Interdisciplinary Care Summary of Orthodontic Treatment (PDF)

Interdisciplinary Care Summary Dec 13^th^ 2024 1. Impact of Microbial Risk factors During Orthodontic Treatment - The presentation is about perio/plaque relationship in the oral cavity, etiology of the periodontal diseases, caries disease, maintenance therapy during Ortho tx (profession...

Interdisciplinary Care Summary Dec 13^th^ 2024 1. Impact of Microbial Risk factors During Orthodontic Treatment - The presentation is about perio/plaque relationship in the oral cavity, etiology of the periodontal diseases, caries disease, maintenance therapy during Ortho tx (professional and self-care) - Dental Plaque definition: - Dental plaque is a complex microbial population that comprises salivary polymers, water, bacteria, present in teeth surface. - 80-90% of the total amount of plaque mass is water. - 70% of the dry weight is bacteria, the remaining 30% is polysaccharides, and glycoproteins. - Evolution of the plaque, when not removed is to get calcified by the calcium present in the saliva and becoming hard calcified deposit. Why is that important for orthodontists to manage OH? - Supragingival: (+) Stp. Sanguinis, Stp. Mutans, Stp. Viscosus - Subgingival: (-) Fusobacterium, Prevotella, Anaerobic Spirochtes - Formation - Initial Adhesion \> transport to the surface, initial adhesion, strong attachment - Colonization / plaque maturation CLINICAL EVALUATION OF PERIODONTAL STATUS IN SUBJECTSWITH MULTIBRACKET APPLIANCES AND THE ROLE OF AGE ANDGENDER DURING INITIAL MONTHS OF FIXED ORTHODONTICTREATMENT Method and outcome: - Method: gingival and plaque index were measured at the beginning and during 1, 2, 3, and 6 months after ortho tx started. - Patients were probed before and on the 6^th^ month of treatment. - Outcome: there were significant increase in inflammatory periodontal changes and significant increase in plaque due to the presence of orthodontic appliance - Regardless of gender and age. - No change was detected in the probing depth during the initial 6 months of tx. Relationship btw Perio and Ortho is important given the ortho tx should not become a deleterious process. Studies indicate positive outcomes when the two specialties work alongside each other. IMPROVEMENT OF PERIODONTAL PARAMETERS WITH THE SOLE USE OF FREE GINGIVAL GRAFTS -- ORTHODONTIC PATIENT JOURNAL Methods and outcome: - Method: patients who presented poor keratinized tissue I some areas, and orthodontic movement could worsen and ease the occurrence of periodontal disease. - Gingival grafts have been performed during orthodontic tx - Ideal score should be \< 5. Index score varies according to furcation, mobility, probing depths etc. - Smoking increases the chance of developing Perio disease and loosing teeth in 246 - Classification of Periodontal and Peri-Implant diseases and conditions:  - Periodontitis STAGING: Triade\>\>\> severity , complexity and extent/distribution Severity: related to the amount of CAL (clinical loss attachment) In the case CAL could not be measured, then, RBL (radiographic bone loss) would be taken as parameter. - Conclusion\>\> the more CAL, more prone to lose teeth. - Stage I (1-2 mm Cal) and II (3-4 mm Cal) no tooth loss detected. - Stage 3 (\>= 5mm) and 4 (\>5mm ) teeth loss detected. Complexity: - Stage I and II: Up to 4 mm probing depth, mostly horizontal bone loss - Stage III, IV: 6mm and on, more issues associated like furcation involvement, vertical defects, masticatory disfunction, secondary occlusal trauma (mobility), severe ridge defects, and bite collapse. Extent and Distribution: - Add description to each stage as if the disease is local, etc. Periodontitis GRADING: - Progression would be in accordance with the direct evidence, (CAL, RBL, Bone loss and type of defect, risk factors as smoking, diabetes, etc.) and the gradings would be related to all those considerations. Grade A better than B, - Periodontal therapies as SRP, gingival therapy, or regular cleaning have to be completed and the patient has to be seen to revaluate. Important to know: - Patient is referred to DH for SRP - Patient comes back for reval in 6 weeks - Patient is ready to bond in 2 months. Caries - White spots, role of plaque and sucrose, enamel and dentin caries, and root caries  - How dental caries form: \>\>\> Dissolution of Hydroxyapatite (Ca10 (PO4)6 (OH)2) by acids derived from bacterial metabolism of sucrose and other carbohydrates that become sugar. - We need the caries triade, so cavity can occur: PATHOGENESIS OF DIFFERENT TYPES OF CARIES - Types of caries: occlusal, interproximal, and root caries - Streptococcus mutans is the main agent, but various Lactobacilli are related to progression of caries. - Mutans are mainly responsible for occlusal caries, but for root caries and interproximal, there is an association with Lactobacilli. RELATIONSHIP BTW ORTHO TX AND DENTAL CARIES: RESULTS FROM A NATIONAL SURVEY - The aim if the study is to confirm the relationship btw ortho tx and an increase in caries - Patients \>= 19 yo were assessed through DMFT index. - The relationship was that ortho tx is associated with a decrease in the development of dental caries. - However, the assessment could be wrong. Younger patients have immature enamel, and more likely will develop caries if OH is precarious during orthodontic tx. - Younger patients demonstrate less OH care than adults. - DMTF index: The Decayed, Missing, and Filled Teeth (DMFT) index is a clinical indicator that measures the number of decayed, missing, or filled teeth in a person's mouth. It's a common method used in oral epidemiology to assess dental caries prevalence and dental treatment needs. - CAMBRA: ADA's Caries Risk Assessment forms were developed as practice tools to help dentists evaluate a patient's risk of developing caries. One form is for patients ages 0-6 years of age and the other is for patients over 6 years of age. The forms are designed to include factors that are easily observed or discovered during routine oral health evaluations. The first two sections, "Contributing Conditions" and "General Health Conditions," can be completed by a dental team member as determined by the dentist. "Clinical Conditions" should be determined by the dentist. -  - Factors that increase the incident of caries: 1. Dry mouth 2. Nutritional habits 3. OH