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case report a modified orthodontic protocol for advanced periodontal disease in class ii division 1 malocclusion marcos janson,a guilherme janson,b and oscar edwin francisco murillo-goizuetac bauru brazil an interdisciplinary approach is often the best option for achieving a predictable outcome for an adult patient with complex clinical problems this case report demonstrates the combined periodontal/orthodontic treatment for a 49-year-old woman presenting with a class ii division 1 malocclusion with moderate maxillary anterior crowding a 9-mm overjet and moderate to severe bone loss as the main characteristics of the periodontal disease the orthodontic treatment included 2 maxillary first premolar extractions through forced extrusion active orthodontic treatment was completed in 30 months the treatment outcomes including the periodontal condition were stable 17 months after active orthodontic treatment the advantages of this interdisciplinary approach are discussed periodontally compromised orthodontic patients can be satisfactorily treated achieving most of the conventional orthodontic goals if a combined orthodontic/periodontic approach is used am j orthod dentofacial orthop 2011;139:s133-44 rthodontic treatment is no longer a contraindication in the therapy of severe adult periodontal disease or in the maintenance of a healthy periodontium.1 in fact orthodontic treatment could enhance the possibility of saving and restoring a deteriorated dentition advanced periodontal disease is primarily characterized as severe attachment loss and a reduction of alveolar bone support and the periodontal condition is usually characterized by tooth mobility migration spacing and marginal gingival recession in the maxillary anterior region functional discomfort is usually accompanied by compromised esthetics.1,2 orthodontic treatment for realignment of migrated periodontally involved teeth is initiated only after control of the periodontal inflammation has been achieved.3,4 if the patient is o private practice bauru brazil professor and head department of orthodontics bauru dental school university of s~o paulo bauru brazil a c orthodontic graduate student department of orthodontics bauru dental school university of s~o paulo bauru brazil a the authors report no commercial proprietary or financial interest in the products or companies described in this article reprint requests to dr guilherme janson department of orthodontics bauru dental school university of s~o paulo alameda octvio pinheiro brisolla a a 9-75 bauru sp 17012-901 brazil e-mail jansong@travelnet.com.br submitted december 2008 revised february 2009 accepted march 2009 0889-5406 36.00 copyright Ó 2011 by the american association of orthodontists doi:10.1016/j.ajodo.2009.03.053 b a reasonably motivated and responds well to the initial periodontal therapy adult orthodontic treatment has a role in providing complete rehabilitation in terms of both function and appearance with a satisfactory long-term prognosis.5 good oral hygiene at home and professional maintenance visits are important during and after active orthodontic treatment in this periodontally compromised case a successful result was achieved with improvement of oral hygiene periodontal prognosis esthetics masticatory function and self-confidence this case report presents a modified unusual periodontal-orthodontic approach in an adult woman presenting with a class ii division 1 malocclusion with advanced periodontal disease horizontal and vertical loss of alveolar bone in whom 2 first maxillary premolar extractions were performed after forced extrusion both maxillary central incisors were also extruded to correct the bone and gingival levels providing better esthetics and function introduction diagnosis and etiology a 49 year-old female patient with severe periodontal disease came to the private orthodontic office of one of us m.j with the chief complaint about her maxillary anterior dental appearance she had no systemic problems the initial examination demonstrated an acute nasolabial angle and a strained lip closure significant s133

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s134 janson janson and murillo-goizueta fig 1 pretreatment facial and intraoral photographs fig 2 pretreatment dental casts april 2011 vol 139 issue 4 supplement 1 american journal of orthodontics and dentofacial orthopedics

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janson janson and murillo-goizueta s135 fig 3 pretreatment periapical radiographs gingival recession was noted labial to both maxillary first premolars the maxillary and mandibular left molars and the maxillary anterior segment caused by previous periodontal surgery [resection with an open gingival embrasure fig 1 between the central incisors a furcation defect was present on the buccal surface of the mandibular left first molar a complete class ii molar relationship on both sides with severe maxillary protrusion and an overjet of 9 mm was identified the maxillary and mandibular incisors were crowded with mild migration and moderate rotation fig 2 probing of the periodontal attachment has been and still is the gold standard for diagnosis of active disease or progression of disease.6 pretreatment periodontal probing demonstrated depths ranging from 3 to 8 mm except for the maxillary lateral incisors and canines and the mandibular canines examination of radiographs taken before periodontal treatment demonstrated generalized horizontal bone loss in both arches and vertical bone defects in the maxillary first premolars and in the maxillary and mandibular second molars fig 3 the cephalometric analysis showed a skeletal class ii jaw base relationship anb angle 7.4 with mandibular retrusion snb angle 71.3 a convex skeletal profile nap angle 13.7 a dolichofacial pattern with an increased sn-gogn angle 41.6 and protruded and labially tipped mandibular incisors table i fig 4 treatment objectives the main objectives were to reduce or keep the defects at the same level eliminate primary and secondary occlusal trauma by providing a functional occlusion7 and fixed retention between the teeth with bone loss reduce the maxillary incisor protrusion achieve an ideal overjet and overbite and achieve satisfactory facial esthetics it was also desirable to eliminate crowding and to correct the mesial inclination of the mandibular molars treatment alternatives one of the treatment options was to align the teeth without extractions reducing the vertical defects of american journal of orthodontics and dentofacial orthopedics april 2011 vol 139 issue 4 supplement 1

