ORTHODONTIC RETENTION BY PERIO

ESTHETIC PROCEDURES- AN OVERVIEW

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ABSTRACT

Esthetics has become a great concern to attain a perfect

smile and it has given greater importance for dental treatment. The
periodontal tissues react to orthodontic forces. The link between
Orthodontics and Periodontics has become more evident for tooth
movement to occur. In recent days, due to more number of adult
patients seeking orthodontic treatment, the Orthodontist frequently
face patients with complaints of post-orthodontic retentive
esthetic measures of periodontium. Esthetic considerations such
as midline diastema, uneven gingival margins, crown lengthening
or other functional problems related to periodontium is advised in
orthodontic treatment planning. The purpose of this review is to
provide an optimized treatment outcome in relation to periodontium
during orthodontic correction.

KEYWORDS:

Perio esthetics, Gingival Augmentation,

Orthodontic Retention

JIDAM/Chennai/Volume:7/Issue:3/Pages 96 -102 / July- Sep 2020

Address for Correspondence:

Dr. Ramya Rajendran, MDS.,

Reader, Department of Orthodontics and

Dentofacial Orthopaedics,

Adhiparasakthi Dental College and Hospital,

Melmaruvathur, Kanchipuram-603319.

Email:

ramyaraj2884@yahoo.co.in

Received

: 06.09.2020

Accepted

: 15.09.2020

Published

: 27.09.2020

REVIEW ARTICLE

Dr. Ramya Rajendran, Dr. C. Burnice Nalina Kumari*, Dr.Padmalochani**, Dhwani.K.Dedhia*, Dr.Shalini

Arumugam*, Dr.Vijayalakshmi.R*

Department of Orthodontics, Adhiparasakthi Dental College and Hospital, Melmaruvathur, Kanchipuram,

Tamilnadu, India

*Department of Periodontology, Meenakshi Ammal Dental College, Chennai, Tamilnadu, India

**Private Practice, Dubai.

DOI:1.37841/jidam_2020_V7_I3_04

JIDAM/Chennai/Volume:7/Issue:3/Pages 96 -102 / July- Sep 2020

Ramya et Al: Orthodontic Retention By Perio Esthetic Procedures

INTRODUCTION:

Esthetics has become one of the greatest

concern in the present day that gives increased

importance to look for dental treatment, for obtaining

a perfect smile. Some particular areas evaluated

are like, how the periodontal tissues respond to

the orthodontic forces, effect of tooth movement

on the periodontium, reaction of circumferential

supracrestal fiberotomy to prevent orthodontic

relapse, mucogingival alterations and time

relationship which occur during orthodontic tooth

movement and periodontal treatment. In addition

to this, esthetic problem is also caused by midline

diastema and aberrant frenum which presents a

compromise in orthodontic treatment and may lead

to recurrence after treatment.

FRENECTOMY:

Diastema is the presence of space more

than 0.5mm in adult maxillary central incisors.

This condition has often posed an esthetic problem.

The most important etiological factor for midline

diastema is the presence of aberrant frenum1

CLASSIFICATION:

• The labial frenal attachments have been classified

as mucosal, gingival, papillary and papilla

penetrating, by Placek et al (1974) 2.

• Mucosal–when the frenal fibers are attached upto

the mucogingival junction.

• Gingival – when the fibers are inserted within the

attached gingiva.

• Papillary – when the fibers are extending into the

interdental papilla.

• Papilla penetrating – when the frenal fibers cross

the alveolar process and extend upto the palatine

papilla.

INDICATIONS FOR FRENUM REMOVAL:

• The frenum is distinguished as pathogenic and it

is indicated for removal when:

• A maxillary midline diastema may be caused by

the attachment of labial frenum into the notch in

the alveolar bone so that the band of heavy fibrous

tissue lies between the central incisors.

• An inferiorly attached frenum in the gingival

margin has low, thick and fleshy frenal attachment

which causes gingival recession and potential

obstruction for maintaining good oral hygiene.

• An aberrant frenum is often associated with

an inadequate attached gingiva and a shallow

vestibule.

