King Saud University Journal of Dental Sciences (2013) 4, 91–94

King Saud University

King Saud University Journal of Dental Sciences

www.ksu.edu.sawww.sciencedirect.com

CASE REPORT

Periodontium biotype modification prior to

an orthodontic therapy: Case report

* Corresponding author.E-mail addresses: halhulaimi@hotmail.com (H.A. Alhulaimi),

fawartani@me.com (F.A. Awartani).

Peer review under responsibility of King Saud University.

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http://dx.doi.org/10.1016/j.ksujds.2013.04.002

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Open access under CC BY-NC-N

Hassan A. Alhulaimi a,*, Fatin A. Awartani b

a Head of Periodontic Department, Alhassa Dental Center, MOH, Saudi Arabiab Professor at Periodontic and Community Department, College of Dentistry, KSU, Saudi Arabia

Received 29 May 2012; revised 25 February 2013; accepted 29 April 2013Available online 19 June 2013

KEYWORDS

Collagen membrane;

Alloderm;

Periodontium biotype;

Orthodontic treatment

Abstract Introduction: Thin periodontium is frequently characterized by osseous defects and dehis-

cence; moreover, it exhibits pathological changes like gingival recession when subjected to traumatic

surgical insults or orthodontic force more than thick periodontium. Therefore, this case report aimed

to validate the need for bio-modification of thin periodontium before an orthodontic treatment.

Case description: A 30-year old female patient who had started on orthodontic treatment which was

not completed because of hypermobility of the anterior teeth. Periodontal diagnosis revealed a local-

ized chronic slight periodontitis and severe crowding in the anteriormandibular arch and ridge defects

(Siebert class I) at the sites of missing maxillary lateral incisors. The patient was prepared for peri-

odontal surgery by scaling and root planning. Periodontal surgery included frenectomy and simulta-

neous bone augmentation using GBR procedure which was done using 0.5 mg of BioOss� and

20 · 30 mm size/GBR membrane (AlloDerm�) then 625 mg Augmentin� TID and 400 Ibuprofen�TID, were prescribed for 7 days.

Results: The patient responded well to the surgical treatment and neither bleeding pockets nor prob-

ing depth exceeding 4 mmwas detected at the follow-up examinations. Themobility of Teeth #11 and

#21 reduced from grade II to almost normal status. The soft tissues were well adapted and the defects

in the sites of themissingmaxillary lateral incisors disappeared.One year later the orthodontic therapy

was restarted.

Conclusions: The outcomes of this case treatment showed that the thickening of the soft tissues,

before an orthodontic treatment has a clinical positive effect. Moreover; transferring the case from

thin periodontium to thick periodontium would have reduced the possibility of future breakdown

of the periodontium during the orthodontic therapy.ª 2013 Production and hosting by Elsevier B.V. on behalf of King Saud University.

D license.

1. Introduction

Orthodontic therapy is a common dental treatment serving

nowadays all the age groups. The orthodontists usually dealwith variable cases having different periodontal situations inwhich the periodontal health is crucial for the orthodontic

92 H.A. Alhulaimi, F.A. Awartani

therapy. They use different appliances with variable force mag-nitudes in different directions.6,13 Experimental studies demon-strated that when a tooth is moved bodily in a labial direction

toward the cortical plate of the alveolar bone, no bone forma-tion will occur. In addition, bone thinning and dehiscencemight take place as well. Such cortical plate perforation can

occur during an orthodontic treatment in some unavoidablesituations especially with thin periodontium which may leadto gingival recession and root exposure.11,12,15

There are two periodontium biotypes in general: thick per-iodontium (Prevalence: 85%) and thin periodontium (Preva-lence: 15%) while there are few cases which have features ofboth thick and thin types.9 Thick periodontium is character-

ized by thick gingival tissue which is probably the image mostassociated with periodontal health. The tissue is dense inappearance with a fairly large zone of attachment. The gingival

topography is relatively flat with the suggestion of a thickunderlying bony architecture.3,8 Surgical evaluation of theseareas often reveals relatively thick underlying osseous forms.