poor 4. Smoking 5. Associated diseases - Fluoride products minimizes the risk of caries. - Reversible white spots can be tx with MI paste (Ca and Phosphate paste that remineralizes enamel\> contains bioavailable form of these two minerals that are reabsorbed into enamel. - Less concern with and can be used long term. - Chlorhexidine mouth wash: has substantivity and prevents the bacteria to adhere into the enamel surface. - Stains and alters taste if used for long period of time. Diet: - Specific foods should be avoided with braces: - ASSESSEMENT OF FOOD CONSUMPTION CHANGES IN ADOLESCENTS DURING ORTHODONTIC TX - Study evaluated the change in food consumption during ortho tx. - There was a correlation in the decrease of some types of food after ortho tx started. - Decrease in the total of fibers, vit C, and E. - Decrease in fat during early stages of tx, then an increase. - No difference in carbo intake, protein, and total energy - Conclusion: it is important a follow up with a dietitian to decrease the likelihood of inadequate food consumption Maintenance Therapy by Professional - What if ortho patient presents moderate to high risk of caries? \>\> CAMBRA assessment and follow guidelines.  According to CAMBRA: Low risk: OTC paste Moderate: OTC paste, Fluoride rinse, xylitol candy High: Xylitol, candies, prevdent 5000, chlorhexidine rinse, fluoride varnish (5%) Extremely high: xylitol candies, prevdent 5000, chlorhexidine rinse, fluoride varnish, baking soda rinse 6x day - In office tx: Fluoride Varnish or Gel - Varnish more comfortable for the patient and less time - Duraphat 5% - GI (glass ionomer) around brackets - Prophy every 3 months - Biofilm control: brush 2x a day, and floss once a day \>\> ADA recommendation - White spots: MI paste (long term tx) of Fluoride pastes (converts Hydroxyapatite into Fluorapatite) - Regular tooth paste: 1100 ppm - Prevident 5000 : 5000 ppm - Fluoride Varnish: 22600 ppm - 8% Stannous Fluoride: stains, poor taste and lasts 5-8 hours only., and cause gingival irritation - 1.23% Acidulated Phosphate Fluoride (APF) foam or gel\>\> every 6 mo, tray method , Acidic taste Regulating Fluoride in drinking water - In California a judge ordered the removal of fluoride in the drinking water, that would pose a health risk to children. - There is no conclusion that fluoride in the drinking water is harmful, however evidence shows that there is a risk of cognitive decline in children due to fluoride in the water. (may have potential risk). Fluoride vs. Hydroxyapatite pastes: Which one is better? - Nano hydroxyapatite: prevents demineralization and promotes remineralization. - Fluoride: same mechanism, except that it uses fluoride to remineralize your enamel. - Both are effective, there was a comparative study and researchers could get to a conclusion of one being better that than the other. Disclosing Solution: plaque staining to assist in the mechanical plaque removal. Oral Rinses: - Chlorhexidine and Essential Oil Rinse EFFECTS OF CHLORHEXIDINE USE ON PERIODONTAL HEALTHDURING FIXED APPLIANCE ORTHODONTIC TREATMENT -- ASYSTEMATIC REVIEW AND META-ANALYSIS - Decreased probing depths, gingival inflammation, plaque control At-Home care: - Cleaning devices: - Interproximal tooth brushes - Interdental cleaning tools (rubber tips, wooden toothpicks, tufted brushes) - Oral rinses - Floss (orthodontic and regular) - ETB/Manual TB - Patient Motivation - Patient Education IMPORTANT TO KNOW  Key Points - Orthodontic therapy might lead to increased plaque, periodontal disease, and dental caries - Microbial Plaque consists of different types of bacteria including Streptococcus Sanguinis, Strep Mutans, and Fusobacterium - Bracket bonding can be done 2 months after SRP - Dissolution of hydroxyapatite by acids derived from bacterial (mainly Strep Mutans) fermentation of sucrose and other carbohydrates results in dental caries - Plaque HD is a toothpaste that uses patented Targetol technology that effectively identifies and removes plaque - ADA had accepted two agents for treatment of gingivitis: Prescription Chlorhexidine rinse and Non-prescription Essential oil rinse - Adjunct use of Chlorhexidine during fixed appliance therapy is associated with improved gingival inflammation, plaque control, and pocket depth - Interdisciplinary approach is the best method to control and address the potential risks associated with orthodontic treatment Orthodontic Treatment of Patients with Medical Disorders - Commonly medical conditions found among orthodontic patients: - Infective endocarditis - Bleeding disorders - Leukemia - Diabetes - Cystic Fibrosis - Juvenile rheumatoid arthritis - Renal failure Infective Endocarditis (or risk of) - Where endocarditis develops? \>\>\> heart, blood vessels endothelium - Pre medication (prophylaxis) \>\>\> suggested if the mucosa gets perforated. (High Risk!!!) - Procedures that are likely to inflict bleeding and contamination: 1. IPR 2. Banding 3. TADs - Antibiotic regimen: Adults: Amox 500 mg \>\> 2gr (4 caps) 30-60 min prior tx \>\>\> Clindamycin 600 mg or Azi (500mg) Children: 50mg/kg \> max 2gr \>\> 30-60 min prior tx \>\> Clindamycin 20 mg /kg max 600 mg 30-60 min prior tx Patients unable to take med oral: Adults: Ampicilin 2 gr \>\>\> IM/IV 30-60 min prior \>\>\> Clindamycin 600 mg IV/IM Children: Ampicilin 50mg/kg (max 2gr) \>\> IM/IV \>\>\> Clindamycin 20mg/kg (max 600 gr) What to avoid: - Steel ties (prefer O ties) - Bonded attachment - Smooth wires - If banding\>\> decide if prophylaxis is required in accordance with the patient's problem - Avoid fixed appliances like Nance or expanders - Consult Cardiologist and get medical clearance Bleeding Disorders - Severe bleeding disorders - Hemophilia A or congenital coagulation anomalies - Extractions and surgeries should be evaluated case by case. - Non-ext approach Management - Prevent gingival bleeding - Avoid tissue irritation (appliances to be avoided as mentioned above) - Oties better than ST - NSAIDs not recommended Thalassemia - What is it: reduction in the syntesis of HbA (reduction of alpha or beta polypeptide that is part of HbA) Features - Skeletal Class II - Anterior diastema and flaring - Open bite - Increased OJ - Small teeth size - Chipmunk face (due to bone marrow hyperplasia) - Maxillary Enlargement Management - Hematologist (clearance) - Functional