11A. Combined Periodontal and Orthodontic Therapies

Question 1

In orthodontics, we are going to apply a force in a specific part of the tooth. As a consequence of that, you develop an area of a ____.

U7lizing that fulcrum point, the tooth will move within the ____ space.

As a consequence of that, two separate zones are created. One being an area of ____, the other an area of ____.

As a result, the dento-gingival unit undergoes ____. With that remodeling process, the long axis of the tooth changes/is modified. (Recalling the last few slides), through this remodeling process, the zone of tension and the zone of pressure will go through different remodeling processes.

Answer 1

fulcrum
periodontal ligament
tension
pressure
remodeling

Question 2

As a result of that force, the long axis of the tooth is modified. That’s what we call orthodon7cs – apply a force in a controlled fashion and the tooth changes ____. That’s what orthodon7cs is all about.

Answer 2

position

Question 3

In normal bone physiology (bone remodeling): The area of pressure goes through ____ process (lose bone), and the area of tension undergoes ____ process (gain bone).
Again, when you apply pressure, you lose bone. And when you apply tension, you gain bone.

Answer 3

resorption

apposition

Question 4

Basic Principles:
Utilization of light and constant \_\_\_\_ 
Inflammation free environment 
\_\_\_\_ Occlusal Trauma
Solid and Stable Anchorage
Presence of \_\_\_\_ Space

Newton’s Third Law of Physics: When you apply force, it reacts and pushes back in the opposite direc7on. To get the benefit of the bone physiology, when we apply the occlusal load (force), there must be a solid and stable ____. If the anchorage is not there, there are consequences.

Answer 4

force
controlled
PDL
anchorage

Question 5

For us to create the areas of tension and pressure, there has to be a PDL space. Otherwise, if there is no PDL space, ortho doesn’t work. In other words, if the tooth is ____ (in direct contact with bone, no PDL space), ortho is not doable.

Presence of normal healthy, inflamma9on-free ____ space is A MUST.

Answer 5

ankylosed

PDL

Question 6

Adjunctive orthodontic treatment is defined as the tooth movement carried out to facilitate other dental procedures necessary to control disease, restore function and/or enhance appearance.

Adjunctive orthodontic treatment usually does not last more than ____ months. Closure of midline diastema, elimination of ____, uprighting of the tilted teeth, relieving ____ and anterior space redistribution usually fall under this category.”

Answer 6

six
anterior black triangle
cross bite

Question 7

“Alveolar bone is a component of the tooth. And the alveolus, in health, will accompany the tooth in changes in position.”


Alveolar bone is a component of the ____. It’s not the bone that owns the tooth, but, rather, the other way around: The ____ owns the bone, PDL space, PDL ligament, and soM 9ssue. Therefore in health, inflamma7on-free environment, the dento-gingival unit (alveolus) belongs to the tooth and will follow the tooth to the ____ we move it (the tooth).

Answer 7

tooth
tooth
direction

Question 8

Orthodontic Tooth Movement
Alignment of clinical crowns by leveling and aligning ____

Classical orthodontics is ____

Answer 8

marginal ridges

beautiful

Question 9

Periodontal Tooth Movement

Alignment of the ____,
leveling of the osseous crest and gingival margin.

Answer 9

roots

Question 10

Periodontal tooth movement

• Control the ____
• Establishment of favorable occlusal landmark relationship
• ____ and parallel adjacent teeth for maximal axial loading of teeth
• Establish favorable ____ of occlusal forces and excursive guidance
• Establish adequate ____ distance for proper embrasure spaces

Answer 10

disease
upright
distribution
inter radicular

Question 11

Periodontal Tooth Movement

Objective is to modify the position of teeth and ____ in order to better prepare dental arches and dentition for periodontal, restorative, prosthetic and implant solutions among others.
Its never the ____ goal, establishment of ideal occlusion

So, periodontal tooth movement is not a complete therapy because it is an ____ therapy. Something will come ____ to finalize it.

Answer 11

attachment apparatus
primary
adjunctive/supportive
after

Question 12

The goal of this type of treatment is NEVER ____ occlusion/perfect alignment. So, if we look at a case like this where we have pathologic migra7on of the teeth and periodontal involvement, we’re going to u7lize the technique of conven7onal orthodon7cs.

Answer 12

ideal

Question 13

Periodontal Tooth Movement

We’re star7ng where the long axis of the teeth are perpendicular to the basal bone - that’s what we want. But the upper posterior den77on has medial 7l7ng/dri^ing - called accelerated mesial dri^ing. We want to maintain normal physiology and within normal physiological func7on/movement - the teeth tend to shi^ ____. If the rate of this movement occurs too ____, it becomes pathologic and we call it accelerated ____.

