Orthodontic treatment in stage IV periodontitis patients. Spyridon Papageorgiou. EFP Euro series

Join me for a summary of the EFP’s lectures on periodontitis and orthodontic treatment. The orthodontic lecture was by Spyridon Papageorgiou and two lectures from periodontists, The topic explored related to stage IV periodontitis and orthodontics

Stage IV – new classification from world workshop Papapanou 2017

· Clinical attachment loss 5mm+

· Bone loss extend to mid third of root

· Malocclusion / masticatory dysfunction

o Bite collapse:  Loss of posterior support resulting in tooth movement in the direction of force – (complex), over-eruption and incorrect relationship with antagonistic teeth

o Drifting Due to mastication forces

o hypermobility due to secondary occlusal trauma

o Even if periodontally stable Further tooth movement 33% at 2 years Zhang 2017.

§ Orthodontic pathological tooth movement: Loss of space in the arch, mesial migration, crowding, crossbites

Periodontal Treatment for stage IV Sanz 2020 Kloukos 2021

1. Stage 1 : Supragingival debridement, oral hygiene, professional plaque removal, risk factors

2. Stage 2 – Supra and subgingival debridement – change the subgingival biofilm Interventions: Repeat subgingival therapy, surgical: flap, reactive, regenerative (Barrier membrane, Enamel matrix derivative)

3. Supportive periodontal care

Effects of appliances on the periodontium R/V Papageorgiou 2018 / 2021

· Transient change in microbiology from orthodontic appliances

· Bone loss marginal 0.5mm

· Clinical attachment loss 0.11mm

· Recession

o Greater recession 1.9mm

o Gingival recession and loss of attachments Salti 2017

· Greater if hyperdivergent

· GTR no consistent clinical benefit

· Fixed better than aligners PPD 1.6mm – small study

· No difference in ligation, conventional self ligating

· 1-3 months periodontal intervals in orthodontic treatment better outcomes than 6 monthly Jiang 2021

Biomechanics

Adapting orthodontic treatment

· Centre of rotation moves apically

o Same force = larger moment

o Greater extrusion forces

· Simulate intrusion in normal periodontal support vs reduced Kettenbeil 2013 Bagdadi 2019

o Centre of resistance moves apically 2-3mm

o Increased tooth movement 1.6-2.5, increase strain in PDL 1.4-2  possible harm to periodontium

Retention

· Generally different fixed retainers compatible with periodontal health and not detrimental Arn 2020

· Metal bonded retainers still allow physiological movement

· Effect of mobility – UNKNOWN

· Greater failure of bonded retainers in more severe periodontal cases (up to stage 3) Han 2021

· 10 year follow up of ortho and perio = no significant recession or tooth loss BUT increase in root fracture – possibly due to increased forces?

Conclusions

· Orthodontics does not negatively impact periodontal condition

· Initial anti-infective periodontal treatment

o Unsure type of periodontal treatment, GTR unclear, unsure what time to start after perio

· Appliances

o Fixed maybe better

o Segmental better than continuous archwire

o Adapt biomechanics due to attachment loss

· In orthodontic treatment – patients attend periodontics at 1-3 months

· Retention after orthodontic treatment – greater failure rates

· Possible increase in root fractures

· Limited evidence

ORTHODONTICS IN CONFERENCE

Join me for DAY THREE of the BOC 2021. Day 3 covers 4 lectures; the lectures covered the following topics; Research, Chapman Prize 2021, Timing of functional appliances and Clinical Pearls

· Searching for a needle in a haystack Kevin O’Brien

· Chapman Prize 2021 - Orthodontic trials: Are we measuring the right things? Aliki Tsichlaki

· Functional appliance treatment: Do long waiting lists really matter? A multicentre RCT. Nicky Mandall

· Clinical Pearls session: Preetpal Bhogal, Ian Murphy, Mohammed Al -Muzian, Safoora Keshtgar, Megan Hatfield