appliances / extra oral appliances - High pull head gear and fractures (osteopenia and osteoporosis) - Tooth movement with light forces - Segmental osteotomy of the face Leukemia - Malignant disease - More prevalent in children\>\>\> Acute Lymphoblastic Leukemia (ALL) - Prior to diagnosis: Be suspicious\>\>\> gingival bleeding, pain, hypertrophy, mucosal parlor, pharyngitis, lymphadenopathy - REFERRAL TO HEMATOLOGIST/ONCOLOGIST - After diagnosis: Increased risk of infection, High risk of developing dental issues (enamel defects, caries, tooth agenesis, root shortening - During tx: emotional sensitivity, delayed healing, prone to infections, xerostomia, terminate tx. Management - Refer to physician - Delay tx until chemo completed + 2years  Cystic Fibrosis - Disorder of the exocrine glands - Median survival of 30 years Orthodontic Considerations - Referral to physician - No general anesthesia - Limited ortho tx - Salivary Glands (dryness) Juvenile Rheumatoid Arthritis - Occurs before 16 yo - More severe than adult arthritis - Joint involvement - TMJ damage -- ankylosis - Restricted mandibular growth \*\*\* Classic signs: condylar flattening, and large joint space Orthodontic considerations - Hygiene difficulty - Stress on TMJ - Mandibular surgery avoided Renal failure - Dietary restriction - Delayed growth and tooth eruption - Dialysis or transplantation Orthodontic Considerations: Non dialysis dependent: - Coordibate with physician if tx is convenient or should be postponed. On dialysis: - No major contraindication Kidney transplant - Calcium channel antagonist: gingival overgrowth - Immunosuppressant drugs Thyroid Disorders - Hypothyroidism: slower bone response, so slower orthodontic movement. - Reduced bone remodeling and metabolic activity in the periodontal tissue. - Hyperthyroidism: faster bone remodeling, so faster ortho movement. However bone density is reduced, and there higher risk of root resorption or bone loss. - Monitoring carefully. Asthma - Xerostomia - Possible sulfa allergy (sulfite containing anesthetics) - Avoid NSAIds, narcotics, aspirin - Avoid Macrolides in patients taking theophylline. (Erythromycin, Clarithromycin, Azythromycin). Orthodontic management - Stress and anxiety - Inhaler available - Increased risk of root resorption - Good OH \>\> xerostomia - Aspirin and NSAIDs not recommended. HIV - Weakens the immune system, patients more susceptible to infections - Long term use of antiretroviral can cause dysregulation of calcium homeostasis, which leads to bone loss. - Oral health problem: xerostomia, fungal infections, gingivitis, canker sores, oral warts, fever blisters, hairy leukoplakia. Organ Transplantation - Compromised immunity - Susceptible to infections - Immunosuppressants affect bone metabolism, and tooth movement. Orthodontic Consideration - Communication with medical team - NO TX first 6 months after transplant - Minimal duration of ortho tx - Tooth movement accelerated due to medications, so lighter forces and more frequent visits - Gingival overgrowth concern - Non extraction preferred (difficulty in space closure). Seizure Disorders - Not contraindicated if well managed - Be careful with dental trauma - Gingival hyperplasia due to medications - TMJ subluxation - MRI needed: use ceramic brackets Orthodontic considerations - Educate your patient in regards to facial trauma Austism - Neurodevelopmental condition before 3 yo - Impaired communication, cognitive issues, and limited and repetitive behavior Orthodontic considerations - Higher prevalence of class II - Increase OJ - Narrow upper arch - Posterior xbite - Open bite - Removable appliances preferred - Depends on the level of autism - Patient better managed in hospital setting Schizophrenia - Severe mental disorder \>\> delusions, hallucinations - Not recommended for patients with Florid Schizophrenia - Dystonia, tardive dyskinesia \>\> not recommended removable appliances ADHD - Hyperactivity, inattention, forgetfulness - Not much info about the effect of ADHD in teeth movement - Regarding oral health, the children have more parafunctional habits - Can present dental anxiety and avoid dental care Orthodontic management - Poor compliance - Short appts preferred in the morning - Simple instructions - Tell-show-do method. Diabetes  - Major effect: development of periodontal disease - Disruption of enamel and dentin formation - Acceleration of teeth eruption - Higher expression of MMP 8 and 9 and accelerated tooth movement in the diabetes rat model supports it.​ Clinically: No associated data Effects of Diabetes - Xerostomia - Oral acetone odor - Perio disease - Gingival inflammation - Caries - Mouth ulcerations  Hypophosphatasia - Rare condition, also known as HPP - Defect in ALPL gene which encodes the enzyme (TNSALP). - The TNSALP is crucial for bone mineralization and the regulation of various biochemical processes - Inorganic pyrophosphate is not degraded and phosphate not produced. - Calcium and phosphate cannot bind, and hydroxyapatite formation is disrupted. Diagnostic Criteria - Premature loss of primary teeth - Bone mineralization defects - Serology: low serum ALP - Definitive diagnostic: Gene testing Classification: - There are 6 types: Perinatal, Prenatal benign/ infantile, Childhood, Adult, Odonto - Perinatal: fetal to neonatal\> severe, includes respiratory disorders, convulsion, severe bone hypomineralization, bowed long bones. - Prenatal/Infantile: \< 6mo. \>\>failure to thrive, hypercalcemia, premature craniosynostosis - Childhood: 6mo to 18 yo \> early exfoliation of primary teeth, bone pain, and short stature - Adult: \>18 yo \> fracture and periodontitis - Odonto: regardless of age\>\> early exfoliation of primary teeth and periodontitis HPP and Orthodontics: - Orthodontic tx is necessary to manage the early loss of primary teeth, insufficient space for permanent dentition, small jaws due to poor bone mineralization - When ortho tx is performed, we should consider that teeth are not well fixed into the bone, due to cementum dysplasia - Less force preferred. Eating Disorders - Prevalence: 30.000.000 americans develop eating disorders - Precise etiology unknown - Other mental health issues associated: anxiety, depression - Medications could cause xerostomia Anorexia - Fear of gaining weight - Distorted body image - Do not