IOSR Journal of Dental and Medical Sciences (IOSR-JDMS)

e-ISSN: 2279-0853, p-ISSN: 2279-0861.Volume 18, Issue 4 Ser. 1 (April. 2019), PP 22-31
www.iosrjournals.org

Impacts of Orthodontic Treatment on Periodontium: A Review

Lisa Chacko1, Shikha Singh2, P.S. Rakhewar3, Saurabh Patil4, Vaibhav Kumar
Choudhary5, Anju Prajapati6
1
Department of Periodontology, SMBT Dental College and Hospital & Post Graduate Research Centre,
Sangamner, Maharashtra, India
2
Department of Periodontology, SMBT Dental College and Hospital & Post Graduate Research Centre,
Sangamner, Maharashtra, India
3
Department of Periodontology, SMBT Dental College and Hospital & Post Graduate Research Centre,
Sangamner, Maharashtra, India
4
Department of Periodontology, SMBT Dental College and Hospital & Post Graduate Research Centre,
Sangamner, Maharashtra, India
5
Department of Orthodontics and Dentofacial Orthopaedics, Modern Dental College and Research Centre,
Indore, Madhya Pradesh, India
6
Department of Periodontology, SMBT Dental College and Hospital & Post Graduate Research Centre,
Sangamner, Maharashtra, India
Corresponding Author: Shikha Singh

Abstract: With a number of patients opting for orthodontic therapy for esthetic reasons, it becomes necessary
to evaluate the resulting effects of orthodontic treatment on the periodontal tissues. In many cases, orthodontic
tooth movement improves the periodontal conditions, and also, periodontal therapy often facilitates orthodontic
tooth movement. The orthodontic treatment for the patients need to be carefully planned and carried out in
order to prevent unwanted effects on the periodontium. So it is of great importance to determine the need and
consequences of interdisciplinary periodontal-orthodontic approach in order maintain harmonious periodontal
and orthodontic relation and bring out the best results for the patient. Thus, the aim of this review is to discuss
in detail the effects of various orthodontic forces on the periodontal tissues.
Keywords:Orthodontic forces, periodontal tissues, excessive,infrabony, recession
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Date of Submission: 20-03-2019 Date of acceptance: 06-04-2019
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I. Introduction
An increasing number of adult patients are seeking orthodontic treatment, many of whom are likely to
have some degree of periodontal disease. A reduction in periodontal support can be associated with labial
flaring, extrusion, rotation, spacing and drifting of the teeth 1. Such changes are believed to occur when the
periodontal ligament is no longer able to stabilize the teeth against external forces 2. Maxillary incisors are
particularly susceptible to pathological migration and over-eruption 3. These acquired occlusal changes, along
with any underlying skeletal discrepancy, often result in a complex malocclusion that necessitates an
interdisciplinary treatment approach.
Periodontal disease is not necessarily a contraindication to orthodontic treatment provided that the
condition has been stabilized; however, loss of alveolar bone and soft-tissue architecture may pose considerable
challenges to oral rehabilitation. It has been concluded that adjunct orthodontic treatment may play an important
role in developing the optimal base needed for re-establishing an esthetic and functional dentition in these cases
4
. Orthodontic extrusion of unrestorable teeth, for instance, may assist the periodontist and restorative team in
harnessing alveolar bone and improving the soft-tissue architecture1. This adjunct treatment is particularly
useful for patients who require dental implants in esthetic zones.
Orthodontic therapy may also have detrimental effects, including root resorption 5 and bone dehiscence
6
. The introduction of fixed orthodontic appliances into the oral cavity also increases the amount of acidogenic
biofilm, thus increasing the risk of gingivitis and caries. A critical issue in the treatment planning of any patient
revolves around how much orthodontic movement the periodontium can tolerate before it becomes adversely
affected.