Individual lecture podcasts are available in the description from the website www.orthoinsummary.com

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Join me for day TWO of the BOS 2021. Day 2 covers 5 lectures; Trauma and the orthodontic patient, periodontal management, impacted canines, orthognathic surgery, 2021 Northcroft lecture,

Speakers: Susan Kindelan, Claire Rooney, Ian Dunn, John Scholey, Lucy Davenport-Jones, Johnathan Sandler

Lectures covered

1. Paeds/trauma - what I wish I'd known Susan Kindelan, Claire Rooney

2. Are we heading into a recession - periodontal considerations in orthodontic management Ian Dunn

3. Canines - what I wish I'd known John Scholey

4. What I Orthognathic surgery - what I wish I'd known Lucy Davenport-Jones

5. Northcroft lecture And all the roads we have to walk are winding. Johnathan Sandler

Individual lecture podcasts are available in the description from the website www.orthoinsummary.com

Join me for day one of the BOS 2021. Day one covers 5 lectures; research presentations, the Chapman prize looking at full or part-time functional appliances, retention and what’s new, paediatric orthodontic management and lingual appliances

Speakers: Pratik Sharma Padhraig Fleming, Simon Littlewood, Sarah Good, Esfandiar Modjahedpour

Individual lecture podcasts are available in the description from the website www.orthoinsummary.com

Lectures covered

1. Research presentation: University Teachers Group

2. Chapman Prize 2020: Prescription of full or part-time Twin Block wear: A randomised controlled trial and qualitative evaluation Pratik Sharma Padhraig Fleming

3. Retention – science, clinical tips and comedy disaster Simon Littlewood

4. Things I have learned from hanging out with the kids. Sarah Good

5. From diagnosis to retention. Is it clinically that easy? Esfandiar Modjahedpour

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Join me for a summary of Dalia El Bokle’s lecture exploring finishing in orthodontics. Part 3 focuses on digital indirect bonding, from scan to tray production

Introduction

Straight wire appliance – based on bracket placement will correct tooth in 3 planes of space

· Not true – evidenced by finishing bends

Ideal bracket placement through indirect bonding IDB

· Level marginal ridges posteriorly

· Constant smile arc anteriorly

Digital indirect bonding time saving

· Brackets placed Layman 2019

o Time saving

§ 21 minutes – digital indirect bonding Vs manual direct bonding

§ 8 minutes – clinical time indirect Vs direct bonding

Different methods of making an indirect digital bonding tray

Method 1:

· Printed model

· VFR transfer tray

· Transfer tray made from the model

Method 2

· Printer tray (not model)

· Cost $105

· Tray biocompatible tray

· Cover occlusal half of the teeth and lingual aspect

· Insert bracket into model

· Advantage

o No model printing

o Clean base technique

Method 3 –

· Key pads – digitally planned material between bracket base and tooth

o Customises the bracket base

o Advantage

§ Less flash

§ Accuracy of bracket position in on the keypad

§ Torque + in and out can be customised per tooth

· Models printed

· Lab place the brackets manually with composite onto the model with jigs

· Transfer tray made from the model

Case submission for DIDB

· Send STL file to lab

· Prescription for set up, e.g.

o Bracket selection customisation: Standard Damon Brackets, low torque lower incisors, high torque LL4.

o Teeth bonded: 7-7 Upper and lower

o Bracket positioning customisation: Smile arc – 0.5mm incisal U1s Vs U2s

· Clinician approval of set up

o Library of brackets – specify which type of bracket

Digital indirect bonding workflow overview

1. Scan patients

2. Orthodontist prescription

3. CAD –Software system to place bracket and customise base / bracket

4. Print model

5. Brackets placed on model: allowing for bracket base customisation through either keypads or jigs, customising bracket base with composite