eat (starvation or excessive body exercise) Oral manifestations: - Recession - Caries - Attritions - Dry lips - Chronic dry mouth Bulimia Nervosa - Binge eating and compulsive behaviors to avoid gaining weight (vomiting / over exercising) Oral manifestations - Caries, - Recession - Abfractions - Erosion - Salivary gland swelling - Dentinal hypersensitivity - NO relation btw bulimia an anorexia and inflammatory gum disease and bone loss. There are other papers that found evidence but is not confirmed. Rumination Syndrome - Functional GI disorder - Systematically regurgitation of newly ingested food. - Before correlated with individuals with mental impairment, now with individuals without any cognitive impairment. Symptoms include: weight loss, GI issue, malnutrition, electrolytes disturbance, avoidance of work or social eating, dehydration Oral manifestations: - dental erosion and caries PICA - repeated consumption of nonnutritive foods. - Dirt, chalk, paper - To be considered PICA, these habits have to be at least 4 weeks Health issues - GI obstruction - Metal toxicity - Parasitic infection Dental issues: - Fractures - Abfraction - Increased risk of oral disease - Cervical erosion (non-carious) Recommendations from us: - Educate your patients after detection - Inducing vomit will cause erosion - Caries - Stay hydrated, avoid sugar, use fluoride/hydroxyapatite pastes - Mucosa lubricants and salivary stimulus - Smoking not advised - Multidisciplinary approach Before start tx: - Dental clearance - Dental issues caused by eating disorders should be fixed before tx. - Consider MI paste, PreviDent, Fluoride therapy during. - Clear aligners would be better to preserve the enamel and dental surfaces. GERD (Gastro-Esophageal Reflux Disease) - GERD is a digestive disease which the acid or bile irritates the esophagus by constant reflux. - Issue with the lower esophageal sphincter that does not shut properly. Symptoms: - Burning sensation - Regurgitation - Upper abdominal chest pain - Laryngitis - Ashtma - Trouble swallowing Dental symptoms are the same as bulimia when patient induces vomit.  Bisphosphonates - Antiresorptive action to bone (decreases bone resorption) - Low doses Pharmacology of Bisphosphonate In a study, after 6-12 months of oral bisphosphonate administration: - Clinical improvement of periodontitis - Decrease in N-telopeptide (bone marker for resorption) - Increase in bone mineral density Types of Bisphosphonates: there many, but the most popular is the Zoledronic acid. Nitrogenous vs. Non-nitrogenous - First more potent than second. - Nitrogenous: prevents protein lipidation by inhibiting the production of isoprenoid compounds in the mevalonate pathway: - Non-Nitrogenous: act by inhibiting protein synthesis and inducing osteoclast apoptosis - What happens? Because it destroys osteoclasts the bone healing is impaired. - Recommended 2-3 months suspension prior to any dental surgery or interventions that will need healing. - Intercurrence: osteonecrosis, dry socket - Orthodontic intercurrence: prevent tooth movement  Hypertension - Blood pressure high - Be careful with placing TADs and anesthesia Key Points 1. Asthma, Infective endocarditis, Thalassemia and uncontrolled HIV need clearance from appropriate specialists before starting orthodontic treatment 2. Hypothyroidism leads to slower orthodontic tooth movement, and hyper, faster. 3. Asthmatic patients have an increased risk of external root resorption 4. Diabetes Mellitus can result in accelerated tooth eruption,​ periodontal disease and disrupted enamel and dentine formation 5. Hypophosphatasia patients often need space maintenance due to early primary tooth loss, but there are currently no published reports of orthodontic treatments in HPP cases Asthma, Infective endocarditis, Thalassemia and uncontrolled HIV need clearance from appropriate specialists before starting orthodontic treatment 6. Eating disorder cause enamel erosion and periodontal issues which can be identified early by an orthodontist 7. Bisphosphonates slow tooth movement, prevent relapse, and may cause osteonecrosis. Never extract for pts on Bisphosphonates. Extrusion, Intrusion Worn Dentition Anterior Restorative Space - Orthodontics play an important role preparing patients for future restorative work, by gaining space, aligning, extruding or intruding dentition to better receive prosthetic work as well. - Main objective is to restore function and esthetics for patients - **Intrusion Achieved**: Mandibular incisors intruded by 2.6 mm on average. - **Retention**: Minor relapse of 0.8 mm post-treatment (\~30% of initial intrusion). - **Other Changes**: Increased interincisal angle (21.4°) and reduced overjet by 6.3 mm. - **Long-Term Stability**: Intrusion demonstrated stability over 5 years. Worn teeth: - Bruxism - Restorative dentist may utilize: crown lengthening, intrusion/extrusion, increasing VDO (vertical dimension of occlusion) Evaluation: What to see in worn teeth and smile: - Incisal edge display at rest - Midline - Incisor inclination, - Lips - Gingival levels Esthetic Plan - Gingival esthetics (Chris Coachman virtual planning) - Invisalign virtual planning with Smile Architect - Esthetics first : wax up to measure the changes to be done on the dentition - Then transferred to patient with a silicon guide - In the case of gingival cant, crown lengthening and intrusion/extrusion should be done to achieve a harmonious smile. - As soon as alignment is completed, restorations will be also done (debond necessary prior to restorations) - Intrusions/extrusion: teeth should be fixed for 6 months to avoid relapse Define the cause of the Overbite: - Extrusion of upper anterior teeth - Angulation of the upper anterior teeth (Class II div 2) - Imbalance of facial proportions (45%-55%) Summary The problem typically seen in patients with anterior tooth wear is that they experience compensatory eruption. Orthodontists have the ability to intrude these over-erupted incisors to achieve interocclusal space to allow for conservative restoration of these teeth. In essence, it allows for the replacement of the lost tooth structure, while aligning the gingival margins to an optimal position Ideal treatment plan whether incisor intrusion is possible along with a need to increase the vertical dimension through other means such as