PERSPECTIVES AND LIMITS OF MANDIBULAR LATERAL INCISOR ... · Romanian Journal of Oral...

Romanian Journal of Oral Rehabilitation

Vol. 10, No. 4 October- December 2018

60

PERSPECTIVES AND LIMITS OF MANDIBULAR LATERAL INCISOR

INTRUSION ASSOCIATED WITH PERIODONTAL DISEASE. A FEM

STUDY.

Ionut Luchian1, Mihaela Moscalu

2*, Ioana Martu

1*, Ioana Vata

3, Cristel Stirbu

4, Daniel

Olteanu3, Liliana Pasarin

1, Maria Alexandra Martu

5, Sorina Solomon

2, Diana Anton

3 ,Silvia

Martu1

1”Grigore T. Popa” University of Medicine and Pharmacy, Periodontology Department, Iaşi, Romania

2”Grigore T. Popa” University of Medicine and Pharmacy, Faculty of Medicine, Iaşi, Romania

3Orthodontist, Private Practice, Iasi, Romania

4“Gh. Asachi” Techical University of Iasi, Romania, Faculty of Mechanics.

5”Grigore T. Popa” University of Medicine and Pharmacy, Pedodontic Department Iaşi, Romania

6PhD Student, ”Grigore T. Popa” University of Medicine and Pharmacy, Iaşi, Romania

Corresponding authors:

*Mihaela MOSCALU e-mail: [email protected]

*Ioana MARTU e-mail: [email protected]

ABSTRACT

Introduction. FEM is a reliable tool for researching the impact of orthodontic therapy on the affected

periodontal tissues. Material and methods. Using Catia V5R16 and Abaqus software we analysed various

clinical scenarios for intruding the lateral mandibular incisor in different situations of horizontal bone loss

(HBL). Results and Discussions. When intruding the lateral mandibular incisors we noticed that the equivalent

tensions are increasing together with the extent of HBL and the magnitude of the applied force. Conclusions.

When optimal intrusive forces are applied at the level of the mandibular lateral incisor, the periodontal status of

the patient will not represent a restriction for the interdisciplinary treatment.

Keywords: finite elements method, periodontal disease, mandibular lateral incisor, intrusion

Introduction

Orthodontic treatment applied on

patients with periodontal disease can bring

significant benefits to the patients in terms of

periodontal rehabilitation, but at the same

time it involves a number of precautions.

The patient with periodontal pathology who

calls on the specialist in order to obtain

orthodontic treatment usually faces major

aesthetic and, in particular, functional

problems.

Adult patients that require

interdisciplinary treatment pose a number of

special bioethical implications that require a

holistic handling of the case, aiming for a

complex oral rehabilitation. [1-4]

A gain in attachment to the

periodontium, such as the improvement of

implantation is an important aim for

clinicians, bearing in mind that subsequent

implant treatment solutions may be affected

by inflammation around the implant.[5]

Material and methods

Using Catia V5R16 we created a

mathematical model of the mandibular arch

and of a mandibular lateral incisor based on

a Nissin didactic model and on the data from

the literature regarding the standard

anatomical dimensions of the involved

structures.

We designed three clinical scenarios: one

with no horizontal bone loss (HBL), one

with 33% HBL and another one with 66%

HBL. The analysis of the simulations was

performed using the attached Abaqus

software.

The models were tested using optimal (0,25

N) and supraoptimal (1N, 3N, 5N) forces in

order to comparatively assess the equivalent

mailto:[email protected]

mailto:[email protected]



61

tension (σ ech), the tension on the direction

of the intrusive force (σ c) and the tooth

movement (f).

Results and Discussions

The results of the tested situations are

presented in the following table. (Table I)

Table I. Simulation of intrusion at the level of the mandibular lateral incisor (MLI)

Applied force Horizontal Bone Loss (HBL)

No HBL 33% HBL 66%HBL

0,25 N σ ech=0,464 MPa σ ech=0,623 MPa σ ech=1,36 MPa

σ c=0,227 MPa σ c=0,305 MPa σ c=0,671 MPa

f=0,0675 mm f=0,0602 mm f=0,124 mm

1 N σ ech=1,86 MPa σ ech=2,49 MPa σ ech=5,42 MPa


f=0,81 mm f=0,723 mm f=1,48 mm



f=0,81 mm f=0,723 mm f=1,48 mm



f=1,35 mm f=1,2 mm f=2,47 mm

Fig.1A –1N F, von Mises tensions, no HBL Fig. 1B- 1N F, tooth movement, no HBL

Fig. 2A– 1N F, von Mises tensions, 33%HBL Fig.2B- 1N F, tooth movement , 33%HBL



62

Fig.3A – 1N F, von Mises tensions, 66%HBL Fig. 3B- 1N F, tooth movement , 66%HBL

Fig. 4A 3N F, von Mises tensions, no HBL Fig. 4B- 3N F, tooth movement, no HBL

Fig.5A – 3N F, von Mises tensions, 33% HBL Fig.5B-3N F, tooth movement, 33% HBL

Fig.6A – 3N F, von Mises tensions, 66% HBL Fig. 6B- 3N F, tooth movement, 66% HBL

