The Synergy of Periodontic and Orthodontic Collaboration in Contemporary Oral Health Practice

Among the various oral health professionals, orthodontists and periodontists are pivotal to enhancing patients' smiles and well-being. The synergy between these two specialized fields is vital for addressing complex dental issues comprehensively, ensuring not only esthetically pleasing results but also the long-term health and stability of the patient's oral cavity. Traditionally, orthodontic treatment (OT) has been focused on adolescent demographics, but with advancements in modern dentistry, more adult patients are undergoing OT. According to the World Health Organization, every country in the world is experiencing growth in both the number and proportion of older persons within their populations.¹ These population changes rationalize the rise of adult patients seeking OT. Research shows that adult orthodontic cases in the United States grew from 15.4% to 21% between 1981 and 2017.² Moreover, the American Association of Orthodontists notes that one in three orthodontic patients are adults.³ Often times, the treatments for this patient demographic can be demanding and require interdisciplinary cooperation.⁴

A periodontitis diagnosis, the likelihood of which is higher in adult populations when compared to children, results in a smaller reaction zone between the root surface and the convertible alveolar bone.² However, this does not necessarily exclude adult patients from receiving OT, and indeed, they can still be candidates for orthodontics. Periodontitis patients undergoing OT may require individualized and specialized periodontic-orthodontic collaboration, and treatment frequently also could include prosthodontic and general dentist expertise. The key to treating these types of patients is communication and proper diagnosis before OT as well as continued dialogue during treatment.^5-7

OT not only can improve a person's psychosocial well-being and enhance occlusal function, but also help patients obtain normal oral physiologic function, coordinated facial profiles, and healthy dentomaxillofacial development.^8,9 Orthodontic tooth movement, however, is only possible with the assistance of the periodontal tissues and sufficient tooth anchorage. Therefore, to achieve optimal results, individually tailored supportive periodontal therapy intervals should be scheduled during and after completion of OT to maintain stable long-term outcomes of periodontal/orthodontic therapy.¹⁰

In 2017, the American Academy of Periodontology (AAP) made changes to the previous 1999 periodontal classification, with the aim of enabling accurate communication among dentists, educators, and periodontists alike.¹¹ The new classification is based on the currently understood pathophysiology of periodontitis, aligning periodontal diseases to the current understanding of evidence. Some of the major changes include the elimination of the term "aggressive periodontitis" due to lack of specific immune-inflammatory responses and microbial profiles among chronic and aggressive periodontitis.¹² The 2017 classification scheme promotes a patient-centered approach by encompassing characteristics such as the nature of disease upon presentation and the general health status of the patient. Chronic periodontitis patients are diagnosed based on their clinical presentation during initial examination or follow-up, and former aggressive periodontitis diagnoses are diagnosed rather as stage 3/4 grade C, with a molar-incisor distribution. A patient is diagnosed with periodontitis when at least one of the following is present: interdental clinical attachment loss (CAL) detected at two or more non-adjacent teeth, or buccal or oral CAL ≥3 mm in addition to ≥3 mm pocketing detectable at two or more teeth.¹³

Correcting malocclusions with OT can help improve the periodontal status and overall health of the patient.¹⁴ In classic literature, Angle identified three classes of malocclusion whereby each class was identified according to the location of the mesiobuccal cusp of the maxillary first molar and its relationship with the buccal groove of the mandibular first molar.¹⁵ Furthermore, class I presents with the mesiobuccal cusp occluding with the buccal groove, class II presents with the mesiobuccal cusp mesial to the groove, and class III distal to the buccal groove. Orthodontists can facilitate OT by means of fixed (ie, buccal, lingual) or removable (ie, clear aligners) appliances based on the patient's needs and requests. In recent years, patients have become increasingly involved in the treatment planning process by communicating their interest and expectations regarding esthetics and quality of life throughout treatment.¹⁶ While patient expectations are a core component of evidence-based dentistry, appliance selection is based on thorough individual patient evaluation and the long-term goals of the case.

Evaluation of the periodontal status prior to and during orthodontic therapy is key to successful long-term outcome. If uncontrolled inflammation of the periodontium occurs during orthodontic therapy, periodontal destruction will be accelerated resulting in further loss of attachment.¹⁷ To overcome these circumstances, a combination orthodontic-periodontic therapy can be effectively utilized to repair periodontal-loss tissues while also achieving effective tooth fixation and correction, promoting the recovery of a patient's occlusal function as well as pain relief.¹⁸

With an increased number of general practitioners providing OT, it is imperative to evaluate periodontal status and establish an appropriate periodontic-orthodontic treatment plan with phased treatment to facilitate control of the patient's periodontal health before and during OT.^5-7 A comprehensive oral examination utilizing periodontal screening and recording should be part of the initial presentation. A periodontal probe is used to score each sextant based on probing depths, attached gingiva, radiographic appearance, and parafunction.^5-7 Furthermore, with current advancements in technology, such as intraoral scanners (IOSs), which enable monitoring of soft-tissue changes, and 3-dimensional (3D) cone-beam computed tomography (CBCT) imaging, which allows improved visualization of anatomy, hard- and soft-tissue phenotype should be evaluated prior to orthodontic therapy to ensure movement of teeth that is within the confines of the patient's anatomy and to prevent hard- and soft-tissue defects.

