ORTHODONTICS PERIODONTICS RELATIONSHIP.pptx

Orthodontics-Periodontics Relationship
ntroduction
Biological basis for orthodontic therapy
Periodontal tissue response to orthodontic force
Effects of orthodontic tooth movement on the periodontium
Orthodontic tooth movement in adults with periodontal tissue breakdown
Specific factors associated with orthodontic tooth movement
Implants and orthodontic therapy 
Systematics of combined ortho – perio treatment
Periodontally Accelerated Osteogenic Orthodontics (PAOO)
Minor periodontal surgery and orthodontic treatment
Review of literature

1. ORTHO-PERIO INTERRELATIONSHIP Dr. BEENA VIJAYAN PARVATHY

2. CONTENTS Introduction Biological basis for orthodontic therapy Periodontal tissue response to orthodontic force Effects of orthodontic tooth movement on the periodontium Orthodontic tooth movement in adults with periodontal tissue breakdown Specific factors associated with orthodontic tooth movement Implants and orthodontic therapy  Systematics of combined ortho – perio treatment Periodontally Accelerated Osteogenic Orthodontics (PAOO) Minor periodontal surgery and orthodontic treatment Review of literature Conclusion References

3. INTRODUCTION BETTER MASTICATION, SPEECH, FACIAL ESTHETICS. GENERAL AND ORAL HEALTH ORTHODONTIC TREATMENT With appropriate tooth movements FUNCTIONAL AND ESTHETIC OCCLUSION BENEFITS ADVERSE EFFECTS ACCUMULATION OF PLAQUE AND CALCULUS ROOT RESORPTION PERIODONTAL COMPLICATIONS PSYCHOLOGICAL DISTURBANCES GI COMPLICATIONS

4. Clinical conditions which predispose to periodontal disease are: Crowding Increased over jet and overbite Cross bite Open bite Inadequate or poor lip seal Mouth breathing Tooth rotations

5. Bollen 2008 , conducted two systematic reviews to address the following questions: (i) does a malocclusion affect periodontal health ?? (ii) does orthodontic treatment affect periodontal health?? The first review found a correlation between the presence of a malocclusion and periodontal disease The second review identified an absence of reliable evidence on the effects of orthodontic treatment on periodontal health.

6. Periodontal ligament structure and function :- Each tooth is attached to and separated from the adjacent alveolar bone by a heavy collagenous supporting structure, the periodontal ligament (PDL ). Major component of this PDL is collagen fibers, inserting in to cementum of the root on one side and into to the bony plate of lamina dura, on the other side. PERIODONTAL LIGAMENT AND BONE RESPONSE TO ORTHODONTIC FORCE

7. The response to sustained force against the teeth is a function of force magnitude: In orthodontic practice, the objective is to produce tooth movement as much as possible by frontal resorption . Lighter forces are compatible with survival of cells within the PDL and a remodeling of the tooth socket by a painless “frontal resorption” of the tooth socket. Heavy forces lead to rapidly developing pain, necrosis of cellular elements within the PDL, and the phenomenon of “undermining resorption ” of alveolar bone near the affected tooth.

8. BIOLOGIC CONTROL OF TOOTH MOVEMENT It is necessary to consider the biologic control mechanism that lead from the stimulus of sustained force application to the response of orthodontic tooth movement.

9. BIOELECTRICITY THEORY/PIEZOELECTRIC THEORY/BONE BENDING THEORY Farrar et al, 1876

10. PRESSURE – TENSION THEORY (CLASSIC THEORY) Schwarz et al,1932

11. MECHANOTRANSDUCTION THEORY

12. CHANGES IN PRESSURE ZONE

13. CHANGES IN TENSION ZONE

14. EFFECT OF FORCE MAGNITUDE

15. TIME EVENT  1 SEC PDL fluid incompressible, alveolar bone bends, piezo electric signal generated. 1-2 SEC PDL fluid expressed, tooth moves within PDL space. 3-5 SEC Blood vessels within PDL partially compressed on pressure side, dilated on tension side; PDL fibers and cells mechanically distorted. MINUTES Blood flow altered, oxygen tension begins to change; prostaglandins and cytokines released. HOURS Metabolic changes occurring: chemical messengers affect cellular activity, enzyme levels change.  4 HOURS Increased cAMP levels detectable, cellular differentiation begins with in PDL  2 DAYS Tooth movement beginning as osteoclasts / osteoblasts remodel bony socket. LIGHT PRESSURE