1. Equivalent tension in the tooth-periodontal ligament - alveolar bone complex [σ ech]

Tabel II. Values of the equivalent tension in the tooth-periodontal ligament - alveolar bone complex

[σ ech]

Lower lateral

incisor

Applied force

Extent to which it is affected by periodontal disease

(Horizontal Bone Loss)

No HBL 33% HBL 66% HBL

0,25 N σ ech=0,464 MPa σ ech=0,623 MPa σ ech=1,36 MPa






63

Plot of Means and Conf. Intervals (95.00%)

σ ech [MPa]

Include condition:Incisiv Lateral Inferior

grad de afectare

neafectat

afectat 33%

afectat 66%

0.4641.86

5.57

9.28

0.4641.86

5.57

9.28

0.623

2.49

7.48

12.5

0.623

2.49

7.48

12.5

1.36

5.42

17.3

27.1

1.36

5.42

17.3

27.1

0.25 N 1 N 3 N 5 N

forta aplicata (N)

-5

0

5

10

15

20

25

30

Va

lue

s

0.4641.86

5.57

9.28

0.623

2.49

7.48

12.5

1.36

5.42

17.3

27.1

Fig. 7 - Values of σ ech as a function of the extent of HBL and applied force

Table II.1. Test for comparing the values of σ ech / applied force vs. extent of HBL

Kruskal-Wallis test H (95% confidence interval) p

70.76533 0.033212

The σ ech values show a linear growth,

depending on the force applied wherever the

periodontium is not affected and where it is

affected up to 33%. In the cases in which the

periodontium is affected up to 33%, the σ

ech values do not show significant

differences compared to those seen in the

cases in which the periodontium of the lower

lateral incisor is not affected.

Wherever the periodontium is

affected up to 66%, the increase of σ ech

shows an exponential evolution, with

significant higher σ ech values than those

found in the cases in which the periodontium

was unaffected or affected up to 33% . (Fig.

7)

Predictive factors in the modification of

the equivalent tension values in the tooth-

periodontal ligament - alveolar bone

complex [σ ech]

The subsequent study analysed, using

multivariate analysis, the importance of the

parameters that influence the σ ech tension

values, the included parameters being the

applied force and the extent to which the

periodontium is affected.

Table II.2 – The resulting multiple correlation

Multiple-correlation coefficient 0.90898

Multiple R2 0.82624

Adjusted R² 0.78763

F 21.39842

p (95%CI) 0.00038

Std.Err. of Estimate 3.69623

Table II.3- The result of the multivariate analysis– the partial correlation coefficients

Partial correlation σ

ech

vs.

Correlation

coefficient

(Beta)

Std.Err.

(Beta) B

Std.Err.

B t

p

95% CI

Intercept -433.531 133.3059 -3.25215 0.009963

Applied force 0.788655 0.138947 3.276 0.5771 5.67595 0.000303

Extent of periodontal 0.451960 0.138947 4.251 1.3068 3.25276 0.009953



64

disease

* CI, confidence interval; SE, standard error.

The analysis of the results of the

multiple correlation shows that both the

applied force (βf=0.788, p=0.0003) and the

extent to which the periodontium is affected

(βAfP=0.451, p=0.009) have a major impact

on the σ ech values when dealing with the

intrusion of lower lateral incisors. (Table

II.2-3)

2. Tension in the direction the force is applied, in this case a force that is perpendicular

to the tooth's incisal surface [σ c]

Table III.1 - Values of the tension in the direction the force is applied [σ c]

Lower lateral

incisor

Applied force




0,25 N σ c=0,227 MPa σ c=0,305 MPa σ c=0,671 MPa

1 N σ c=0,907 MPa σ c=1,22 MPa σ c=2,68 MPa




σ c [MPa]

Include condition: Incisiv Lateral Inferior

grad de afectare

neafectat

afectat 33%

afectat 66%

0.2270.907

2.72

4.54

0.2270.907

2.72

4.54

0.305

1.22

3.66

6.1

0.305

1.22

3.66

6.1

0.67

2.68

8.05

13.40

0.67

2.68

8.05

13.40

0.25 N 1 N 3 N 5 N

forta aplicata (N)

