcation lesions require special consideration because they are
are positioned relative to the marginal ridges. If the incisal edges the most dificult lesions to maintain and can worsen during orth-
and marginal ridges are at the correct level, the CEJ will be at the odontic therapy. These patients should be maintained on a 2- to
same level. This relationship creates a lat, bony contour between 3-month recall schedule. Detailed periodontal instrumentation and
the teeth. However, if a patient has underlying periodontal problems bioilm control of these furcation lesions will help to minimize further
and signiicant alveolar bone loss around certain teeth, it is not periodontal breakdown.
appropriate to use the anatomy of the crown to determine bracket If a patient with a class III furcation defect will be undergoing
placement (eFig. 56A.7). orthodontic treatment, a possible method for treating the furcation
In a patient with advanced horizontal bone loss, the bone level is to eliminate it by hemisecting the crown and root of the tooth
may have receded several millimeters from the CEJ. As this occurs, (eFig. 56A.8). However, this procedure requires endodontic, peri-
the crown-to-root ratio becomes less favorable. By aligning the crowns odontal, and restorative treatment. If the patient will be undergoing
of the teeth, the clinician may perpetuate tooth mobility by maintaining orthodontic treatment, it is advisable to perform the orthodontic
an unfavorable crown-to-root ratio. In addition, aligning the crowns treatment irst. This is especially true if the roots of the teeth will
of the teeth and disregarding the bone level leads to signiicant bone not be moved apart. In these patients, the molar to be hemisected
discrepancies between healthy and periodontally diseased roots. This remains intact during orthodontic therapy. These patients require
could require periodontal surgery to ameliorate the discrepancies. recall visits every 2 or 3 months to ensure that the furcation defect
Many of these problems can be corrected by using the bone does not lose bone during orthodontic treatment. Keeping the tooth
level as a guide to position the brackets on the teeth (see eFig. intact during orthodontic therapy simpliies the concentration of tooth
56A.7). In these situations, the crowns of the teeth may require movement for the orthodontist. After orthodontic treatment, endodontic
considerable equilibration. If the tooth is vital, the equilibration therapy is required, followed by periodontal surgery to divide the
should be performed gradually to allow the pulp to form secondary tooth.
dentin and insulate the tooth during the equilibration process. The In some patients requiring hemisection of a mandibular molar
goal of equilibration and creative bracket placement is to provide a with a class III furcation, moving the roots apart during orthodontic
more favorable bony architecture and a more favorable crown-to-root treatment may be advantageous (eFig. 56A.9). If the hemisected
ratio. In some of these patients, the periodontal defects that were molar will be used as an abutment for a bridge after orthodontics,
apparent initially may not require periodontal surgery after orthodontic moving the roots apart orthodontically permits a favorable restoration
treatment. and splinting across the adjacent edentulous spaces. In these patients,
hemisection, endodontic therapy, and periodontal surgery must be
Furcation Defects completed before the start of orthodontic treatment. After completion
Furcation defects can be classiied as incipient (class I), moderate of these procedures, bands or brackets can be placed on the root
(class II), or advanced (class III). Chapter 62 discusses furcation fragments, and coil springs can be used to separate the roots. The
problems in detail.) These lesions require special attention in amount of separation is determined by the size of the adjacent
patients undergoing orthodontic treatment. Often, the molars require edentulous space and the occlusion in the opposing arch. About 7
bands with tubes and other attachments that impede access to the or 8 mm may be created between the roots of the hemisected molar.
buccal furcation for home care and instrumentation at the time This process eliminates the original furcation problem and allows
of recall. the patient to clean the area with greater eficiency.
 CHAPTER 56 Orthodontics 583.e5

A B C

D E F
eFig. 56A.8 This patient had a class III furcation defect before orthodontic treatment (A and B). Orthodontic
treatment was performed (C), and the furcation defect was maintained by the periodontist with 2-month recalls
until after orthodontic treatment. After appliance removal, the tooth was hemisected (D), and the roots were
restored and splinted together (E). The final periapical radiograph (F) shows that the furcation defect was
eliminated by hemisection and restoration of the two root fragments.

A B C

D E F
eFig. 56A.9 Before orthodontic treatment, this patient had a class III furcation defect in the mandibular left
second molar (A and B). Because the patient had an edentulous space mesial to the molar, the tooth was
hemisected (C), and the root fragments were separated orthodontically (D). After orthodontic treatment, the
root fragments were used as abutments to stabilize a multiunit posterior bridge (E and F).