16. TIME EVENT  1 SEC PDL fluid incompressible, alveolar bone bends, piezo electric signal generated. 1-2 SEC PDL fluid expressed, tooth moves within PDL space. 3-5 SECS Blood vessels within PDL occlused on pressure side MINUTES Blood flow cut off to compressed PDL area. HOURS Cell death in compressed area 3-5 DAYS Cell differentiation in adjacent marrow spaces, undermining resorption begins 7-14 DAYS Undermining resorption removes lamina dura adjacent to compressed PDL, tooth movement occurs. HEAVY PRESSURE

17. S E Q U E N C E O F E V E N T S A F T E R F O R C E APPLICATION Movement of PDL fluid Development of strain in cells and ECM Direct transduction of mechanical forces to nucleus of cells leading to activation of specific genes Release of nociceptive and vasoactive neuropeptides Interaction with endothelial cells Adhesion of circulating leucocytes to endothelial cells

18. Plasma extravasation from dilated blood vessels Diapedesis of leucocytes into extravascular spaces Synthesis and release of signal molecules(cytokines, GF, CSFs) from leucocytes Interaction with various paradental cells Activation of cells to participate in modeling and remodeling of paradental tissues

19. SIGNALING MOLECULES AND METABOLITES IN ORTHODONTIC TOOTH MOVEMENT

20. EFFECT OF ORTHODONTIC FORCES ON PERIODONTIUM When a removable appliance is worn less than 4 to 6 hours per day , it will produce no orthodontic effects, but above this duration threshold, tooth movement does occur. Experiments have shown increase levels of PG and IL-1ß in PDL within short time after pressure application. Yamasaki et al (1980)  prostaglandins that were produced during orthodontic tooth movement may increase bone resorption activity. PG E was injected in the gingiva of the teeth to be moved. They reported enhanced rate of tooth movement. Also, evidence shows PG release when cells are mechanically deformed.

21. Now increasing evidence proves that although PG E is involved in the transduction of mechanical stress on the PDL and alveolar bone during orthodontic tooth movement, several other inflammatory mediators are also active. Cytokines and NO and other regulators of cellular activity are also involved For tooth movement to occur, - Osteoclasts must be formed to remove bone from the area adjacent to compressed PDL. - Osteoblasts are needed for formation of bone on tension side. PG E stimulates both osteoclastic and osteoblastic activity.

22. In mechanical deformation of PDL  it is up to 48 hrs before osteoclasts appear, they arrive in 2 waves : first wave is derived from local cell population, while the larger second wave are brought from distant areas via blood flow. These cells attack adjacent lamina dura on pressure side, removing bone by frontal resorption and tooth movement begins soon thereafter. At the same, lagging behind osteoblasts appear (locally from progenitor cells in PDL) from bone on tension side and begin remodeling activity on pressure side.

23. In clinical orthodontic it is difficult to avoid pressure that produces at least some avascular area in the PDL, and it has been suggested that releasing pressure against a tooth at intervals while maintaining the pressure for enough hours to produce the biologic response, could help in maintaining tissue vitality. Because of its histological appearance as the cells disappear, an avascular area in the periodontal ligament traditionally has been referred to as hyalinized .

24. After a delay of several days, cellular elements begin to invade the necrotic ( hyalinized ) area. More importantly, osteoclasts appear within the adjacent bone marrow spaces and begin an attack on the underside periodontal ligament area - "undermining resorption “ . When hyalinization and undermining resorption occurs, an inevitable delay in tooth movement occurs. This is caused by : – delay in stimulating differentiation of cells within marrow spaces – considerable thickness of bone must be removed from the underside before any tooth movement can take place.

25. So, it is apparent that optimum force levels for orthodontic movement should be just high enough to stimulate cellular activity without completely occluding blood vessels in the periodontal ligament area. Both the amount of force delivered to a tooth and also the area after periodontal ligament over which that force is distributed are important in determining the biologic effect. The periodontal ligament response is determined not by force alone, but by force per unit area, or pressure.

26. Effects of force distribution and types of tooth movement Optimum forces for orthodontic tooth movement Type of movement Force (gm) Tipping 35 – 60 Bodily movement 70 – 120 Root uprighting 50 – 100 Rotation 35 – 60 Extrusion 35 – 60 Intrusion 10 - 20

27. Effects of continuous force Effects of light continuous force : Smooth tooth movement will result from frontal resorption. Effects of heavy continuous force : Tooth movement will be delayed until undermining resorption can remove the bone necessary for tooth movement. Tooth will change its position rapidly. It is destructive for both the tooth and PDL.