6. CAM - Lab design indirect bonding tray (IBT)

a. VFR

b. Silicone transfer tray / Memosil material

7. Process IBT

8. Post processing chemical and UV light

9. Insert bracket into tray with key holes as guides

Advantages of DIDB

· Full digital pathway with scanning

· Less working time

· Fewer appointments

· Can alter prescription

Disadvantage

· Cost

· Learning curve

· Production waste

Join me for a summary of Dalia El Bokle’s lecture exploring finishing in orthodontics. Part 2 focuses on indirect bonding, a step by step process from model analysis to clinical delivery

Mark position on models

Intersection of horizontal and vertical lines

· Posterior teeth

o Vertical line: Long axis using OPG buccal, occlusal and lingual

o Horizontal line x 2

§ 1/ Marginal ridge line (outcome of treatment)

§ 2/ Slot line (position of bracket, depending on bracket system 2mm from marginal ridge line

§ Start with 1st molar

§ Measure cusp to slot line using gauge distance marginal ridge to slot line

§ Mark slot line for rest of the teeth, using the difference in height from marginal ridge to slot line from the 1stmolar measurement

§ Ensure gauge is used perpendicular to the teeth

· Anterior teeth

o Vertical line: Draw long axis using OPG, labially and lingually

o 1/ Horizontal line start with canine

§ Slot line marginal ridge level distal canine and mesial 1st premolar

§ Position canine mesial to the long axis

o 2/ Lateral = bracket gauge of the canine to tooth tip, 0.25mm more cervical or same as canine if lateral small

o 3 / Central – add 0.25-0.5mm than canine

§ = subtle smile arc

Transfer tray

· Intersection of long axis to slot line – mark with wax knife

o Mark where brackets should go

· Tacky Glue to stick bracket to the model  – water soluble glue, remove excess with probe

o Tip – use loupes / magnifying lens

· Allow set for 10 minutes

· Check occlusally, vertically and tip

o Digitally check glue is set

o Marginal ridge to slot line should be consistent

o Visualise tooth movement

· Relieve over the bracket hooks – wax or Tachy glue

· Vacuum forming machine

o 1mm soft sheet

· Check brackets have not moved – check vertical and horizontal lines

· Trim excess retainer material

· Soak 10 minutes, wash with water and interdental brush (ensure mesh of brackets clean)

· Slits from the gingival aspect of the retainer to the gingival aspect of the bracket

o Purpose is to expose the hooks of the brackets – difficult to remove when bond, aiming to uncover the hook from the retainer

· Wax placed under the hooks – prevent composite

· Section the tray if significant crowding

Clinical bonding IDB

· Etch bracket surface only – looking at model of the tooth

· Composite (light cure)

o Small quantity on mesh base of each bracket

o Microbrush to cover all surface and imbed into bracket mesh base

· Bond

· Seat IDB tray

o Apply perpendicular pressure on each bracket with scaler

§ Avoids excessive composite on the bracket base

· Light cure 20 seconds each tooth

· Remove tray – from palatal aspect from distal molar

· Flash removal

Trouble shooting

· Bracket off

o Don’t panic!

o Maintain isolation

o Remove excess composite, sharp scaler

o Trim tray

o Replace bracket in tray and re-insert transfer tray

· Bracket positioning incorrect

o Defective impression

o Bracket not glued well on model

o Defective vacuum forming

o Ensure no drags

Disadvantage of IDB

· Extra lab time

o 1 hour lab time

§ However reduced time in treatment and repositions / bends

o Extra cost

§ $12 if in house

o Excess flash

o Technique sensitivity

§ Multiple check points

o Accuracy

§ In Dalia’s opinion more accurate than direct bonding

Join me for a summary of Dalia El Bokle’s lecture exploring finishing in orthodontics. Part 1 focuses on bracket positioning concepts and Dalia’s own take to achieve more predictable ideal outcomes

