Managing Orthodontic Treatment for Patients with Periodontal Problems Dr. Vince Kokich, Sr. Summary by: Dr. Tucker Haltom The presentation by Dr. Vince Kokich was exceptional. He is one of our very best and he makes orthodontics better with his lecturing, excellent research and his willingness to share. An average of 17% of orthodontic patients are adults. In children and adolescents and also in non-restored, non-periodontal adults, brackets can be placed using incisal edges and marginal ridges as guides. However in adults with underlying gingival or osseous periodontal defects brackets cannot be placed in this traditional manner. How do you handle your periodontally challenged patients? We must not allow the restorative dentist to decide treatment procedures. We must do a periodontal charting for all adult patients. Periodontal problems that escalate or occur during treatment are our responsibility. Sending all adult patients to a periodontist is not the answer. If you do refer to a periodontist make sure the patient actually does go. There are seven osseous defects possible in adults. We will: name each can periodontist correct? can orthodontist correct? when to start treatment In general 6-7 mm pockets that bleed mean active periodontal disease is present. All defects are identified with probing. Periodontal treatment by: 1)Scaling and root planing 2)Regenerative therapy bone addition 3) Resective surgery Defect #1 Interproximal Osseous Crater A two wall defect buccal and lingual walls remain Orthodontics will not correct. Periodontist can correct usually by taking lip of buccal and lingual so patient can keep it clean. Start orthodontics when healed. Defect #2 - One Wall Defect (defects # 2 & 3 are hemiseptal defects often found around mesially tipped teeth or super erupted teeth.) One wall remains Periodontist cannot correct Orthodontics can correct by intruding, erupting, and/or uprighting until bone levels and no bleeding. Can start after periodontal inflammation is controlled. Defect #3 Two Wall Defect either buccal or lingual wall remains: Periodontist can not correct a two wall defect either. Orthodontist can correct by moving tooth to level bone. Can start after periodontal inflammation is controlled. (often scaling and root planning required prior to orthodontics) Defect #4 Three Wall Defect Periodontist can correct. A perfect situation for regenerative procedures Orthodontist can not correct New research shows a quicker start than the traditional 3-6 months after surgery is indicated. Now Dr. Kokich starts as soon as flaps are healed. This converts mesenchymal cells to osteoblasts and fibroblasts to aid the healing process. Defect #5 Class II Furcation Defect (mid-buccal pocket usually) Furcation lesions are the most difficult lesions to maintain and can worsen during orthodontic therapy. Periodontist can treat regenerative therapy is best answer, 74% success rate. Orthodontist can not correct. Can start within 1-2 months of surgery Defect #6 Class III Furcation Defect Often can probe mid buccal and mid lingual Periodontist cannot correct Orthodontist can correct with hemisection of tooth. Root fragments can be separated for bone fill and clean-ability. CIII furcation on a tooth with short roots often is an indication for extraction and use of implants. Defect #7 Circumferential or Horizontal deflect (advanced horizontal bone loss) Any time bone levels are flat, the orthodontist should not alter tooth position vertically as hemiseptal defects can be created. 3-4 mm depths with no bleeding. Be careful charting a smoker, pockets may not bleed and can be misleading and healing will be compromised. Probing is mostly the same and radiographs show bone level to be even Ok to treat this area but do not change position of teeth vertically as defects might be created Teeth are trimmed, or added to, incisally or occlusally.