28. Effects of interrupted force Effects of light interrupted force : Tooth will move a small amount by frontal resorption and then remain in that position until the appliance is activated again. Effects of heavy interrupted force: Heavy forces produce undermining resorption, tooth will move when undermining resorption is eliminated. Since the force has dropped to zero, the tooth will remain in same position until next activation. Although the original force is heavy, after the tooth moves there is a period of regeneration and repair of the PDL before force is applied again.

29. GINGIVAL RESPONSE TO ORTHODONTIC FORCE

30. CLINICAL CHANGES The teeth that approximated resulted in an accumulation of gingival tissue and enlargement of the interdental papilla . The tissue accumulation is the result of both retraction and compression. The gingiva retracts together with the tooth movement, although at a less distance . At the mesial surface of orthodontically retracted tooth, a triangular patch of red tissue appears.

31. During orthodontic treatment: The gingiva rotates to the same degree and in the same direction of the tooth . Extensive rotational movement causes the rotational gingiva to be compressed in the interdental area at the direction of rotation From a clinical point of view, special attention should be given to the possible consequences of excessive labial tooth movement, especially that of incisors, which may bring about irreversible gingival recession .

32. HISTOLOGIC FINDINGS Discontinuation of the transseptal fibers is seen after a tooth has been extracted. During healing of the extraction site, newly formed collagen fibers bring about a reestablishment of continuity of the transseptal fibers, thus creating a fibrous bridge connecting the seperated teeth . The orthodontic approximation is accompanied by papillary hyperplasia. The newly formed transseptal fibers are coiled and compressed, and have a ' 'foot ball' shaped appearance . (Parker GR et al.,1972)

33. According to another study by Edwards JG et al.,1971 , the new transseptal fibers have a normal morphologic appearance after closure of the extraction site. In the transeptal region, distant to the alveolar crest, significant increase in oxytalan fibers as well as increased level of GAG has been described. This elevates the elastic proportion of the tissue at the extraction sites.

34. In rotational movement , an increase in oxytalan fibers and reorientation ("Stretching") of the gingival collagen fibers has been reported. The clinical instability of the rotated tooth, which almost always relapse has been attributed to these stretched collagen fibers . The stretched fibers that originate from the gingiva and are inserted in to the cementum , pull the tooth back to the pre-treatment position . It has been reported that proline uptake of the newly formed collagen increased significantly in both the lamina propria and transeptal region thus suggesting that orthodontic force stimulates collagen production in the gingiva ( Boison M et al., 1981 )

35. International Journal of Preventive and Clinical Dental Research, July-September 2016;3(3):206-212

36. ULTRA STRUCTURAL ANALYSIS The effect of orthodontic tooth movement on both collagen and elastin in the gingiva has been investigated also by ultra structural analysis . ( Franchi M et al., 1989 ) The diameter of collagen fibers is significantly increased in both pressure and tension aspects when compared to untreated controls . In some areas with in the compressed papilla, degraded collagen fibers have been longitudinally split and without the typical banding pattern. On the pressure aspect of the gingiva , a slight increase in the number and size of elastic fibers has been seen. On the tension aspect , however, only few elastic fibers have been observed.

37.   MOLECULAR ANALYSIS The effect of mechanical force on gene transcription of collagen type I and tissue collagenase (MMP I, Matrix metalloproteinase - I) has been studied on gingival fibroblasts in vitro using the reverse transcriptase polymerase chain reaction. ( Reidlich M et al., 1998 ) Under these observations the transcription level of collagen type I has been significantly increased whereas that of collagenase has been significantly decreased. These changes indicate disturbed equilibrium between collagen synthesis and degradation required to maintain adequate tissue stability at the pre-translational level.

