Effect of orthodontic therapy in periodontitis and non-periodontitis patients: a systematic review with meta-analysis

Clear orthodontic aligners in patients with a history of severe periodontitis: Two case reports with 12 months of follow-up

BACKGROUND

The orthodontic treatment of patients with a history of severe periodontitis helps to improve periodontal health, functional occlusion, and esthetics. The use of aligners in patients with a history of severe periodontitis, with a single protocol of periodontal treatment, and the report of periodontal parameters throughout the orthodontic treatment has not yet been evidenced. Therefore, this manuscript aimed to describe the treatment with a clear orthodontic aligner system in two patients with reduced periodontium associated with a history of severe periodontitis.

METHODS AND RESULTS

Two male participants (43-year-old and 62-year-old, respectively) were diagnosed with generalized, stage III, grade B periodontitis and treated with the same periodontal treatment protocol. After a 12-month follow-up of periodontal maintenance, the subjects were referred for tooth migration and Class II malocclusion orthodontic treatment. The subjects received orthodontic treatment with clear aligners. After starting orthodontic therapy, the patient received periodontal maintenance and clinical monitoring at 3, 6, 9, and 12 months. The periodontal parameters remained stable throughout the aligner treatment. At 12 months of orthodontic treatment, an improvement in angulations, inclinations, and dental positioning was observed, obtaining a stable occlusion, and reaching the proposed objectives for the treatment stage.

CONCLUSIONS

A significant improvement in the occlusal relationship could be achieved with the clear orthodontic aligner system in adult patients with reduced periodontium by a history of severe periodontitis. Orthodontic therapy with clear aligners was shown to be safe in maintaining good periodontal health with the protocol of periodontal treatment used in the clinical cases presented.

PLAIN LANGUAGE SUMMARY

This case presentation is a contemporary and innovative approach to orthodontic and periodontic treatment of patients with a history of severe periodontitis that in the recent past would not be referred to an interdisciplinary treatment because of the lengthy orthodontic treatment time and the difficulty of hygiene that fixed appliance brings, putting at risk the permanence of these teeth in the oral cavity even with adequate periodontal treatment. The keys to the success of this partnership intervention are a precise diagnosis and careful treatment planning of orthodontic treatment and a correct periodontal intervention to keep teeth and periodontium in good health. The primary limitation is without a doubt, the patient's collaboration both in the correct use of the aligners and in the adherence to periodontal treatment.

Supportive periodontal care during active orthodontic therapy in patients with history of stage IV periodontitis: A narrative review

The present narrative review aims to summarize the existing literature on recommendations for supportive periodontal care (SPC) in patients undergoing combined periodontal-orthodontic treatment. It outlines a comprehensive step-4 treatment sequence in patients diagnosed with stage IV periodontitis and concurrent orthodontic problems. The delivery of SPC characterizes step 4 of the comprehensive treatment sequence, focusing on the prevention of bacterial re-infection and the recurrence of the disease. Step 4 includes repeated assessments of residual probing pocket depths (PPD) greater than 5 mm, bleeding on probing (BoP) and/or suppuration around teeth and implants, as well as evaluation of furcation involvement. Extensive evidence indicates the efficacy of rigorous self-performed plaque control and adherence to regular SPC following active periodontal therapy as vital for managing caries and periodontitis, thereby reducing possible tooth loss. Current evidence indicates that patients with stage IV periodontal disease can safely proceed with orthodontic treatment following active periodontal therapy. Nonetheless, it is the authors' recommendation for patients undergoing periodontal-orthodontic treatment to participate in an SPC program scheduled every 3-4 months.

Expert consensus on orthodontic treatment of patients with periodontal disease

Patients with periodontal disease often require combined periodontal-orthodontic interventions to restore periodontal health, function, and aesthetics, ensuring both patient satisfaction and long-term stability. Managing these patients involving orthodontic tooth movement can be particularly challenging due to compromised periodontal soft and hard tissues, especially in severe cases. Therefore, close collaboration between orthodontists and periodontists for comprehensive diagnosis and sequential treatment, along with diligent patient compliance throughout the entire process, is crucial for achieving favorable treatment outcomes. Moreover, long-term orthodontic retention and periodontal follow-up are essential to sustain treatment success. This expert consensus, informed by the latest clinical research and practical experience, addresses clinical considerations for orthodontic treatment of periodontal patients, delineating indications, objectives, procedures, and principles with the aim of providing clear and practical guidance for clinical practitioners.

Profile of Inflammatory Cytokines in Gingival Crevicular Fluid and Plasma in Patients With Grade C Periodontitis During Orthodontic Treatment: A Longitudinal Case Series Report

AIM

To examine the immune responses in patients diagnosed as grade C periodontitis during orthodontic treatment.

MATERIALS AND METHODS

Our study included seven orthodontic patients with grade C periodontitis and measured their levels of inflammatory cytokines in gingival crevicular fluid and plasma before orthodontic treatment, during the alignment and levelling phase, and during the detailing and finishing phase. The key signal pathways in the orthodontic process of patients with periodontitis were detected by KEGG analysis.

RESULTS

Studies have shown that orthodontic treatment brings great improvement to patients with grade C periodontitis, and most of the local/systemic inflammatory cytokines can be reduced after orthodontic treatment. Simultaneously, orthodontic treatment can reduce the percentage of IFN-γ+ Th1 cells in patients with grade C periodontitis. Through KEGG analysis, the IL-17 signalling pathway and TNF signalling pathway are closely interrelated in the orthodontic treatment of patients diagnosed with grade C periodontitis (p-value < 0.001).