TISSUE RESPONSE TO ORTHODONTIC FORCES

When orthodontic forces are applied to teeth, both compressive and tensile stresses develop in the
surrounding tissues. Areas under tension have classically been described as sites of bone apposition, while those

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 Impacts of Orthodontic Treatment on Periodontium: A Review
under compression undergo bone resorption. The net effect of this remodeling process is the movement of teeth
along the direction of the applied force and into the space created by the recently resorbed bone. It has recently
been demonstrated by Cattaneo PM et al (2005), however, that the distribution of compressive and tensile
strains in the periodontal tissues is more complex than initially believed 7.
The magnitude of the applied force is believed to play a role in determining the pattern of stresses and
strains in the dento-alveolar tissues. It has also been suggested that different force systems may determine
whether a tooth will move „through‟ bone or „with‟ bone 8. A tooth is thought to move through bone when
undermining resorption, rather than frontal resorption, occurs in response to heavy orthodontic forces 8. Such
forces cause constriction of the microvasculature and localized necrotic areas within the periodontal ligament
(hyalinization), which are then removed by tartrate-resistant acid phosphatasepositive macrophages and
multinucleate giant cells migrating from adjacent bone marrow sites.Undermining resorption is typically
characterized by a delay in tooth movement because no bone apposition can occur on the tension side until the
necrotic tissue on the compression side has been removed. Under ideal conditions, it is thought that teeth move
with their alveolus when resorption occurs directly at the alveolar–periodontal ligament interface on the
compression side, while bone apposition occurs on the tension side and on the external surface of the alveolar
process 4. The net outcome of this near simultaneous process is the movement of a tooth beyond its original
alveolar boundary 8.
There has been awareness of the relationship between force magnitude and the type of resorption that
occurs on the pressure side ever since Carl Sandstedt‟s classical experiments (1904-1905) on dogs in the early
1900s 9,10. In some experiments on Beagle dogs, the use of light forces did not seem to prevent hyalinization of
the periodontal ligament in the initial stages 11 or influence the rate of tooth movement 12. The use of light force
systems, however, may still prevent further hyalinization from occurring after the initial period of tooth
movement 13.Movement of teeth through bone, for example, may be desirable in cases where the clinician is
interested in extruding a root-fractured tooth without the accompanying bone 4. On the other hand, movement of
teeth with bone may help augment bone as teeth are moved into sites with atrophic alveolar ridges 4.

ORTHODONTIC SPACE CLOSURE

One of the most challenging clinical problems in orthodontics is the closure of large edentulous spaces
with severely resorbed alveolar ridges. These situations may arise following the loss of a deciduous tooth with
no permanent successor or after extraction of an unrestorable tooth. In nongrowing patients, the loss of a
permanent molar often leads to progressive tipping, rotation and lingual rolling of the adjacent teeth 14. Over
time, these uncontrolled tooth movements can result in scissor bites, nonworking side interferences, poor
gingival contours,deepening of the bite and over-eruption of theopposing teeth 14. Pseudopockets may
alsodevelop because of the bone‟s tendency to follow theinferiorly displaced cemento–enamel junction ofthe
tipped tooth.There are several biomechanical and anatomic challenges in closing long-standing edentulous
spaces with narrow ridges. Space closure is particularly problematic in the mandible because of the denser
cortical plates and greater susceptibility to ridge resorption. Orthodontic space closure may reduce costs for
ridge augmentation and placement of implant-supported restorations 15. Despite these potential benefits, most
orthodontists are often reluctant to close large edentulous spaces because of the risk of localized gingival
dehiscence, poor root parallelism, incomplete space closure, increased treatment duration, and relapse 15,16.
Reopening or incomplete closure of these spaces can lead to further periodontal breakdown if they result in open
interproximal contacts and food traps.
Two retrospective human studies by Hom BM et al (1984) and Stepovich ML et al (1979) have
investigated the effect of space closure and found clinically significant reductions in posterior space and
moderate increases in the width of the alveolar ridge 16,17. Both studies used small convenience samples and did
not report on any quantitative measurements of gingival recession or attachment loss. Two notable findings
from these studies were the slight loss of crestal bone height mesial to the tooth being protracted 16 and the age-
dependent effect on the amount of increase in alveolar bone width 17. The loss of crestal bone height reported in
these two studies may be related to the tipping movements that occur when a tooth is moved along an arch-wire
18
. Tipping movements usually result in an unequal distribution of stresses within the periodontal ligament, with
higher active forces and levels of compression found in the marginal tissues.
According to Frost‟s „mechanostat‟ theory, both low and excessive bone strains can cause osteopenia
and bone loss. On the other hand, strain levels in the range of 1,500–3,000 microstrains tend to favor a modeling
process which is associated with bone deposition 19. The type of bone deposited during this modeling process is
thought to be dependent on the amount of bone strain, with higher levels resulting in the formation of woven
bone.Recent advancements in the fields of orthodontics and periodontics have had a large impact on the
management of edentulous atrophic ridges. Skeletal anchorage has been useful for uprighting tipped teeth,
facilitating bodily tooth movements during space closure and reinforcing anchorage 20. The risk of anchorage
loss is particularly high in patients with reduced periodontal support. The relatively apical position of
miniscrews is also useful for applying orthodontic forces closer to a tooth‟s center of resistance, thus reducing
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 Impacts of Orthodontic Treatment on Periodontium: A Review
the likelihood of unwanted tipping movements 20. Despite the potential advantages of skeletal anchorage
systems, there is still a lack of high-quality evidence regarding their clinical efficacy. Another important
development has been the application of periodontal regeneration therapies during orthodontic treatment. The
clinical outcomes of this combined approach are promising as shown by Nemcovsky CE (1996), with increased
connective tissue attachment levels reported in selected cases 21.

