11B. Combined Periodontal and Orthodontic Therapies

Question 1

Fracture/caries

• …So not only when we have a pocket depth but what if I have a fracture? Subgingivally? What if I have a caries subgingivally? How do I treat that?
• I cannot go and put a crown all the way up to the bone level because I will be invading biologic width. Thats unacceptable.
• If that is the situation then we must do a ____ of that. To apically relocate the biologic width. BUT we know what happen when do the crown lengthening here because we don’t do one tooth crown lengthening, we need to level the two adjacent (????) area we know the consequence of that.
• So we are going to utilize exactly same idea for different purpose – not for the purpose of eliminating the bony defect periodontal lesion– but as a ____ procedure we are going to go and do exactly the same thing.

• So from before where we have the bone is completely level (lower blue line) and normal and free of pathology we are going to go and put the brackets the way I want for the purpose that I’m thinking…

Answer 1

crown lengthening

pre-prosthetic

Question 2

Post orthodontic
- Osseous crest level

• …and we are going to erupt this tooth as you can appreciate on leveling of the apical apex of the root equal amount of a coronal part that we erupted.

• And intentionally now we create abnormality of ____, which we don’t want, but intentionally we create anomaly here. Why? Because now I can go do ____ tooth crown lengthening, eliminating excessive bone around this tooth, eliminating excessive soft tissue around it (circled).
• By doing that I go back to level bone and soft tissue I can afford the luxury of…

Answer 2

low HIGH low

one

Question 3

Localized tooth lengthening surgery
Post multi discipline approach treatment

• …Luxury of doing single tooth crown lengthening. So I can do single tooth crown lengthening we are doing orthodontic in preparation to that. Otherwise I couldn’t do it.
• So often you get to here this a simple situation (????) I just need one tooth crown lengthening – but those are the most difficult ones! Because you know what I need to do. To do crown lengthening of that one tooth I need to remove the ____ here and here (he points to a bunch of areas in the immediate surrounding teeth).
• When 2,3,4 teeth are problem those are ____.

Answer 3

bone

easy

Question 4

• …But so we can create a favorable environment clinically for the restoration of this tooth we are going to do the orthodontics.
• As you see pre-op where gingival margin is level (top left pic) – of course as we saw on the radiograph bone was level – we are going to position the bracket at a ____ level (top right pic).
• We are going to erupt this tooth. As the eruption happens what happens to the soft tissue? Soft tissue will follow? Why? It belongs to the ____.
• Free of inflammation I move the tooth up and soft tissue and bone will follow. Move to left or right the same thing will happen, attachment apparatus will follow the tooth.

• So we create an unleveling of the gingival margin so I can do one tooth crown lengthening now and pulpal flap elevation (bottom left).
• What I see? This is what we see (circled, bottom right). This bone moved from here to there (orange).
• Equal amount of the eruption of the tooth that we did.
• Does orthodontics create new bone? NO! Orthodontics does NOT create new ____.
Orthodontics does NOT create ____. Orthodontics ____ attachment.
• When we pull the tooth up the attachment followed the tooth. He again emphasizes that ortho does not create new bone or soft tissue.

Answer 4

different
tooth

bone
soft tissue
relocated

Question 5

• So that relocated attachment level we are going to do a localized ____ and put the margin back where it was (bottom left picture).
• So we did the entire surgery there and removed the soft tissue and removed the bone but did not affect the adjacent teeth. Did not affect adjacent attachment level.
• Thats post surgery free gingival margin.

Answer 5

crown lengthening

Question 6

Patient was referred for replacement of tooth #8 with implant

• Here is a case where the patient was referred to us because there was a crown in here and she cracked the crown so this tooth is not ____.
• Can you extract this tooth and put an implant in there? Of course we can do that.

