Periodontal diagnosis in orthodontics Dental Course

Periodontal diagnosis in orthodontics

Introduction

The movement of teeth by orthodontic means which is done thanks to the histological reactions which take place at the level of the periodontium is not without danger for this organ which will represent it, hence the need for its meticulous examination since it will have to support the forces which will be delivered in order to move the teeth.

This periodontal examination will be done in the form of inspection, palpation, probing to which X-rays will be added.

1. Anatomical reminder

The periodontium is composed of several elements namely;

-the gum

-the alveolo-dental ligament or desmodontal ligament

-alveolar bone

Figure 1

2. Periodontal examination

2. 1. Inspection

• A healthy gingiva has a pale pink color, a thin gingival margin intimately attached to the tooth and an “orange peel” appearance. Therefore, a normal gingiva should be without inflammation, bleeding or color change with sufficient height of attached gingiva (3 to 4 mm) (figure 2 and 3).
• In some ODF patients, the gingiva may be inflamed, may have recession in one or more teeth while the insertion of the labial frenum may be low (figure 4, 5, 6)

Figure 2: Appearance of healthy gums:

Figure 3: Adequate attached gingival height

Figure 4: Appearance of an inflamed gum

Figure 5: Gingival recession

Periodontal diagnosis in orthodontics

Figure 6: Upper lip frenum inserted low

2. 2. Palpation

Palpation of the periodontium, from the bottom of the vestibule towards the sulcular area, sometimes reveals suppuration. This is a quick test that can diagnose active periodontitis. However, the absence of suppuration on palpation does not indicate a healthy periodontium.

2. 3. Survey

The pathognomonic sign of periodontal infection is the periodontal pocket. A periodontal pocket is a deepening of the gingivodental sulcus. The gingivodental sulcus is the space between the marginal margin of the gingiva and the coronal part of the epithelial attachment.

This deepening of the gingival-dental groove is measured by the periodontal probe

The examination is performed by inserting the probe along the free gingiva parallel to the root and perpendicular to the gingival margin (figure 7).

Figure 7: Insertion of the probe into the gingival sulcus

Values ​​below 4 mm without bleeding are considered normal; the situation remains manageable with good periodontal control.

If it is greater than 4 mm, the orthodontist will move towards the diagnosis of periodontitis and the patient must be referred to a periodontologist.

Periodontal diagnosis in orthodontics

Figure 8 and 9: Pocket survey

In some patients the gum is thin, there is a risk of gingival recession when moving the teeth. Probing can reveal the thinness of this gum if the probe inserted into the groove appears through the thickness of it.

Figure 10: the probe appears through the thickness of the gum (this is thin)

2. 4. Radiological signs

Radiological signs objectify the level of the alveolar bone.

We have at our disposal; panoramic radiography, retroalveolar radiography, dental scan and cone beam.

2. 4. 1. Panoramic radio

It allows you to visualize the quality of the periodontium of all the teeth and to possibly notice bone lysis or any other pathologies (which contraindicates any orthodontic therapy before the sanitation of the periodontium)

Figure 11: Visualization of alveolar bone lysis

2. 4. 2. Retroalveolar radiography or Radiovisiography (RVG)

It allows to better specify the altered periodontal state of one or more teeth already visualized in the panoramic radiograph

Periodontal diagnosis in orthodontics

Figure 12: Retroalveolar radiograph showing moderate alveolar bone lysis

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Figure 13: visualization of a very altered periodontium (there is danger in moving the teeth given the periodontal state)

3. Influence of tooth eruption on periodontal anatomy

3. 1. location of the tooth emergence point

The location of emergence determines the distribution of bone tissue and the distribution of gingival tissue

Figure 14: emergence of the tooth in its socket

If the tooth is vestibular, the vestibular bony cortex is thin, the tooth must be moved with caution (figure 15), on the other hand, if the tooth is in linguoposition, the cortex is thicker, there will be less danger when moving the tooth (figure 17)

Figure 15: vestibular tooth, thin vestibular bone cortex

Figure 16: Tooth in linguoposition; thicker buccal bone cortex

3. 2. Age and gender
   • Attached gingiva would be thinner in young subjects than in older subjects.
   • Gum thickness at chewing sites may be thinner in women than in men
4. 3. type of mandibular rotation
   • The periodontium is thick in subjects with anterior rotation of the mandible while subjects with posterior rotation have rather thin gingiva.