CONCLUSION

Orthodontic treatment can effectively control the local and system levels of inflammation in patients with grade C periodontitis, with IL-17A and TNF-α as potential distinctive inflammatory markers for orthodontic-periodontal combined treatment in individuals with periodontitis.

Changes in alveolar bone remodeling after maxillary anterior retraction using fixed appliances with different periodontal conditions: A retrospective study based on cone-beam computed tomography

INTRODUCTION

This study aimed to compare changes in maxillary anterior alveolar bone remodeling and complication rates in adult patients with different periodontal conditions after maxillary anterior tooth retraction using fixed appliances. In addition, this study analyzed potential factors affecting alveolar bone thickness in patients with periodontitis.

METHODS

A total of 55 adult patients (mean age, 23.53 ± 4.55 years) with Angle Class I or II Division 1 malocclusion with maxillary protrusion were recruited and categorized into the healthy control group (n = 23), stage I periodontitis (P-I) group (n = 17), and stage II periodontitis (P-II) group (n = 15). The maxillary anterior teeth were retracted using a fixed appliance. Cone-beam computed tomography was used to measure the thickness, height, and density of the alveolar bone in the maxillary anterior region before (T1) and after (T2) treatment. The incidences of bone dehiscence and fenestration were documented. Statistical analysis was conducted to evaluate intergroup and intragroup differences. Clinical and cephalometric data were collected to identify factors affecting the changes in alveolar bone thickness using multivariate linear regression analysis.

RESULTS

The labial alveolar bone thickness increased significantly after treatment in all groups, but no differences were observed among the groups. In contrast, the palatal alveolar bone thickness decreased, particularly in the P-I and P-II groups, at the midroot and apical levels (P <0.05). A significant decrease in alveolar bone height was observed in the P-I and P-II groups (P <0.05). The incidence of palatal bone dehiscence was higher in the P-II (84.44%) and P-I (69.61%) groups. Multivariate linear regression analyses revealed that sex, treatment duration, periodontal treatment, changes in tooth inclination, and initial thickness significantly affected palatal alveolar bone thickness changes in patients with periodontitis.

CONCLUSIONS

After retraction of the maxillary anterior teeth with a fixed appliance, the labial alveolar bone of the maxillary anterior teeth thickened, whereas the palatal bone exhibited thinning in adults with periodontitis. The reduction in palatal bone height was more significant in this population than in healthy subjects, along with a higher incidence of palatal bone dehiscence. Bone morphology must be carefully assessed, considering these relevant factors before and during orthodontic treatment.

Biomechanical and Biological Multidisciplinary Strategies in the Orthodontic Treatment of Patients with Periodontal Diseases: A Review of the Literature

Orthodontic treatment aims to correct malocclusions and ensure the overall health and stability of the periodontium. The relationship between orthodontic therapy and periodontal health is intricate and multifaceted, and a comprehensive approach is often required to achieve optimal outcomes. Firstly, this article delves into the impact of orthodontic mechanics on periodontal tissues, emphasizing the importance of minimizing iatrogenic effects such as root resorption and gingival recession. Understanding the biomechanical principles allows for the development of treatment plans that mitigate these risks while achieving the desired tooth movement. Effective communication and coordinated treatment protocols are essential for managing periodontal issues before, during, and after orthodontic intervention. To optimize outcomes, periodontal considerations such as gingival biotype, attachment levels, and bone support must be integrated into treatment planning. Additionally, adjunctive periodontal therapies such as selective alveolar decortication and regenerative procedures are explored as valuable tools to enhance periodontal support and optimize treatment outcomes. This narrative review explores strategies to attain periodontal goals in orthodontic patients, thereby facilitating successful treatment. Furthermore, the review examines the role of interdisciplinary collaborations between orthodontists and periodontists. In conclusion, achieving periodontal goals in orthodontic patients requires a comprehensive approach that addresses biomechanical principles, interdisciplinary collaboration, patient education, and adjunctive periodontal therapies. By integrating periodontal considerations into orthodontic treatment planning and execution, clinicians can ensure straight teeth and a healthy and stable periodontium, ultimately leading to successful treatment outcomes and long-term oral health.

Immediate orthodontic treatment after regeneration of periodontal intrabony defects: A long-term retrospective study

BACKGROUND/PURPOSE

Orthodontic movement is often necessary for periodontally compromised patients to enhance esthetics, function, and long-term occlusal stability. However, the impact of orthodontic treatment immediately following the regeneration of intrabony defects on periodontal healing remains a topic of debate. The objective of this long-term case series study was to test the hypothesis that orthodontic treatment performed immediately after regenerative procedures for periodontal intrabony defects did not adversely affect periodontal healing.

MATERIALS AND METHODS

This case series study involved nine periodontally compromised subjects with a total of 17 intra-bony defects. Orthodontic brackets were applied immediately before surgery. Flaps were raised, and diseased roots were debrided. All intra-bony defects were filled with alloplastic bone grafts and covered with resorbable membranes, except for one defect treated with Emdogain. All patients initiated orthodontic treatment immediately after periodontal regenerative surgery. Clinical parameters, including probing depth, attachment level, and bone fill, were assessed at baseline and during final maintenance therapy.

