A 49-year-old woman with several missing and periodontically compromised teeth was referred to the orthodontic department of National Health Insurance Service Ilsan Hospital by the periodontic department for interdisciplinary treatment. Multiple posterior teeth had been extracted 10 days earlier. Her chief complaint was crowding of the anterior teeth, and she wanted to improve both esthetics and function. Orthodontic, periodontic, and prosthodontic treatments were undertaken in the proper timing and sequence with an interdisciplinary approach. As a result, improved periodontal health and a stable occlusion and vertical dimension were achieved. Although there were limited teeth and alveolar bone for anchorage, good esthetic and functional treatment results were obtained through the application of temporary anchorage devices and proper biomechanics.
Highlights
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Periodontal treatment and disease control resulted in improved periodontal health.
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The posterior teeth were restored with a stable occlusion.
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Interdisciplinary treatment included periodontics and prosthodontics.
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Orthodontic treatment was completed with TADs and proper biomechanics.
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Good esthetic and functional results were obtained.
Recently, the numbers of adult patients requiring comprehensive orthodontic treatment have increased. Many patients have some missing teeth and others that are periodontically compromised. An interdisciplinary approach is needed to restore the occlusion for these patients. If associated with the periodontal tissues, when periodontic treatment is completed before orthodontic treatment and oral hygiene is well-controlled, periodontal support can achieve tooth movement without compromising the situation. Also, the orthodontic movement of teeth can improve their level of attachment.
In patients with many missing teeth, anchorage sites might not be available, and tooth movements such as distalization, retraction of anterior teeth, and intrusion are challenging. However, temporary anchorage devices (TADs) can be used for the anchorage of those types of tooth movements even in edentulous areas with a limited amount of alveolar bone support. Although the procedure is challenging with conventional mechanics, the desired tooth movements can be obtained through the application of proper biomechanics with TADs.
In patients with missing posterior teeth, the vertical dimension should also be considered. When implantation is planned, the early placement of implants restored with temporary crowns can support or increase the vertical dimension during the orthodontic treatment.
This case report describes the interdisciplinary approach to treat a partially edentulous patient with periodontitis. The report focuses on the consideration of the treatment plan and sequence for a patient with multiple missing teeth and periodontitis, the improved periodontal health after orthodontic treatment with strict periodontic control and oral hygiene instructions, the support of the vertical dimension with dental implants during the orthodontic treatment, and the application of goal-oriented biomechanics with TADs.
Etiology and diagnosis
A 49-year old woman with several missing and periodontically compromised teeth was referred to the orthodontic department of National Health Insurance Service Ilsan Hospital by the periodontic department for interdisciplinary treatment. She had multiple missing teeth in the posterior area that had been extracted 10 days previously. Her chief complaint was crowding of the anterior teeth, and she wanted to improve both esthetics and function. Her medical history was noncontributory, and she had no signs of temporomandibular joint disorder. The extraoral examination showed facial symmetry, incompetent lips at rest, an acute nasolabial angle, and protruded lips. Her mandibular dental midline had shifted to the left of the facial midline ( Fig 1 ).
Intraorally, due to periodontitis, her maxillary right first and second premolars, maxillary right first and second molars, maxillary left first and second molars, and mandibular right first molar were missing. Periodontal probing showed deep pockets in the molar areas and the mandibular left lateral incisor area, as well as bleeding ( Table I ). There was crowding of the maxillary and mandibular anterior teeth and a crossbite of the left lateral incisors, with overeruption of the mandibular left lateral incisor. Overjet was 5 mm, and the maxillary incisors were labially tilted. In the maxillary arch, the canines and premolars were mesially tilted, and the right canine was overerupted. Moreover, the mandibular right second molar was mesially tilted. The canines were in a Class I relationship, but the molar relationship could not be evaluated ( Figs 1 and 2 ).