Figure 17: Anterior rotation of the mandible

Figure 18: Posterior rotation of the mandible

4. Periodontal classifications

Several periodontal classifications have been proposed by different authors with the aim of making a precise diagnosis regarding the typology of the periodontium .

-The classification of Maynard and Wilson

-The classification of Seiberd and Lindhe

-The classification of Muller and Eger

-Rou’s classification

The Maynard and Wilson classification

Type I	3 and 5mm	Thick periodontium
Type II	< 2mm	Reasonable thickness of underlying bone
Type III	Between 3 and 5 mm	Bone and root palpable
Type IV	< 2mm	Bone and root palpable

According to the author, only type IV patients are at risk because the lesions of the attachment system are real during orthodontic movement.

• Type 1: vestibulolingual thickness of the alveolar process is normal. The dimension of the keratinized tissue is normal.
• Type 2: The vestibulolingual thickness of the alveolar process is normal. The dimension of the keratinized tissue is reduced.
• Type 3: The vestibulolingual thickness of the alveolar process is thin . The keratinized tissue is of normal or ideal dimension .
• Type 4: The vestibulolingual thickness of the alveolar process is thin. The tissue

keratinized is reduced.

F

Figure 19: Type of periodontium

5. Clinical examination of the periodontium

5.1. Shape and texture of the gingiva

Healthy, it appears as a thin orange peel appearance, pressed tightly against the tooth.

5. 2. Lindh gingival index

0: normal gum, no inflammation, no change in color, no bleeding

1: slight inflammation, slight alteration of the gingival surface

2: moderate inflammation, erythema, edema, bleeding on pressure 3: severe inflammation, significant erythema and edema , bleeding

spontaneous.

5. 3. Plaque index

0: no plate

1: thin plate film

2: Moderate plaque accumulation 3: Large plaque accumulation

4. .bleeding

The test with a probe or by pressure allows to provoke or not the bleeding. In the 2nd ^case there is gingival inflammation

• 
• Figure 20: appearance of bleeding

6. Diagnosis of a weakened periodontium
7. 1. Attached gingiva present but too thin

Attached gingiva is present for at least 2 mm. The metallic color of the probe. Periodontal is visible by transparency.

The attached gum is too thin.

Vestibuloversion movements should be performed with caution, otherwise gum recession may occur.

Periodontal diagnosis in orthodontics

Figure 21: Thin attached gingiva

6. 2. Attached gingiva is absent

• Before any orthodontic treatment, it is essential to recreate an attached gum environment.

Figure 22: Absence of attached gingiva

6. 3. Bone level below the coronal half

Attachment loss is assessed by the radiological image of the bone level.

• This radiological image is correlated with mobility and the presence or absence of attached gingiva.

Figure 23: Significant loss of epithelial attachment

Periodontal diagnosis in orthodontics

6. 4. The Mulheman Index

He distinguishes several degrees of mobility:

-0: Ankylosis.

1. Physiological mobility of firm tooth.
2. Increased mobility, but the displacement is less than 1 mm in the vestibulo -lingual direction .
3. The tooth can be moved +1 mm in the horizontal direction, but not in the apical direction. The function is not impaired.
4. Tooth displacement in vertical direction. Disturbed function.

-If attached gingiva is present and the mobility index is less than II, orthodontic movement is not contraindicated.

• -If the attached gingiva is absent and the mobility index is less than II, an attached gingiva environment must be recreated.
• -If the attached gingiva is absent and the mobility index is III or IV, orthodontic intervention is contraindicated and the conservation of the tooth is questioned.

Conclusion

Each case treated in orthodontics must be the subject of a periodontal diagnosis beforehand in order to check its state of health .

Diagnostic tools are available to help us carry out this task (inspection, palpation, probing and X-rays).

If faced with a healthy periodontium, orthodontic treatment could be immediate, on the other hand faced with an altered periodontium (at the level of the gum

attached or at bone level) rehabilitation should be done by the practitioner himself or most often by a periodontologist before starting orthodontic treatment.

Bibliography

1. Hourdin S, Glez D, Sorel O. Periodontal diagnosis in ODF. Ortho Fr 2010; 81:9-17
2. Pignoly M, Monnet –Corti V. Mucogingival diagnosis in orthodontics: before, during, after. When should intervention be performed? Clinical Realities 2017; 2: 129-138

Periodontal diagnosis in orthodontics