RESULTS

The mean follow-up duration was 12.8 years. None of the 17 surgically regenerated teeth were lost. The mean reduction in probing depth was 3.94 mm (95% confidence level, 3.19-4.68; P < 0.001), with a mean clinical attachment gain of 3.47 mm (95% confidence level, 2.90-4.03; P < 0.001). The mean radiographic bone fill was 4.89 mm (P < 0.001).

CONCLUSION

Based on the findings of this long-term case study, it can be concluded that immediate orthodontic treatment does not adversely affect the maturation process of periodontal regeneration outcomes and can be maintained for more than ten years.

Investigation of Oxidative-Stress Impact on Human Osteoblasts During Orthodontic Tooth Movement Using an In Vitro Tension Model

In recent years, there has been a growing number of adult orthodontic patients with periodontal disease. The progression of periodontal disease is well-linked to oxidative stress (OS). Nevertheless, the impact of OS on orthodontic tooth movement (OTM) is not fully clarified. Therefore, we applied an OS in vitro-model utilizing H2O2 to study its effect on tension-induced mechanotransduction in human osteoblasts (hOBs). Experimental parameters were established based on cell viability and proliferation. Apoptosis detection was based on caspase-3/7 activity. Gene expression related to bone-remodeling (RUNX2, P2RX7, TNFRSF11B/OPG), inflammation (CXCL8/IL8, IL6, PTRGS2/COX2), autophagy (MAP1LC3A/LC3, BECN1), and apoptosis (CASP3, CASP8) was analyzed by RT-qPCR. IL6 and PGE2 secretion were determined by ELISA. Tension increased the expression of PTRGS2/COX2 in all groups, especially after stimulation with higher H2O2 concentration. This corresponds also to the measured PGE2 concentrations. CXCL8/IL8 was upregulated in all groups. Cells subjected to tension alone showed a general upregulation of osteogenic differentiation-related genes; however, pre-stimulation with OS did not induce significant changes especially towards downregulation. MAP1LC3A/LC3, BECN1 and CASP8 were generally upregulated in cells without OS pre-stimulation. Our results suggest that OS might have considerable impacts on cellular behavior during OTM.

Orthodontic management of uneven gingival margins in patients with healthy or reduced periodontium to improve smile aesthetics

Uneven gingival margins may cause visible asymmetries during smiling and may reflect alterations in the tooth shape and morphology, particularly in cases requiring restorative procedures. Despite being perceived as a minor health condition, presence of uneven gingival margins usually impacts the smile aesthetics and could affect the individual's appearance, self‐esteem, and overall quality of life, especially in subjects with a high smile line. Uneven gingival margins may result from different causes, which makes an accurate diagnosis fundamental for its treatment planning. Orthodontic treatment often serves as a conservative approach for leveling these margins, by achieving the most appropriate tooth position. This article reviews the rationale, differential diagnosis, and clinical management of uneven gingival margins using orthodontic tooth movements, providing insights for orthodontists, periodontists, and restorative dentists on the interdisciplinary care needed to correct this condition, and hence, to improve the subject's smile aesthetics.

Analysis of risk indicators for implant failure in patients with chronic periodontitis

Dental implant restoration shows an effective method for the rehabilitation of missing teeth. The failure rate of periodontal implants in patients with chronic periodontitis is associated with periodontal flora, inflammation, and long-term periodontal bone resorption caused by chronic periodontitis. However, the therapeutic effects of dental implant restoration on inflammation in patients with chronic periodontitis have not addressed. The purpose of this study is to evaluate the risk indicators for inflammation, bone loss and implant failure in patients with chronic periodontitis. A total of 284 patients with dental implant restoration were recruited and divided into periodontally healthy patients (n = 128) and chronic periodontitis patients (n = 156). Periodontal indices including probing depth (PD), sulcus bleeding index (SBI), plaque index (PLI), gingival bleeding (GIL) and bleeding on probing (BOP) were compared in two groups. Inflammatory cytokines including tumor necrosis factor-α (TNF-α), interleukin-6 (IL-6), interleukin-1 (IL-1), matrix metalloproteinase-2 (MMP-2) and matrix metalloproteinase-9 (MMP-9) levels at baseline, 6 and 12 months after surgery, and the implant survival rate at 12 months after surgery, as well as the risk factors associated with failure of dental implant were also assessed. Outcomes demonstrated that patients in the chronic periodontitis group had higher values of periodontal indices than those in the periodontally healthy group. All inflammatory parameters in the chronic periodontitis group were higher than those in the periodontally healthy group and negatively associated with the chronic periodontal index (CPI) in chronic periodontitis patients. Chronic periodontitis patients had higher the prevalence of mucositis and peri-implantitis than patients with healthy periodontium. Implant diameter, length and design was associated with the risk of implant failure for chronic periodontitis patients receiving dental implant. The cumulative implant failure rate and incidence of implant fractures for chronic periodontitis patients at 12 months after surgery were 12.10% and 7.23% (p < 0.05), respectively, while were lower in the heathy periodontitis patients. Location, diameter, implant design, immediate loading and bone defect were risk indicators for bone loss for dental implant patients. The risk factors associated with failure of dental implant was higher in chronic periodontitis patients than patients in the periodontally healthy group (14.25% vs. 4.92%, p < 0.05). In conclusion, data in the current study indicate that inflammation is a risk indicator bone loss, implant fracture and implant failure in patients with chronic periodontitis.