• Depending upon the extent and severity of the

tissue growth, the correction of high frenal

attachment can be done before or after orthodontic

procedures. There are number of methods to assess

the involvement of frenum in the etiology of

midline diastema such as : 1)direct visualization 2)

blanching of tissue on lifting the upper lip (Tension

test) 3) notch or triangular shaped intermaxillary

segment on radiographic examination.

• There is excess tissue growth in some cases which

may require additional corrective procedure

before and after space closure.

• In most orthodontic midline diastema cases, it

is preferable to delay the procedures regarding

the frenum until the orthodontic space closure is

completed. After the space closure completion, if

the frenectomy is done, the scar tissue contraction

phenomenon takes place which will lead to

prevention of relapse. This procedure is done only

in the permanent dentition by following eruption

of maxillary canines.

TREATMENT:

Normally the aberrant frenum can be treated

by frenectomy or frenotomy. Frenectomy is the

complete removal of frenum including its attachment

to bone. Frenotomy is to create a zone of attached

gingiva between the gingival margin and the frenum

by giving an incision and relocating the frenum2.

Frenectomy can be skilled by three techniques. They

are:

• Routine scalpel technique

• Electrocautery3and

• By using lasers4

By using a scalpel, the routine scalpel

technique has been carried out in the conventional

method which involves excision of frenum. But

this conventional method results in a regular

postoperative complications (Fig 1, Fig 2 and Fig 3).

JIDAM/Chennai/Volume:7/Issue:3/Pages 96 -102 / July- Sep 2020

Ramya et Al: Orthodontic Retention By Perio Esthetic Procedures

Fig 1: Pre-operative view

Fig 2: Intraoperative view- Frenectomy

Fig 2: 2 weeks Post-operative view

Electrocautery and lasers are used and also

been proposed for frenectomy4. Electrocautery

probe is used due to the effectiveness of treatment,

for the safety of the procedure, for the mild bleeding

and for the absence of post-operative complications.

The electrocautery has been associated with some

complications such as the risk of an explosion

when combustible gases are used, like burns,

involvement with pacemakers and surgical smoke.

The new improvements introduced in electrosurgical

techniques have eliminated the complications

reported like the Argon Beam Coagulation (ABC)5.

In recent times, in frenectomy procedure,

the use of CO

laser has been reported as a safe and

an effective option. The advantages of CO

laser in

frenectomy are shorter duration of surgery, simple

procedure, less pain, absence of post-operative

infection and no scar4. In labial frenectomies, for

infants the application of diode and Er:YAG lasers

are used and in adults and prepubescent Er,Cr:YSGG

lasers

are used.

CROWN LENGTHENING:

The esthetic teeth and gingival relationship

includes some established and recommended

characteristics such as:

Tooth proportionality

Contacts, connectors, and embrasures

Gingival characteristics

TOOTH PROPORTIONALITY:

The golden proportion of the ideal maxillary

incisors should be approximately 80% of width

when compared with height. In some cases the ideal

proportion can vary based on the ideal height of

the tooth. The corresponding solutions to the tooth

height - width problem are all variant, including

bonding, to increase the length of the tooth,awaiting

completion of passive eruption or the periodontal

crown lengthening.

CONTACTS, CONNECTORS , AND

EMBRASURES:

The tooth contact, connectors and embrasures

are the real significance for planning the treatment

of smile. The exact place where the anterior teeth

touch is called as contacts (Interdental contacts).The

connector is where the incisor and canine “appear”

to touch. There are certain appropriate ratios for

connectors; the connector between the central

incisors is about 50% of tooth height; the ratio for

central and lateral incisor connector is of about 40%

of central incisor tooth height; and the ratio for lateral

incisor and canine connector is of about 30% of the

central incisor tooth height. The embrasures appear

to be smaller between central incisors and as they

progress posteriorly in dentition they grow larger.