Answer 6

restorable

Question 7

• So here is the initial presentation. Number 8 is fractured subgingivally.
• Tooth is not restorable as it is. What do I need to do? I need to do a ____
here. What is going to happen when I do the crown lengthening here?
• I need to remove the bone here, I need to remove the bone there (points to green spots).
As I remove the bone, the interdental papilla is going to ____ and I”ll create adequate tooth structure so I can put a crown in there but I’ll create other problems. Esthetic problems.
• Thats why the referring dentist don’t do the crown lengthening. Extract this tooth and put an ____ there so it doesn’t affect the esthetics of the adjacent teeth. Thats one way of doing it.

Answer 7

crown lengthening
recede
implant

Question 8

• We do the endo. We put a cast, post, and core.

Forced eruption of tooth #8 with temporary crown in place

• We are going to do the orthodontics. So why orthodontics? Why don’t we extract the tooth and put an implant there? Well that’s a template/terrible (????) way of doing it. We don’t do that. WE save the teeth in here.
• So we go and we do the endo. Cast, post, and core. Put a temporary there. We are going to ____ this tooth.
• You see the reason why it is into the slot. You see where the wire is? Tooth is erupting. And you are going to erupt this tooth as much as you need to.
• We put the bracket, rebound the bracket, bring the tooth down. Now what do I have? Look at the soft tissue where it is. (green line). Compared to before.
• Did orthodontics create more soft tissue? It did not! It ____ soft tissue to the coronal level…

Answer 8

erupt

relocated

Question 9

Adequate inter occlusal space for the eruption of tooth is required to prevent uncontrolled trauma from the occlusion

• Intentionally unleveling it… always making sure that you control the occlusion because orthodontics is a ____ trauma.

• And we are going to do the ____ limited to that one tooth. Leveling the
osseous crest the way it should be (blue line).
• So change of a gingival margin because attachment is following the tooth and crown lengthening is done. From pre-op we unleveled ____ intentionally ____ the bone so that we can do one tooth crown lengthening.

Answer 9

controlled
crown lengthening
high, low, high
unleveled

Question 10

• And that’s before the surgery (left picture).
• That’s after the surgery (right picture). ____ has been done without affecting
the adjacent teeth or without removing healthy attachment apparatus of an adjacent area.
Level the gingival margin.

Answer 10

crown lengthening

Question 11

Post orthodontics and pre prosthetic crown lengthening surgery

• Now I can go and if you look at preorthodontics where the margin of the post was and post orthodontic where the margin of the post stays.
• Why the post go from gold to white?It’s a cast post and core and metal post under the porcelean crown it modify the shade and esthetics, so we cut back the gold and we masked that with ____. That’s why.
• Its not only periodontics. Not only restorative, not only prosthodontics, not only perio, not only orthodontics. It’s a combo of everything. You use everything you know to maximize the outcome of it. That is going to make you different from john smith at the corner over there.

Answer 11

composite

Question 12

Normal condition w/ Crown tooth #8

• In a situation where you have a crown restoration on the adjacent tooth and something happened to the tooth next to it. What happened?
• If you have an existing crown here and something happens to the adjacent tooth you do the surgery — you already know what the outcome will be. You don’t need to do it to find out. We know that. You need to be able to ____ what the outcome is going to be so that you can properly plan and select what type of therapy you will be implementing or recommending. You don’t do it – oops, maybe this is not the best way. You need to be able to visualize what the outcome of the treatment is going to be.
• So you properly select what the best is for you and the patient.
• He clicks through the next few slides as an animation.

Answer 12

visualize

Question 13

Other than for that prosthetic purpose-restorative purpose—what other situations we do orthodontics is to modify the environment. There is situations where ____ proximity is present and because of the root proximity you have bone loss, you have a pocket depth, you have inflammation in all – and there is no perio treatment that is going to give you satisfactory outcome here.

Because what is the etiology? Is the root to root relationship is etiology unless you modify that nothing is going to work. How do you modify this root to root relationship? You only have two options.
Either you take one ____ out, or you move them ____.