PGC-1α/LDHA signaling facilitates glycolysis initiation to regulate mechanically induced bone remodeling under inflammatory microenvironment

The mechanosensitivity of inflammation can alter cellular mechanotransduction. However, the underlying mechanism remains unclear. This study aims to investigate the metabolic mechanism of inflammation under mechanical force to guide tissue remodeling better. Herein, we found that inflammation hindered bone remodeling under mechanical force, accompanied by a simultaneous enhancement of oxidative phosphorylation (OXPHOS) and glycolysis. The control of metabolism direction through GNE-140 and Visomitin revealed that enhanced glycolysis might act as a compensatory mechanism to resist OXPHOS-induced osteoclastogenesis by promoting osteogenesis. The inhibited osteogenesis induced by inflammatory mechanical stimuli was concomitant with a reduced expression of peroxisome proliferator-activated receptor gamma coactivator 1-alpha (PGC-1α). PGC-1α knockdown impeded osteogenesis under mechanical force and facilitated osteoclastogenesis by enhancing OXPHOS. Conversely, PGC-1α overexpression attenuated the impairment of bone remodeling by inflammatory mechanical signals through promoting glycolysis. This process benefited from the PGC-1α regulation on the transcriptional and translational activity of lactate dehydrogenase A (LDHA) and the tight control of the extracellular acidic environment. Additionally, the increased binding between PGC-1α and LDHA proteins might contribute to the glycolysis promotion within the inflammatory mechanical environment. Notably, LDHA suppression effectively eliminated the bone repair effect mediated by PGC-1α overexpression within inflammatory mechanical environments. In conclusion, this study demonstrated a novel molecular mechanism illustrating how inflammation orchestrated glucose metabolism through glycolysis and OXPHOS to affect mechanically induced bone remodeling.

Periodontal considerations during orthodontic intrusion and extrusion in healthy and reduced periodontium

In patients with advanced periodontal disease, pathological tooth migration may occur, which may require subsequent orthodontic treatment for both aesthetic and functional purposes. When planning orthodontic treatment mechanics, intrusive or extrusive forces are frequently indicated. Understanding tissue reactions during these movements is essential for clinicians when devising a comprehensive orthodontic-periodontal treatment plan. This knowledge enables clinicians to be fully aware of and account for the potential effects on the surrounding tissues. The majority of our understanding regarding the behavior of periodontal tissues in both healthy and compromised periodontal conditions is derived from animal studies. These studies offer the advantage of conducting histological and other assessments that would not be feasible in human research. Human studies are nevertheless invaluable in being able to understand the clinically relevant response elicited by the periodontal tissues following orthodontic tooth movement. Animal and human data show that in dentitions with reduced periodontal support, orthodontic intrusion of the teeth does not induce periodontal damage, provided the periodontal tissues do not have inflammation and plaque control with excellent oral hygiene is maintained. On the contrary, when inflammation is not fully controlled, orthodontic intrusion may accelerate the progression of periodontal destruction, with bacterial plaque remnants being displaced subgingivally, leading to further loss of attachment. Orthodontic extrusion, on the other hand, does not seem to cause further periodontal breakdown in dentitions with reduced periodontal support, even in cases with deficient plaque control. This is attributed to the nature of the tooth movement, which directs any plaque remnants coronally (supragingivally), reducing the risk of adverse effects on the periodontal tissues. This specific type of tooth movement can be leveraged to benefit periodontal conditions by facilitating the regeneration of lost hard and soft periodontal tissues in a coronal direction. As a result, orthodontic extrusion can be employed in implant site development, offering an advantageous alternative to more invasive surgical procedures like bone grafting. Regardless of the tooth movement prescribed, when periodontal involvement is present, it is essential to prioritize periodontal therapy before commencing orthodontic treatment. Adequate plaque control is also imperative for successful outcomes. Additionally, utilizing light orthodontic forces is advisable to achieve efficient tooth movement while minimizing the risk of adverse effects, notably root resorption. By adhering to these principles, a more favorable and effective combined orthodontic-periodontal approach can be ensured. The present article describes indications, mechanisms, side effects, and histological and clinical evidence supporting orthodontic extrusion and intrusion in intact and reduced periodontal conditions.

Orthodontic treatment in patients with periodontitis - a narrative literature review

Patients with periodontitis often require an inter-disciplinary approach, including orthodontic treatment, for effective rehabilitation of masticatory function, aesthetics and quality of life. The aim of this narrative review was to comprehensively discuss literature focusing on the biology, indications and inter-disciplinary connections related to the orthodontic approach in patients with periodontitis and to present clinical concepts in accordance with valid guidelines. The outcomes of the experimental studies indicate that orthodontic tooth movement (OTM) can be performed safely for teeth with reduced periodontium, provided infection and inflammation are controlled. Orthodontic treatment can correct pathological tooth migration, is not associated with deterioration of clinical periodontal parameters and improves aesthetics. Intrusion is safe when performed with light forces and under a strict oral hygiene regimen. Teeth can be moved either towards or away from the intrabony defect previously subjected to regenerative procedures, and research suggests that OTM has the potential to enhance bone formation after regenerative therapy. The data on orthodontic movement of teeth with furcation involvement are very scarce. The improvement in furcation involvement following either combined periodontal and orthodontic treatment was only documented in animal model studies. Due to bone and tooth loss, special consideration should be given to orthodontic treatment mechanics. © 2023 Australian Dental Association.

