0% found this document useful (0 votes)

43 views24 pages

Periodontology 2000 - 2023 - Jepsen - Complications and Treatment Errors Involving Periodontal Tissues Related To

This review article discusses complications and treatment errors related to periodontal tissues during orthodontic therapy, emphasizing the complex interplay between orthodontic forces and periodontal health. It highlights the potential for transient and sometimes severe complications, such as gingival inflammation, overgrowth, and root resorption, while also noting the importance of maintaining periodontal health and proper oral hygiene throughout treatment. The article is structured around three main sections: orthodontic treatment in relation to periodontal health, periodontitis, and mucogingival conditions, providing recommendations to mitigate risks associated with orthodontic therapy.

Uploaded by

marcelaespinosa123

We take content rights seriously. If you suspect this is your content, claim it here.

Available Formats

Download as PDF, TXT or read online on Scribd

0% found this document useful (0 votes)

43 views24 pages

Periodontology 2000 - 2023 - Jepsen - Complications and Treatment Errors Involving Periodontal Tissues Related To

Uploaded by

marcelaespinosa123

We take content rights seriously. If you suspect this is your content, claim it here.

Available Formats

Download as PDF, TXT or read online on Scribd

You are on page 1/ 24

Received: 28 June 2022 | Revised: 25 October 2022 | Accepted: 4 January 2023

DOI: 10.1111/prd.12484

REVIEW ARTICLE

Complications and treatment errors involving periodontal

tissues related to orthodontic therapy

Karin Jepsen1 | Anton Sculean2 | Søren Jepsen1

1
Department of Periodontology, Operative and Preventive Dentistry, University of Bonn, Bonn, Germany
2
Department of Periodontology, University of Bern, Bern, Switzerland

Correspondence
Karin Jepsen, Department of Periodontology, Operative and Preventive Dentistry, University of Bonn, Welschnonnenstrasse 17, 53111 Bonn, Germany.
Email: [email protected]

1 | I NTRO D U C TI O N Orthodontics continue to see consistent problems, including lack of

attention to finishing details, inappropriate treatment objectives, ex-
The interplay between the application of orthodontic forces to stim- cessive proclination of mandibular incisors, excessive expansion of
ulate tooth movement and the reaction of the affected periodon- mandibular intercanine width, closing skeletal open bites with extru-
tal tissues is complex. While most of the time possible damage to sion of anterior teeth leading to excessive gingival display, and failure
the periodontal tissues is transient with no long-term detrimental to recognize the importance of controlling the eruption or extrusion of
effects on periodontal health, in some instances major undesirable molars during treatment.5 It is obvious that all of these problems may
consequences have been reported. In other situations, orthodontic have implications for the status of the periodontal tissues involved.
therapy (OT) can be of benefit in solving problems caused by peri-
odontitis or by mucogingival conditions. Corresponding to the new
classification on periodontal diseases and conditions,1 this article is 2 | OT I N R E L ATI O N TO PE R I O D O NTA L
structured into three major sections: H E A LTH

• OT in relation to periodontal health, Most of the time, OT is performed in children and adolescents with
• OT in relation to periodontitis, and healthy periodontal conditions. Gingival and periodontal health
• OT in relation to mucogingival conditions. have been described in detail and defined clinically in a recent World
Workshop on the classification of periodontal and peri-implant dis-
In each chapter we have tried to illustrate typical scenarios en- eases and conditions. 2,6
countered in the clinic that may be accompanied by complications and Orthodontic therapy moves teeth from one position in the jaw,
possibly even be induced by treatment errors, together with recom- through bone and the surrounding soft tissues, to another position,
mendations on how they can be avoided or how they can be rescued, in response to forces applied by specific appliances. This movement
based on the currently available evidence and on expert opinion. of teeth is accompanied by tissue remodeling, which modifies the
While clinical periodontal health and also the end points of suc- morphology of the periodontal tissues. The periodontal ligament,
cessful periodontal therapy to establish periodontal health on a re- as a dynamic structure, makes this possible. The whole periodon-
duced periodontium are clearly defined, 2,3 these may differ from tal attachment apparatus, including the alveolar bone, shows bio-
how clinical success of OT is defined. Orthodontic treatment is logical responses and changes, including a modification of the local
considered successful when the treatment goal is achieved and the vascularization. Even though there are many innovative mechani-
result remains stable. In general, these treatment goals may be de- cal devices for tooth movement, therapists are still not completely
fined as achievement of oral health, esthetics, occlusion, function, successful in preventing trauma to the periodontium, resulting in
and stability, although the treatment goals may vary among patients.4 undesirable side effects. This may be due to lack of complete under-
Chung et al concluded that the examiners of the American Board of standing of cellular complexities.7 In general, most adverse effects

This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in
any medium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made.
© 2023 The Authors. Periodontology 2000 published by John Wiley & Sons Ltd.