We are going to move them apart. That root proximity over there. And we are going to do the orthodontics, and we are going to separate those roots. From that relationship, to that relationship. We have a little over there to move this tooth over there, move this tooth – we augment, we enlarge edentulous space in here, and we make a ____ with a pontic there. This serves as a prosthetic replacement of tooth, serving as a periodontal splint. To reduce the mobility of it. That is the only way that we can solve this problem, reducing that ____ to a healthy situation. Modifying the environment of it.

Answer 13

root to root
tooth
apart
lingual splint
environment

Question 14

Same thing over here. Root proximity issue there (green circle, bottom left) – we are going to do anatomy of anterior teeth triangular toward the incisal edge we have a thicker enamel layer.

We are going to do what we call ____. We are going to reduce the width and align them. Going from there to there (green arrows, bottom right pictures)– from that proximity– to that much of a cervical embrasure opening over there. There is no other periodontal or any other therapy that can solve that because the problem there is not a plaque or hygiene or nothing. Problem is a ____ proximity and you gotta modify the ____.

Answer 14

interproximal stripping
root
environment

Question 15

Mesially drifted molar w/ osseous defect

Utilizing the orthodontics as a pre-prosthetics. In the posterior for example where the molar is mesially tilted, it should result in what? ____. Not vertical defect but angular crest.

IN that angular crest where plaque and calculus and all other local and etiologic factors is super-imposed now you have further bone loss– that healthy angular crest now became what? ____. It’s a very different you need to analyze (?????) many different aspects of the tooth and the defect before defining or diagnosing that as a pathology or not because angular crest is a state of health. That’s a physiology of it.

____ is a pathology that needs to be treated. So, situation like this if I wanna do a bridge it cannot be done because you don’t have a path of ____. It cannot be done because you have a ____ periodontal pocket there.

Answer 15

angular crest
infrabony defect
infrabony defect
draw
deep

Question 16

Orthodontic molar uprighting

Or, we can utilize orthodontics. So now, just look at the drawing going back to discussion we had. Why suddenly I’m using wire like this? Because from here to there (arrow, green) is too close, wire is too ____ too ____ too much force. We are going to lengthen the wire length to increase the ____ and you incorporate any type of mechanics that you want to in a design that you want to– to achieve the purpose of the lengthening and increase the flexibility. For what purpose we are going to upright this molar? ….\

Answer 16

short
stiff
flexibility

Question 17

Post orthodontics
Eruption during uprighting

….That way. Depending on the mechanics that you used. Amount of eruption doing orthodontics as a molar uprighting for example – amount of eruption you get can be controlled, but certain amount of eruption is always a possibility.

You can reduce the eruption but the eruption is super eruption above the occlusal plane is always a possibility. And if orthodontic itself is a trauma, and you don’t control the occlusion, you put that tooth under ____ – you are going to lose that tooth.

So, its not only the ____ of the periodontium but controlling the ____ is a key factor. Not only in periodontal tooth movement but in periodontal therapy in general. Because occlusion is a part of perio. So, we will erupt that tooth as the eruption come as you see super uprighting, super eruption of the molar there (circled) and that occlusion has to be always ____ and adjusted as needed….

Answer 17

hyperocclusion
inflammation
occlusion
controlled

Question 18

Once restored -> single crown, bridge or implant

….or we are going to put an implant that restores that. Now, when molar uprighting is done. Every orthodontics at the end of the orthodontic movement comes what? ____. That’s why you wear a retainer after braces. Your retention has to be there and if the retention is there – its going to collapse in front of your eyes.

You upright this tooth – you get the brackets on, you keep looking at it, you see that tooth going back. It moves that fast. When we consider retention post orthodontics is a mandatory that the retention is means of a ____ appliance. Never removable.

Meaning, case like this once you upright it this molar (as he did a couple slides back) – once the uprighting is done, if your final prosthetic plan is to give it ____ partial. Its not going to work. Because by the time you took the impression and framework came back. Its not going to fit. That tooth has moved already.