Knowledge, attitudes, and interest in orthodontic treatment: a cross-sectional study in adults with stage III-IV periodontitis and secondary malocclusions

BACKGROUND

An increasing number of patients with advanced stages of periodontitis are seeking for treatment options. The study aimed to determine interest in orthodontic treatment (OT) and its association with oral health status and knowledge about the disease in adult subjects with stage III-IV periodontitis.

METHODS

96 subjects ≥ 30 years, with stage III-IV periodontitis agreed to fill in a questionnaire and undergo a comprehensive periodontal-orthodontic examination. The questionnaire included 44 questions: demographic, dental, health related habits, self-perceived overall and oral health, knowledge of periodontitis, and attitude toward OT. The statistical analysis was performed using a paired-sample T-test, Receiver Operating Characteristic (ROC) and binary logistic regression analysis (LRA).

RESULTS

Stage IV periodontitis was observed in 32.3% of subjects and Class II malocclusion was most prevalent (53.1%). More than half of subjects were interested in OT. Oral health, knowledge about periodontitis and age were significant predictors for interest in OT.

CONCLUSIONS

Knowledge spread about OT possibilities in advanced stages of periodontitis is very important both for the dental community and older subjects to save natural dentition.

Analysis of oral microbiome on temporary anchorage devices under different periodontal conditions

BACKGROUND

Temporary anchorage devices (TADs) are maximum anchorages that have been widely used in orthodontic treatment. The aim of the study was to uncover whether a history of periodontitis would influence microbiome colonization on the TAD surface.

RESULTS

Patients were grouped by periodontal evaluations before the orthodontic treatment. Patients with healthy periodontal conditions were classified as the healthy group, and patients diagnosed with periodontitis stage II or even worse were classified as the periodontitis group. Scanning electron microscopy (SEM) was used to analyze the existence of biofilm on the surface of 4 TADs from the healthy group and 4 TADs from the periodontitis group. Fifteen TADs from the healthy group and 12 TADs from the periodontitis group were collected. The microorganisms on the surface of TADs were harvested and analyzed by 16S rRNA gene sequencing. α-diversity indices and β-diversity indices were calculated. Wilcoxon's test was used to determine differences between genera, species as well as KEGG functions. SEM analysis revealed bacteria colonization on the surface of TADs from both groups. Principal coordinate analysis (PCoA) based on β diversity revealed differential sample clusters depending on periodontal conditions (P < 0.01). When comparing specific genera, Fusobacterium, Porphyromonas, Saccharibacteria_(TM7)_[G-1], Dialister, Parvimonas, Fretibacterium, Treponema were more enriched in TADs in the periodontitis group. In the KEGG analysis, TADs in the periodontitis group demonstrated enriched microbial activities involved with translation, genetic information processing, metabolism, and cell motility.

CONCLUSIONS

This analysis elucidated the difference in total composition and function of TADs oral microorganisms between patients periodontally healthy and with periodontitis.

Long-term stability of regenerative periodontal surgery and orthodontic tooth movement in stage IV periodontitis: 10-year data of a retrospective study

BACKGROUND

This study aimed to evaluate the long-term effectiveness of regenerative treatment of intra-bony defects in combination with consecutive orthodontic therapy (OT) in stage IV periodontitis.

METHODS

Twenty-two patients with a total of 256 intra-bony defects were analyzed after regenerative surgery followed by OT initiated 3 months later. Changes in radiographic bone level (rBL) and probing pocket depths (PPD) were evaluated after 1 year (T1), final splinting (T2), and 10 years (T10).

RESULTS

Mean rBL gain was significant with 4.63 mm (±2.43 mm) after 1 year (T1), 4.19 mm (±2.61 mm) at final splinting (T2), and 4.48 mm (±2.62 mm) after 10 years (T10). Mean PPD was significantly reduced from 5.84 mm (±2.05 mm) at baseline to 3.19 mm (±1.23 mm) at T1, to 3.07 mm (±1.23 mm) at T2, and to 2.93 mm (±1.24 mm) at T10. Pocket closure (PPD ≤ 4 mm) was achieved in 90% of all defects. Tooth loss amounted to 4.5%.

CONCLUSIONS

Within the limitations of this retrospective study design, these 10-year findings suggest that in motivated and compliant patients with stage IV periodontitis and in need of OT an inter-disciplinary treatment can lead to favorable and stable long-term results.