Current bracket positioning technique

1. Middle middle – middle vertically and horizontally (FA point)

o Challenges

§ Accuracy = measure each tooth

§ If gingival swelling / not fully erupted = inaccuracy

2. Bracket charts – use of bracket gauges

o Accurate and reproducible, introduced in 1994

§ Typical chart

· Upper incisor 4-4.5mm from invasive edge

· Lateral 0.5mm incisal than lateral

· Canine 1mm more gingival than central

o Challenges

§ Appropriate for ideal tooth sizes only, can result in uneven marginal ridge heights if tooth size discrepancy present = bone loss, food impaction, premature contact and relapse

§ Can flatten smiles

3. Smile arch protection (SAC) Tom Pitts

o Bonding for consonant arch

o Method

§ Canine gingival to the contact point

§ Lateral 0.75-1mm cervical to the canine

§ Central 1.5mm more cervical to the canine

· Side effects – oral hygiene and deep bite

Solution by Dalia

Customised approach

· Factors

§ Marginal ridge heights, Upper incisor show, tooth size and shape, Incisor inclination, Overbite

· Method of positioning

1. Mesiodistal

§ All teeth bond in centre of the teeth

§ Molars – if extra cusp = tube design = mesial position and distal in rotation

· Solution = bond centre of the tooth, even if not in Mesiobuccal grove = extra composite used or modify bracket

§ Canine = EXCEPTIONS

· Place bracket mesial to long axis

· Mesial in rotation if placed in the centre

o Requires mesial out rotation to align with the lateral incisor

o Solution

§ Place upper and lower canines mesially

2. Axial (tip)

§ Draw long axis on the model

§ Use of OPG / CBCT to draw long axis

§ Modifications

· Overcorrect 5 degrees adjacent to extractions = prevent dumping in

· Overcorrect severely tipped teeth (usually in case of early loss of 1st molar)

3. Vertical

§ Posterior bond first 7-3

· Bond relative to marginal ridges – not incisal edges Kelange technique 2007

· Draw marginal ridge height line, then slot line

· Canine same level as premolars for marginal height

§ Anterior positioning

·  Lateral = bracket gauge of the canine to tooth tip, add 0.25mm (more cervical)

· Central – add 0.25-0.5mm than canine

o = subtle smile arc protection

o Subtle smile arc – less steep difference in connectors when compared to SAP by Tom Pitts

§ Modifications

· 3-3 bonded 1mm more gingival = AOB / reduced incisal show, or 1mm more incisal for deepbite / gummy smile

§ Lower arch

· Canines are bonded 0.5mm more cervical for canine guidance

· Deep bite = 1mm more incisal

Incisal recontouring

· At the beginning of treatment = visually aid final position and improve aesthetics for patient

Join me as I summarise Mona Ghoussoub’s lecture looking at the excessive gingival display (EGD).

Mona looked at the diagnosis and treatment of EGD, with a focus on aetiology leading to treatment method, effect of age, and input of multidisciplinary care for appropriate cases.