Answer 18

retention
fixed
removeable

Question 19

Post orthodontics and single tooth implant

If you are lucky you made the partial that, that patient take the partial out in the night time. Try to put back in in the morning. That partial is not going to go in. So your retention has to be a means of a ____ appliance, never removable. If it’s a removable. Your retainer must be worn ____ hours a day. Otherwise its not going to fit. That’s why the option of restoring this tooth as a single crown and that’s it– is not ____. Because this tooth will move back. Its going to relapse. So either you need to have a fixed ____ (last slide), or you have an ____ in there because that’s going to serve as a fixed splint.

Answer 19

fixed
24
acceptable
fixed bridge
implant

Question 20

As an example, here. CEJ is right here. And your bone follows a drop (top right picture, green). It’s a angular crest or infrabony defect? Now it became an ____. If this bone was coming straight this way, parallel to CEJ, there would be an angular crest and you don’t treat that, which is not the case (blue line, top right pic).

Answer 20

infrabony defect

Question 21

This is a very old case that today probably we would treat this very differently. But, first molar decay down and how are we going to treat this tooth? Don’t forget we are talking about orthodontics we do ortho. Whats the problem we have here besides inadequate tooth structure? The furcation. We section the root, we put a single crown on each root. But we have a ____ proximity! Look at the anatomy of the root. These are converging. We don’t have enough of an embrasure there (in between the roots). Prosthetically it does not work….

MANAGEMENT OF INTER RADICULAR DISTANCE

So we split that. Separate the ____. Much more favorable prosthetically speaking now. We are going to restore them as individual premolars. Today probably we are not going to treat this case this way. Probably we are going to extract and put an implant in here because the bone is perfect size for an implant. The point is how you think – you look at it, analyze it. Just DON’T assume that this tooth is hopeless. That an implant HAS to be put in there.

Answer 21

root

root

Question 22

So we analyze this and what is the problem why this is breaking? Why the anteriors breaking (circled)? Because of trauma. Why the anteriors is under trauma? Because ____ is not effective. Posterior support is not working. But you just got this bridge done! I’m sorry. Whoever put the bridge there was not thinking or was thinking only about the bridge. Nothing about something else. So what is the solution here? You are going to solve this problem here (the posterior bridges). The posterior support has to (????).

Answer 22

posterior

Question 23

So we go and as you see anterior teeth are frayed out. Under trauma. That’s why teeth breaking. The chief complaint is right here. How do you solve this chief complaint over here. I’m going to do something on the back first so I can solve this problem. Remember way back hour and half ago you don’t do orthodontics and anterior retraction —- without properly establishing ____ support.

We are going to open the ____ dimension.

Answer 23

functional posterior

vertical

Question 24

Increased ____
Increased ____
Decreased ____

Restore the posterior support proper way. Provisional (circled). Because we open the vertical now and have anterior open bite. Now I can retract this the way I want. To the proper position. You see the excessive.

Remember the vertical dimension I talk about it. You open the vertical what are the consequence of that? You modify the ____, the ____. It’s a triad. You always these three factors always follow together. You cannot modify the vertical dimension without modifying the overjet or overbite, or vise versa.

Answer 24

VDO
overjet
overbite
overjet
overbite

Question 25

Orthodontic retraction of ____ segment for proper anterior buccolingual relationship and functional excursive guidance

Going from there to there (arrow). Much more favorable anterior relationship. To establish proper guidance for proper disocclusion of the posterior. This is only doable – why? Because we restore the posteriors.

Answer 25

anterior

Question 26

____ SUPPORT MUST BE ADJUSTED. DOING ANYTHING ELSE IS A WASTE OF YOUR TIME

Answer 26

posterior

Question 27

From before, during ortho, and final. If you look at where the bone level is. Amount of clinical crown length compared to the root, and if you look at where the bone level is– The length of a clinical crown to the root length is ____ (top and bottom circles). Why?

During retraction what did we do? We did not only retract but we also erupted. As we erupted we ____ the length of the clinical crown to improve the crown to root ratio as we visualized before. It’s a combination of everything.