38. DECISION TREE

39. Pini Prato GP, Chambrone L. Orthodontic treatment in periodontal patients: The use of periodontal gold standards to overcome the “grey zone”. Journal of Periodontology. 2020 Apr;91(4):437-41

40. ORTHODONTIC TREATMENT MODALITIES Method for tooth movement fall into two basic categories

41. Three important points used to be addressed when utilizing orthodontic treatment as a part of periodontal therapy:

42. BENEFITS OF ORTHODONTIC TREATMENT

43. REDUCING PLAQUE RETENTION Crowded teeth are frequently difficult to clean, making the introduction of dental floss and other cleaning devices practically impossible. This occurs most frequently in lower anterior areas of the mouth. Arch length discrepancies also create abnormal occlusal relationship that may favor trauma from occlusion. Crowding also creates enlarged contact surfaces and altered embrasure spaces that lead to smaller papillae and a soft tissue facial ridge.

44. IMPROVING GINGIVAL OSSEOUS FORM There is an inter relationship between the position of the tooth and the shape of the gingiva and bone that surround it. Osseous contouring may correct the bony defect but will also create a tomography inconsistent with a healthy gingival sulcus . Orthodontic therapy may improve the shape of the periodontium and reduce the indication for bone injury.

45. FACILITATING PROSTHETIC REPLACEMENTS The up righting of titled abutment teeth may be important in restorative dentistry Parallel abutment teeth less frequently require hemisection or removal, are less likely to sustain pulpal damage are can accommodate better-contoured crowns.

46. IMPROVING AESTHETICS Migration and diastema , one of the frequent features of advanced periodontal disease may be caused by tongue thrusting or other habits. Posterior prematurities are usually associated with periodontal disease.

47. INDICATIONS Closure of anterior diastema Crowded teeth Mesial tilting of molars Open contacts. CONTRA INDICATIONS Persistence of active disease despite adequate phase I therapy procedures. Superimposition of tooth movement on inflamed gingiva may exacerbate the periodontal problem. When vertical defects persist, any type of orthodontic tooth movement may produce additional loss of connective tissue.

48. ORTHODONTIC TOOTH MOVEMENT IN ADULTS WITH PERIODONTAL TISSUE BREAKDOWN With properly performed treatment, extensive orthodontic tooth movement can be made in adults with a reduced but healthy periodontium without further periodontal deterioration. Boyd et al. (1989) described 10 adults with generalized periodontitis who received pre-orthodontic periodontal treatment including surgery, and then regular maintenance at 3-month intervals during a 2-year orthodontic treatment period. They were compared with 10 control adults who had normal periodontal tissues, and 20 adolescent orthodontic patients.

49. The results demonstrated that : Adults were more effective than adolescents in removing plaque, especially late in the orthodontic treatment period. Tooth movement in adults with reduced, but healthy, periodontium did not result in significant further loss of attachment (none of the adults had additional mean loss of attachment of more than 0.3 mm) Adults with teeth that did not have healthy periodontal tissues may experience further breakdown and tooth loss due to abscesses during orthodontic treatment.

50. ORTHODONTIC TREATMENT OF OSSEOUS DEFECTS PRE-ORTHODONTIC OSSEOUS SURGERY A)Osseous Craters: interproximal , two-wall defect that does not improve with orthodontic treatment . Shallow defect: nonsurgically . Based on patient response. B) Three-Wall Intrabony Defects: pocket reduction with regenerative periodontal therapy. 3-6 months  ORTHODONTIC TREATMENT

51. Hemispetal defects : Commonly located around mesially tipped teeth or those which are supra-erupted Tipped teeth  uprghting and eruption of the tooth levels the bone defect Supraerupted teeth  intrusion and leveling of the adjacent CEJs useful for leveling the osseous defect

52. Furcation Defects : Hemisected roots when seperated orthodontically , permits favourable restoration and splinting. (Grant et al 1988) Endodontic therapy and periodontal surgery precede the orthodontic treatment. Bands or brackets and coil springs are placed on the root fragments to be seperated Space created between the roots help better maintenance of the area.

53. Root proximity : Orthodontic treatment helps maintain or improve space between approximating roots of posterior teeth 2-3mm of root seperation leads to adequate bone and embrassure space to achieve optimal periodontal health Fractured teeth- Forced eruption : In cases of crown fractures, extending till the level of alveolar bone , the tooth can be extruded and then restored . Elastic traction or orthodontic banding and bracketing can be performed.

54. Hopeless tooth maintenance : Can prove useful for orthodontic anchorage as well as space maintenance , when periodontal inflammation is controlled. Flap surgery can be performed for the debridement of roots to control inflammation during the treatment.