On the other hand, thin gingival tissue tends to be delicateand almost translucent in appearance (Fig. 1a and b). The tis-sue appears friable with a minimal zone of the attached gingi-

vae. The soft tissue is highly accentuated and often suggestiveof thin or minimal bone over the roots labialy. Moreover, thingingival tissues are frequently characterized by osseous defectslike fenestration and dehiscence.9 Moreover, thin periodon-

tium usually exhibits pathological changes like gingival reces-sion when subjected to inflammatory, traumatic or surgicalinsults. Scientific reports found that an orthodontic force

and appliances may cause gingival recession in cases of thinperiodontium7. Therefore; preparatory periodontal therapy isneeded to prevent periodontal tissue breakdown during an

orthodontic treatment.4,5 The periodontal treatment includesnon-surgical periodontal therapy and/or surgical correctionof any soft tissue or bone defects. Surgical corrective therapy

includes different interventions like frenectomy, soft tissue

Figure 1 Thin and delicate gingival tissues at facial sites of teeth

from canine to canine are translucent in appearance. The tissues

are friable with a minimal zone of attached gingivae which suggest

thin or minimal bone over the root labial as well.

augmentation and bone augmentation.4,5 Both soft tissuesand bone augmentations have been reported to have high suc-cess rate if the case was cautiously selected.1,14 It is possible to

modify the thin periodontal tissues by using these surgicaltechniques before or during an orthodontic therapy to avoidtissue collapse.

One of the key factors for the successful treatment of pa-tients with orthodontic problems is the interdisciplinary inter-vention, which involves teamwork approach to achieve an

optimal result. Only few clinical reports presented such situa-tion which shows the importance to prepare the case beforean orthodontic therapy. Therefore, this case report aimed topresent a clinical evidence for the need in some cases, to modify

the periodontal tissue biotype prior to an orthodontic therapy.

2. Case presentation

The patient is a 30-year-old, well-educated woman in good gen-eral health; she had started the orthodontic therapy on Febru-ary 2009, for teeth arrangement. The patient had been seeing

her orthodontist monthly for follow-up. The orthodontistwas notified by the patient about the hypermobility of upperteeth during the treatment about 5–6 months later. The ortho-

dontist had referred the patient to the periodontal clinic in Alh-assa dental center for periodontal assessment and care sincethen. The patient was thoroughly examined, and investigated.

Periodontal examination showed a shallow pocket formationin general, with no gingival recession, but a grade II mobilityof maxillary central incisors, with thin gingival tissues and theroot shadow were clearly seen at anterior segments of both ar-

ches (Fig. 1a and b). Periodontal diagnosis revealed a localizedchronic slight periodontitis and severe crowding in the anteriormandibular arch and ridge defects (Siebert class I) at the sites of

missing maxillary lateral incisors (Fig. 1a and b). Moreover, thepatient was worried and apprehensive about her situation,therefore; the orthodontist was advised to delay the orthodon-

tic treatment. Agreement was done with the patient to startperiodontal therapy before an orthodontic teeth alignment.

Periodontal treatment plan included full mouth scaling and

root planning then periodontal surgery at the area of maxillaryanterior sites to correct the ridge defect, and to augment thethin gingivae.

3. Treatment

The periodontal therapy was initiated, which included patienteducation, oral hygiene instructions, supragingival/subgingival

scaling and root planning of the entire dentition. One monthlater, the patient was booked for surgical correction. The sur-gery was started by frenectomy which was done to relieve tis-

sue tension and to enhance future teeth alignment. Suturingwas done at the frenectomy site. Facial mucoperiosteal flapwas reflected from distal site to distal site of teeth #13 and

#23. Exploration of the surgery sites showed osseous defectsat both sites of missing teeth #12 and #22. Dehiscences at teeth#11 and #21, and bone fenestrations at tooth #13 were de-

tected. Curettage of granulation tissues was done using surgi-cal curette. Bone augmentation was started by decorticationusing round surgical bur at defect sites. Bone granules of0.5 gm (BioOss�) were used to fill the defects, and to thicken

the cortical plate, and to cover the fenestration (Fig. 2a and b).

Figure 2 Mucoperiosteal flap reflection from distal site to distal

site of teeth #13 and #23. The surgery sites showed osseous defects

at both sites of missing teeth #12 and #22. Dehiscences at teeth

#11 and #21, and bone fenestrations at tooth #13 were detected.

Figure 4 GBR membrane (AlloDerm�) of 20 · 30 mm size/was

used to cover the augmented sites. Resorbable suture was used to

fix the membrane in situ, and then the flaps were repositioned and

sutured to completely cover the wound.