In some molars with class III furcation defects, the tooth may LEARNING BOX 56A.3
have short roots, advanced bone loss, fused roots, or other problems Furcation problems, especially class III and IV lesions, are challenging to
that prevent hemisection and crowning of the remaining roots. In treat and maintain because of the difficulty in attaining access for biofilm
these patients, extracting the root with a furcation defect and placing control and for scaling and root planing. Hemisection of a furcated molar
an implant may be more advisable11 (eFig. 56A.10). If this type of after endodontic therapy followed by orthodontic separation of the remaining
plan has been adopted, extraction and placement of the implant can roots is expensive and time-consuming and may still have a questionable
occur at any time relative to the orthodontic treatment. In some outcome. With the advent of predictable implant therapy, extraction of
patients, the implant can be used as an anchor to facilitate prerestor- such a tooth should be considered.
ative orthodontic treatment.
583.e6 PART 3 CLINICAL PERIODONTICS

A B C

D E F
eFig. 56A.10 This patient was missing several teeth in the mandibular left posterior quadrant (A). The
mandibular left third molar had a class III furcation defect and short roots (B). The third molar was extracted,
and two implants were placed in the mandibular left posterior quadrant (C). The implants were used as anchors
to facilitate orthodontic treatment (D) and help reestablish the left posterior occlusion (E and F).

The implant must remain embedded in bone for 4 to 6 months the gingival margin and terminates at the level of the alveolar ridge
after placement before it can be loaded as an orthodontic anchor. It (eFig. 56A.11). Restoration of the fractured crown is impossible
must be placed precisely so that it not only provides an anchor for because the tooth preparation would extend to the level of the bone.
tooth movement but also may be used as an eventual abutment for This overextension of the crown margin could result in an invasion
a crown or ixed bridge. If the implant will not be used as an anchor of the biologic width of the tooth and cause persistent inlammation
for orthodontic movement, it may be placed after the orthodontic of the marginal gingiva. It may be beneicial in such cases to erupt
treatment has been completed. Considerations regarding timing are the fractured root out of the bone and move the fracture margin
determined by the restorative treatment plan (see later discussion). coronally so that it can be properly restored.10 However, if the fracture
extends too far apically, it may be better to extract the tooth and
Root Proximity replace it with an implant or bridge. The following six criteria are
When roots of posterior teeth are close together, the ability to maintain used to determine whether the tooth should be forcibly erupted or
periodontal health and accessibility for restoration of adjacent teeth extracted:
may be compromised.4 However, for the patient undergoing orth- 1. Root length. Is the root long enough so that a one-to-one crown-
odontic therapy, the roots can be separated and bone will form between to-root ratio can be preserved after the root has been erupted?
adjacent roots (see eFig. 56A.2). This opens the embrasure beneath To answer this question, the clinician must know how far to erupt
the tooth contact, provides additional bone support, and enhances the root. If a tooth fracture extends to the level of the bone, it
the patient’s access to the interproximal region for hygiene. This must be erupted 4 mm. The irst 2.5 mm moves the fracture
approach generally improves the periodontal health of this area. margin far enough away from the bone to prevent a biologic
If orthodontic treatment will be used to separate the roots, this width problem. The other 1.5 mm provides the proper amount
plan must be understood before bracket placement. It is advantageous of ferrule for adequate resistance form of the crown preparation.
to place the brackets so that the orthodontic movement to separate Therefore, if the root is fractured to the bone level and must be
the roots will begin with the initial archwires (see eFig. 56A.2). erupted 4 mm, the periapical radiograph must be evaluated (see
Brackets must be placed obliquely to facilitate this process. Radiographs eFig. 56A.10B) and 4 mm subtracted from the end of the fractured
are needed to monitor the progress of orthodontic root separation. tooth root. The length of the residual root should be compared
In general, 2 to 3 mm of root separation provides adequate bone and with the length of the eventual crown on this tooth. The root-to-
embrasure space to improve periodontal health. During this time, crown ratio should be about 1:1. If the root-to-crown ratio is less
patients should be maintained on recall to ensure that a favorable than that, there may be too little root remaining in the bone for
bone response occurs as the roots are moved apart. In addition, these stability. In this situation, it may be prudent to extract the root
patients need occasional occlusal adjustment to recontour the crown and place a bridge or implant.
because the roots are moving apart. As this occurs, the crown may 2. Root form. The shape of the root should be broad and nontapering
develop an unusual occlusal contact with the opposing arch. This rather than thin and tapered. A thin, tapered root provides a
should be equilibrated to improve the occlusion. narrower cervical region after the tooth has been erupted 4 mm.
This could compromise the aesthetic appearance of the inal
Fractured Teeth and Forced Eruption restoration. The internal root form is also important. If the root
Occasionally, children and adolescents fall and injure their anterior canal is wide, the distance between the external root surface and
teeth. If the injury is minor and results in a small fracture of enamel, the root canal illing will be narrow. In these patients, the walls
this can be restored with light-cured composite or porcelain veneer. of the crown preparation are thin, which could result in early
In some patients, however, the fracture extends beneath the level of fracture of the restored root. The root canal should not be more
 CHAPTER 56 Orthodontics 583.e7