surgery -\> more conservative restorative plan is possible. For the mandibular teeth is similar. - Importance of the mandibular teeth position\>\>\> speech, lip support, and lower facial profile - Evaluate the mand incisal edges relative to the face and maxillary teeth. (adequate OB and OJ) - Plan for gingival level adjustment, surgical (osseous or not) - Gingival margins move naturally with teeth. Intrusion if excessive dental/gingival display, extrusion if poor. Restoration selection: - Consider the type of teeth: max ant vs posteriors, vs mandibular ant vs post - Veneers, crowns and materials Establishing Occlusal Relationship btw Arches - Key Outcomes: Functionally balanced, esthetically pleasing, and long-lasting occlusal relationship. Intrusion - Relative intrusion: when the incisor eruption is restricted to allow the posterior teeth to erupt. (ex. Anterior bite plate, twin blocks, reverse curve of spee - Absolute intrusion: the real intrusion, without any extrusion of posterior teeth. - (ex. J hook HG, TADs, bypass and segmental mechanics). Therapeutic Biomechanical Systems - Ricketts Utility Arch - Burstone Intrusion arch Intrusion of Ant Teeth. Gummy Smile - Absolute intrusion preferred in : vertical growers w/ excess incisal display - Cases that post eruption is ineffective - Ideal candidate: class II div 1 with increased OJ, long lower facial height, gummy smile and incisor exposure (more than average) at rest. Deep Bite and long LAFH - Intrusion of lower anterior teeth with utility arch (Burstone or Ricketts) however the wire should be cinched back to avoid proclination. - For adults with normal incisor display, but deep bite, the mand incisors intrusion is the best option (stable overtime) - Intrusion: more root resorption Key Points: Intrusion techniques such as the utility arch, segmental arch mechanics, reverse curve of spee, TADs allow controlled intrusion, preserving tooth structure while optimizing space for restorations in cases with significant anterior wear. The orthodontic-restorative interdisciplinary relationship is enhanced by virtual smile design tools The repositioning of teeth prior to restoring the worn dentition supports a conservation approach to treatment planning This process is particularly important for anterior guidance, protecting against future wear, and redistributing occlusal forces more evenly. Long term retention is crucial to prevent relapse and stability of occlusion Perio Plastic Surgeries Objectives of Perio Plastic surgeries: - Periodontal-prosthetic corrections - Crown lengthening - Ridge augmentation - Esthetic surgical corrections - Coverage of the denuded root surface - Esthetic surgical correction around implants - Surgical exposure of unerupted teeth for orthodontics Main reason for recession: traumatic toothbrushing habits - In Orthodontics: pushing dental roots towards a thin buccal bone wall. - Frenal and muscle attachments. - How to treat recession? Increasing keratinized attached gingiva. - Free gingival autograft: harvested from palate. - Partial thickness graft is harvested. The periosteum is kept in place. - Once is immobilized, protect with surgical cement (Coe-Pack) - The success of the graft depends on the connective tissue, that have to stand the transfer to another site. - Part of the graft will be necrotic, but new tissue will be formed from the borders towards the center. - Revascularization starts after 2-3 days. From ischemic area it starts to turn pink. - Recovery of a partial thickness graft takes 10.5 weeks. - Bigger thickness may take up to 16 weeks - After 24 weeks the graft will shrink. The greatest amount of shrinkage occurs in 6 weeks. - Over denuded areas, the graft will shrink 25% - Over periosteum, the graft will shrink 50% Free Connective Tissue Graft - Connective tissue carries genetic information and stimulates the formation of keratinized tissue. Diastema Closure - - More common in: - Maxilla of females compared to males. - Populations of African descent compared to Caucasians and Mongoloids. - Spring aligners:  - **Bonded Power Chains**: Used in conjunction with power arms for effective diastema closure (e.g., a 9-year-old case with closure in 5 months via translation of teeth).  **KEY POINTS** - **Midline diastema can be closed using full or sectional fixed appliances, maxillary removal appliances and clear aligners** - **Spring aligners are designed to make small, precise adjustments to the alignment of anterior teeth** - **Simple, cost-effective and time-efficient** - **Inside-out perforation on the VFR and formation of the mechanical lock enhanced the mechanical retention of the elastic hooks** - **Bonded fixed retainers aids in the prevention of relapse.** Black Triangles Definition - Black spaces in the gingival embrasures - May have food trapped - May have inflammatory gum disease Risk Factors - Severity of crowding: For every 1 mm of crowding beyond a total of 8 mm of crowding, the chances for a black triangle increases in 7%. - Divergent roots: 1 degree in root divergence increases in 14-21% in the occurrence of black triangles. - Patients \>20 years old associated w/ incidence of black spaces due to slower healing capacity of inflammation and bone processes with increasing age. - A relatively **high incidence** of gingival black triangles **(38-58%)** has been reported following orthodontic treatment in patients ≥ 12 years old with fixed orthodontic appliances - No concrete conclusion due to variations and discrepancies in reported results between studies in regards to the higher incidence of black spaces in patients having ortho tx. What can we do? - Incidence of black spaces have to be discussed with patient. - Black spaces trap bacteria, food - Poor esthetics - Higher incidence following ortho tx due to preexistent conditions (thin periodontium) and significant tooth movement. Laser in Orthodontics - L.A.S.E.R An acronym for Light Amplification by Stimulated Emission of Radiation. -- First effective laser developed in the 1960s. - LLLT: \[Low-level laser therapy\] Operate under 500 mW. Used to relieve pain, accelerate bone regeneration, and enhance tooth movement, but limited by frequency of application. - HILT:\[High-intensity laser therapy\] Operate over 500 mW. Beneficial for managing soft tissue complications with benefits like better