55. ORTHODONTIC TREATMENT OF GINGIVAL DISCREPANCIES Uneven gingival margins The relationship of the gingival margin of the 6 maxillary anterior teeth is crucial in maintaining the esthetic appearance of the crowns. Significant attrition and over-eruption Intrusion movement is applied on 4 incisor which level the gingival margin apically. Then the incisal edges are restored and final crowns are placed. Open gingival embrasures During the tooth movement orthodontically , the gingival tissue present in between – squeezes into the shape of an interdental papilla.

56. CORRECTION OF PATHOLOGICAL MIGRATION Basic appliances used for intra-arch tipping movements: Hawley’s appliance Crozat appliance Spring retainer

57. IMPLANT PLACEMENT Orthodontic extrusion of a single tooth that needs to be extracted is considered as an ideal method for improving marginal bone levels before single implant placement. During orthodontic extrusion, both the bone and its supporting soft tissues will move vertically with the teeth. Useful for esthetic improvement of marginal gingival levels associated with the implant placement.

58. PERIODONTAL APPLICATIONS IN ORTHODONTICS On many occasions, a stable and esthetically acceptable outcome cannot be achieved with orthodontics without adjunctive periodontal procedures. For instance, a high labial frenum attachment is considered to be a causative factor of midline diastema . Frenectomy is recommended in such cases as the fibres are thought to prevent the mesial migration of the central incisors. According to Vanarsdall , surgical removal of a maxillary labial frenum should be delayed until after orthodontic treatment unless the tissue prevents space closure or becomes painful and traumatized.

59. Retention of orthodontically achieved tooth rotation is a problem that has always plagued the orthodontist. Circumferential supracrestal fiberotomy (CSF) is a procedure that is frequently used to enhance post-treatment stability. Edwards concluded from his long-term prospective study that CSF is more successful in preventing relapse in the maxillary arch. According to him, CSF does not affect the periodontium adversely. Mucogingival surgeries may be needed during the course of orthodontic treatment to maintain sufficient width of attached gingiva .

60. FRENOTOMY / FRENECTOMY Abnormal frenum attachment: results when a v-shaped bony cleft is formed between the two central incisors and a thick frenum resists orthodontic forces and is responsible for the relapse of space closure. Frenectomy is more commonly performed procedure; however the undesirable loss of interdental papilla is a common complication encountered with this procedure. Hence, the frenotomy despite being a superficial procedure, is esthetically preferable. Angle concluded that the presence of an abnormal frenum is a cause for midline diastema .

61. Also, crown lengthening procedures can facilitate easy placement of orthodontic attachments on teeth with short clinical crowns. This procedure can also be used for smile designing. Alveolar ridge augmentation and placements of dental implants are the other adjunctive periodontal treatment procedures undertaken to facilitate achievement of orthodontic treatment goals.

62. Gingivectomy / gingivoplasty One of the most common soft tissue problems associated with fixed orthodontic appliances is gingival enlargement or hyperplasia. The prevalance rate of 10% is reported. Sinclair PM 1987 Nonsurgical periodontal treatment is the conventional management approach for GE but is not always effective when it is extensive and self care is compromised .

63. Corticotomy assisted Orthodontics Corticotomy -assisted orthodontics has been employed in various forms to accelerate orthodontic treatment. Rapid tooth movement associated with corticotomy was first introduced by Henry Kole . (RAP- Regional accelerated phenomenon) The cortical plates of the bone are believed to be the main resistance to orthodontic tooth movement. In corticotomy -assisted orthodontics, rapid tooth movement is achieved by disrupting the continuity of the cortical bone by a selective cut and preserving the vitality of the teeth and marginal periodontium .

64. The biology behind corticotomy -assisted orthodontics is the regional acceleratory phenomenon (RAP). It is a local response of the tissue to noxious stimuli, through which the tissue regenerates at a faster rate than normal (without corticotomy ). The areas around the cuts are associated with intensified bone response, i.e., increased osteoblastic-osteoclastic activity and increased level of inflammatory mediators, which accelerate the bone turnover and facilitate rapid orthodontic tooth movement.

65. Periodontally Accelerated Osteogenic Orthodontics (PAOO) Periodontally accelerated osteogenic orthodontics (PAOO), also termed Wilckodontics , was introduced by Wilcko et al. in 2001 . Clinical procedure that combines selective particulate bone grafting, alveolar corticotomy and the application of orthodontic forces. It is a revised corticotomy -associated technique , which involves a full-thickness labial and lingual flap elevation accompanied by selective surgical scarring of the labial and lingual cortical bones ( corticotomy ) followed by placement of the graft material, surgical closure, and orthodontic force application.