Periodontology 2000. 2023;92:135–158. wileyonlinelibrary.com/journal/prd | 135

16000757, 2023, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/prd.12484 by Cochrane Colombia, Wiley Online Library on [12/09/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
136 JEPSEN et al.

are believed to be transient and not associated with any lasting det- cells. 29 The tissue enlargement in hyperplastic gingivitis is generally
rimental effect on the surrounding periodontal tissues.8–12 mild and occurs in about 10% of patients undergoing treatment with
a fixed othodontic appliance.17 An example of a patient with gener-
alized gingival enlargement is shown in Figure 1. Slight hyperplastic
2.1 | Plaque/Biofilm changes of the interdental papillae in patients with good oral hygiene
disappear following removal of orthodontic appliances, but notably
It is well established that orthodontic fixed appliances make mainte- the results of one study30 showed that even 2 years after debond-
nance of proper oral hygiene more difficult, resulting in increased ac- ing not all periodontal parameters had returned to normal, indicating
cumulation of plaque and subsequent mild inflammation of the gingival that some changes are only partially reversible. As further changes
tissues, thus acting as a local risk factor for the development of gingivi- occurred between 3 months and 2 years after debonding, the au-
tis.2,13 With regard to facilitation of oral hygiene, a recent randomized thors suggested not to carry out a gingivectomy or gingivoplasty
clinical trial (RCT) found no differences when comparing clear aligners, As further changes occurred between 3 months and 2 years after
self-ligated brackets, and traditional fixed orthodontic appliances.14 debonding, the authors suggested not to carry out a gingivectomy
However, there was a significant change in biofilm composition after or gingivoplasty procedure already at 3 months after completion of
the placement of orthodontic appliances15 including an increase in orthodontic therapy.
the percentage of potentially pathogenic gram-negative bacteria,16
and a significant impact of bracket design was found.17 Such changes
in microbial parameters were only partially normalized 3 months fol- 2.3 | Periodontal alterations
lowing the removal of fixed orthodontic appliances.10 Placement of
orthodontic fixed appliances was shown to be associated with a quali- 2.3.1 | Clinical attachment level
tative change of the subgingival microbiota, with increased prevalence
of subgingival Aggregatibacter actinomycetemcomitans and Tannerella A systematic review investigated periodontal clinical attachment
forsythia persisting for up to 6 months after appliance removal18,19; changes in periodontally healthy patients undergoing OT. The aver-
however, another review reported transient increases in the levels of age clinical attachment loss after values were pooled was 0.11 mm
subgingival pathogens with a return to pretreatment levels several (nine studies; 335 patients; 95% CI = 0.12 mm gain to 0.34 mm loss;
20
months later. Studies on the effect of orthodontic appliances/ther- P = .338), but it should be noted that the studies demonstrated high
apy on the composition of the oral microbiome using next-generation heterogeneity and the quality of evidence was overall low.18
sequencing of the bacterial 16S rRNA gene confirmed significant These findings are confirmed by another systematic review
changes21; however, this effect was transient22 and only minor com- and its recent update, in which minimal changes were reported in
positional changes were found after completion of treatment.23 clinical attachment levels (three studies; 43 patients; Mean effect
(ME) = 0.248 mm; 95% CI [−0.055 to 0.551]; P = .109).31,32