That’s why we call this a multidiscipline integrated approach. You don’t need to do ortho or endo but you must know about it so you can seek the help.

Answer 27

different

reduce

Question 28

Modification of the soft tissue architecture by altering adjacent root relationship and interproximal bone morphology

There is no other way of creating interdental papilla surgically. Why did this happen – because we modify ____ distance orthodontically. You bring the roots together. You ____ the papilla. You take the roots apart. You ____ the papilla. Why? Farther the roots are what do you have? Edentulous space.

If one tooth is a one tooth over there its edentulous space you don’t have papilla there (????). You bring them together. You squeeze the teeth in it. You gain the papilla. Up to certain point if bring them too close what do you have? Root proximity. You lose everything. How close is too close? ____ mm. You don’t wanna get any closer to that. That’s a rough guide. 2-3 mm of interradicular distance to maintain health of your perio.

Answer 28

interradicular
gain
lose
2-3

Question 29

Orthodontic modifying the soft tissue architecture. This patient came to us. PhD candidate at temple. This was just done over there at temple. Whats the problem? That’s the problem. Because of recession they sort of did pink porcelain on a bee like (?????). So lets analyze why this happen.

That difference there (between red and green lines on tooth, pink area). Unleveling of a soft tissue there and that’s the chief complaint. What solution you have? You solve this with a ____. That’s what you generally do. BUT its not going to work. Why? Because first of all bone level is different. Your ____ has to be there for the soft tissue graft to work. Not only that but it’s a too ____ of a root surface that has to be kept for crown. Your soft tissue graft is very unlikely to work. That’s why were going to do ortho…

Answer 29

soft tissue graft
bone
wide

Question 30

But before doing that lets see what the problem is. Its not about just doing ortho and erupting everything. Ortho is not magic. You must analyze it. What is happening. To find what the etiology is. Lets analyze was happened. Here is the buccal view. Here is the occlusal view. Something doesn’t look right in here. Long axis of the teeth. Teeth are not positioned properly. Consequence of that you have too much ____ distance. We don’t have enough.

When you have too much what happens. Tissue ____. When you don’t have enough what happens? Tissue get ____ because of proximity. Select of embrasure space and too much embrasure space and that’s a problem (too much/little embrasure space is an issue).

Not only that but B-L tooth position is different. This is too far out (labial). This is too palatal. That’s what the problem is. There’s only one way we can fix it. Which is ____. Not to make this smile pretty, but to modify the periodontal environment for future prosthetic treatment to come.

Answer 30

interradicular
flattens
inflamed
ortho

Question 31

So what did we do? We temporize them. We section them just like like the lower molar number 19 as before. We section the temp. We are going to erupt the ____. Why? Because alveolus part of the tooth and (???????). We are going to move this tooth down (arrow) with the proper inflammation and control we know the soft tissue will follow and that’s whats happening. So we did the eruption there (circle, bottom left). Now we do a localize ____ (bottom right). ____. Get the excess tissue out

Answer 31

canine
surgery
crown lengthening

Question 32

What do you see as a something not quite normal here? There is no endo here. But they have a huge post in there. They kept telling me that ortho must be done in an inflammation free environment, but there is no endodontics in here and you are doing orthodontics. Why? How can you do that?

What if there was an apical lesion there? Could you have done this? Yes, no? I would have done it. Why? Because the lesion is here on the apex, and where are we moving this tooth to? ____ from the infection. So you could have. If you are moving this tooth ____ or apically or anywhere else, probably that would have an adverse effect.

Answer 32

away

laterally

Question 33

This another patient that was referred to us. This is not good. My doctor had done a flap in here and now this tooth is a free mobility there. And there’s a fracture. So this tooth is not restorable.

What are you going to do. Just as a reminder we are talking about orthodontics here. Of course you are going to do ortho right? You fractured this tooth (right picture) and you are going to erupt this tooth. You erupt the tooth – bone everything comes, I do one tooth crown lengthening, I put a crown there… correct? ____. Why?