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s136 janson janson and murillo-goizueta table i cephalometric analysis 49 y 03 mo 8/4/04 variables pretreatment maxillary component 78.8 sna angle a-nperp mm À 1.8 mandibular component 71.3 snb angle pog-nperp mm À17.1 maxillomandibular relationship 7.4 anb angle wits appraisal mm 9.3 growth pattern 30.6 fma angle 19.0 sn.op 41.6 sn.gogn 78.7 facial axis lower anterior facial 72.6 height lafh mm profile 13.7 convexity 99.3 nl angle dentoalveolar component 20.0 upper 1 to na upper 1 to na mm 5.8 31.8 lower 1 to nb lower 1 to nb mm 8.3 96.6 lower 1 to mp dental relationships 117.3 interincisal overjet mm 9.0 overbite mm 4.1 52 y 07 mo 5/25/07 posttreatment 78.3 À1.5 70.1 À18.4 8.2 6.4 31.4 22.6 42.6 77.4 75.2 14.6 101.5 7.3 À0.1 37.0 10.1 103.1 fig 4 pretreatment lateral cephalogram 123.8 1.6 1.7 first premolars the patient preferred and chose the second option treatment planning the maxillary premolars and the coronal height of central incisors by selective forced eruption and to perform interproximal enamel reduction in the maxillary arch to reduce the overjet this option although not ideal would be more conservative decreasing the root resorption risk of the anterior teeth the second option was extraction of the maxillary first premolars but only after both teeth were forced to gradually extrude slow extraction inducing bone and gingival apposition and remodeling of the alveolar ridges subsequently maxillary protrusion would be reduced endodontic root treatment as well as extraction of the maxillary first premolars would be the biological and additional cost of this alternative this slow forced eruption would also be applied to the maxillary central incisors to obtain a better crown-root proportion and to re-establish anterior esthetics with proper crown height the last treatment option was to reduce maxillary protrusion with orthognatic surgery and to reduce the periodontal pockets and bony defects of the maxillary the key element in orthodontic management of adult patients with periodontal complications is to eliminate or reduce plaque accumulation and gingival inflammation in this patient this would imply an emphasis on oral hygiene instruction appliance construction and 3-month periodontal check-ups throughout treatment.8 the extraction of 2 maxillary premolars with more periodontal involvement would be performed only after both teeth were gradually extruded forced extrusion with concurrent occlusal trimming to allow gingival and bone apposition and remodeling of the alveolar process once leveling and alignment were completed anterior retraction would be performed with maxillary and mandibular 0.018 3 0.025-inch stainless steel arch wires after anterior retraction forced extrusion would also be induced for the maxillary central incisors to achieve better gingival margin levels and create new papillae after appliance removal a modified maxillary hawley retainer and a canine-to-canine mandibular retainer would be installed and bonded respectively reinstructing the april 2011 vol 139 issue 4 supplement 1 american journal of orthodontics and dentofacial orthopedics

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janson janson and murillo-goizueta s137 fig 5 intraoral progress photographs and periapical radiographs to show bone topography on maxillary premolars american journal of orthodontics and dentofacial orthopedics april 2011 vol 139 issue 4 supplement 1

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s138 janson janson and murillo-goizueta fig 6 posttreatment facial and intraoral photographs patient about oral hygiene measures would be carried out to prevent an increase of the labial gingival recession finally she would be referred to her periodontist methods initial periodontal conditions were improved by scaling and root planing before starting the orthodontic treatment after a 4-month observation period a careful clinical examination and recording of the periodontal status were performed before orthodontic treatment was initiated this examination consisted of probing every tooth and checking for mobility bleeding points and exudation treatment was simultaneously initiated in the maxillary and mandibular arches with 0.022 3 0.028-inch preadjusted appliances elation esthetic brackets dentsply gac international bohemia ny and morelli metal brackets roth prescription sorocaba sp brazil progressively bonded 1 mm more gingivally in the first maxillary premolars than the other brackets to induce extrusion of these teeth during leveling and alignment with increasingly thicker round nickel-titanium niti arch wires as the teeth extruded they were gradually equilibrated after 5 months of treatment leveling and alignment continued with progressively larger round stainless steel arch wires 0.014 to 0.018 inch with an accentuated and reversed curve april 2011 vol 139 issue 4 supplement 1 american journal of orthodontics and dentofacial orthopedics