Answer 13

meisally
quickly
mesial drifting

Question 14

Periodontal Teeth Movement

To modify that, before we go and do what we need to do, where the long axis of the teeth are not favorable due to pathologic movement as a consequence of that were have what we call angular crest which is different from an infra bony defect. The crest of the bone is determined by the CEJ level. If level of the CEJ is disturbed because of tooth movement, as a normal physiological adapta7on of the periodontal apparatus, the bone will ____ that.

That’s why it’s different from infra bony defect. So we would never call it an infra bony defect, but rather an ____. If you see a radiograph with a ver7cal component in the alveolar crest and you call it an infra bony defect, you will fail!!!

These are very different. this type of angular crest compared to healthy, normal leveling of the crest, this type of environment is predisposed to breakdown into an ____ defect.

Answer 14

unlevel
angular crest
infra bony

Question 15

Periodontal tooth movement

Mesial drifting -> corrective mechanics -> functional posterior support

From that we’re going to utilize a technique u7lizing the 99% of perspira7on to go from mesial dri^ing to correc7ve mechanics to func7onal posterior support. The purpose is not to make the teeth preNy, but rather to modify the ____ environment to something more ____.

Answer 15

periodontal

favorable

Question 16

Periodontal Tooth Movement

In transversal analysis – we have a ____ rela7onship, not cusp-fossa rela7onship, from which a whole different pathology process can be triggered by an improper occlusal rela7onship.

Perio is a dents-gingival unit, involving the periodon7um and the tooth. If one component of the dentogingival unit is in ____ status we’ll suffer the consequences of it.

Answer 16

cusp-cusp

pathologic

Question 17

Periodontal Tooth Movement

Retraction of posterior and anterior segments

Mandibular anteriors perpendicular to basal bone

So if we look at the lower arch of the same pa7ent and follow the arrow, where the lingual cusp of the second bicuspid is related to the buccal cusp and as you see over here, the arch itself is constricted. We need to upright the roots to create an axial loading on the tooth. Teeth were designed for ____ (not off-axis) loading because the major fiber component within the PDL is the ____ fibers.

Why are the oblique fibers the main component of it? If the teeth are supported by the oblique fibers and we apply pressure, we have a ____ (not a pressure). Recall that pressure causes ____ (bone loss).

Answer 17

axial
oblique
tension
resoprtion

Question 18

Periodontal Tooth Movement

the goal is to place the roots “____” to the basal bone

So upper arch, we’re using a removable appliances. Today, we would probably use something much more elegant than that. But, as you visualize from before and after, look at the meal clips compared to the position of the teeth. We’re bringing the teeth back over the basal bone to be supported properly to u9lize the ____ fibers.

Answer 18

roots

oblique

Question 19

Periodontal Tooth Movement

Retraction of ____ segment after establishment of
effective posterior support

So anterior and posterior segments in periodon7cs in normal health and prosthodon7cs work in close symbiosis. Anteriors will protect the posteriors, and vice versa. So anterior guidance has to be effec9ve to have a posterior ____ and posterior occlusion has to be solid and stable to ____ the anterior segment in func9onal occlusion.

So the end result of the orthodon7cs we are doing in here: the arch was ____ to put the teeth over the basal bone.

Answer 19

upper anterior
disocclusion
stable

constricted

Question 20

Periodontal Tooth Movement

Creation of ____ form
Proper form is a pre requisite for proper function

Mesially inclined teeth were ____ for maximal use of the oblique fibers for axial occlusal loading so posterior support can func7on properly so the anterior segment can be protected so the anterior teeth can pay back protec7ng the posterior teeth, providing proper lateral anterior guidance. (whew! but good summary)

I thought this was about perio? Perio cannot be managed/treated without controlling the occlusal forces. Why? because alveolus belongs to the tooth. If the teeth are not properly posi7oned, perio cannot be controlled. Perio treatment will not succeed if teeth are not properly ____ and protected and ____ is created.

Answer 20

proper
uprighted
positioned
functional occlusion

Question 21

You cannot make a central incisor shaped like a first molar and expect this molar-shaped central incisor to incise. Central incisor must be shaped as a central so it can func7on as a central incisor. A molar has to be shaped as a molar. you can’t put a central incisor back on the molar and expect it will support the occlusion - it won’t work.