CONSIDERATIONS FOR TIPPED TEETH WITH INFRABONY DEFECTS

Infrabony pockets are often associated with periodontally compromised teeth or severely tipped teeth
adjacent to edentulous spans. Some authors have warned that orthodontic movements can aggravate the
periodontal issues and lead to widening of the defect 22. An important consideration in these treatments is
therefore the response of infrabony pockets to orthodontic tooth movement. The response of periodontal tissues
to orthodontic tooth movement has been investigated in dogs with poor oral hygiene and experimentally induced
infrabony pockets 23. In contrast to the maxillary control teeth, bodily movement of the mandibular test teeth
resulted in a significant increase in pocket depth and loss of connective tissue attachment, especially when the
teeth were moved toward the infrabony defects. One probable reason for the continued destruction of the
periodontal tissues and the persistence of infrabony pockets in these situations is the apical displacement of the
adjacent supragingival plaque into subgingival sites.
Other studies, however, have reported improved healing of infrabony defects when good oral-hygiene
measures were implemented. In a study by Weltman B et al (2010)24, infrabony pockets were experimentally
produced around the incisors of four Rhesus monkeys and the effect of tooth movement into these defects was
investigated. Histologic findings from that study showed the potential for complete resolution of these defects in
the presence of reduced, but healthy, periodontal tissues. Using a rat model, Vardimon et al. 25 performed a
histomorphometric analysis on 62 decalcified hemimaxillary blocks following the movement of teeth into
surgically created bony defects. Although a 6.5-fold increase in the total area of bone apposition was reported in
the experimental group, this increase was not statistically significant. An important clinical implicationfrom
both animal and human studies is the need tomaintain healthy periodontal tissues throughout theprocess of
uprighting and space closure. Regularmonitoring of oral health should therefore be carried out throughout the
course of orthodontic treatment.

CONSIDERATIONS FOR DENTAL IMPLANTS

Space closure can often be challenging in patients with severe Class II or Class III malocclusions
unless the underlying skeletal discrepancy is corrected. Single dental implants are useful in these cases provided
there is adequate bone at the recipient site. Unfortunately, absence or extraction of teeth can lead to significant
reductions in the width and height of the alveolar ridge over time.
Strategic repositioning of teeth in the arch can result in extensive regeneration of the alveolar bone and
supporting tissues (Fig. adapted from Periodontology 2000)

Fig. Large osseous defect associated with three missing

mandibular incisors. (A) The alveolar bone level was at
the apical third of the root of the mandibular right lateral
incisor (tooth 42) with gingival recession (B) Tooth 42
was moved mesially along the alveolar ridge using fixed
appliances. Both the clinical appearanceand periapical
radiograph show significant bone formation distal to
tooth 42 (yellow arrows). (C) The final implant-supported
restoration.Gingival inflammation around tooth42 has
resolved, with no significantchange in connective tissue
attachment.