GINGIVAL CHARACTERISTICS:

The gingival shape and gingival contour are

the two most important concepts for the final esthetic

outcome of the orthodontic patients. Gingival shape

refers to the curvature of gingival margin of the

tooth. The gingival margin of the tooth is determined

by the cementoenamel junction and the osseous

crest. According to the accreditation criteria for the

American academy of dentistry, “The shape of the

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Ramya et Al: Orthodontic Retention By Perio Esthetic Procedures

gingiva in mandibular incisors and the maxillary

laterals shows a symmetrical half - oval or half -

circular shape and the maxillary centrals and canines

shows a gingival shape which is more elliptical”.

Gingival zenith plays pivotal role in the anterior

esthetics and is the most apical point of the gingival

tissue. It should be distal to the longitudinal axis of

the maxillary central incisors and canines. The most

apical point of the gingival tissue in maxillary lateral

incisors and mandibular incisors should correspond

with their longitudinal axis8.

TREATMENT:

Gingival overgrowth is often seen post-

orthodontic treatment. This results in dysmmetry

in the gingival characteristics with an unesthetic

appearance. This discrepancy can be corrected by

crown lengthening by gingivectomy to get proper

tooth proportionality and gingival characteristics

and maintaining the biologic width of the teeth post-

orthodontically. (Fig 4, Fig 5 and Fig 6)

Figure 4: Preoperative View

Figure 5: Intraoperative View- Crown

Lengthening by Gingivectomy

Figure 6: 2 weeks Postoperative View

GINGIVOPLASTY:

Gingivoplasty is the surgical recontouring of

the gingiva during or any post-orthodontic gingival

discrepancy in order to achieve a physiologic contour

of the gingiva. The attached gingiva surrounding

the teeth is reshaped to provide more esthetic and

functional contour of the gingiva (Fig 7, Fig 8 and

Fig 9).

Fig 7: Pre-operative view

Fig 8: Intraoperative view- Gingivoplasty

Figure 9: 2 weeks post-operative view

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Ramya et Al: Orthodontic Retention By Perio Esthetic Procedures

100

GINGIVAL RECESSION:

Gingival recession is the apical shift of the

marginal gingiva from its normal position on the

crown of the tooth to levels on the root surface

beyond the cementoenamel junction and it may

affect the labial and lingual or interproximal areas.

The etiology is multifactorial in nature, with both

predisposing and precipitating factors implicated.

The factors to establish the anatomic and morphologic

property in the gingival recession are the alveolar

bone dehiscence, ectopic tooth eruption, the thin

buccal mucosa, crowding and presence of aberrant

frenula. The precipitating factors include traumatic

and aggressive tooth brushing and piercing. The

debate exists in the relationship between the role

of orthodontic treatment and the role of gingival

recession. The most common risk factor for gingival

recession is associated with the movement of teeth

outside the alveolar bone though others have found

no such league.

Good, long term (5years) results have been

announced with coronally advanced flaps and

connective tissue grafts. Few alternative methods

include the laterally positioned flap with or without

connective tissue graft and the free gingival graft is

used in single and multiple gingival recessions. In

this gingival recession management, graft is removed

from the palate and the necrosis of the graft causes

high morbidity. The patients are re- educated about

the importance of brushing technique and other

cleaning aids such as toothpicks, floss and interdental

tooth brushes are also highlighted.

To reduce the risk of gingival recession and

to increase the importance of orthodontic treatment,

the orthodontist must be conscious of and should

take account of considering not just of the crowns,

but also the cortical plates and roots are also more

important.

Thus, to minimize the risk of treatment procedures in

gingival recession include the following:

• To maintain proper and a good oral hygiene

throughout the orthodontic treatment and identify

potential risk factors.

• Eliminate potential causes of recession (piercing,

smoking, traumatic tooth-brushing)

• Avoid uncontrolled dento-alveolar expansion and

maintain arch form

• Customize bonding and mechanics.

• Modify tooth anatomy whenever indicated.

• Consider segment arch mechanics.

• The space should be created before using it and

the created space should be used wisely.

• Consider atypical extractions using analysis. e.g.

compromised teeth.

• Avoid fidget because it may cause periodontal

problems.

• Treatment should be done early (“interceptive

procedure and treatment in mixed dentition”).

