On this course running in April 2017, we were told about the relationship between periodontics and orthodontics, in other words, how gum condition affects orthodontics treatment, and, vice versa, how orthodontics affects the gums, improving them or making them worse depending on the case.
The symposium focused on adult orthodontics and on certain special orthophonic movements. Having listened to the explanations of this interesting subject, I would like to highlight the following:
The importance of gum condition
The percentage of adult patients receiving orthodontics treatment is on the rise and varies between 25% and 50%. To be able to treat a patient, they must have no periodontal disease, i.e. they must not have swollen, reddish or bleeding gums.
To improve the position of the teeth, a diagnosis must be made and a decision taken on the mechanics and duration of the treatment, taking the periodontal condition of each piece into account. We therefore take an ultrasound of the gum around the tooth and, in the case of deep pockets with bleeding, prescribe a periodontal treatment to heal the gums, deciding whether there are teeth that require extraction. The patient is given fillings if needed.
Finally, maintaining gingival health is essential. This involves careful brushing with interdental brushes by the patient and tooth cleaning at the surgery when considered necessary by the dentist.
To begin orthodontics treatment, the gums must be pink and firm, even if they have previously lost some of their depth.
Characteristics of orthodontics in periodontal patients
The danger when treating adults, particularly in cases where their gums have a tendency to suffer inflammation, is the shrinking of gums away from the tooth. This causes receding gums, meaning that the root becomes more visible.
The risk of receding gums is lower:
- With very good dental and gum hygiene.
- When brackets are used on the rear molars instead of bands in the case of weak gums.
- When, if possible, the dental arch is maintained by using non-expanding arches.
- Sometimes, when gum grafts are made to the lower incisors prior to treatment.
Treatment must be carefully planned in these patients, using moderation in regard to dental movements. We must be realistic and improve their smile and bite, without causing risk to the gums.
Care must be taken every monthly check-up to ensure correct gum hygiene and condition, making sure that there is no bleeding. Patients must have a light or exhaustive mouth cleaning session every two months during treatment. It is advisable to make three X-ray check-ups every year while the orthodontics brace is in place.
Special orthodontic movements
These are cases where orthodontics can solve problems which affect the gums.
Fanning out of the front teeth
This is generally due to posterior bite collapse: when the back molars start to fail, either because of extractions due to tooth decay or to molars which move and sit at an angle due to poor gum condition, applying excessive weight to the front teeth.
If, added to this, the front gums are weak, spaces start to appear between the front teeth, causing them to fan out. The weight on these teeth does not move in the normal direction, meaning that they continue to separate and can even fall out due to excessive movement.
In cases such as this, the first step is to treat the gums, followed by orthodontic treatment to straighten the molars and front teeth. Implants will also be needed to ensure that the patient bites correctly with their back teeth, thereby releasing overload on the front teeth. Sometimes the gums have receded to the extent that they reveal a great deal of root, in which case porcelain veneers must be fixed to the front teeth. This results in an impressive change of smile in affected patients.
This means partial displacement of a tooth to achieve greater exposure, using brackets or a flexible orthodontics arch. It can be used to:
- Show more tooth, for example, in the case of a broken tooth where we need a larger piece to fit a crown or porcelain veneer. Here rapid extrusion is used, i.e. 1mm every two weeks. When the tooth is at the desired height, it must be left to stabilise for a month before proceeding with the crown, reconstruction or required treatment.
- Increase the height of gum and bones pulled out along with the extruded tooth. Often the procedure involves a root to be extracted, but it also serves to create more gum and bone in order to achieve the same height as the neighbouring teeth and subsequently fit an implant. The procedure involves slow traction, with a movement of 1mm every month. The bone must be allowed to stabilise before fitting an implant. To proceed with dental extrusion the gums must be healthy, there must be no infection in the tooth or root and the patient must have good oral hygiene. It also requires the patient to make several visits to their dentist.
This means deeper repositioning of a tooth by means of orthodontics. This treatment is less common than extrusion given that, in intrusions, the tooth can be reabsorbed and therefore make the roots shorter. It is used in:
- Gummy smile. This is when a patient shows excessive upper gum when they smile. Here the teeth are repositioned and the gum shortened. It often involves bone surgery, reducing the bone height and readapting the gum to show less.
- Anterior open bite. These are cases when the top and bottom teeth are unable to meet, prevented by the rear molars coming together prematurely. In cases such as these the upper molars are sometimes repositioned. However, a check must first of all be made to ensure that the cause is not a tongue habit, i.e. that, when swallowing, the tongue does not come between the upper and lower incisors. To proceed with intrusion, the gums must be healthy and show no bleeding.