A B

C D

E F
eFig. 56A.11 This patient had a severe fracture of the maxillary right central incisor (A) that extended apical
to the level of the alveolar crest on the lingual side (B). To restore the tooth adequately and avoid impinging
on the periodontium, the fractured root was extruded 4 mm (C). As the tooth erupted, the gingival margin
followed the tooth (D). Gingival surgery was required to lengthen the crown of the central incisor (E), so that
the final restoration had sufficient ferrule for resistance and retention as well as the appropriate gingival margin
relationship with the adjacent central incisor (F).

than one-third of the overall width of the root, so that the root tooth can vary from elastic traction to orthodontic banding and
can still provide adequate strength for the inal restoration. bracketing. If a large portion of the tooth is still present, orthodontic
3. Level of the fracture. If the entire crown is fractured 2 to 3 mm bracketing is necessary. If the entire crown has fractured, leaving
apical to the level of the alveolar bone, it is dificult, if not only the root, elastic traction from a bonded bar may be possible.
impossible, to attach to the root to erupt it. The root may be erupted rapidly or slowly. If the movement is
4. Relative importance of the tooth. If the patient is 70 years of age performed rapidly, the alveolar bone will be left behind temporarily,
and both adjacent teeth have prosthetic crowns, it would be more and a circumferential iberotomy may be performed to prevent bone
prudent to construct a ixed bridge. However, if the patient is 15 from following the erupted root. However, if the root is erupted
years of age and the adjacent teeth are unrestored, forced eruption slowly, the bone follows the tooth. In this situation, the erupted root
would be much more conservative and appropriate. requires crown lengthening to expose the correct amount of tooth
5. Aesthetics. If the patient has a high lip line and displays 2 to to create the proper ferrule, resistance form, and retention for the
3 mm of gingiva when smiling, any type of restoration in this inal restoration.
area will be more obvious. Keeping the patient’s own tooth would After the tooth root has been erupted, it must be stabilized to
be much more aesthetic than any type of implant or prosthetic prevent it from intruding back into the alveolus. The reason for
replacement. reintrusion is to orient the principal ibers of the periodontium.
6. Endodontic/periodontal prognosis. If the tooth has a signiicant During forced eruption, the periodontal ibers become oriented
periodontal defect, it may not be possible to retain the root. In obliquely and stretched as the root moves coronally. These ibers
addition, if the tooth root has a vertical fracture, the prognosis eventually reorient themselves after about 6 months. Before this
would be poor, and extraction of the tooth would be the proper occurs, the root can reintrude signiicantly. Therefore, if this
course of therapy. type of treatment is performed, an adequate period of stabiliza-
If all these factors are favorable, forced eruption of the fractured tion is necessary to avoid signiicant relapse and reintrusion of
root is indicated. The orthodontic mechanics necessary to erupt the the root.
583.e8 PART 3 CLINICAL PERIODONTICS

A B

C D

E F
eFig. 56A.12 This patient had an impacted mandibular right second molar (A). The mandibular right first
molar was periodontally hopeless because of an advanced class III furcation defect. The impacted second molar
was extracted, but the first molar was maintained as an anchor to help upright the third molar orthodontically
(B through D). After orthodontic uprighting of the third molar, the first molar was extracted and a bridge was
placed to restore the edentulous space (E and F).