-2

0

2

4

6

8

10

12

14

16

Va

lue

s

0.2270.907

2.72

4.54

0.305

1.22

3.66

6.1

0.67

2.68

8.05

13.40

Fig. 8 - Values of σ c as a function of the extent of HBL and applied force

Table III.2 Test for comparing the values of σ c / applied force vs. extent of HBL


18.1938 0.0029035

The σ c values show a linear growth,

depending on the force applied wherever the

periodontium is not affected and where it is

affected up to 33%. In the cases in which the

periodontium is affected up to 33%, the σ c

values do not show significant differences

compared to those seen in the cases in which

the periodontium is unaffected. (Fig.8)


affected up to 66%, the increase of σ c shows

an exponential evolution, with significant

higher σ c values than those found in the

cases in which the periodontium was

unaffected or affected up to 33%. (Table

III.2)

Predictive factors in the

modification of the tension values



65

in the direction the force is

applied, in this case a force that is

perpendicular to the tooth's incisal

surface [σ c]

The subsequent study analysed,

using multivariate analysis, the importance

of the parameters that influence the σ c

tension values, the included parameters

being the applied force and the extent to

which the periodontium is affected.

Table III.3 - The multiple correlation of the predictive factors for the σ c values

Multiple correlation Estimated value


Multiple R2 0.82649


F 21.43449

p (95%CI) 0.00038


Table III.4 - The result of the multivariate analysis– the partial correlation coefficients

Partial correlation

σ c

vs.

Correlation

coefficient

(Beta)

Std.Err.

(Beta) B

Std.Err.

B t

p

95% CI

Intercept -209.189 64.94444 -3.22104 0.010472

Applied force 0.791471 0.138850 1.603 0.28117 5.70019 0.000294

Extent of

periodontal disease 0.447280 0.138850 2.051 0.63666 3.22131 0.010467


The analysis of the results of the

multiple correlation shows that both the

magnitude of the applied intrusive force, and

the extent to which the periodontium is

affected have a major impact on σ c (βf=0.79,

p=0.0002, (βAfP=0.44, p=0.01). (Table III.3-

4)

3. Movement as a result of applied force [f]

Table IV.1 -Values of movement as a result of applied force [f]

Lower lateral

incisor

Applied force




0,25 N f=0,0675 mm f=0,0602 mm f=0,124 mm

1 N f=0,81 mm f=0,723 mm f=1,48 mm

3 N f=0,81 mm f=0,723 mm f=1,48 mm

5 N f=1,35 mm f=1,2 mm f=2,47 mm



66


f [mm]


grad de afectare

neafectat

afectat 33%

afectat 66%

0.07

0.81 0.81

1.35

0.07

0.81 0.81

1.35

0.0602

0.723 0.723

1.2

0.0602

0.723 0.723

1.2

0.124

1.48 1.48

2.47

0.124

1.48 1.48

2.47

0.25 N 1 N 3 N 5 N

forta aplicata (N)

-0.5

0.0

0.5

1.0

1.5

2.0

2.5

3.0

Va

lue

s

0.07

0.81 0.81

1.35

0.0602

0.723 0.723

1.2

0.124

1.48 1.48

2.47

Fig. 9 - Values of f as a function of the extent of HBL and the applied force

Table IV.2 - Test for comparing the values of f / applied force vs. extent of HBL


15.488912 0.0049899

The values of movement resulting from the

application of force maintain a significant

increase together with the increase in the

magnitude of the applied force, with no

significant differences between the cases

with no initial periodontal disease and those

affected up to 33%. (Fig. 9)


affected up to 66%, the values of movement

in the case of the lower lateral incisors are

significantly higher (H=15.48, p=0.004,

95%CI). One particular aspect occurs in the

cases in which the applied force is 1N and

3N, respectively, cases in which the values

of movement do not show significant

differences. (Table IV.2)

Predictive factors in the modification of

the values of movement as a result of

applying an intrusion force

The subsequent study analysed,

using multivariate analysis, the importance

of the parameters that influence the values of

movement as a result of applied forces, the

included parameters being the applied force

and the extent to which the periodontium is

affected.

Table IV.3 - The multiple correlation of the predictive factors for the f values

Multiple correlation Estimated value


Multiple R2 0.69041


F 10.03552

p (95%CI) 0.00511


Table IV.4- The result of the multivariate analysis– the partial correlation coefficients

Partial correlation

f

vs.

Correlation

coefficient

(Beta)

Std.Err.

(Beta) B

Std.Err.