Oral hygiene should be administered before OT and repeated at every follow-up appointment.⁹ In the event soft- or hard-tissue defects are present, periodontal referral may be needed for consultation and surgical intervention.^5-7 Several factors, such as those noted above as well as the appliance's effects on periodontally involved teeth, influence the clinical decision of selecting either fixed appliances or removable clear aligners.¹⁹ After OT has been completed, patients should maintain a 3-month periodontal maintenance program.^5-7

In less-than-ideal conditions, clinicians may need to "think outside the box" to achieve the desired treatment outcomes. Adjunctive treatment methods, such as temporary anchorage devices (TADs), CBCT-guided identification of bony limits, and surgically facilitated orthodontic therapy (SFOT), can be useful for these unique clinical scenarios. (Table 1 presents recent advancements in orthodontics and periodontics and the benefits to patient outcomes.)

The use of mini-implants as TADs has greatly benefited patients. TADs have been shown to help with maxillary expansion, tooth intrusion, and space closure.²⁰ A main benefit of TADs is the ability to avoid bonding and banding, thereby reducing plaque-retentive areas and lessening unwanted induced stressors on anchored teeth and side effects on other dentition in the arch.^21,22 Before placement of TADs, patient periodontal status must be addressed as the oral inflammatory response is a major cause of failure of these devices.²³

For adult patients, transverse maxillary discrepancies pose a difficult clinical scenario. The maturation of the median palatal suture is an obstacle clinicians must overcome. Fortunately, the mini screw-assisted rapid palatal expansion (MARPE) technique has proven to be an effective alternative. MARPE has been documented as a relatively simple technique with a lower impact on patient outcomes and cost when compared to surgical interventions.²⁴

Although the aforementioned treatments may help adult patients achieve their goals, the timeline in which this is accomplished is a critical factor for many patients, as they may wish to seek results in short time periods. SFOT can help reduce the barrier of time. Through two different primary methods, SFOT may produce tooth movement three to four times quicker than traditional methods.²⁵ The acceleration of tooth movement is achieved by the use of corticotomies and tooth osteotomies. With corticotomies, the interface between cortical bone and teeth is weakened, allowing medullary bone turnover that results in new bone formation, low bone density, and less root resorption.²⁵ Furthermore, utilizing osteotomies, the mechanism of distraction osteogenesis is observed. This procedure allows orthodontists to treat severe alveoloskeletal discrepancies and move implants or ankylosed dentition into ideal positions.²⁵ While these procedures may seem invasive, research has highlighted their ability to shorten the time required for OT and minimize adverse effects on teeth.²⁶

To alleviate patient anxiety related to unfamiliar procedures, especially surgical ones, the AAP has issued a best-evidence consensus guideline related to CBCT imaging and its applications to orthodontic treatment planning.²⁷ Diagnostic inquiries can be resolved and optimal conditions obtained through the use of data acquired from CBCT imaging.²⁸ As technology continues to develop, digital workflows are more likely to be implemented into dental practices. IOSs are paving the way, as they provide today's clinicians with a simplified, streamlined process of acquiring patients' impressions, allowing for enhanced communication between treating doctors and dental laboratories.²⁹ IOSs can be used to create digital patient profiles, enable intraoral data acquisition, and, compared to analog techniques, minimize patient discomfort and reduce clinic- and laboratory-related errors.³⁰

While an IOS is the gateway tool to the digital world, additional digital-friendly equipment can be used to enhance clinical workflows. CBCT units have improved over the years, and their volume scanning mechanism permits quick 3D data acquisition without being influenced by the shape of the subject around the area of undercuts and proximal contacts.³¹ When digital imaging and communications in medicine (DICOM) files obtained from CBCTs are merged with IOS standard triangle language (STL) files, a total 3D craniofacial model of the patient can be created. According to literature, these models are accurate and beneficial for diagnosis, preoperative planning, and patient education.³²