The development of the alveolar bone using this

technique may be particularly useful in patients with
congenitally missing lateral incisors. In these cases, the
alveolar ridge of the lateral incisors can be prepared for
receiving future implants by allowing the canines to erupt
adjacent to the central incisors and then distalizing them
back to their normal positions within the arch 26. Following treatment, bone deposition would be expected to
occur on the mesial aspect of the distalized canine because this represents a site of tension.Use of this particular
treatment protocol has been reported by Spear FM (1997) and Kokich V (1994) to result in adequate alveolar
bone width, which is relatively stable up to 4 years after treatment 26,27. Similar findings were recently reported
in a larger retrospective study of 80 patients with 128 missing lateral incisors 28. Over the study‟s 5-year
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 Impacts of Orthodontic Treatment on Periodontium: A Review
retention period, the width and height of the alveolar bone were reduced by only 2% and 0.4 mm, respectively.
A similar treatment protocol has been recommended for managing congenitally missing second premolars 26.
The late removal of ankylotic primary molars may result in significant ridge resorption and vertical bone
defects, prohibiting the placement of dental implants in an optimal position 29. Instead, a dental implant may be
placed at the site of the first premolar tooth after it has been distalized into the second premolar space 26,29. An
important consideration in these situations is the potential effects of moving teeth into areas with reduced
alveolar bone.
The management of large edentulous spaces is an important part of oral rehabilitation. Despite the
limited evidence available, sagittal movement of teeth into longstanding edentulous sites seems to be a viable
method for closing residual spaces and redeveloping variable amounts of alveolar bone. Several treatment
factors may also help to reduce the risk of marginal tissue breakdown during space closure, including the use of
light forces, bodily tooth movement, absence of inflammatory periodontal disease and the maintenance of good
oral hygiene throughout treatment. Nonetheless, the risk of gingival recession and attachment loss should be
carefully assessed in individual patients before closing residual spaces.

ORTHODONTIC INTRUSION
Orthodontic intrusion may be a useful treatment adjunct in a wide range of cases, including the management of
elongated incisors and traumatic deep-bite, and the restoration of severely worn incisors.

INTRUSION OF FLARED AND ELONGATED TEETH

Flaring and elongation of the incisor teeth is commonly seen in patients with advanced periodontal
disease 1. One consequence of these unwanted occlusal changes is the development of a traumatic deep-bite,
which can cause significant soft-tissue and hard-tissue trauma . In adults, severe skeletal deep-bites are often
treated using ajoint surgical–orthodontic approach, although intrusion of the anterior teeth is also possible in
some cases30. Two important advantages of intruding elongated incisor teeth are the improvement in smile
esthetics and reduction in soft-tissue trauma.The intrusion of teeth has a number of important effects on the
periodontal tissues 31. Bone deposition occurs along the stretched periodontal ligament fibers in the middle and
coronal thirds of the root 32. The intensity and direction of the intrusive force, however, seem to play an
important role in influencing the responses of these tissues. Light forces are likely to reduce stresses in the
marginal part of the periodontal ligament, while forces directed through the long axis of a tooth favor bodily
intrusion and limit the extent of hyalinization 33. Force magnitude also affects the reaction of the tissues at an
apical level, with heavy intrusive forces associated with a higher degree of root resorption 31,32.

Fig. (adapted from Carranza 12th edition) Patient with a

bruxing habit with the objective to level the gingival margins
during orthodontic therapy. Intrusion of right central incisor
facilitated the both gingival margin correction as well as
restoration of abrasion

The clinical effects of intrusion have been

extensivelyinvestigated in both animals and humans
31,32,33,34,35
. In one animal studyby Melsen B et al (1989), the
useof light and continuous forces resulted in pure
intrusionwithout any loss of marginal bone 33.
Followingsurgical debridement, the intruded teeth in thefive
Macacafascicularis monkeys had greater attachmentlevels,
which were attributed to coronal migrationof the periodontal
ligament cells. Meticulous periodontal therapy during
intrusion exposes the root surface to the periodontal ligament
cells and increases the likelihood for connective tissue
regeneration 35.
The effects of intrusion are not limited to the marginal tissues, with bone deposition reported by
Bondevik O et al (1980) and Melsen B et al (1986) on the labial and palatal surfaces of the alveolar process and
near the root apices 32,34. The formation of new bone in these areas is reported to result in a small increase in the
buccolingual width of the alveolar process. It has been hypothesized that this new bone forms in response to the
negative loading created by the intrusive forces on the adjacent structures 32,34. Similar findings have also been
reported in a sample of deep-bite adult patients with horizontal bone loss 35. In that study, following intrusion,
bony support increased and clinical crown length decreased by approximately 7% and 1.1 mm, respectively.
Although orthodontic intrusion has been shown to improve periodontal support under optimal conditions,
careful consideration should still be given to some of the adverse side effects that may occur as a result of this
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 Impacts of Orthodontic Treatment on Periodontium: A Review
tooth movement, especially root resorption and shortening 31. Findings from both animal models and human
samples suggest that force magnitude plays an important role in the extent of tissue loss, with heavier forces
associated with a higher degree of root resorption 31,32. The magnitude of the intrusive force seems to play a
more important role in the development of root resorption than does the amount of tooth displacement 31. It is
important to note that other factors, such as genetic susceptibility and history of previous trauma, may also
increase the risk of root resorption in some patients. Fortunately, most of the resorption lacunae undergo repair
once the intrusive force is terminated and healing is permitted 34.