2.2 | Gingival inflammation and overgrowth/

enlargement 2.3.2 | Probing pocket depth

The biofilm-retentive characteristics of orthodontic appliances re- A systematic review reported 0.23 mm of increased probing pocket
sult in the development of gingivitis as a natural consequence of depth (PPD, two studies; 95% CI = 0.5–0.3 mm; P = .0001) compared
incomplete removal of plaque. The presence of gingivitis is charac-
terized by increased pocket probing depth, increased bleeding on
probing, increased crevicular fluid volume, as well as elevated gingi-
val and bleeding indices,10,24 although mostly found to be transient
after the first 3–6 months post-treatment.8–10
Abnormal inflammatory overgrowth of gingival tissues is a com-
plication that may occur after orthodontic appliance insertion, as
verified by histological examination. 25 Several studies found a pos-
itive association among duration of orthodontic treatment, gingival
inflammation, and gingival enlargement in subjects undergoing fixed
OT. 26–28 The exact mechanism for the development of overgrowth
is not yet completely understood but it probably involves increased
production by fibroblasts of amorphous ground substance with a
high level of glycosaminoglycans. Increased expression of type I col- F I G U R E 1 Inflammatory gingival overgrowth in the premolar
lagen mRNA and upregulation of keratinocyte growth factor recep- and molar areas as a result of insufficient and challenging plaque
tor may play an important role in excessive proliferation of epithelial control after placement of orthodontic devices.
|

with no orthodontic treatment.13 A more recent systematic review inflammation induced by the orthodontic load brings about resorp-
and its update observed a statistically significant reduction in PPD tion of the superficial root cementum, or the inflammation can be-
(mm) (five studies; 63 patients; ME = 0.325 mm; 95% CI = 0.123– come more severe with eventual resorption of the underlying dentin
0.526; P < 0.001), although this can be considered as being not clini- and loss of overall root length. The underlying biological events are
cally relevant (as PPD reduction was <0.5 mm).31,32 not completely understood. A classification of external root resorp-
tion, proposed by Feller,38 is displayed in Table 1.
Depending on the severity of orthodontically induced apical ex-
2.3.3 | Bone level ternal root resorption data on the incidence/prevalence vary among
studies and range from 2.9% for severe root resorption to 98.1%
13
The same systematic review demonstrated that OT was associated for mild root resorption.39 In other publications values range from
with 0.13 mm of alveolar bone loss (three studies; 95% CI = 0.07– 14.8% 40 up to 46%.34,41,42
0.20 mm; P = .0001) when compared with no treatment. More Apical external root resorption is considered to be an invariable
recently, Martin et al31 reported in their systematic review also a iatrogenic side effect/complication of orthodontic treatment38 and
slight loss in radiographic bone level (one study; 122 patients; is associated with several treatment-related risk factors, such as
ME = −0.400 mm; 95% CI = −0.579 to −0.221 mm; P < .001) in pa- extraction treatment, long treatment duration, heavy continuous
tients without periodontitis undergoing OT. These results were treatment force, and large distance of tooth movement with apical
based on the analysis of conventional radiographs. displacement especially of the maxillary incisors.37,39,40,43–48 Even
With the introduction of three-dimensional computerized tech- though genetics may account for the variation in external apical
nology (cone beam computed tomography [CBCT]), marginal bone root resorption there is insufficient evidence for specific genetic risk
level changes following OT could also be evaluated on the vestibular factors.47 More recently, CBCT was shown to be a reliable tool for
33
and oral tooth surfaces. Lund et al examined patients before and examining orthodontically induced external root resorption.49 An
after orthodontic treatment following premolar extraction. In ante- example of a patient with severe root resorption is shown in Figure 2.
rior jaw regions in which retraction of teeth causes remodeling of the As some degree of apical external root resorption is a frequent
alveolar bone, 84% of lingual surfaces of mandibular central incisors and unavoidable complication of OT, during treatment planning, the
exhibited a bone-height decrease of >2 mm. Fewer than 1% of proxi- patient or parent should be informed about this risk. Strategies to min-
mal surfaces exhibited changes of >2 mm. Castro et al used CBCT to imize external root resorption should include limitation of prolonged
evaluate the distance between the cemento-enamel junction (CEJ) treatment, the use of light intermittent forces, and biannual radio-
and the alveolar bone crest before and after nonextraction ortho- graphic monitoring in order to detect any possible root resorption at
dontic treatment; they found that this distance increased in 822 the earliest stage.48,50 If any apical external root resorption is detected,
(57%) of the 1440 surfaces after orthodontic treatment.34 The buc- active treatment should be suspended for 2–3 months, with the aim of
cal surfaces of the lower central incisors had the greatest frequency preventing further resorption and to allow some healing with cellular
of increased distance (75%). Jager et al performed scans using the i- cementum. If further resorption is detected after active treatment has
CAT Next Generation technology and reported a significant decrease been resumed, the orthodontic treatment plan should be modified.38,51
in periodontal bone height (dehiscence: −0.82 ± 1.47 mm) and bone In summary, OT can be safely performed in periodontally
thickness (−0.56 ± 0.7 and − 0.69 ± 0.9 mm at 5 mm and 10 mm apical healthy patients and has no detrimental effects on periodontal tis-
to the CEJ, respectively) after orthodontic treatment.35 Changes in sues. However, it is well established that orthodontically induced
alveolar bone height and cortical bone thickness around the man- inflammatory gingival overgrowth and/or apical external root re-
dibular incisors after orthodontic treatment were also observed by sorption are common complications that need to be recognized
Garlock et al.36 In patients who did not undergo tooth extraction, and adequately addressed to prevent more severe damage. Most
the average facial and lingual vertical bone loss was 1.16 ± 2.26 and importantly, periodontal health and adequate oral hygiene have to
1.33 ± 2.50 mm, respectively. be assured prior to OT and constantly monitored throughout treat-
ment. Failure to do so has to be viewed as treatment error.