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janson janson and murillo-goizueta s139 fig 7 posttreatment dental casts of spee on the maxillary and mandibular arches respectively extrusion of the maxillary first premolars continued with a step-down arch wire bend until normal gingival and bone levels were obtained fig 5 retraction of the anterior maxillary teeth was performed with 0.018 3 0.025-inch stainless steel arch wires with sliding mechanics and without anchorage reinforcement and labial crown torque leveling and alignment of the mandibular teeth were obtained following the same wire sequence as the maxillary teeth slight proclination of the mandibular anterior teeth was allowed to correct crowding when retraction was completed the maxillary central incisor brackets were rebonded more gingivally to also induce forced extrusion simultaneous and progressive incisal trimming was performed to obtain a better crown-root proportion reducing the open gingival embrasure finally vertical intermaxillary elastics were used 12 hours/day for 2 months to improve interdigitation after fixed appliance removal a modified hawley retainer was temporarily installed in the maxillary arch until final esthetic restorations of the central incisors were performed a fixed maxillary retainer was then considered a mandibular canine-to-canine retainer was bonded to the lingual surfaces of the teeth during orthodontic treatment professional cleaning by a dental hygienist was performed every month and a clinical evaluation by her periodontist was made at 3-month intervals active treatment time was 2 years and 6 months results the extraoral frontal and profile photographs show significant improvement posttreatment intraoral photographs show no increase in gingival recession an ideal overjet and good interdigitation of the lateral segments figs 6 and 7 a class i canine on the left and a mild class ii relationship on the right side was obtained the class ii molar relationship was maintained with slight deviation between maxillary and mandibular midlines there is no evidence of significant root resorption and the bone levels remain the same in most areas excluding those where forced eruption was performed fig 8 the most significant cephalometric changes were the lingual tipping and retrusion of the maxillary incisors labial tipping and protrusion of the mandibular incisors and reduction in the overjet and overbite table i figs 9 and 10 the follow-up after 17 months shows maintenance of the bone level sound gingival tissues and stability of the american journal of orthodontics and dentofacial orthopedics april 2011 vol 139 issue 4 supplement 1

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s140 janson janson and murillo-goizueta fig 8 posttreatment periapical radiographs final results figs 11 and 12 the final restoration of the maxillary incisors was concluded and the maxillary right second premolar underwent a root fracture and was replaced by an implant the patient did not choose permanent retention of the maxillary arch but preferred instead to wear a removable hawley retainer discussion obtaining a successful treatment outcome in this 49-year-old woman who had advanced periodontal disease and a severe class ii division 1 malocclusion was a challenge this patient had moderate to severe adult periodontitis that led to gingival retraction in the maxillary anterior and posterior teeth a complete class ii molar relationship with 9 mm of overjet mesial tipping of the mandibular molars and proclination and extrusion of the mandibular incisors was aggravated by the periodontal condition she had been undergoing periodontal maintenance for 5 years in this situation periodontal preparation was very important before initiating orthodontic treatment this included scaling and root planning in all 4 quadrants surgical resection of the maxillary central incisors although performed in this patient is not necessary and is not a recommended procedure since it causes esthetic problems in the anterior region.8 additionally a 4-month observation period before appliance installation was recommended to ensure that the tooth movement would occur in a healthy environment.8 in the present case after the 4-month observation period a careful clinical examination and recording of periodontal probing status was performed before orthodontic treatment was initiated in patients with advanced periodontitis the crucial issue is often to what extent the osseous topography can be favorably influenced by orthodontic tooth movement.9 previous experimental reports10,11 and clinical studies12 have shown that a reduction in vertical bone height is not a contraindication for orthodontic tooth movement and that alveolar bone is recreated ahead of moving the tooth since movement is performed with light forces.11,13 therefore it is possible to move teeth in a horizontal direction with a reduced healthy periodontium without attachment loss.11,14 in the present case forced april 2011 vol 139 issue 4 supplement 1 american journal of orthodontics and dentofacial orthopedics