INTRUSION OF WORN INCISORS

Long-term incisal wear is typically associated with over-eruption, reduction in clinical crown length,
uneven gingival margin heights and a „gummy‟ smile 36. The gingival tissues of fractured or severely worn teeth
often migrate coronally if these teeth are allowed to continue erupting. In addition to clinical crown-lengthening
surgery, orthodontic intrusion may be a viable option for displacing the bone and soft tissues in an apical
direction. During intrusion, the gingival tissues typically follow the path of the teeth, although to a lesser
extent37. Following orthodontic treatment, however, mucogingival surgery may still be needed to increase
clinical crown heights and eliminate pockets that develop from the stretching of the gingival fibers 37.Several
animal and human studies have investigated the effect of orthodontic intrusion on the periodontal soft tissues
and alveolar bone, although direct comparison between studies is generally difficult because of differences in
appliance design, force levels, oralhygiene care and treatment durations. Of these different treatment factors, the
maintenance of healthy gingival tissues throughout intrusion appears to reduce the risk of marginal bone
breakdown. In order to facilitate oral hygiene, surgical periodontal debridement may be needed in some patients
to reduce the depth of existing periodontal pockets.
Orthodontic intrusion may be useful for the intrusion of elongated and flared incisors, management of
traumatic deep-bites and the intrusion of overerupted worn or fractured incisors. Posterior teeth may also be
successfully intruded for receiving prosthetic restorations, managing open-bites and correcting occlusal plane
discrepancies. The decision to use intrusive forces in patients with advanced periodontal disease should take into
account the risk of root resorption because this may create an unfavourable crown-to-root ratio. In these cases,
light forces should be used in order to reduce this risk.

ORTHODONTIC EXTRUSION
The extrusion of teeth has been advocated as an effective method for managing one- and two-wall
infra-osseous defects 38. Numerous case reports have been published to illustrate the potential benefits of tooth
extrusion on the adjacent soft and hard tissues 28,39,40. Some of these reports have found favorable effects on pre-
existing periodontal pockets, including a reduction in pocket depth, an increased zone of attached gingiva and
crestal bone apposition 39. Although some of these changes have been attributed to the regular periodontal
maintenance often implemented during treatment 38, it seems biologically reasonable that stretching of the
periodontal ligament fibers would induce some bone apposition at the alveolar crest 41.

Implant site development

The extrusion of hopeless teeth can help develop theinvesting soft and hard tissues before implant
placement42,43. The effect of orthodontic extrusionon the alveolar bone has been studied using variousanimal
models. In Rhesus monkeys, in a study by Batenhorst KF et al (1974), significantamounts of bone apposition
were found on the lingual,interproximal and apical surfaces followingspontaneous extrusion of the mandibular
incisors44. Although the distance between the cemento–enamel junction and alveolar crest had slightlydecreased
at the three sites (by 1 mm or less), thiswas considered to be minimal given that the teethhad undergone nearly 5
mm of extrusion. These findingsare consistent with those of another study by Skerry TM et al (2006) inwhich
extrusion of premolars in three Beagle dogsresulted in a similar pattern of bone appositionwithin 2 weeks of
starting treatment 45. After7 weeks, mature bone was found at the crestal surfaceand the periodontal fibers had
assumed a similarorientation to controls.
The effect of orthodontic extrusion on the adjacenttissues has been studied by vaVenroov JR et al
(1985) in Beagle dogs with a significantlyreduced periodontium and poor oral hygiene 46. Using light forces,
ranging from 20 to 25 g,hemisected premolar teeth were gradually extrudedto the point of extraction and then
stabilized for aperiod of 3 weeks. Following retention, new-boneformation was radiographically and
histologicallydetected coronal to the marginal bone level, as wellas apical to the root apices.Similar findings
have also been reported by Amato F et al (2012) in a small sample of patients in whom the average ratio of
bone-to-tooth displacement was 70% and soft tissue-to-tooth displacement was 65%42. By extruding teeth
approximately 6 mm (to the point of extrusion), the authors were able to achieve nearly 4 mm of bone and soft-
tissue augmentation. Interestingly, no soft-tissue migration occurred in any of the patients with established
periodontal pockets.