hemostasis, reduced pain and infection, and shorter surgical stages, decreased edema and scarring Indications - Primarily for soft tissue surgeries like gingivectomy, gingivoplasty, impacted teeth exposure, frenectomy, and fiberotomies. Benefits - Improve homeostasis and reduce postoperative pain - Minimal tissue damage - Accelerate bone regeneration Gingivectomy in Orthodontics - Alleviate gingival hyperplasia - Enhance esthetics - Facilitate bonding - 1 mm JE, 1mm supracrestal CT, 1 mm gingival sulcus Gingivectomy vs Gingivoplasty - Gingivoplasty is the recontouring of the gingiva to create physiologic gingival contours. There is no need to reduce pocket depth in gingivoplasty. - HILT Other uses of laser in orthodontics: - Fiberotomy: Circumferential supracrestal fiberotomy is a valuable technique for reducing relapse by modifying the supracrestal fibers responsible for tooth rotation. - Removal of ceramic brackets: Damage to pulp and enamel? - Preventing white spots: the CO2 laser can change enamel surface by reducing carbonate and phosphate contents → reducing caries potential. - Recycling of bracket: use of laser to remove the adhesive from the bracket pad, causing minor impacts on material → close to new bonding strength. - Lingual and labial frenectomy (HILT) Key points In Orthodontics, lasers are used in two major applications: Biostimulation and Surgery. Two different types of lasers are used, LLLT and HILT, the former is used for pain relief and bone regeneration acceleration and facilitate tooth movement. The HILT is used for bloodless atraumatic perio surgeries. Main usage is the soft tissue surgeries like gingivectomy, impacted teeth exposure, frenectomy, and fiberotomies as well as the tooth movement acceleration. Congenitally Missing Laterals - After third molars, the upper lateral incisor is the most prevalent tooth absent in a population. - It affects 2% of the population - More frequent bilaterally - More common in women - Order of prevalence, from highest to lowest Third molars, U2s, L5s - PMs are the most frequent missing tooth when there are more than 2 teeth missing. - Lateral is the opposite (when only one tooth is missing) - Involves 5 genes: (PAX9, EDA, SPRY2, SPRY, WNT10A) - **Microdontia Prevalence:** 44.8% of patients with unilateral agenesis had a smaller contralateral lateral incisor. - **Gender Consistency:** Agenesis effects on tooth size were similar for males and females, showing no significant gender interaction. - Bolton discrepancy: a. Overall 6-6: 91.3 (above means mand excess, below max excess) b. Anterior 3-3: 77.1 (above mandibular excess, below max escess) Canine Substitution - Color (too yellow) - Reshape tooth - Brackets for torque; Upper central, lateral, or flip the canine Dental and facial Criteria for Canine Substitution - Dental malocclusion: Class II with no lower crowding OR Class I with crowding with possible mandibular extraction. - Profile: balanced, straight preferred, but slightly convex would also be accepted - Lip level and gingival margin Canine shape and color - The ideal lateral incisor substitute is one that has the same color as the central incisor - Is narrow at the CEJ Buccolingually and Mesiodistally - Flat labial surface - Narrow midcrown width buccolingually - The gingival margin of the canine should be positioned slightly incisal to the central incisor gingival margin. Helps camouflage the substituted canine. Lip Protrusion - The maintenance/ opening of spaces would be contraindicated in case of lip/dental biprotrusion Severe Lower Crowding - L4s extraction and closing Upper and Lower spaces Class II malocclusion - Use existing upper spaces to close and retract Gummy Smile - Preferred: canine substitution - If bridge is the option: depression or atrophy on the alveolar ridge. Canine Guidance (or protected occlusion) \>\>\> does not show leverage compared to others Lowest percentage of the population has CPO It is unstable due to the max canine wear (palatal surface) Evidence does not show less TMD associated with CPO( canine protected occlusion) No perio issues diffente, no occlusal shift different from other types of guidance (group guidance) Conclusion Younger patients the tx of choice is canine substitution, as it is reversible and has an array of esthetics options. Narrow-Diameter Implants for Congenitally Missing Maxillary Lateral Incisors - **Narrow-Diameter Implants**: NDIs provide a more minimally invasive approach that requires less bone volume, which is crucial in younger patients or those with space constraints. - **There are 2 sizes platform sizes**: 2.9 mm and 3.3 mm - **Survival Rate**: - Reported 99% survival rate, showing that NDIs were reliable over the follow-up period. - **Crestal Bone Level (CBL) Changes**: - Minimal bone remodeling after implant placement. - Average changes were -0.19 ± 0.25 mm (2.9 mm group) and -0.25 ± 0.31 mm (3.3 mm group). - Function, esthetics, self confidence - **6-12 % loss in ridge height after orthodontic movement** Key Points - **Implant Success**: High implant survival rate with stable outcomes over the 3-year period for both implant diameters - **Bone Stability**: Minimal bone resorption observed around the implants, indicating good bone preservation - **Aesthetic Satisfaction**: High patient and clinician satisfaction with aesthetic outcomes, with the implants blending well with natural teeth. Crown Width of Congenitally Missing Maxillary Lateral Incisors - The study investigates congenital agenesis (absence) of maxillary lateral incisors, to determine if affected patients have smaller overall tooth widths, suggesting **a genetic link** **between tooth absence and reduced tooth size in patients with one or both lateral incisors missing. \>\>\> TRUE** - There is a correlation btw agenesis of U2s and overall tooth MD widths. - Most affected teeth 1. Max and Mand Incisors (central and lateral) 2. Canines 3. PMs. - Maxillary first molars were the exception demonstrating no significant reduction in width compared to control. - No difference btw unilateral/bilateral agenesis. Both demonstrated the same similar reductions. - Microdontia prevalence: 44.8% of patients demonstrated a smaller contralateral tooth, when agenesis of 1 lateral incisor. - No differences btw genders Options for rehabilitation - Space for implants: reduced space (6mm recommended) - Restorative and perio adjustments: composite widening of crowns - Interdisciplinary approach: ortho + perio +restorative Conclusion - Patients missing lateral incisors have smaller teeth, except for first molars. - Restoration of the maxillary teeth could be recommended to improve overall aesthetic and functional outcomes. - There is no difference in the amount of mesiodistal width reduction between patients with unilateral and bilateral agenesis. Preserving Alveolar Bone Height and Width - ** 6-12 % loss in ridge height after orthodontic tx (opening space)** - **The depth of the labial concavity between the maxillary central incisor and canine nearly doubles** - **Significant decrease in the width and height of the alveolar ridge that receive orthodontic treatment to create space for implant.