Despite these technological advancements, the digital machinery available to dental providers is still behind that which is accessible to those in medicine. However, digital dental advocates are closing this gap. For example, an Ohio-based company, Surgical Theater^®, is contributing to the profession by providing 360-degree, 3D visualization capabilities. Using innovative imaging, this disruptive technology allows surgeons to add augmented reality (AR) to their treatment arsenal. AR has been employed in both hospital and educational settings for surgical disciplines (ie, neurosurgery, vascular, and cardiac surgery), and its use has been expanded to dental specialties. In dentistry, the use of AR has been applied to orthodontics for guided bracket placement and endodontics for root canal detection.³³ With AR, a surgeon's perception of the physical environment can be enhanced by the superimposition of preoperative data on the surgical site.³⁴ This 3D planning is permitting the placement of dental implants in their correctly planned ideal position, inclination, and depth.³⁵

An overview of a clinical case highlighting a successful periodontic-orthodontic collaboration is provided in Figure 1 through Figure 10.

A 24-year-old female patient presented at Tufts University School of Dental Medicine with the chief complaint that her teeth "are moving" and she was concerned that she would lose her teeth. Upon comprehensive examination, significant findings included probing depths greater than 4 mm localized to the molar and incisor areas, pathologic tooth migration, severe bone loss around teeth Nos. 24 and 25, and localized bony defects around the maxillary incisors and molars on both arches. The patient was diagnosed with generalized periodontitis stage 4 grade C molar-incisor pattern.¹² The Kwok and Caton prognostic system was used to determine that the maxillary incisors had a questionable prognosis, the mandibular central incisors an unfavorable prognosis, and the remaining teeth a favorable prognosis (Figure 1 through Figure 5).^36,37 Periodontal nonsurgical and surgical procedures (osseous surgery and guided tissue regeneration where applicable) were completed to restore the patient to clinical health on a reduced periodontium. The patient was referred to a general dentist for routine dental care and an orthodontist for correction of malocclusion.

Upon orthodontic consultation, the patient was diagnosed with class I malocclusion with excessive overbite/overjet, severe bimaxillary spacing, and severe bimaxillary protrusion. Given the guarded prognosis of the involved dentition, the pretreatment orthodontic goals included a reduction in overbite, overjet, spacing, and protrusion of the anterior dentition to center the teeth within alveolar bone. Prior to initiation of OT, a periodontal referral was made to improve the tissue biotype of the mandibular incisors and for a periodontally assisted osteogenic orthodontics procedure in the maxillary anterior region. A free gingival graft procedure was performed on teeth Nos. 24 and 25 to improve tissue thickness before orthodontic therapy (Figure 6 through Figure 8), followed by decortication in the maxillary anterior region to facilitate orthodontic movement.

Following fixed OT with routine 3-month periodontal maintenance, space closure and ideal overbite/overjet was obtained, and class I molar/canine occlusion was maintained. At debond, the overall prognosis of the teeth was favorable with a questionable prognosis for the mandibular incisors. The authors acknowledge the compromises and limitations of the final orthodontic result, including minor residual spacing and midline discrepancy. However, the pretreatment goals of OT were met, post-treatment prognosis of the initially hopeless dentition was improved, and the patient's expectations of treatment results were exceeded. Prior to OT in conjunction with periodontal therapy, the patient's treatment options included extraction of the anterior dentition with implant placement. The improvement in prognosis of the teeth in question will help the patient to maintain the dentition longer, considering her young age at the time of presentation (Figure 9 and Figure 10).

As the global population continues to age, the remarkable technological advancements in dentistry underscore the importance of interdisciplinary collaboration, where dental professionals, healthcare providers, and researchers work together in synchronized efforts to achieve common goals. While patients may present with a variety of clinical challenges, cooperation among the treatment team and patient can enable these challenges to be overcome and both patient and provider expectations to be met.

Demetrius Flood completed this work as a 2023 Summer Research Scholar at Tufts University. The authors thank the team of faculty and residents at Tufts University School of Dental Medicine - Complex Cases program for their collaborative work in the treatment of the clinical case presented, especially Tofool Alghanem, DMD, MPH, MS; Carl Carlamere, DDS; and Camille Neste, DDS, MPH.

The authors declare no conflicts of interest.

DMD Candidate, Tufts University School of Dental Medicine, Boston, Massachusetts

Adjunct Associate Professor of Periodontology, Tufts University School of Dental Medicine, Boston, Massachusetts; Lecturer, Department of Oral Medicine, Infection, and Immunity, Harvard School of Dental Medicine, Boston, Massachusetts; Private Practice limited to Periodontology and Implant Dentistry, Boston, Massachusetts

Assistant Professor of Orthodontics, Tufts University School of Dental Medicine, Boston, Massachusetts

Assistant Professor of Periodontology, Tufts University School of Dental Medicine, Boston, Massachusetts

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