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 Impacts of Orthodontic Treatment on Periodontium: A Review
Several characteristic soft-tissue responses have also been described by Mantzikos T et al (1997) when
teeth are extruded to the point of extraction 47. Initially, the gingival margin exhibits a red-collar appearance;
pocket depth also tends to decrease during the extrusion process. With continued extrusion, a nonkeratinized red
patch may appear coronal to the free gingival margin. This thin tissue, which later becomes keratinized to
resemble the surrounding gingival tissues, is formed from eversion of the pocket lining 48.
Extrusion of teeth has a number of desirable effects on the position of the gingival margin, pocket
depth and width of attached gingiva. The gingival margin normally follows the direction of tooth displacement,
but to a variable extent 42. In teeth with deep periodontal pockets, for example, the coronal displacement of the
soft tissues lags behind that of the hard tissues 47. In general, however, extrusion of teeth causes the attached
fiber bundle to be displaced coronal to the epithelial attachment, thereby inverting the periodontal pocket and
reducing its depth 47,48. The width of the attached gingiva also increases because the free gingival margin is
displacedmore coronal than the mucogingival margin 42.

CONSIDERATIONS FOR THE DIRECTION OF TOOTH EXTRUSION

There is some controversy regarding the ideal angle and direction of extrusion when preparing implant
sites. In general, teeth may either be extruded along their long axis 42, or with progressive application of labial
root torque 43. In the presence of an angular defect, gradual mesiodistal tipping of the teeth toward the defect
may also be considered. Each method has a number of advantages and disadvantages. When extruding teeth
with labial root torque, the marginal tissues are believed to follow the root apex as it moves both buccally and
coronally 43. This scenario may be particularly useful in cases with severely resorbed labial bone plates. On the
other hand, excessive application of root torque in cases with reduced, but intact, labial plates is likely to
compromise the integrity of the remaining buccal bone and create unwanted bony dehiscences/fenestrations. In
such cases, it would seem more reasonable and less destructive to extrude teeth along their long axis so that the
entire periodontium is displaced coronally.Regardless of the method used, however, extrusion should be carried
out using light and controlled forces, and in the absence of deep periodontal pockets 42,43. Moreover, a short
stabilization period following extrusion is recommended to allow the new bone to mineralize and mature 42.
Although most orthodontists are aware of the potential to develop prospective implant sites through
tooth extrusion, data on the efficacy of this technique are lacking. Most of the evidence in this area originates
from case series and small experimental studies. Based on the evidence available, however, orthodontic
extrusion seems to be an effective method for developing the investing soft tissues and alveolar bone. During
orthodontic extrusion, the alveolar bone and soft tissues are displaced coronally, along with the cemento–enamel
junction. There is some evidence that elimination or reduction of periodontal pockets, before extrusion,
increases the likelihood of soft-tissue migration. In general, orthodontic extrusion may offer an effective and
less-invasive method for developing prospective implant sites, especially if orthodontic treatment is already
indicated.

ORTHODONTIC EXPANSION AND INCISOR PROCLINATION

There is an increasing trend toward nonextraction treatment in orthodontics, whereby crowding is
managed by increasing the arch length. Lateral expansion of the buccal segments, and labial advancement of the
incisors, can theoretically provide a variable amount of additional space for the alignment of displaced teeth 49.
Proclination and advancement of the mandibular incisors has been suggested as a viable alternative to
extractions and orthognathic surgery in adult patients with increased overjets and moderate-to-severe crowding.
Nonetheless, there is still some controversy regarding the risks of non-extraction treatment, especially in
patients with significant arch-length discrepancies. One important concern is the effect of orthodontic expansion
on the gingival tissues and alveolar bone.