If you go look at the root anatomy of this. This a pre-op (right picture). Look at the size of the crown, relative size of the root. If you erupt this tooth how much a root do you have left within the bone? Maybe about that much. What about the crown ratio? (Arrow, right picture) This is a situation where that would not be acceptable. You picture the final outcome before you start.

Answer 33

NO

Question 34

What are we going to do then? You extract this tooth put an implant there. We have a soft tissue defect already. Deficiency of soft tissue there. You go erupt, extract this, what do you think is going to happen to that soft tissue? Its going to recede further. I told you once you lose the ____ there is NOTHING out there that you can do to get that back. So we are not going to extract this tooth. Although this tooth is hopeless, so what are we doing to do? We are going to ____ this tooth.

Answer 34

interdental papilla

erupt

Question 35

We are going to erupt, but the bracket you see where the wire is? ____ of the bracket (top picture). Why am I doing braces in here. Why ortho? Now the wire is ____ the bracket (middle picture). Now its ____ the bracket (bottom picture). Whats happening with the soft tissue there? I’m going to augment the soft tissue in preparation of what? ____. We are going to do the orthodontics to the eruption of this so that we can extract this tooth.

Answer 35

out
in
above
extraction

Question 36

That’s a pre-op. That’s at the end of the orthodontics (middle pic). Look at the soft tissue there. Look at the soft tissue of this compared to that. Now we ____ that tooth. Put an ____. And temporary all simultaneous immediate placement in there (bottom pic). How much excess soft tissue you have? Now it’s a better situation for you to extract this tooth.

Answer 36

extract

implant

Question 37

Implant is right there. Final crown is right there. That’s what we call orthodontic as for the implant site development. I’m not going to just extract that tooth. I’m going to extract that tooth yes, but I’m going to extract that tooth very different than the guy next door. Why? Because I have an interdental papilla deficiency already. And I know exactly what will happen once I extract that tooth. Once I lose that volume that I didn’t have to start with, there is no other procedure I can do to augment that. And that’s a 46 month’s after treatment completion. And maintaining that tissue very well. Because we did orthodontics for the extraction of this tooth. So we don’t’ just do ____ ortho to save the teeth, we do the orthodontics to ____ the tooth AS WELL. You keep erupting till tooth falls out.

Answer 37

adjunctive

extract

Question 38

This patient was referred from orthodontist now. Orthodontist doing ortho and then they realized this tooth is ____. And as you see number 9 is placed much more apical and palatal and now we are stuck. And he can’t bring this tooth down.

It’s a three dimensional defect we have. You have only one other option you could do. Extract this (circle) surgically and do a GPR. And if you think you can bring the bone buccally and vertically, forward without compromising the esthetics. Its not easy to do. So we offer the solution. Which is orthodontics. But you said ortho cannot be done in the absence of PDL? Correct, you cannot MOVE the tooth in the absence of ____.

Answer 38

ankylosed

PDL

Question 39

“TAD” Temporary Anchorage Device

Segmental osteotomy

But, you have an option of moving the bone. So we utilize what we called a TAD. Temporary anchorage Device. You can imagine a mini implant. We screw right into ____. We ____ the block of the bone surrounding the ankylosed root and we are going to move the section of the bone ____ (circled, right).

Answer 39

bone
section
down

Question 40

Partial extraction therapy (PET)

Root Submergence Technique

After the segmental osteotomy, we brought a section of bone together with the ankylosed root. The remaining portion of the root was useless, then what we do a procedure called PET. Partial extraction therapy. We remove the ____ part of the root tooth, and keep the ____ in it, and we submerge that.

We convert that into an ____ pontic. Here is a six unit bridge with a temporary. Maintaining the periodontal architecture around the pontic area.

Answer 40

coronal
root segment
ovate

Question 41

Here is a segment of the ____ that we submerge there. That is what we will maintain the soft tissue volume around that.

Answer 41

root