As the root erupts, the gingiva moves coronally with the tooth. teeth may be useful for orthodontic anchorage if the periodontal
As a result, the clinical crown length becomes shorter after extrusion inlammation can be controlled. In moderate to advanced cases,
(see eFig. 56A.10). In addition, the gingival margin may be positioned some periodontal surgery may be indicated around a hopeless
more incisally than the adjacent teeth. In these patients, gingival tooth. Flaps are relected for debridement of the roots to control
surgery is necessary to create ideal gingival margin height. The type inlammation around the hopeless tooth during the orthodontic
of surgery varies, depending on whether bone removal is necessary. process. The important factor is to maintain the health of the bone
If the bone has followed the root during eruption, a lap is elevated around the adjacent teeth. Periodontal recall is imperative during
and the appropriate amount of bone is removed to match the bone this process.
height of the adjacent teeth. If the bone level is lat between adjacent Treatment of orthodontic, periodontal, and restorative cases can
teeth, a simple excisional gingivectomy corrects the gingival margin be planned from many perspectives based on the choices made by
discrepancy. the patient after discussion with the clinician, inancial and time
After gingival surgery, an open gingival embrasure may exist commitment, complexity of the case, and other factors that must
between the erupted root and adjacent teeth (see eFig. 56A.10). The be considered before deciding on the therapy that will be insti-
space occurs because the narrower root portion of the erupted tooth tuted. The case presented in eFig. 56A.12 involved a dificult and
has been moved into the oral cavity. This space may be closed in complex therapy that was beautifully executed using a hopeless
two ways: (1) overcontouring of the replacement restoration or (2) irst molar as an anchor to upright and move a third molar mesi-
reshaping of the crown of the tooth and movement of the root to ally into the position of the impacted second molar, which was
close the space. The second method often helps improve the overall extracted. The third molar was eventually used as an abutment
shape of the inal crown on the restored tooth. for a ixed bridge. Removal of all three molars would have been
an alternative and possibly simpler treatment in this case. Bone
Hopeless Teeth Maintained for Orthodontic grafting of the extraction site could be done if necessary, waiting
Anchorage for healing before placement of implants at the sites of the irst and
Patients with advanced periodontal disease may have speciic second molars.
teeth that are diagnosed as hopeless and would be extracted After orthodontic treatment, there is a 6-month period of stabiliza-
before orthodontic therapy (eFig. 56A.12). However, these tion before reevaluation of the periodontal status. Occasionally, the
 CHAPTER 56 Orthodontics 583.e9

hopeless tooth may be so improved after orthodontic treatment that 2. The gingival margins of the central incisors should be positioned
it is retained. In most cases, however, the hopeless tooth requires more apically than the lateral incisors and at the same level as
extraction, especially if other restorations are planned in the segment. the canines.13
Again, these decisions require reevaluation by the clinician. 3. The contour of the labial gingival margins should mimic the
CEJs of the teeth.
4. A papilla should exist between each tooth, and the height of
LEARNING BOX 56A.4 the tip of the papilla is usually halfway between the incisal
Periodontal diagnosis, prognosis, and treatment planning are important edge and the labial gingival height of contour over the center
in deciding when a tooth is hopeless because there are orthodontic cases of each anterior tooth. Therefore, the gingival papilla occupies
where this knowledge is utilized to decide when a tooth can be used as half of the interproximal contact and the adjacent teeth form the
a temporary anchor. When a tooth is used for this purpose, the patient other half.
is instructed on biofilm control and the tooth is scaled and root planed to However, some patients have gingival margin discrepancies
eliminate the inflammation. When the tooth is no longer needed for between adjacent teeth (eFig. 56A.13). These discrepancies may be
orthodontic anchorage, it can be extracted. caused by abrasion of the incisal edges or by delayed migration of
the gingival margins. When gingival margin discrepancies are present,
the proper solution for the problem must be determined: orthodontic
movement to reposition the gingival margins or surgical correction
Orthodontic Treatment of Gingival of the discrepancies.
Discrepancies To make the correct decision, it is necessary to evaluate four
Uneven Gingival Margins criteria. First, the relationship between the gingival margin of the
The relationship between the gingival margins of the six maxillary maxillary central incisors and the lip line should be assessed when
anterior teeth plays an important role in the aesthetic appearance of the the patient smiles. If a gingival margin discrepancy is present but
crowns. The following four factors contribute to ideal gingival form: is not exposed, it does not require correction.
1. The gingival margins of the two central incisors should be at the If a gingival margin discrepancy is apparent, the second step is
same level. to evaluate the labial sulcular depth over the two central incisors.