TRANSVERSE EXPANSION
Both maxillary and mandibular arches undergo a significant amount of transverse development during
normal growth 50,51. In addition to these growth-related changes, arch expansion can be achieved using a number
of orthodontic appliances, including arch-wires, removable plates, fixed expanders and orthognathic surgery.
Several animal and human studies have investigated the relationship between arch expansion and gingival
recession, attachment loss and bony dehiscence.
Rapid maxillary expansion has been shown to cause significant changes in alveolar bone thickness
following treatment 52. Recently, a comparison between pre- and post-treatment spiral computed tomography
images in a small sample of adolescents receiving rapid maxillary expansion identified several areas of bony
dehiscence and a 0.6–0.9 mm reduction in buccal bone plate thickness of the banded teeth 52. Interestingly, the
presence of thinner buccal bone plates at the onset of treatment was associated with greater changes in crestal
bone levels and the occurrence of a bony dehiscence following expansion.A few studies have investigated the
effects of maxillary expansion on the long-term health of the periodontal tissues. In one such study by Graber
LW et al (2005), which included young patients, the prevalence of gingival recession on one or more teeth in the
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 Impacts of Orthodontic Treatment on Periodontium: A Review
rapid maxillary expansion and fixed appliance groups were 20% and 6%, respectively 53.Ballanti et al. (2009)54
measured bone thickness from computed tomography scans at the level of the root furcation and did not account
for the relatively thinner marginal regions in which periodontal breakdown would be expected to occur during
tooth movement.
Surgically assisted rapid maxillary expansion is often used to manage transverse skeletal discrepancies
in adult patients. The effect of surgically assisted rapid maxillary expansion on the periodontal tissues seems
less detrimental, with minimal change in attachment levels reported. One reason for the more pronounced
effects of conventional rapid maxillary expansion on the periodontal tissues may be related to the heavy forces
delivered by these appliances to the supporting periodontium.
The adverse effects of heavy forces on the supporting periodontium have fueled interest into the use of
light-force appliances, which may theoretically favour the movement of teeth „with bone‟. Self-ligation brackets
are reported to produce low friction, which permits light forces to be delivered to the teeth 55. Using a well-
designed randomized clinical trial, the changes in buccal bone were assessed following transverse expansion
with self-ligating brackets. Transverse expansion was found to occur mainly as a result of buccal tipping, rather
than by true translation of the teeth „with‟ buccal bone. Unlike the other tooth movementsdiscussed previously,
it is plausible that bone apposition does not accompany transverse and sagittal tooth movements to the same
extent because the overlying cortical plate in this direction is far too thin for the osteogenic progenitor cells to
form new bone 56.
While a small amount of bone may be formed by periosteal apposition, excessive tooth movements are
likely to cause the periodontal ligament to fuse with the adjacent periosteum, thus creating a bony dehiscence.
This theory seems to be well supported by work of Batenhorstet al.(1974)57, who found distinctive tissue
changes when teeth were both extruded and advanced labially. During these tooth movements, the alveolar bone
and epithelial attachment increased at the lingual, interproximal and apical sides of the experimental teeth. On
the labial aspect, however, bony dehiscence was noted and the epithelial attachment was located more apically.
The effect of retaining the apices of premolar teeth outside the cortical plate has also been studied by
Wainwright WM et al (1973) in a small group of Macaca speciose monkeys 58. Histologic analysis of the
premolar teeth, immediately after expansion, revealed thinning of the buccal cortical plate, lack of bone over the
root apex and disorganization of the periodontal ligament. It has been suggested that thinning out of the buccal
tissues during expansion may predispose to long-term gingival recession as a result of mechanical trauma and/or
periodontitis 58.