66. Advantages: Reduces the treatment time  Facilitates expansion of the dental arch  Root resorption is less compared to normal tooth movement due to reduced resistance from cortical bone. Provides improved prosthodontic stability and reduces relapse tendencies.                                                                         Amit G et al;2012

67.    Piezocision -Assisted Orthodontics New minimally invasive surgical procedure introduced by Dibart et al. in 2009 . In this technique microincision is performed on the buccal gingiva that allows the piezoelectric knife to give osseous cuts to the buccal cortical plates and initiate RAP. This procedure provides rapid tooth movement without an extensive traumatic surgical approach. Maintains the clinical benefit of the bone or soft tissue grafting, along with tunnel approach.

68. Piezosurgery works only on mineralized tissues, sparing soft tissues and producing micrometric and selective osteotomy cuts without any osteonecrosis. Compared to the classic decortication procedure, piezosurgery has added advantages such as being minimally invasive, safe, and less traumatic to the patients. Piezocision can also be combined with Invisalign in selected cases to produce outcomes that are less time-consuming as well as satisfy the patient's desire of aesthetic appliance.

69. Gingival Recession and Root Coverage in Orthodontic patients I f the area has recession and inadequate gingiva , then the procedure may be done before or during orthodontic treatment. ( David P. Mathews and Vincent G. Kokich,1997)

70. Labial tooth movement or tooth proclination does not cause gingival recession, but in specific cases can result in thin soft tissues or bone dehiscences that comprise low-resistance regions to inflammation or trauma . Based on similar observations, several authors suggest that the thickness of periodontal tissues should be surgically increased before orthodontic tooth movement when it is estimated that it will cause bone dehiscence. ( Wennstro¨m 1996, Holmes 2005, Melsen B 2009)

71. On the other hand, animal studies have shown that no such precaution is necessary for lingual movement of labially displaced teeth with dehiscences , as it leads to new bone formation and soft tissue thickness augmentation. ( Karring T 1982, Wennstrom 1987)

72. Orthodontic treatment should not be started until the inflammation of the gingiva has been reduced to a minimum through adequate scaling, root planning & correcting other irritational factors. Periodically during the orthodontic therapy, the periodontist should check the condition of the tissues, remove all irritants and reinforce the patient’s oral hygiene as needed. The frequency of these examinations is usually every 8-12 weeks . Maintaining a good oral hygiene is a challenge to everyone. But particularly for orthodontic patients whose appliances make them more susceptible to gingivitis, hyperplastic tissues, decalcification and dental caries. ORAL HYGIENE FOR ORTHODONTIC PATIENT

73. Use of bi-bevel bristles Use of powered tooth brush Fixed appliances make plaque removal more difficult because of the increase in surfaces & the inaccessibility in some areas .

74. Use of stimudent to remove plaque Use of floss threader

75. Use of interproximal brush to clean around the brackets Rubber stimulator to disrupt plaque and massage the papilla

76. REVIEW OF LITERATURE

77. Conclusion:  In the inter-disciplinary treatment of periodontitis stage IV, OT can be initiated already 4 weeks after regenerative surgery of IDs with favourable results, thus reducing the overall treatment time Int J Periodontics Restorative Dent 2018;38:801–809. doi : 10.11607/prd.3756 Conclusions: If periodontal infection is under control, the orthodontic treatment does not reduce the longterm benefits of periodontal regeneration, even where the disease has caused massive tissue destruction.

78. CONCLUSION Every dental treatment requires good periodontal health especially orthodontic treatment. The orthodontic procedure is the double-action procedure regarding the periodontal tissue, it provides healthy state of the periodontal ligament, but on the other hand, it produces negative effects on periodontium including the gingival recession, gingivitis and bone defects. In the recent years, because of the increased number of adults seeking orthodontic treatment, orthodontists frequently face patients with periodontal disease. Adult patients must undergo regular oral hygiene performance and periodontal maintenance in order to maintain healthy gingival tissue during active orthodontic therapy. The development of new methods to accelerate tooth movement via periodontal procedures has shortened the treatment time, therefore, increased patient compliance. Thus the harmonious correlation among the two specialties provides the best treatment for combined orthodontic-periodontal problems.

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