** - **Treatment implications:** - **Bone grafting procedures before implant placement to achieve adequate bone volume for proper implant stability. ** - **TAD placement to preserve alveolar ridge width and height in growing patients.**  **Formula to calculate the MD width for lateral incisors (for rehabilitation)** 1. Sum of mand 3x3 MD widths/ 0.77 = ideal MD width for the Maxillary teeth (3x3) 2. Sum of max 3x3 MD widths. Do not include the missing teeth. 3. **Subtract the Mand -- Max = space needed for 2 lateral incisors** 4. For 1 lateral divide the number by 2. Bolton Analysis - **Determines the ratio of the mesiodistal widths of the maxillary teeth to the mandibular teeth** - **Formula introduced by Dr. Wayne A. Bolton.** - **Shows whether there is any tooth size discrepancy between the upper and lower teeth.** - **Recommended only in the permanent dentition, after the eruption of all permanent teeth.** - **Used to assess maxillary or mandibular arch length deficiencies or tooth size discrepancies.** - **Quick diagnostic tool to contribute to finishing in "excellent occlusion" with ideal overbite and overjet.**  Treatment options for optimal occlusion fixing Bolton discrepancy: IPR, Venners, Build ups, Crowns Differential movement: reverse curve causes a anti cw movement on the anterior teeth, as the force is located buccally to the center of resistance. And reciprocal clockwise movement on the molar. Gummy Smile - Smiles Types - Mini esthetics: Smile characteristics related to the teeth and face. - Micro esthetics: smile characteristics related to teeth and gingiva. - Social smile vs. Emotional smile MINI ESTHETICS Teeth to face relationship a. Incisor exposure at rest: - adult 2-4 mm - upper incisor display reduces age. - Excessive: excess maxilla, overeruption of incisors - Short upper lip - Diminished: vertical maxillary deficiency, longer upper lip, attrition/bruxism of the upper incisors. b. Incisor/ gingival exposure on smile  c. Midlines: - Relative to each other and relative to the face. - Use the interocular perpendicular line, passing central through the cupids bow. d. Cant of the occlusal plane: - Clock/counterclockwise - Measured using the interoccular line as reference or intercomissure line. - Differentiate btw soft tissue (smile) crooked compared to the real cant. - Roll issue e. Buccal corridor: - 16% ideally (of the intercommiisure distance). \> distance from molars/premolars to cheek. f. Transverse proportion of the face compared to the upper arch: - Bizygomatic width corresponds to the upper arch width. - Larger, broader smile is more harmonious with a large Bizygomatic large width. g. Smile arc: - Consonant / non consonant - Non consonant: straight / reverse - Consonant: upper teeth follow the lower lip line. MICRO ESTHETICS Teeth to gingiva esthetics a. Dental proportions: - Width: 1.0/0.8 (width is 80% of the height which is 1.0) -  - Imbalance: incomplete eruption (short tooth), attrition, excess gingival height, distortion of the crown shape. - Golden proportion\>\>\> the width of each tooth should be 62% of the adjacent tooth (anterior) - Clinical application\>\>\> canine substitution or recontouring or replacing laterals. b. Dental contacts and connectors:  - Contact: is the point that teeth contact each other. - Connector: areas that look as if teeth are touching. They move apically and progressively towards distal (see the red lines) c. Dental color and shade: - Upper central: the brightest - Progressively becomes more yellow, and less bright - The age makes teeth darker to natural wear and staining d. Gingival color and texture: - Healthy: coral pink with stippling - Inflammation: redness, no stippling, bright (edema), and rolled gingival margins - Gingival color: related to race, skin color and disease. e. Gingival contour: f. Papillary appearance: - Many stages and related to height. Ideal is 3  g. Black triangles: - Open gingival embrasures opened above the connectors - The distance btw alveolar crest and the contact point has to be within 5 mm. If more, more risks to have a black triangle. - Etiology: periodontal disease, aging, root angulation, triangular shape crowns - Aligning, due to excessive crowding can cause black triangles due to bone loss. Other factors: - Time (ideals of attractiveness change overtime. - Cultural influences - Person who is judging (layperson vs dentist) - Patient self perception. Article about midline deviation, smile arc and, axial midline angulation, buccal corridors, and smile attractiveness Conclusions: - 4 PMs ext had no predictable effect on smile esthetics. (4 pms vs non ext) - Midline deviation of 2.2 mm acceptable (orthodontists are able to detect deviations \> 2.2 mm and laypeople are able to detect \> 3mm. Key points - Orthodontists use social smile vs emotional smile - Normal incisor exposure at rest (young adult) is 2-4 mm - Acceptable range for gingival display on smile is 4 mm to -4 mm (lip covering upper incisor) - Use interocular perpendicular line to determine midlines - Use interocular line and intercommisure line to determine presence of cant and differentiate it from lip animation - Normal buccal corridor is 16% of intercommisure distance - Ideal smile arc is consonant vs straight or reverse - Normal width of upper central incisor is 80% of height - Width of upper teeth should be 62% of the mesial/distal width of the anterior adjacent tooth. - Dental connectors become shorter and move apically, while embrasures become wider as they progress distally - Upper lateral incisor gingival margin is 1.5 mm more incisal than central incisor and canine - Black triangles may be a result of periodontal disease, aging, root angulation, triangular shaped crowns What is it??? - It is a 12 index points developed to assess dento-facial parameters. - Index points are 5 extra oral and 7 intra oral. - Each criterion includes 5-point rating scale - The sum of the score categorizes the esthetic score  - The final DESI had only 3 extraoral items and 7 intraoral ones.