SAGITTAL EXPANSION
The ideal position of the mandibular incisors has long been the subject of intense debate. Significant
changes in the pretreatment position of the mandibular incisors are associated with a greater risk of relapse,
which makes it an important factor to consider when planning orthodontic cases. Still, a more pressing issue is
often the effect of incisor proclination on the health of the periodontal soft tissues and alveolar bone. The effect
of incisor position on the adjacent alveolar bone has been studied both in dogs 17 and in monkeys 57. Nearly all
of these animal studies have found a consistent reduction in the level of the alveolar bone following incisor
tipping or bodily displacement. Interestingly, marginal bone levels increased and experimentally induced
fenestrations/dehiscences resolved following the repositioning of previously expanded teeth within the alveolus
60
. However, that eruption of the incisors during this repositioning process may also have influenced the level of
the marginal bone in these studies, as the alveolar crest migrates coronallyto maintain its relationship with the
cemento–enamel junction 61.
Alveolar bone defects may also occur in theabsence of any deliberate attempt to protrude theteeth
outside the cortical plate. In addition to the development of a bony dehiscence or fenestration, labial
advancement of the mandibular incisors is reported to cause tension at the free gingival margin, which reduces
its apicocoronal height and buccolingual thickness 62. Several predisposing factors have been reported, including
patient age 63, gingival biotype 62 and width of the attached gingiva 64. The extent of incisor proclination and the
presence of visible plaque have also been linked with gingival recession 62. In particular, a thin gingival
biotypes, coupled with excessive proclination of the incisors, can render the gingival tissues less resistant to
plaque-induced inflammation and traumatic toothbrushing 62. A recent systematic review by Joss-Vassalli I et al
(2010) in this area described the current level of evidence as low and highlighted a number of methodological
weaknesses, including the use of retrospective study designs, inadequate clinical records and lack of follow-up
data 65. The standard of oral hygiene is often not accounted for in these studies. These limitations highlight the
need for well-designed prospective studies to investigate the factors that predispose to gingival recession during
orthodontic treatment.
Based on the data available, it would seem prudent to maintain the position of the teeth within the
alveolar process. Excessive bodily advancement or proclination of the teeth for the purpose of gaining additional
arch space may adversely affect the health of the periodontal tissues, especially in the presence of specific
triggering factors, such as overzealous toothbrushing 4. There may be some cases, such as dentoalveolar
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 Impacts of Orthodontic Treatment on Periodontium: A Review
retrusion, where the incisors can be advanced with less risk of recession 56. Careful evaluation of the periodontal
tissues, oral hygiene, underlying skeletal structures and magnitude of tooth movement is therefore recommended
for individual patients.

BENEFITS OF ORTHODONTIC THERAPY

Orthodontic therapy can provide several benefits to the adultperiodontal patient. The following six factors
should be
considered:
1. Adult patients will be able to have better access to clean all surfaces of their teeth adequately by aligning
crowded or malposed maxillary or mandibularanterior teeth permits. Patients who are susceptible to periodontal
bone loss or do not have the dexterity to maintain their oral hygiene could be a benefitted tremenduously by this.
2. Certain types of osseous defects in periodontal patients can be improved by vertical orthodontic tooth
repositioning as thetooth movement eliminates the need for resective osseoussurgery.
3. The esthetic relationship of the maxillary gingival margin levels before restorative dentistry can be improved
by Orthodontic treatment. Alignment of the margins of the gingiva orthodonticallyprevents gingival
recontouring, which could require boneremoval and exposure of the roots of the teeth.
4. The patient with a severe fracture of a maxillary anterior tooth that requires forced eruption to permit
adequate restoration of the root is also benefitted by orthodontic therapy.
5. Open gingival embrasures to be corrected by orthodontic treatment to regain lost papilla. These open
gingivalembrasures become unesthetic if they are located in the maxillary anterior region. These areas can be
mostly correctedwith a combination of orthodontic root movement,tooth reshaping, and restoration.
6. Adjacent tooth position can be improved by Orthodontic treatment before implant placement or tooth
replacement. This becomes necessary for the patient who has been missing teeth forlong duration and has
drifting and tipping of the adjacentdentition.

II. Conclusions
In general, the controlled movement of teeth seems to have a positive, but highly variable, effect on the
supporting tissues. The correction of some orthodontic problems, such as excessively tipped molars, traumatic
deep-bites and flared and spaced incisors, may be particularly beneficial in periodontally compromised patients
who are motivated to undergo treatment and demonstrate stable periodontal conditions. Specific tooth
movements can also help develop alveolar bone sites for placing dental implants. However, several factors may
contribute to a harmful periodontal response including the use of heavy forces, inappropriate force systems and
poor oral hygiene. Excessive and unrealistic tooth movements are also likely to result in reduced alveolar bone
thickness, especially in patients with thin cortical plates. On the other hand, the response of the soft tissues is
less predictable and likely to be influenced by multiple factors. Well-designed long-term prospective studies are
therefore needed to identify these patient and/or treatment factors.

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