2.4 | Root resorption

3 | OT I N R E L ATI O N TO PE R I O D O NTITI S
Loss of periodontal attachment in the course of OT can also occur
from external apical root resorption, also referred to as ortho- There is an increase in the number of adult patients with various
dontically induced inflammatory root resorption.37 The sterile stages of periodontitis who seek orthodontic treatment for esthetic

TA B L E 1 Classification of the degree of Mild Apical root resorption <2 mm of the original root length
external root resorption.
Moderate Apical root resorption >2 mm but <1/3 of original root length
Severe Root resorption >4 mm or 1/3 of original root length
|

F I G U R E 2 Radiographic image of
a 28-year-old healthy male patient
presenting with severe apical root
resorption after orthodontic treatment.

and functional concerns.52 The reduction of periodontal support • Patient with undetected incipient periodontitis undergoing or-
can be associated with elongation, labial flaring, extrusion, rotation, thodontic treatment
53
spacing, and drifting of teeth. Maxillary incisors are reported to • Periodontally healthy but periodontitis-susceptible patient un-
be particularly susceptible to pathological migration.54 In fact, this dergoing orthodontic treatment
clinical scenario is recognized as one of the specific phenotypic varia-
tions of patients with stage IV periodontitis amenable to orthodontic
correction.32 3.1 | Successfully treated periodontitis patient in
There is consensus that the periodontal inflammation must need of orthodontic treatment
be controlled before orthodontic tooth movement and remain
controlled during OT. This is based on evidence derived from There is consensus regarding what a clinical case of a successfully
well-controlled experimental animal studies demonstrating that treated periodontitis patient with stable periodontal conditions should
orthodontic forces on teeth which have a reduced, but healthy, look like. In the World Workshop on the 2018 Classification, a case
periodontium did not cause additional attachment loss,55 whereas, of clinical health on a reduced periodontium has been defined2 and,
if associated with plaque-induced inflamed periodontal tissues and in line with this, a European S3-Level Clinical Guideline Workshop
intrabony defects, orthodontic movement of teeth was found to in- has determined an end point of active periodontal therapy.3 At the
56
crease loss of connective tissue attachment. same time, there is consensus that these patients—even when treated
Thus, an interdisciplinary approach is required to control successfully—always remain at risk of recurrent periodontitis and there-
the periodontal infection and to realign the migrated teeth. 57–6 0 fore should be enrolled in a supportive periodontal care program.3
However, according to recent reviews, there has been minimal Earlier clinical studies confirmed that in patients with good
clinical investigation of the complex interaction between ortho- plaque control, teeth with a reduced (but healthy) periodontium
dontic and periodontal treatment and there are a lack of well can undergo successful tooth movement without compromising
controlled studies of patients with periodontal and orthodontic the periodontal support.64,65 In a recent systematic review with
treatment needs to determine whether orthodontic treatment meta-analysis31 it was shown that the periodontal outcomes of OT
may improve or aggravate periodontal conditions in patients with in patients with treated periodontitis are similar to those obtained
periodontitis. 31,61–63 in patients with a healthy periodontium. Based on these findings,
Very recently, a European Workshop has addressed these chal- the new S3 level clinical practice guideline32 gave the following
lenges in a European Federation of Periodontology (EFP) S3 level clin- evidence-based recommendation (R7.1):
ical practice guideline on the treatment of stage IV periodontitis.32
In periodontal clinical practice, different scenarios can be “In successfully treated stage IV periodontitis pa-
encountered: tients in need of orthodontic therapy (OT), we sug-
gest undertaking OT based on evidence that: a) it
• Successfully treated periodontitis patient in need of orthodontic does not significantly affect periodontal outcomes
treatment (probing pocket depth - PPD and clinical attachment
• Patient with undiagnosed, untreated periodontitis undergoing or- levels -CAL); b) it does not significantly affect gingival
thodontic treatment inflammation (bleeding on probing—BOP) and gingival
• Patient with untreated periodontitis in need of periodontal and recession; c) it does not lead to a significant increase
orthodontic treatment in root resorption.”
|