Crea9on of ____ is a MUST (it’s not an op9on), it’s a MUST to obtain proper func9on.

Answer 21

proper form

Question 22

____ relationship is
of higher significance than ____ one in periodontal and restorative dentistry

When we analyze occlusion for periodontal purpose, the Buccal-Lingual occlusal landmark rela9onship is far more important than the Antero-Posterior rela9onship. Recall in conven7onal orthodon7cs, conven7onally we use ____ classifica7on (class 1,2,3). But in perio management Angles classifica7on is absolutely useless because the ____ rela7onship is far more important.

Answer 22

bucco-lingual
antero-posterior
angles
bucco-lingual

Question 23

In managing the occlusion, as we discussed before, the cusp height was flaNened. So if the fossa is very deep, and the cusp is very steep and your occlusion is locked in (suppor7ng cusp occluding against the central fossa), if your fossa is deep, you must have much more ____ anterior guidance to be able to disocclude this.

We’ve been talking about axial loading and if your anterior guidance is very steep and you’re you’re doing a guidance in this very steep anterior incline, you are punng much more intense off-axis loading. If anterior guidance is less steep far less off-axis loading than steeper situa7on.

To minimize off-axis loading we want to ____ the posterior occlusion/____ the fossa and cusp incline to provide ____ anterior guidance and minimize ____ loading.

Answer 23

accentuated
flatten
shallow
off-axis

Question 24

Periodontal Tooth Movement

____, Dental or Skeletal, is a factor of prime importance in periodontal and restorative health maintenance

So if we were to compare (before and a^er) of upper and lower arches and were superimpose that arch form pre and post-ortho, we know how much contrac7on/retrac7on of the arch form we have to put the teeth over the basal bone.

Answer 24

transversal discrepancy

Question 25

Incations:
• Modification of the osseous morphology
• \_\_\_\_ defect
• Implant site development
• \_\_\_\_ surgery 
• Post root resection
• Alteration of \_\_\_\_ relationship
• Modification of the soft tissue morphology

Answer 25

osseous
pre tooth
tooth to tooth

Question 26

Unleveled osseous crest

In perio, nothing that unleveled, meaning the ____ level of your periodontal apparatus is considered a normal condi9on.

We like to have everything level. Because of a pathology, regardless of e7ology, we lost the bone around the tooth, and as a consequence of that we have an unleveling of the bone.

How do we treat that? Not an angular crest now, but an ____ because ____ is level and so must be the bone, but it’s not! Thus this is not an ____.

Answer 26

low-high
infrabony defect
CEJ
angular crest

Question 27

Infrabony defect

How do we treat this classically speaking? ____ surgery
We will go and remove anything that is unleveled and try to ____ it and create a leveling of the osseous crest. That’s how we do osseous surgery.

Answer 27

resective osseous

ramp

Question 28

Apically positioned flap

What’s a consequence of that? We eliminate the pocket but now we have a recession of the so^ 7ssue that wasps inten7onally created as a part of a surgical periodontal treatment. That’s what we do. But the problem is we solved one problem and created another ____. But that’s how we treat inflammatory periodontal disease.

Answer 28

problem

Question 29

Resective Osseous Surgery

So in a situa7on like this where, clinically it looks reasonably okay but probing going from 2 to 10mm and bleeding, suppura7on, mobility, etc. How do we treat this? ____ surgery.

We open the flap, remove ____ bone (ostectomy) and ____ bone (osteoplasty). We’re going to try to create a favorable architecture, move everything up.

Answer 29

resective osseous
supporting
nonsupporting

Question 30

Resective Osseous Surgery

And we go from here to there. Successful periodontal surgical treatment where we eliminate a pocket but now we have a ____ tooth there. We solve perio inflamma7on but now we have an ____ complica7on in here. It’s great you had a 10mm pocket and went down to a 3-4 mm pocket, but now what?

We give pa7ents the op7on – the pa7ent can have longer teeth or teeth no longer?
O^en the pa7ent will choose longer teeth. That’s what ____ respec7ve periodontal surgery is.

Answer 30

longer
aesthetic
conventional

Question 31

Alternative Approach

Periodontal lesion

But is there any choice to that? What’s another op7on?
Star7ng with the same inflammatory lesion – were control ____ first.

Answer 31

inflammation

Question 32

Inflammation control

We put the pa7ent under ortho, u7lizing the concept and objec7ve of periodontal tooth movement we put the bracket on a specific tooth at a more ____ posi7on and ____ the tooth (force tooth to super erupt).