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janson janson and murillo-goizueta s141 fig 9 posttreatment lateral cephalogram extrusion of both maxillary first premolars altered their vertical position before extraction was performed once the alveolar ridge was restored anterior retraction was also performed using light elastic forces fig 5 when extrusive forces are applied elongation of periodontal fiber bundles promotes bone deposition at the crest at the walls and at the apical alveolar area dislocating alveolar bone and the tooth.15 considering that supportive and protective tissues move together with teeth this approach was performed to correct vertical bone defects from the most apical bone defect to the crest of the alveolar ridge of adjacent teeth with forces less than 30 g.16 to determine how much extrusion is necessary periodontal probing is conducted at the most apical area of the defect and then 2 mm is subtracted from that measurement which corresponds to a normal gingival sulcus.17 forced eruption might be considered only as an alternative to correct an isolated vertical defect with 1 2 or 3 walls involved in each quadrant and when the neighboring bone structures are healthy or show only small changes.17 computer tomographic analysis18 and human histological findings19 indicate that buccal or lingual bone dehiscences may be exacerbated by tooth movement into areas of reduced bone width this possibility was prevented in this case because the premolars were extruded before being extracted an open gingival embrasure between the maxillary central incisors was one of the main esthetic problems in this case after maxillary anterior retraction forced extrusion of both central incisors and incisal edge equilibration were conducted to increase the height of the alveolar crest and the gingival margin figs 5 and 7 a better crownroot proportion with reduction of the open embrasure between these teeth was achieved.17,20,21 the mesial surfaces of the central incisors were also recontoured and flattened to lengthen the interproximal contact toward the papilla.22 although these procedures did not completely eliminate the open embrasure they substantially improved the clinical appearance fig 6 it should be emphasized that both maxillary central incisors underwent periodontal surgical resection before orthodontic treatment was initiated probably increasing the gingival recession that had already occurred figs 1 and 3 recession can be improved with lingual movement of the teeth.23 however in this patient it did not seem that lingual tipping of the maxillary incisors helped to reduce the gingival recession the patient had a furcation defect on the buccal surface of the mandibular left first molar that remained stable with no increase after orthodontic treatment24,25 figs 1 and 6 the most significant skeletal cephalometric changes consisted of minor increases in mandibular retrusion the anteroposterior base discrepancy anb angle the growth pattern angles and facial convexity table i from a dental perspective the maxillary incisors were tipped lingually and retruded and the mandibular incisors were tipped labially and protruded which decreased the amount of overjet and overbite increase in the lower anterior face height is a usual treatment consequence of this relationship.26-30 lingual tipping of the maxillary central incisors may be regarded as excessive however one should also consider that application of lingual root torque on these teeth is not advisable because of the increased risk of apical root resorption.31 most important in these cases is knowledge of which objectives should be obtained and what the biological costs are it is common in periodontal patients to reduce osseous defects increase tooth longevity facilitate patient oral hygiene and improve self confidence.8 however small emphasis is given to the final anteroposterior relationship in these cases an ideal class i canine relationship may not be obtainable because of periodontal limitation therefore one should strive to obtain satisfactory functional occlusion with anterior and canine guidance without striving for ideal anteroposterior canine relationships and labial incisor inclination this philosophy will result in less horizontal body movement less american journal of orthodontics and dentofacial orthopedics april 2011 vol 139 issue 4 supplement 1

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s142 janson janson and murillo-goizueta fig 10 pretreatment and posttreatment superimposition a lateral cephalometric tracing b individual cephalometric superimposition of the maxilla palatal plane c individual cephalometric superimposition of the mandible mandibular plane fig 11 follow-up intraoral photographs at 17 months treatment time and consequently less root resorption risk with similar facial esthetic results while obtaining reasonable static anteroposterior relationships.7,32,33 conclusions periodontally compromised orthodontic patients can be treated satisfactorily if a combined orthodontic periodontal approach is used an interdisciplinary treatment plan that included orthodontic movement to encourage bone remodeling and a strictly supervised oral hygiene program resulted in restoration of function to this periodontally involved dentition correction of the malocclusion and a marked improvement in esthetics for this patient april 2011 vol 139 issue 4 supplement 1 american journal of orthodontics and dentofacial orthopedics