Synergy of Regenerative Periodontal Surgery and Orthodontics Improves Quality of Life of Patients with Stage IV Periodontitis: 24-Month Outcomes of a Multicenter RCT

In stage IV periodontitis patients with pathologic tooth migration (PTM), interdisciplinary treatment includes regenerative periodontal surgery (RPS) with an application of biomaterials and orthodontic therapy (OT) to restore function, esthetics and thereby quality of life (QoL). In a 24-month randomized trial we explored the synergy between regenerative medicine and biomechanical force application. The following methods were used: Forty-three patients had been randomized to a combined treatment comprising RPS and subsequent OT starting either 4 weeks (early OT) or 6 months (late OT) post-operatively. Clinical periodontal parameters and oral health-related QoL (GOHAI) were recorded up to 24 months. We obtained the following results: Mean clinical attachment gain (∆CAL ± SD) was significantly higher with early OT (5.96 ± 2.1 mm) versus late OT (4.65 ± 1.76 mm) (p = 0.034). Pocket closure (PPD ≤ 4 mm) was obtained in 91% of defects with early OT compared to 90% with late OT. GOHAI-scores decreased significantly from 26.1 ± 7.5 to 9.6 ± 4.7 (early OT) and 25.1 ± 7.1 to 12.7 ± 5.6 (late OT). Inconclusion, teeth severely compromised by intrabony defects and PTM can be treated successfully by RPS followed by early OT with the advantage of an overall reduced treatment time. As a result of the combined periodontal-orthodontic therapy, the oral health-related QoL of patients was significantly improved. Early stimulation of wound healing with orthodontic forces had a favorable impact on the outcomes of regenerative periodontal surgery.

Complications and treatment errors involving periodontal tissues related to orthodontic therapy

In this review, typical clinical complications involving periodontal tissues are illustrated that can be encountered in conjunction with orthodontic therapy (OT). Special considerations are given for various clinical scenarios, such as the patient presenting in periodontal health, with periodontitis, or with mucogingival conditions. While some of the complications are seen as common side effects of OT, other, more severe, problems that could have been avoided may be viewed as treatment errors. Recommendations are made on how to prevent these complications, based on the currently available evidence, on clinical practice guidelines, and on expert opinion. In conclusion, while there are several areas in which OT can have unwanted adverse effects on periodontal/mucogingival conditions, there is also great potential for synergies, offering opportunities for close cooperation between the two specialties (periodontics and orthodontics) for the benefit of patients affected by tooth malpositioning and/or periodontal or mucogingival problems.

Impact of Clear Aligners versus Fixed Appliances on Periodontal Status of Patients Undergoing Orthodontic Treatment: A Systematic Review of Systematic Reviews

The present umbrella review of four systematic reviews with meta-analysis aimed to assess whether clear aligners are associated with better periodontal conditions compared with fixed appliances in patients undergoing orthodontic treatment. The present study protocol was developed in accordance with the PRISMA statement before the literature search, data extraction, and analysis and was registered on PROSPERO (CRD42023401808). The question formulation, search, and study selection strategies were developed according to the PICO model. Systematic reviews with a meta-analysis published in English without date restriction were electronically searched across the Cochrane Library, Web of Science (Core Collection), Scopus, EMBASE, and MEDLINE/PubMed databases until 10 February 2023. An assessment of study quality was performed using the AMSTAR 2 tool. Differences in the PI, GI, and BOP in the short- and medium-term follow-ups, in the PPD in long-term follow-up, and the gingival recessions in the short-term follow-up were found between subjects with clear aligners and fixed appliances, revealing a slight tendency for clear aligners to be associated with healthier periodontal conditions. However, even if statistically significant, such differences would be negligible in a clinical environment. Therefore, the impact of orthodontic treatment with clear aligners and fixed appliances on periodontal health status should be considered comparable.

Levels of Pro-Inflammatory and Bone-Resorptive Mediators in Periodontally Compromised Patients under Orthodontic Treatment Involving Intermittent Forces of Low Intensities

During orthodontic treatment, diverse cytokines, enzymes, and osteolytic mediators produced within the teeth surrounding periodontal tissues determine the rate of alveolar bone remodeling and consequent teeth movement. In patients with teeth presenting reduced periodontal support, periodontal stability should be ensured during orthodontic treatment. Thus, therapies based on the application of low-intensity intermittent orthodontic forces are recommended. To determine if this kind of treatment is periodontally well tolerated, this study aimed to analyze the production of receptor activator of nuclear factor kappa-B ligand (RANKL), osteoprotegerin (OPG), interleukin (IL)-6, IL-17A, and matrix metalloproteinase (MMP)-8 in periodontal tissues of protruded anterior teeth with reduced periodontal support and undergoing orthodontic treatment. Patients with periodontitis-associated anterior teeth migration received non-surgical periodontal therapy and a specific orthodontic treatment involving controlled low-intensity intermittent orthodontic forces. Samples were collected before periodontitis treatment, after periodontitis treatment, and at 1 week to 24 months of the orthodontic treatment. During the 2 years of orthodontic treatment, no significant differences were detected in the probing depth, clinical attachment level, supragingival bacterial plaque, and bleeding on probing. In line with this, the gingival crevicular levels of RANKL, OPG, IL-6, IL-17A, and MMP-8 did not vary between the different evaluation time-points of the orthodontic treatment. When compared with the levels detected during the periodontitis, the RANKL/OPG ratio was significantly lower at all the analyzed time-points of the orthodontic treatment. In conclusion, the patient-specific orthodontic treatment based on intermittent orthodontic forces of low intensities was well tolerated by periodontally compromised teeth with pathological migration.