A B

C D

E F
eFig. 56A.13 This patient had a protrusive bruxing habit that resulted in abrasion and overeruption of the
maxillary right central incisor (A). The objective was to level the gingival margins during orthodontic therapy.
Although gingival surgery was a possibility, the labial sulcular depth of the maxillary right central incisor was
only 1 mm, and the cementoenamel junction was located at the bottom of the sulcus. Therefore, the best
solution involved positioning the orthodontic brackets to facilitate intrusion of the right central incisor (B through
D). This permitted the restorative dentist to restore the portion of the tooth that the patient had abraded (E),
resulting in the correct gingival margin levels and crown lengths at the end of treatment (F).
583.e10 PART 3 CLINICAL PERIODONTICS

If the shorter tooth has a deeper sulcus, excisional gingivectomy Two options are available. One option is extensive crown lengthening
may be appropriate to move the gingival margin of the shorter by elevating a lap, removing suficient bone, and apically position-
tooth apically. However, if the sulcular depths of the short and ing the lap to expose adequate tooth length for crown preparation.
long incisors are equivalent, gingival surgery does not correct the However, this procedure is contraindicated in the patient with short,
problem. tapered roots because it could adversely affect the inal root-to-
The third step is to evaluate the relationship between the shortest crown ratio and potentially open gingival embrasures between the
central incisor and the adjacent lateral incisors. If the shortest central anterior teeth.
incisor is still longer than the lateral incisors, the other possibility The other option for improving the restorability of these short
is to extrude the longer central incisor and equilibrate the incisal abraded teeth is to intrude the teeth orthodontically and move the
edge. This moves the gingival margin coronally and eliminates the gingival margins apically (see eFig. 56A.14). It is possible to intrude
gingival margin discrepancy. However, if the shortest central incisor up to four maxillary incisors by using the posterior teeth as anchors
is shorter than the lateral incisors, this technique would produce an during the intrusion process. This is accomplished by placing the
unaesthetic relationship between the gingival margins of the central orthodontic brackets as close to the incisal edges of the maxillary
and lateral incisors. incisors as possible. The brackets are placed in their normal position
The fourth step is to determine whether the incisal edges have on the canines and remaining posterior teeth. The patient’s posterior
been abraded. This is best accomplished by evaluating the teeth from occlusion resists the eruption of the posterior teeth, and the incisors
an incisal perspective. If one incisal edge is thicker labiolingually gradually intrude and move the gingival margins and the crowns
than on the adjacent tooth, this may indicate that it has been abraded apically. This creates the space necessary to restore the incisal edges
and the tooth has overerupted. In such cases, the best method of of these teeth temporarily and eventually to place the inal crowns.
correcting the gingival margin discrepancy is to intrude the short When abraded teeth are signiicantly intruded, it is necessary to
central incisor (see eFig. 56A.13). This method moves the gingival hold these teeth for at least 6 months in the intruded position with
margin apically and permits restoration of the incisal edges.3,6-9 The orthodontic brackets or archwires (or both) or some type of bonded
intrusion should be accomplished at least 6 months before appliance retainer. The principal ibers of the periodontium must accommodate
removal. This allows reorientation of the principal ibers of the to the new intruded position, a process that takes a minimum of 6
periodontium and avoids reextrusion of the central incisor or incisors months in most adult patients. Orthodontic intrusion of severely
after appliance removal. abraded and overerupted teeth usually carries a distinct advantage
compared with periodontal crown lengthening, unless the patient
Significant Abrasion and Overeruption has extremely long and broad roots or has had extensive horizontal
Occasionally, patients have destructive dental habits, such as pro- periodontal bone loss.
trusive bruxing, that can result in signiicant wear of the maxillary
and mandibular incisors and compensatory overeruption of these Open Gingival Embrasures
teeth (eFig. 56A.14). The restoration of these abraded teeth is The presence of a papilla between the maxillary central incisors is
often impossible because of the lack of crown length to achieve a key aesthetic factor in any individual. Occasionally, adults have
adequate retention and resistance form for the crown preparations. open gingival embrasures or lack gingival papillae between their