Furthermore, based on expert opinion and data from preclinical “In stage IV periodontitis patients with pathological
studies, the following expert consensus-based recommendation (R7.2) tooth migration, we suggest undertaking orthodontic
regarding the appropriate time point for starting OT was provided: therapy once the endpoints of periodontal therapy
have been reached, based on the evidence that this
“In successfully treated stage IV periodontitis pa- therapy: a) does not significantly affect periodontal
tients in need of orthodontic therapy, we recommend outcomes [CAL, PPD, and radiographic bone lev-
starting OT once the endpoints of periodontal ther- els (RBL)]; b) seems to reduce gingival inflammation
apy have been achieved (no sites with PPD = 5 mm (BOP); c) does not significantly alter gingival margin
and BOP and no sites with PPD ≥6 mm).”3 levels; d) seems to improve inter-dental papilla height;
e) does not significantly affect root resorption and
Therefore, in patients with a history of treated periodontitis, seems to reduce tooth mobility.”
healthy periodontal conditions should be assured and documented at
the start of OT.66 A deviation from this may be looked upon as a treat- There is ongoing debate regarding how long after active periodon-
ment error. tal therapy the clinician has to wait before OT can be initiated:66 im-
A clinical example of a patient with treated periodontitis, for mediately,67 1–2 weeks,57,68–70 2–6 months,67,71 or 8–12 months.72,73
whom the successful outcome was not assessed by a re-evaluation Taking into consideration the healing dynamics of the periodontium fol-
and OT was immediately initiated is shown in Figure 3. lowing the different modalities of periodontal therapy,24,74,75 Pini Prato
and Chambrone66 proposed a periodontal–orthodontic treatment
algorithm, where orthodontic therapy should start 3–6 months after
3.2 | Patient with undiagnosed, untreated non-surgical therapy, 6–9 months after surgical periodontal treatment,
periodontitis undergoing orthodontic treatment and 12 months after regenerative periodontal procedures (Figure 4).
Patients with advanced or severe attachment loss as a result of
Based on the information given above, the scenario of a patient with periodontitis often present with intrabony defects and pathologi-
undiagnosed, untreated periodontitis undergoing orthodontic treat- cal tooth migration.76 There is an evidence-based clinical practice
ment has to be considered as a treatment error. It can, and must, be guideline on how to manage patients with stage I–III periodontitis, 3
avoided by periodontal screening, followed by a careful periodontal including regenerative procedures for intrabony defects.77 A com-
examination and diagnosis in patients of all age groups, before or- prehensive combined periodontal–orthodontic treatment would
thodontic treatment is initiated. include steps 1 and 2 of periodontal therapy to control the peri-
odontal infection, followed by step 3 including regenerative peri-
odontal surgery to reconstruct the defects, and subsequent OT to
3.3 | Patient with untreated periodontitis in realign the migrated teeth. So far, clinicians have had to rely mainly
need of periodontal and orthodontic treatment on case reports and on prospective, as well as retrospective, clini-
cal case series. In particular, the optimal time interval between re-
The orthodontic treatment of the typical sequela of advanced peri- generative periodontal surgery and the initiation of OT has been a
odontal attachment loss (pathological tooth migration) usually in- matter of ongoing debate. It may be safe to wait until the end point
volves intrusive, retrusive, and alignment tooth movements, which of regenerative therapy has been reached (up to 12 months) and
may potentially cause adverse effects (further periodontal attach- not to interfere with periodontal wound-healing. 66 Case reports
ment or bone loss, increased gingival inflammation, or increased and series with long-term follow-up periods have reported favor-
root resorption) or secondary effects (undesired esthetic outcomes, able periodontal outcomes using such a delayed approach.72,73,78,79
such as gingival recession and loss of interdental papilla) on the af- The question then arises of whether a deviation from these rec-
fected teeth. A recent systematic review with meta-analysis63 on ommendations would have to be considered as a treatment error.
periodontal–orthodontic treatment of teeth with pathological flar- This is an intriguing question, as other reports have suggested that
ing, drifting, and elongation in patients with severe periodontitis orthodontic tooth movement may be initiated almost immediately
concluded that orthodontic treatment might be associated with or up to 3 months after regenerative surgery. 80–83 No adverse ef-
small improvements of periodontal parameters and negligible ad- fects were reported, and some authors speculated that early tooth
verse effects. These analyses were hampered by the fact that the movement could even stimulate periodontal wound healing. More
periodontal status after periodontal therapy and before initiation of recently, a large retrospective case series of patients with stage IV
OT was not reported in most of the studies, and the authors em- periodontitis, in whom OT was started 3 months after regenerative
phasized that their conclusions were based on limited evidence of surgery, showed substantial improvements after 12 months that
moderate quality because of the absence of adequate studies and could be maintained up to 4 years. 84 As many patients affected by
therefore should be viewed with caution. Nevertheless, in the new such a condition are interested in seeking orthodontic treatment
S3 level clinical practice guideline32 the following evidence-based because of the esthetic and functional changes caused by patho-
recommendation (R7.3) was stated: logic tooth migration, 52 this question of early versus late initiation
|