B t

p

95% CI

Intercept -

31.769

15.6712

5

-

2.02722

0.07326

3



67

1

Applied force 0.739051 0.185468 0.2704 0.06785 3.98478 0.00318

3

Extent of

periodontal disease 0.379760 0.185468 0.3146 0.15363 2.04757

0.07089

2


The analysis of the results of the multiple

correlation shows that the applied force has

an important impact on f (βf=0.73,

p<<0.001), but the presence of periodontal

disease does not influence to a statistically

significantly extent the value of movement f

(βAf.P=0.37, p=0.07). (Table IV.3-4)

Correlation aspects of σ ech, σ c and f depending on the value of the applied force

Table V - Result of the Pearson correlation test: σ ech, σ c and f vs. applied force

Pearson (partial correlations)

r (correlation coefficient)

(95% confidence interval) p

Applied force vs.

σ ech 0.7887 0.002

σ c 0.7915 0.002

f 0.7391 0.006

Scatterplot: forta aplicata vs. σ ech [MPa] (Casewise MD deletion)

σ ech [MPa] = .04521 + 3.2758 * forta aplicata

Correlation: r = .78865


0.25 1 2 3 4 5.00 6.00

forta aplicata

-2

0

2

4

6

8

10

12

14

16

18

20

22

24

26

28

30

σ e

ch

[M

Pa

]

95% confidence Scatterplot: forta aplicata vs. σ c [MPa] (Casewise MD deletion)

σ c [MPa] = .31E-3 + 1.6027 * forta aplicata



0.25 1 2 3 4 5.00 6.00

forta aplicata

-2

0

2

4

6

8

10

12

14

σ c

[M

Pa

]

95% confidence

Scatterplot: forta aplicata vs. f [mm] (Casewise MD deletion)

f [mm] = .31627 + .27036 * forta aplicata



0.25 1 2 3 4 5.00 6.00

forta aplicata

-0.2

0.0

0.2

0.4

0.6

0.8

1.0

1.2

1.4

1.6

1.8

2.0

2.2

2.4

2.6

f [m

m]

95% confidence Fig. 10 - Regression line in the correlation σ ech, σ c and f vs. applied force

The values that were most affected by the

magnitude of the applied intrusive forces

were those of the tension registered in the

direction the force was applied (σ c –

r=0.79), followed by the values of the

equivalent tensions in the tooth-periodontal

ligament-alveolar bone complex (σ ech –

r=0.78) and lastly by the values of the

registered movements (f – r=0.73). (Fig. 10)



68

During the intrusion of the lower lateral

incisors we have found that the equivalent

tensions increase together with the increase

in the extent to which the periodontium is

affected and together with the increase in

magnitude of the applied force. Previous

studies on maxillary central incisors, carried

out using similar methods, have yielded

slightly different aspects. [6]

In the cases in which the periodontium

was affected up to 33%, the values of σ ech

did not show significant differences

compared to those present in the case of

unaffected periodontium.

In the lower frontal group, the tension

values in the direction the force is applied, σ

c, show an exponential increase depending

on the applied force whether the

periodontium is affected or not, a similar

situation with the numerical simulation of

molar uprighting. [7]

Dental movement through intrusion

increases exponentially together with the

increase in magnitude of the applied forces,

but also with the increase of the extent of

periodontal trouble (horizontal bone loss),

even becoming double when the tooth is

affected up to 66% compared to 33%.

Dental intrusion is a means for

improving implantation and for gaining

attachment, but bacterial plaque must be

under strict control. This is highlighted in

literature in numerous studies on identifying

bacteria through molecular biology

techniques. [8-11] It appears that antioxidant

markers, CRP and cytokines in the saliva can

be very useful instruments in predicting

periodontal disease during orthodontic

treatment in a clinical setting. [12-20]

The magnitude of the intrusive forces

applied to the lower frontal group influences

firstly the values of the equivalent tensions,

then those of the tensions in the direction the

force is applied, and lastly the movement of

the lower central incisor; on the other hand,

it influences firstly the values of the tensions

in the direction the force is applied, then

those of equivalent tensions, and lastly the

movement of the lower lateral incisor[21-

26].

Conclusions

Our study pointed out that the intrusion of

the mandibular lateral incisor associated with

moderate bone loss can be an optimal

solution for improving the implantation and

for regaining the periodontal attachment.

When optimal intrusive forces are applied at

the level of mandibular lateral incisor, the

periodontal status of the patient will not

represent a restriction for the

interdisciplinary treatment.

It appears that the precise control of the

magnitude of the force is the key element in

order to avoid periodontal hazards at the

level of the lateral mandibular incisor.

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