A B C

D E F
eFig. 56A.14 This patient had a protrusive bruxing habit that caused severe abrasion of the maxillary anterior
teeth, resulting in the loss of over half of the crown length of the incisors (A and B). Two possible options
existed for gaining crown length to restore the incisors. One option was an apically positioned flap with osseous
recontouring, which would expose the roots of the teeth. The less destructive option was to intrude the four
incisors orthodontically, level the gingival margins (C and D), and allow the dentist to restore the abraded incisal
edges (E and F). The orthodontic option was clearly successful and desirable in this patient.
 CHAPTER 56 Orthodontics 583.e11

A B

C D

E F
eFig. 56A.15 This patient initially had triangular-shaped central incisors (A and B), which produced an open
gingival embrasure after orthodontic alignment (C). Because the roots of the central incisors were parallel to
one another, the appropriate solution for the open gingival embrasure was to recontour the mesial surfaces of
the central incisors (D). As the diastema was closed (E), the tooth contact moved gingivally and the papilla
moved incisally, resulting in the elimination of the open gingival embrasure (F).

central incisors. These unaesthetic areas are often dificult to resolve repositioned so that the root position can be corrected (see eFig.
with periodontal therapy. However, orthodontic treatment can correct 56A.1). In these patients, the incisal edges may be uneven and
many of these open gingival embrasures. This open space is usually require either composite or porcelain restoration. If the periapical
caused by (1) tooth shape, (2) root angulation, or (3) periodontal radiograph shows that the roots are in their correct relationship,
bone loss.9 the open gingival embrasure is caused by a triangular tooth shape
The interproximal contact between the maxillary central incisors (eFig. 56A.15).
consists of two parts: the tooth contact and the papilla. The papilla/ If the shape of the tooth is the problem, two solutions are possible:
contact ratio is 1:1. Half the space is occupied by papilla, and half (1) restore the open gingival embrasure or (2) reshape the tooth
is formed by the tooth contact. If the patient has an open embrasure, by lattening the incisal contact and closing the space (see eFig.
the irst factor that must be evaluated is whether the problem is 56A.15). This second option results in lengthening of the contact
caused by the papilla or the tooth contact. If the papilla is the problem, until it meets the papilla. In addition, if the embrasure space is large,
the cause is usually a lack of bone support for the papilla due to an closing the space squeezes the papilla between the central incisors.
underlying periodontal problem. This helps create a 1:1 ratio between the contact and the papilla and
In some situations, a deicient papilla can be improved with restores uniformity to the height between the midline and adjacent
orthodontic treatment. By closing open contacts, the interproximal papillae.
gingiva can be squeezed and moved incisally. This type of movement
may help create a more aesthetic papilla between two teeth despite
alveolar bone loss. Another possibility is to erupt adjacent teeth LEARNING BOX 56A.5
when the interproximal bone level is positioned apically. Orthodontic therapy to assist the periodontal patient with the aesthetic
Most open embrasures between the central incisors are caused problem of missing interdental papilla is important because it is dif-
by problems with tooth contact. The irst step in the diagnosis of ficult, and in many cases impossible, to surgically create a missing
this problem is to evaluate a periapical radiograph of the central papilla.
incisors. If the root angulation is divergent, the brackets should be
583.e12 PART 3 CLINICAL PERIODONTICS

CASE SCENARIO 56A.1

Orthodontic, periodontal, and restorative treatment can be approached in therapy that was beautifully executed using a hopeless irst molar as an
multiple ways, depending on choices made by the patient after discussion anchor to upright and move mesially a third molar into the position of
with the clinician, inancial and time commitment, complexity of the the impacted second molar, which was extracted. The third molar was
case, and other factors that must be considered before deciding on eventually used as an abutment for a ixed bridge.
therapy. The case presented in eFig. 56A.12 was a dificult and complex

QUESTION
What would be another alternative and possibly a simpler way to
treatment plan this case?

ANSWER
(Please refer to eFig. 56A.12) The removal of all three molars. Possibly wait for the healing of the extraction site, and then place implants at the
bone graft the site, if necessary, where the three molars are extracted, site of the irst and second molars.

8. Kokich V: Esthetics: the orthodontic-periodontic-restorative connection,

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