F I G U R E 3 Clinical situation of a 22-year-old healthy male patient with a diagnosis (retrospective, based on documentation available)
of localized periodontitis stage IV (tooth #12, 25), grade B. The patient was worried about his elongated upper right lateral incisor from
an esthetic point of view. A, Flaring of the maxillary front, and severe elongation and spacing of tooth #12. B, Occlusal view of tooth #12,
with large spaces (>2 mm) between it and the neighboring teeth. C, Elongation and rotation of tooth #12. D, Panoramic radiograph, taken
before orthodontic treatment, showing very limited accuracy and detail for adequate periodontal evaluation. E, As reported by the patient,
nonsurgical periodontal therapy was given followed immediately by orthodontic intrusion movement. F, Directly after debonding, frontal
view. G, Occlusal view, with crowns perfectly aligned. H, Tooth #12 appears to be intruded perfectly. I, Evidence of severe vertical bone
loss on the mesial and distal aspects, as well as apical root resorption #12. K, Panoramic radiograph showing limited accuracy and detail
for adequate periodontal evaluation. L, Three years after debonding, the patient was referred to our periodontal clinic; he presented with
an increasing gingival recession type 3 (RT3) on tooth #12 (this was the patient's main concern). Periodontal examination revealed now
evident signs of recurrent periodontitis and a hopeless tooth #12 with a periodontal abscess and progressive attachment loss of 12 mm. BoP,
bleeding on probing; CAL, clinical attachment loss; Pus, suppuration; PPD, periodontal probing depth. After nonsurgical periodontal therapy,
the severely damaged tooth could be treated successfully with a periodontal regenerative technique, using a connective tissue graft (M, N)
in combination with a bone substitute (Photographs and case courtesy of Dr. Tobias Waller). O, Clinical situation 3 years after periodontal
regenerative surgery with shallow pockets of ≤4 mm on all maxillary incisors, well maintained in a stringent recall program.
|

F I G U R E 4 Periodontal–orthodontic
treatment algorithm proposed by Pini-
Prato and Chambrone.66 BoP, bleeding
on probing; CAL, clinical attachment loss;
PI, Plaque Index; SC/RP, Scaling and root
planing.

of OT is of high clinical relevance. The results of a recently pub- movement in patients with a high level of oral hygiene and infec-
lished multicenter randomized trial could shed new light on this tion control (Figure 5). In view of these findings, early OT after
challenging treatment decision. 85 After 12 months, significant peri- periodontal regenerative surgery of intrabony defects may not be
odontal improvements of similar magnitude were accomplished by viewed as treatment error. Based on systematic reviews, 63,86 the
regenerative treatment of intrabony defects following early (after new EFP S3 level clinical practice guideline32 gave the following
4 weeks) and late (after 6 months) initiation of orthodontic tooth evidence-based recommendation (R7.5):
|

A F I G U R E 5 Twenty-five-year-old
patient with the diagnosis periodontitis
stage IV with pathologic tooth migration
(spacing and flaring). A, Clinical situation
after initial periodontal therapy,
showing flaring teeth #11, 12, 21 and
22 together with severe attachment
loss, labial displacement and elongation’.
B, Regenerative surgical procedure for
an intrabony two-walled defect, 6 mm
deep, followed up at 1 week and 2 weeks.
C, Clinical situation 12 months after
regenerative surgery/11 months after
starting active orthodontic therapy and
after 24 months. (Photographs from
B
Jepsen et al85).