Why? Because the alveolus belongs to the tooth and in a state of ____, bone, soft 7ssue, and everything else will follow the tooth.

Answer 32

apical
erupt
health

Question 33

So we erupt this tooth. And as the tooth comes down, bone and so^ 7ssue come down together.

We contour the occlusion and replace the bracket at a more ____ level to bring the tooth down more.

As the tooth comes down, because inflamma7on is ____ and bone, PDL, so^ 7ssue, and everything else belongs to the tooth, as I bring the tooth down, everything will follow that. With orthodon7cs, that ____ has been eliminated.

Post-ortho, that’s what were have, not only bone came down, but so^ 7ssue came down also. So with that, pre and post-ortho, now we create an unleveling of the ____, but the bone has leveled.

Answer 33

apical
controlled
infrabony defect
soft tissue

Question 34

Excess soft tissue post orthodontics

Now I have an excess of so^ 7ssue and we can do a ____ which we almost never do. Unusual, because by doing one tooth crown lengthening you end up with unleveling of the osseous crest. You do not want aNachment of one tooth to be ____ than others.

But in this situa7on, we inten7onally unleveled the aNachment level in one tooth, so I can limit surgery to that one tooth and everything will go back to normal ____ status and we’re going to restore that one tooth.

Answer 34

single tooth lengthening
higher
physiological

Question 35

We can either remove bone all the way down there to do resec7ve surgery (conven7onal treatment) or we can control the ____ and do ____.

Answer 35

inflammation

orthodontics

Question 36

Pre-op and during radiographs. What’s happening to the bone? In a state of health because the alveolus belongs to the tooth, bone and soft tissue, ____ will follow the root. And that is what we call periodontal tooth movement. We don’t care if endo exposure happens because the tooth was erupted too much. We don’t care if the tooth is leveled or not. We want leveling of the ____. That’s all we want.

The goal of this orthodon7cs is periodontal tooth movement to the point that we can restore this tooth as a single ____ without opening a flap. 10mm perio pocket with bleeding and suppura7on, degree 3 mobility has been controlled with orthodon7cs only.

Answer 36

PDL
osseous crest
crown

Question 37

Crown to Root Ratio

Healthy condition
____ ratio

Post osseous surgery
____ ratio

Post ortho/perio surgery
____ ratio

Answer 37

1/2
2/1
1/1

Question 38

Crown to root ratio

Want crown to root ra7o 1 (crown) to 2 (root) in normal condi7ons. But if we treat this as a conven7onal resec7on, you end up with 2:1 crown to root ra7o, which is much more unfavorable. Whereas perio ortho movement end up with ____ crown to root ra7o which is much more favorable. So does a 1:1 crown to root ra7o work as a normal func7on? It ____. And that has to be taken into considera7on when we treatment plan.

Of course, if we want to save the tooth, these are our only two op7ons, and there is no doubt 1:1 is far more favorable than 2:1. Does that mean that every single tooth, every case, every occlusion with 1:1 is favorable? Of course not, it’s ____. The rule doesn’t apply to every situa7on and that’s why you’re the doctor. to decide if that isa tool that can be applied or not.

Answer 38

1:1
depends

case by case

Question 39

Orthodontics in the presence of inflammation

Conven7onal ortho could take 6 months, a year, 4 years, depending on what purpose you’re doing it for. For forced erup7on of a single tooth, because of the conical root anatomy, there is no resistance to bringing the tooth down, you’re just pulling it out of a socket. how long? Within ____ weeks, you could erupt this tooth 2-3mm no problem.

How many brackets, how many teeth? Enough to control the force and enough to have a solid/ stable occlusion. Shorter wires become more ____. Same thickness of wire, but the shorter the length, the ____ it gets.

When longer, the wire is more ____. Because of that, o^en, you’ll have kids wearing full braces, with loops and hoops to lengthen the wire for increased flexibility, and thus less ____ applied to tooth to prevent resorp7on.

Answer 39

3
stiff
stiffer
flexible
force

Question 40

“Alveolar bone is a component of the ____. And the alveolus,
in health, will accompany the tooth in changes in position.”


Exactly the same situa7on, if you don’t have control of the inflamma7on and you apply the same concept and the same mechanics, but viola7ng the condi7on of health, the same tooth movement will occur, but the ____ will not follow.

You end up pulling the tooth out of the ____, but the aNachment will not follow. That’s why the inflamma7on has to be controlled.

Answer 40

tooth
attachment
socket