( removed parallelism of canine line with bipupillary line & the congruence of facial and dental midline). - Removing 1st and 3rd items from the extraoral part of the index resulted in scoring that represents intraoral grading rather than both. **Results** - Restorative treatment in the anterior region lead to high significant improvement of the final DESI after treatment. - 3 or more treated teeth improved the difference in score - This index is able to discriminate between single esthetic intervention on one or two teeth and complex treatments on multiple maxillary teeth. - The use of both subjective(patient) and objective (dentist) esthetic ratings in this study strengthened the final DESI and allowed sufficient prediction and measurable esthetic improvement. - Conclusion: The newly developed DESI is a reliable and valid tool to quantify clinical situations and treatment outcomes in accordance with the subjective perception of patients. 5 Key points - There are several indexes used to assess smile esthetics in dentistry. - Dental Esthetic screening index is a 12-item index consisting of 5 extraoral and 7 intraoral criteria. - A high score represents poor esthetics and a low score is excellent esthetics. - After conducting this study, two of the extraoral criteria were removed due to the decrease in interrater reliability. - The final DESI is considered to be a reliable and a valid instrument to assess dento-facial esthetics. Ortho\_Endo Summary - External Apical Root Resorption (EARR), Occurs in up to 73% to 100 % of orthodontically treated patients, mostly (maxillary - Incisors) - Local: Hypercementosis, occlusal trauma, chronic low-grade inflammation, orthodontic movements, loss of antagonist. - Systemic: Hypothyroidism, arthritis, genetic factors. - Local: Active periapical lesions, bacterial infections, external root resorption. - Systemic: Osteoporosis, calcium/vitamin D deficiency, corticosteroid or bisphosphonate use. **Effects of Orthodontics on Pulp** **Physiological Effects:** - Orthodontic forces reduce pulpal blood flow, cause reactive hyperemia, and may result in fibrosis, calcifications, or reversiblepulpitis if forces are controlled. - **Neuropeptide Defense Mechanism:** - Neuropeptides (e.g., Substance P, CGRP, VIP) regulate blood flow and promote **angiogenesis** with growth factors (EGF, PDGF, TGF-β). - Tipping: 35--60, Translation: 70--120, Rotation: 35--60, Intrusion: 10--20. - Occurs with excessive forces or poor control. - **Risk Factors:** - **Genetic:** Predisposition in Latinos. - **Anatomical:** Short roots. - **Malocclusion:** Overjet, occlusal trauma. - **Systemic:** Endocrine issues, allergies, asthma. - **Orthodontic Treatment:** Prolonged treatment, heavy forces, intrusion Follow up period after trauma to start orthodontic treatment ------------------------------------------------------------------------------- ----------------- ------------------------------------------------------------------------------ **Injury Type** **Wait Period** **Remarks** Crown/Crown-Root Fractures (No Pulpal Exposure) 3 months Allows healing of dentin-pulp complex and periodontal tissues. Crown/Crown-Root Fractures (With Pulpal Exposure) 6 months Wait for a hard tissue barrier to form after pulpotomy or pulpectomy. Mild Periodontal Damage (Concussion, Subluxation) 3--6 months Shorter wait for minor cases; longer for more significant damage. Moderate to Severe Periodontal Injury (Luxations, Intrusions, Reimplantation) 1 year Allows healing of periodontal ligament and alveolar bone. Transverse (Intra-Alveolar) Root Fractures 1--2 years Ensures stabilization and healing of fractured root segments. Immature Traumatised Teeth 2 years Await continued root growth and apexification. Trauma-Induced Inflammatory Root Resorption 1 year Await radiographic evidence of root and bone healing before applying forces. ------------------------------------------------------------------------------- ----------------- ------------------------------------------------------------------------------ - Orthodontics forces result in pulpal inflammation, but usually it is reversible - External Root Resorption (ERR ) is a multifactorial process, so the etiology most of the time is idiopathic - Teeth with a history of trauma seem to be more susceptible to pulpal and periapical changes with Orthodontic tooth movement (OTM) but will vary depending on the severity of the trauma and the type of Orthodontic tooth movement - Evidence of pre-Orthodontic tooth movement root resorption may predispose to further resorption. - Niduses of calcification within the pulp are common with Orthodontic tooth movement, but pulp canal - calcification (PCC) seems more related to a history of trauma or excessive orthodontics forces. - When a patient sustains dental injury during treatment, the orthodontic rest period depends on the severity of the injury, and current guidelines, should be followed - If the patient needs both Orthodontic tooth movement and endodontic treatment, the order of treatment does not really matter but it is case-dependent. Altered Passive Eruption (APE) Key Features: - APE Type 1: Excess gingival tissue with a normal bone crest CEJ distance. - APE Type 2: CEJ is closer to the bone crest due to failure of active eruption. Prevalence and Risks: - Affects 12.1% of individuals, often leading to periodontal pocketing and esthetic concerns. - Thick flat gingival biotypes are more susceptible. Management: - Surgical : Crown lengthening to expose the anatomical - Orthodontic : Selective intrusion or retraction to reduce gingival - Combination Therapy: Botulinum toxin injections and lip Clinical Outcomes: - Crown lengthening improves clinical crown exposure and esthetics - TSADs effectively facilitate arch intrusion and gummy smile correction with high success rates.