Periodontal Management in Periodontally Healthy Orthodontic Patients with Fixed Appliances: An Umbrella Review of Self-Care Instructions and Evidence-Based Recommendations

The present umbrella review aimed to characterize periodontal self-care instructions, prescriptions, and motivational methods; evaluate the associated periodontal outcomes; and provide integrated, evidence-based recommendations for periodontal self-care in periodontally healthy orthodontic patients with fixed appliances. The presently applied study protocol was developed in advance, compliant with the PRISMA statement, and registered on PROSPERO (CRD42022367204). Systematic reviews published in English without date restrictions were electronically searched until 21 November 2022 across the PROSPERO Register and Cochrane Library, Web of Science (Core Collection), Scopus, and MED-LINE/PubMed databases. The study quality assessment was conducted through the AMSTAR 2 tool. Seventeen systematic reviews were included. Powered and manual toothbrushes showed no significant differences in biofilm accumulation, although some evidence revealed significant improvements in inflammatory, bleeding, and periodontal pocket depth values in the short term with powered toothbrushes. Chlorhexidine mouthwashes, but no gels, varnishes, or pastes, controlled better biofilm accumulation and gingival inflammation as adjuncts to toothbrushing, although only for a limited period. Organic products, such as aloe vera and chamomile, proved their antimicrobial properties, and herbal-based mouthwashes seemed comparable to CHX without its side effects. Motivational methods also showed beneficial effects on periodontal biofilm control and inflammation, while no evidence supported probiotics administration.

Orthodontic treatment in periodontally compromised patients: a systematic review

OBJECTIVES

The aim of this systematic review was to examine the literature on aggressive and chronic periodontitis and orthodontics to clarify the therapy-relevant aspects of orthodontic treatment with altered biomechanics in periodontally compromised dentition.

MATERIALS AND METHODS

Literature searches were conducted in the electronic databases "PubMed" and "DIMDI" using the keywords "aggressive periodontitis AND ortho*," "aggressive periodontitis AND orthodontics," "chronic periodontitis AND ortho*," and "chronic periodontitis AND orthodontics" for the publication period from January 1990 to July 2022. In addition, a manual search was carried out in the selected trade journals "Community Dental Health," "European Journal of Oral Sciences," and "Parodontologie." Human clinical trials were included, whereas animal experimental studies, case reports, and reviews were generally excluded. The appropriate studies were selected, and the relevant data was tabulated according to different parameters, regarding the study design, the study structure, and the conduct of the study.

RESULTS

A total of 1067 articles were found in the preliminary electronic search. The manual search and review of all related bibliographies resulted in an additional 1591 hits. After the first screening, 43 articles were classified as potentially relevant and reviewed in their original form. After the suitability test, 5 studies with a total of 366 participants were included in the final evaluation. These included one randomized controlled trial and four low-evidence intervention studies. The studies were conducted in two university hospitals and three private practices. All participants underwent scaling and root plaining and periodontal surgery before the orthodontic treatment started. Mean probing pocket depth reduction before and after the interdisciplinary treatment was analyzed in all the included studies; mean difference in clinical attachment level in four of the studies was also included. All participants were enrolled in a continuous recall system. In all studies, orthodontic therapy in periodontally compromised patients improved function and esthetics, resulting in lower probing depths and clinical attachment gains.

CONCLUSIONS

Orthodontic treatment can be used for patients with reduced periodontal support to stabilize clinical findings and improve function and esthetics. The prerequisite for this is a profound knowledge of altered biomechanics and an adapted interdisciplinary treatment approach. Due to the large heterogeneity of the included studies and their limited methodological quality, the results obtained in this review must be considered critically. Further randomized controlled long-term studies with comparable study designs are necessary to obtain reliable and reproducible treatment results.

CLINICAL RELEVANCE

Patients with periodontal impairment can be successfully treated with orthodontics as part of interdisciplinary therapy. Orthodontic treatment has no negative impact on the periodontium; if minimal, controlled forces are used under non-inflammatory conditions.

Periodontal and Orthodontic Synergy in the Management of Stage IV Periodontitis: Challenges, Indications and Limits

This retrospective study described the clinical and radiographic long-term outcomes of combined periodontal and orthodontic treatment (OT) with fixed appliances in patients with Stage IV periodontitis and pathologic tooth migration (PTM) in the anterior sextants. OT was performed in either one or both arches, using tooth-supported or skeletal anchorage, following completion of active periodontal treatment and accurate planning of tooth movement biomechanics. Twenty-nine patients were identified and retrospectively examined when presenting for a supportive periodontal care (SPC) appointment. The mean SPC duration was 8.9 years (range 5 to 12 years). All anterior-migrated teeth showed statistically significant periodontal improvement compared to baseline values and stable radiographic bone levels at the final follow-up. Residual probing depths were 2.9 ± 0.5 mm at the end of active periodontal treatment, and they remained stable at the completion of OT (2.9 ± 0.6 mm) and at the last follow-up visit (2.8 ± 0.5 mm). These findings suggest that OT is a safe and effective treatment in improving the long-term prognosis of teeth with PTM in Stage IV periodontitis provided that periodontal health has been re-established and maintained with individualized SPC sessions.

Treatment of stage IV periodontitis: The EFP S3 level clinical practice guideline

BACKGROUND

The recently published clinical practice guideline (CPG) for the treatment of periodontitis in stages I-III provided evidence-based recommendations for the treatment of periodontitis patients, defined according to the 2018 classification. Stage IV periodontitis shares the severity and complexity characteristics of stage III periodontitis, but includes the anatomical and functional sequelae of tooth and periodontal attachment loss (tooth flaring and drifting, bite collapse, etc.), which require additional interventions following completion of active periodontal therapy.