Periodontium biotype modification prior to an orthodontic therapy: Case report 93

GBR membrane (AlloDerm�) of 20 · 30 mm size/was used tocover the augmented sites. Resorbable suture was used to fixthe membrane in situ (Figs. 3 and 4). The flaps were reposi-

tioned and sutured to completely cover the wound and thena periodontal dressing was used. 625 mg Augmentin� TIDand 400 Ibuprofen TID, were prescribed for 7 days. The

Figure 3 Bone granules of 0.5 gm (BioOss�) were used to fill the

defects, and to thicken the cortical plate, and to cover the

fenestration.

Figure 5 Six months after surgery, the soft tissues were well adapted

#22.

patient was advised to rinse with a 0.2% chlorhexidine gluco-nate mouthwash twice daily for 21 days.

4. Treatment evaluation

The patient was reviewed after 2 weeks from the day of surgeryfor initial healing assessment and suture removal. The healing of

soft tissues showed good tissue adaptation with minimum gingi-val margin inflammation and no complications were detected.The sutures were removed under normal saline irrigation. The

patient was instructed to continue on mouthwash for two moreweeks then to resume the oral hygiene practice. The patient wasfollowed after 2 months from the surgery then put on recall sup-porting periodontal therapy every 2 months for one year.

The patient responded well to the treatment and neitherbleeding pockets nor probing depth exceeding 4 mm was de-tected at the follow-up examinations. Mobility of Teeth #11

and #21 reduced from grade II to almost normal status. Thesoft tissues were well adapted and tissue thickness increasedin the sites of missing teeth #12 and #22 (Fig. 5). One year later

the orthodontic therapy was restarted (Fig. 6a, b and c).

5. Discussion

In this case; the regular periodontal visits before the surgicalintervention revealed that the patient had a great interest inhaving a healthier dentition to urge the orthodontic therapy.

and tissue thickness increased in the sites of missing teeth #12 and

Figure 6 (a) One year later the orthodontic therapy was

restarted, (b) before Sx and (c) 6 months later, after Sx.

94 H.A. Alhulaimi, F.A. Awartani

Patient observation of the front teeth in the maxilla had pro-clined and big diastema (3 mm) with missing lateral incisorsand mobility underscores her higher aesthetic consciousness.

However the patient and her orthodontist were not fully awareof the partially periodontal breakdown and osseous defects atthe sites of missing teeth #12 and #22 which was scored as class

I ridge defect according to Seibert classification 10. As a prere-quisite, a thorough periodontal treatment then followed by sur-gical correction was carried out. Surgical therapy aimed to fill

the defects at the sites of missing maxillary lateral incisorsand to thicken the tissues over central incisors. The defect cor-rection gave better soft tissue adaptation at the sites of missing

lateral incisors. Moreover; it gave better tissue adaptation overcentral incisors as well. Although the patient had missing max-illary lateral incisors, proclined central incisors and big dia-stema, good periodontal healing with bone fill at the defects

and tissue thickening enhanced the aesthetic results obtained.This issue was revealed by the response of the patient whereshe had a feeling of better lip fill after the surgery being done.

The presented treatment is in the scope of periodontal sur-gical modalities although predictability of ridge defects healingwith this amount of bone fill is always scarce. However; hori-

zontal ridge augmentation has been used successfully.4 Manyfactors can interfere with the healing response: e.g. the defect

morphology (a three-wall defect will heal with more bone fillthan a two-wall or one-wall defect). Tooth mobility, flap cov-erage of the defect, operator skill, and of course the level of pa-

tient compliance are other important factors. However, clinicaland histomorphometric studies, demonstrated that thecombination of Bio-Oss� with collagen membranes or GBR

AlloDerm� could be used successfully for alveolar ridgeaugmentation.2,4

The outcomes of the short term follow ups of this case

showed that the thickening of the tissues, before or duringan orthodontic treatment has a clinical positive effect. More-over, transferring the case from thin periodontium to thickperiodontium would have reduced the possibility of future

breakdown of the periodontium during an orthodontic ther-apy. In addition, better soft tissue adaptation over the anteriorteeth which was clearly observed could give better gingival

appearance that increased the patient satisfaction.

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