Definition Kokich 1999, Machado 2014

· Negative effects = 4mm + gingival display

Treatment approach

Early treatment

o Medical  ENT allergology

o Excessive gingival show age 7-8 years

o Nasal obstruction causes decrease in lip closing force Sabashi 2011

o Detect and refer ENT if suspect nasal obstruction

§ Dark eyes

§ Flat cheeks

§ Increase LAFH

o Orthodontic – prevention

o Utility arch

§ Intrusion upper anterior teeth

§  4 brackets and molar bands

§ Retain with 2 layers of Essix + brass wire – for rigidity

Late treatment

o Orthodontic

o Alignment

§ 2 occlusal planes in maxilla in 2 div 2, posterior higher, anterior lower

· Straight wire – reciprocal effects

o Intrusion of anterior teeth

o Extrusion of posterior teeth

o Expansion

§ RME

· Posterior expansion = gingival position moves upwards

o When constricted, greater posterior gingival show

o Intrusion

§ Ricketts / Burstone 3 piece intrusion arch

§ Headgear – J hook intrude upper anterior teeth

§ TAD placement for anterior intrusion

·  UR1-UL1 labial

· Powerchain archwire to TAD

§ TAD for posterior intrusion

· U5-U6 region buccal

· Direct retraction U3- TAD

o Below centre of rotation = posterior intrusion

o MDT

o Periodontics

§ Gingivectomy – passive over-eruption of dentition

· Ideal where tooth width:height ratio increased

§ Guided Tissue Regeneration for VME

· Stable after 1 year

· 40-60% improvement in excessive gingival growth, with crown lengthening

· Bony cavity at anterior superior aspect of maxilla

o Results in the lip raising higher

o Bone augmented at the level of the Le-fort 1

o Can be clinically simulated with cotton wool rolls in upper labial sulcus and taking photos

o Orthognathic surgery

§ Decompensate

· Maxillary impaction

o Plastic surgery Pierre 2020

§ Short lip / mild VME = lip repositioning surgery Rubinstein 1973

· Limit the smile muscle pull by reducing the depth of the upper vestibule– zygomaticus minor, levator Angulo, orbicularis oris, levator labil superior Tawfik 2018

· Conservative when compared to OGN

· Technique

o Split thickness flap – expose connective tissue

o Advance mucosa and suture at mucogingival junction

· Limited studies

· Overcorrect as some relapse expected

· Systematic review improve EGD 3-4mm Tawfik 2018

§ Hypermobile lip – Botox Cengiz 2020

· Reduce muscle activity – levator labil superios LLSAN, zygomaticus minor / major, risorius muscle

· NOT classified as an alternate treatment for EGD

o Use = indication for patient outcomes possible for lip reposition

· Temporary effects – relapse at 6 months

· Problems

o Dose related results

o Excessive upper lip ptorsis

o Too little – not achieve desired result

o Smile effected if erroneous

§ = require expert to use

Join me for the next interview in orthodontic, with video!

‘One to watch for 2022’

Grant Isherwood is a recently qualified orthodontist from 2019, Liverpool UK. He is a member of the Royal College of Surgeons of Edinburgh and qualified as a dentist in 2011. Grant has published some exceptionally high quality clinical cases on social media @dr.grant.isherwood. Grant and has been working in both the public national health service and in the private sector as an orthodontist.

We get to hear of Grant’s experiences following qualification, how he navigated the pandemic as a new graduate and how he is developing his skills.

@dr.grant.isherwood

youtube video of interview

Join me for the summary of key lectures from the final day of this year’s American Association of Orthodontics Summer Meeting

10 key lectures are covered in this podcast from day 3 of the AAO meeting, on the topic of TADs, Carriere, Orthognathic surgery first, Skeletal TAD expansion, orthodontic uncertainty

Speakers:Jay Bowman, Kevin O’Brien, Luis Carriere, Bjorn Ludwig, Maschos Papadopoulos, Beom Kim, Jungi Sugawara

Individual lecture podcasts are available in the description from the website www.orthoinsummary.com

Lectures titles:

1. TADs- Keeping it simple while being successful Sebastian Baumgaertel

2. Uno, Dos, Tres/ All the Screws in the Same Place Jay Bowman

3. Class II Minimum-Touch Approach in an Evolving Orthodontic World Luis Carriere

4. The Management of Occlusal Plane with Extra-Alveolar Miniscrews. Marcio Almeida

5. TAD Supported Space Closure in Agenesis Cases Bjorn Ludwig

6. Maxillary Molar Distalization with Mini-screw Implant Supported Appliances Maschos Papadopoulos

7. Navigating Complexities in Surgical Orthodontic Cases Jerry English & Kurt Kasper

8. Tooth Bone vs Tissue Bone MSE Does it matter? Beom Kim

9. Less Invasive Surgery First Approach Jungi Sugawara

10. Orthodontic uncertainty. Research, core outcomes and snake oil. Salzmann Lecture Kevin O’Brien