AIM

To develop an S3 Level CPG for the treatment of stage IV periodontitis, focusing on the implementation of inter-disciplinary treatment approaches required to treat/rehabilitate patients following associated sequelae and tooth loss.

MATERIALS AND METHODS

This S3 Level CPG was developed by the European Federation of Periodontology (EFP), following methodological guidance from the Association of Scientific Medical Societies in Germany and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) process. A rigorous and transparent process included synthesis of relevant research in 13 specifically commissioned systematic reviews, evaluation of the quality and strength of evidence, the formulation of specific recommendations and a structured consensus process with leading experts and a broad base of stakeholders.

RESULTS

The S3 Level CPG for the treatment of stage IV periodontitis culminated in recommendations for different interventions, including orthodontic tooth movement, tooth splinting, occlusal adjustment, tooth- or implant-supported fixed or removable dental prostheses and supportive periodontal care. Prior to treatment planning, it is critically important to undertake a definitive and comprehensive diagnosis and case evaluation, obtain relevant patient information, and engage in frequent re-evaluations during and after treatment. The periodontal component of therapy should follow the CPG for the treatment of periodontitis in stages I-III.

CONCLUSIONS

The present S3 Level CPG informs clinical practice, health systems, policymakers and, indirectly, the public on the available and most effective modalities to treat patients with stage IV periodontitis and to maintain a healthy dentition over lifetime, according to the available evidence at the time of publication.

Effect of periodontal-orthodontic treatment of teeth with pathological tooth flaring, drifting, and elongation in patients with severe periodontitis: A systematic review with meta-analysis

AIM

To assess the beneficial and adverse effects on the dental and periodontal issues of periodontal-orthodontic treatment of teeth with pathological tooth flaring, drifting, and elongation in patients with severe periodontitis.

MATERIALS AND METHODS

Nine databases were searched in April 2020 for randomized/non-randomized clinical studies. After duplicate study selection, data extraction, and risk-of-bias assessment, random-effect meta-analyses of mean differences (MDs) and their 95% confidence intervals (CIs) were performed, followed by subgroup/meta-regression analyses.

RESULTS

A total of 30 randomized and non-randomized clinical studies including 914 patients (29.7% male; mean age 43.4 years) were identified. Orthodontic treatment of pathologically migrated teeth was associated with clinical attachment gain (-0.24 mm; seven studies), pocket probing depth reduction (-0.23 mm; seven studies), marginal bone gain (-0.36 mm; seven studies), and papilla height gain (-1.42 mm; two studies) without considerable adverse effects, while patient sex, gingival phenotype, baseline disease severity, interval between periodontal and orthodontic treatment, and orthodontic treatment duration affected the results. Greater marginal bone level gains were seen by additional circumferential fiberotomy (two studies; MD = -0.98 mm; 95% CI = -1.87 to -0.10 mm; p = .03), but the quality of evidence was low.

CONCLUSIONS

Limited evidence of poor quality indicates that orthodontic treatment might be associated with small improvements of periodontal parameters, which do not seem to affect prognosis, but more research is needed.

Orthodontic treatment in the presence of aggressive periodontitis

Introduction:

Aggressive periodontitis causes periodontal destruction, with loss of supporting alveolar bone. The common symptom is rapid attachment loss in the first molar and incisor area, in young adults.

Objective:

The aim of this study was to discuss the challenges, implications and the impact of orthodontic treatment in patients affected by severe periodontal problems, specifically aggressive periodontitis.

Discussion:

In addition to other bacteria, the main pathogen involved in aggressive periodontitis is the Aggregatibacter actinomycetemcomitans. However, the susceptibility to the disease differs among individuals, being immune deficiencies the main reason for this variability. Many orthodontists are not comfortable about performing treatments on individuals with aggressive periodontitis.

Conclusion:

Orthodontic treatment is feasible in young patients with severe and localized aggressive periodontitis, as long as the limitations imposed by the disease are respected. An interdisciplinary approach is required, with frequent periodontal follow-up before, during and after orthodontic treatment, allowing the correction of dental positions without aggravating bone loss.

The effect of timing of orthodontic therapy on the outcomes of regenerative periodontal surgery in patients with stage IV periodontitis: A multicenter randomized trial

AIM

To compare the outcomes after early (4 weeks post surgery) or late (6 months post surgery) orthodontic therapy (OT) following regenerative surgery of intra-bony defects (IDs).

MATERIALS AND METHODS

In a multi-center, parallel-group, randomized clinical trial, 43 patients with stage IV periodontitis were randomized to receive either early (n = 23) or late OT (n = 20) following regenerative surgery of IDs. Primary outcome was change in clinical attachment level (CAL) in one target ID at 12 months after surgery. Secondary outcomes were changes of probing pocket depth (PPD), bleeding on probing (BOP), and frequency of pocket closure.

RESULTS

No statistically significant differences between groups could be observed for CAL gain (5.4 mm [±2.1 mm] for early; 4.5 mm [±1.7 mm] for late OT). PPD was reduced by 4.2 mm (±1.9 mm) in the early group and by 3.9 mm (±1.5 mm) in the late group (p > .05). Pocket closure (PPD ≤ 4 mm) was obtained in 91% of defects in early compared to 85% in late OT.

CONCLUSION

In the inter-disciplinary treatment of periodontitis stage IV, OT can be initiated already 4 weeks after regenerative surgery of IDs with favourable results, thus reducing the overall treatment time.