| Maxillary teeth | 17 | 16 | 15 | 14 | 13 | 12 | 11 | 21 | 22 | 23 | 24 | 25 | 26 | 27 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Pocket depth (buccal) | 779 | 777 | 799 | 996 | 534 | 335 | 444 | 435 | 444 | 333 | 333 | 333 | 777 | |
| Bleeding on probing | *** | *** | *** | *** | ** | ** | ** | ** | *** | ** | * | ** | *** | |
| Pocket depth (lingual) | 999 | 999 | 999 | 996 | 865 | 555 | 534 | 445 | 444 | 332 | 323 | 223 | 777 | |
| Bleeding on probing | *** | *** | *** | *** | ** | ** | *** | *** | *** | ** | ** | ** | *** | |
| Mandibular teeth | 47 | 46 | 45 | 44 | 43 | 42 | 41 | 31 | 32 | 33 | 34 | 35 | 36 | 37 |
| Pocket depth (buccal) | 557 | 544 | 333 | 333 | 333 | 333 | 333 | 467 | 644 | 433 | 444 | 336 | 755 | |
| Bleeding on probing | *** | ** | ** | * | *** | *** | *** | *** | * | * | ** | *** | *** | |
| Pocket depth (lingual) | 757 | 644 | 333 | 333 | 333 | 333 | 334 | 469 | 654 | 333 | 333 | 334 | 665 | |
| Bleeding on probing | *** | ** | ** | ** | *** | *** | *** | *** | ** | ** | * | *** | *** |
The panoramic radiograph showed overall decreased support of the alveolar bone and extensive bone loss of the mandibular left lateral incisor. The cephalometric analysis indicated a skeletal Class I relationship with a normal vertical facial type, labioversion of the maxillary incisors, and a protruded upper lip in relation to Rickett’s E-line ( Figs 3 and 4 ; Table II ). The patient was diagnosed with a skeletal Class I malocclusion, with chronic generalized moderate periodontitis and multiple missing teeth.
| Measurement | Norm | Pretreatment | Posttreatment |
|---|---|---|---|
| Hard tissue | |||
| SNA angle (°) | 81.6 | 76.9 | 76.9 |
| SNB angle (°) | 79.1 | 75.3 | 74.9 |
| ANB angle (°) | 2.4 | 1.9 | 1.9 |
| Wits appraisal (mm) | −2.7 | −2.4 | −2.6 |
| SN to mandibular plane (°) | 33.3 | 42.9 | 42.5 |
| Bjork sum (°) | 393.3 | 403.9 | 403.6 |
| Gonial angle (°) | 126.0 | 123.1 | 123.2 |
| Mandibular body length (mm) | 78.1 | 76.5 | 77.0 |
| U1 to SN (°) | 107.0 | 120.5 | 110.7 |
| IMPA (°) | 95.9 | 90.8 | 90.8 |
| Anterior facial height (mm) | 128.9 | 129.8 | 129.5 |
| Posterior facial height (mm) | 85.0 | 76.2 | 76.4 |
| Soft tissue | |||
| Upper lip to Ricketts’ E-line (mm) | −1.0 | 1.2 | −1.5 |
| Lower lip to Ricketts’ E-line (mm) | 1.0 | 1.9 | 1.0 |
Treatment objectives
The overall treatment objectives were to treat the periodontal disease, rehabilitate the posterior occlusion, and improve the patient’s smile esthetics. The orthodontic objectives were to alleviate the crowding in the maxillary and mandibular anterior regions, upright the mandibular right second molar, correct the crossbite of the left lateral incisors, and establish proper overjet with torque control of the labially tilted maxillary incisors.
Treatment objectives
The overall treatment objectives were to treat the periodontal disease, rehabilitate the posterior occlusion, and improve the patient’s smile esthetics. The orthodontic objectives were to alleviate the crowding in the maxillary and mandibular anterior regions, upright the mandibular right second molar, correct the crossbite of the left lateral incisors, and establish proper overjet with torque control of the labially tilted maxillary incisors.
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