• The patient should be re-educated about their oral

hygiene technique after the end of the treatment.

TREATMENT:

Gingival recession can also occur post-

orthodontically as a result of orthodontic forces

acting on the teeth. This can be corrected by root

coverage procedures using pedicle flaps, free soft

tissue grafts, connective tissue grafts after the

orthodontic treatment is completed.(Fig 10 and Fig

11)

Figure 10: Preoperative View

Figure 11: Postoperative View

WILCKODONTICS:

The nature of orthodontic tooth movement

needs was revolutionized by a novel treatment method

combining selective alveolar decortication, alveolar

augmentation and orthodontic treatment called

Periodontally Accelerated Osteogenic Orthodontic

Procedure which is patented by “Wilckodontics”

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Ramya et Al: Orthodontic Retention By Perio Esthetic Procedures

101

based on the emerging concepts of Wilckobrothers9.

Wilckodontics is performed during the week

following bracketing and archwire activation. Facial

and lingual selective alveolar decortications are

performed utilizing circumscribing corticotomy cuts

and intra-marrow penetrations. In some cases, the

activated bone and exposed root surfaces are covered

with the bone graft material (allograft/xenograft)

(Fig 7). This treatment procedure provides advantage

of reduced time period for orthodontic treatment

in adult patients together with reduced need for

extraction and elimination of aggressive intervention

of rapid maxillary expansion.

Figure 12: Selective decortication, alveolar

augmentation and orthodontic tooth movement

FORCED TOOTH ERUPTION:

Forced tooth eruption is the orthodontic

tooth moment in a coronal direction from the

alveolar socket into the oral cavity by applying

light continuous orthodontic force. Several factors

such as root length, root form, level of fracture of

tooth, relative importance of tooth, esthetics and

endodontic and periodontal prognosis of the tooth

to be erupted are taken into consideration. If all

these factors are favorable, forced eruption of the

fractured root is indicated. After the tooth root has

been erupted, it must be stabilized to prevent it from

intruding back into the alveolus. The reason for re-

intrusion is the orientation of the principal fibers

of the periodontium. During forced eruption, the

periodontal fibers become oriented obliquely and

stretched as the root moves coronally. These fibers

eventually reorient themselves after about 6 months.

Before this occurs, the root can retrude significantly.

Therefore, if this type of treatment is performed, an

adequate period of stabilization is necessary to avoid

significant relapse and retrusion of the root.

FIBEROTOMY:

A Pericision is an orthodontic surgical

procedure carried out to help for minimizing the

extent of rotational relapse of teeth.This method

was developed by Edwards JG. The main reason

for relapse after orthodontic treatment is rebound of

the network of elastic supracrestal gingival fibers.

When the teeth move to new position, these fibers

are stretched and remodelling of these fibers takes

a long time. Fiberotomy or pericision involves

elimination of the pull of elastic supracrestal gingival

fibers by sectioning these fibers. The teeth are held in

the corrected position; when the fibers heal, thereby

reducing the relapse caused by elasticity of the

gingival fibers.

This is a simple painless procedure performed

using scalpel to sever the fiber attachment around the

tooth. Without damaging the supporting periodontal

structures the “Laser CSF” is used. It is an efficient

procedure to decrease the relapse after tooth rotation

since orthodontically rotated teeth without retainers

have more relapse tendency10.

CONCLUSION:

The most widely applied technique now in

orthodontic treatment is laser technique and it has

proved to have many benefits. Soft tissue lasers

can be used to perform all prosthodontic, retentive,

esthetic measures in periodontium which includes

gingivectomy, frenectomy, fiberotomy and surgical

exposures of the tooth with less bleeding and

wound contraction and reduced pain. The spirit of

interdisciplinary approach between Orthodontic and

Periodontic relation always provide the stable and

evidence based results in the treatment of orthodontic

patients.

FINANCIAL SUPPORT AND

SPONSORSHIP:

Nil

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Ramya et Al: Orthodontic Retention By Perio Esthetic Procedures

102

CONFLICTS OF INTEREST:

There are no conflicts of interest

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