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janson janson and murillo-goizueta s143 fig 12 follow-up periapical radiographs at 17 months references 1 re s corrente g abundo r cardaropoli d orthodontic treatment in periodontally compromised patients 12-year report int j periodontics restorative dent 2000;20:31-9 2 heasman pa millett dt carter ne orthodontic treatment in adults with periodontally involved labial segments dent update 1994;21:122-8 3 marks m tooth movement in periodontal therapy st louis mosby 1980 4 romano r landsberg cj reconstruction of function and aesthetics of the maxillary anterior region a combined periodontal/orthodontic therapy pract periodontics aesthet dent 1996;8 353-61 quiz 362 5 melsen b agerbaek n markenstam g intrusion of incisors in adult patients with marginal bone loss am j orthod dentofacial orthop 1989;96:232-41 6 magnusson i lindhe j current concepts in diagnosis and treatment of periodontitis semin orthod 1996;2:13-20 7 roth rh functional occlusion for the orthodontist part iii j clin orthod 1981;15:174-9,182-98 8 zachrisson bu clinical implications of recent orthodontic-periodontic research findings semin orthod 1996;2:4-12 9 diedrich pr guided tissue regeneration associated with orthodontic therapy semin orthod 1996;2:39-45 10 lindskog-stokland b wennstrom jl nyman s thilander b orthodontic tooth movement into edentulous areas with reduced bone height an experimental study in the dog eur j orthod 1993;15:89-96 11 thilander b infrabony pockets and reduced alveolar bone height in relation to orthodontic therapy semin orthod 1996;2:55-61 12 hom bm turley pk the effects of space closure of the mandibular first molar area in adults am j orthod 1984;85:457-69 13 melsen b tissue reaction following application of extrusive and intrusive forces to teeth in adult monkeys am j orthod 1986 89:469-75 14 ericsson i thilander b lindhe j periodontal conditions after orthodontic tooth movements in the dog angle orthod 1978;48 210-8 15 oppenheim a artificial elongation of teeth am j orthod oral surg 1940;26:931-40 16 reitan k clinical and histologic observations on tooth movement during and after orthodontic treatment am j orthod 1967;53 721-45 17 ingber js forced eruption i a method of treating isolated one and two wall infrabony osseous defects rationale and case report j periodontol 1974;45:199-206 18 fuhrmann ra bucker a diedrich pr assessment of alveolar bone loss with high resolution computed tomography j periodontal res 1995;30:258-63 19 wehrbein h fuhrmann ra diedrich pr human histologic tissue response after long-term orthodontic tooth movement am j orthod dentofacial orthop 1995;107:360-71 20 frank ca pearson bs booker bw orthodontic eruption of furca-involved molars compend contin educ dent 1995 16:664 666,68 passim quiz 682 21 janson mrp janson rrp martins pf tratamento interdisciplinar i verticalizac~o de molares consideracoes cl inicas e biolgicas r o ¸a ¸ dental press ortodon ortop facial maring sp brasil 2001;6 a 87-104 22 kokich vg esthetics the orthodontic-periodontic restorative connection semin orthod 1996;2:21-30 american journal of orthodontics and dentofacial orthopedics april 2011 vol 139 issue 4 supplement 1

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s144 janson janson and murillo-goizueta 23 wennstrm jl mucogingival considerations in orthodontic treato ment semin orthod 1996;2:46-54 24 burch jg bagci b sabulski d periodontal changes in furcations resulting from orthodontic uprighting of mandibular molars quintessence int 1992;23:509-13 25 roberts ww 3rd chacker fm burstone cj a segmental approach to mandibular molar uprighting am j orthod 1982 81:177-84 26 chua al lim jy lubit ec the effects of extraction versus nonextraction orthodontic treatment on the growth of the lower anterior face height am j orthod dentofacial orthop 1993;104:361-8 27 kocadereli i the effect of first premolar extraction on vertical dimension am j orthod dentofacial orthop 1999;116:41-5 28 staggers ja vertical changes following first premolar extractions am j orthod dentofacial orthop 1994;105:19-24 29 taner-sarisoy l darendeliler n the influence of extraction orthodontic treatment on craniofacial structures evaluation according to two different factors am j orthod dentofacial orthop 1999 115:508-14 30 vaden jl harris ef behrents rg adult versus adolescent class ii correction a comparison am j orthod dentofacial orthop 1995 107:651-61 31 parker rj harris ef directions of orthodontic tooth movements associated with external apical root resorption of the maxillary central incisor am j orthod dentofacial orthop 1998;114:677-83 32 clark jr evans rd functional occlusal relationships in a group of post-orthodontic patients preliminary findings eur j orthod 1998;20:103-10 33 svedstrom-oristo al pietila t pietila i helenius h peutzfeldt p varrela j selection of criteria for assessment of occlusal acceptability acta odontol scand 2002;60:160-6 april 2011 vol 139 issue 4 supplement 1 american journal of orthodontics and dentofacial orthopedics

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