“In stage IV periodontitis patients where intra-bony with advanced training and skills in periodontal and orthodontic
defects have been treated following the recommen- therapies.
dations of the clinical practice guideline using the
appropriate regenerative interventions: 1. We recom-
mend undertaking OT based on the evidence that the 3.4 | Patient with undetected incipient
combined treatment significantly improves periodon- periodontitis undergoing orthodontic treatment
tal outcomes (increased CAL gain, PD reduction and
RBL gain) and significantly reduces gingival inflamma- Discriminating between a case of gingivitis2 or of incipient (stage
tion (BOP). 2. We suggest not to wait for a prolonged I) periodontitis87 is not easy and in such a scenario sometimes or-
healing period after the regenerative intervention, thodontic treatment could have been initiated based on an incor-
before initiating OT, since there is evidence that a rect periodontal assessment/diagnosis. The situation may turn into
short (1 month) and a prolonged (6 months) period a treatment error (supervised neglect) if the clinician continues to
between periodontal/regenerative and OT result in ignore (to fail to detect) signs of periodontal inflammation because
comparable outcomes.” of lack of adequate monitoring.
A clinical example of this scenario is illustrated in Figure 6.
It was also emphasized that the combination of such complex peri- In retrospect and based on the radiographs available prior to or-
odontal and orthodontic therapies requires the coordinated ef- thodontic tooth movement (Figure 6E), indicating slight bone loss in
forts of different oral care providers, namely specialists or dentists the molar region, the patient could have been identified as having
16000757, 2023, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/prd.12484 by Cochrane Colombia, Wiley Online Library on [12/09/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
|143

(Continues)
A

FIGURE 6
JEPSEN et al.

B
|

F I G U R E 6 A, Clinical situation of a 17-year-old patient complaining about his upper right lateral incisor, which had Grade II mobility,
bleeding of his gums, and food impaction. His orthodontic therapy had just reached completion, and his primary concern was losing all his
teeth. He presented with a good level of oral hygiene, with a plaque index (PI) of 21% but a high full-mouth bleeding on probing (BOP) score
of 51%. The diagnosis was periodontitis stage III, grade C (Photographs—Courtesy of Ph. Skora). B, Radiographs of the patient showing
distinct bone loss on all first molars. C, Clinical situation, 5 years later, of the now 22-year-old patient after comprehensive periodontal
treatment including steps 1–3 of therapy and a strict maintenance program. D, Over the course of active periodontal treatment and
maintenance the patient could be kept stable with plaque and bleeding on probing scores decreasing to below 10%. E, Comparison of
radiographs taken before and after orthodontic treatment and following comprehensive periodontal therapy. Distinct bone loss on the
maxillary right first molar was already visible before tooth movement, and bone loss was present on all first molars 4 years later.

localized incipient periodontitis (stage I) and should have been re- periodontist. Thus, regular monitoring of the periodontal status is
ferred to a periodontist. The progressive deterioration to a periodon- key in preventing rapid periodontal destruction in highly susceptible
titis stage III situation during orthodontic tooth movement remained patients.
unnoticed and indicates a lack of adequate monitoring. The loss of
periodontal attachment necessitating comprehensive periodontal
treatment after referral to our specialist clinic (Figure 6C–E) could 3.6 | Prevention of treatment errors related to OT
have been avoided.
In order to prevent the treatment errors described above, the follow-
ing recommendations have been made for periodontally susceptible
3.5 | Periodontally healthy but periodontitis- patients undergoing OT.66,88 As routine, prior to commencement of
susceptible patient undergoing orthodontic treatment orthodontic treatment, patients have to be carefully examined for
signs of periodontal disease, followed by individual oral hygiene
In this scenario, the patient who is diagnosed as periodontally instructions and dietary education. Orthodontic fixed appliances
healthy before initiation of orthodontic tooth movement may de- make maintenance of proper hygiene more difficult and have a
velop periodontitis in the course of treatment. Periodontal inflam- major effect on the plaque and bleeding indices documented, result-
mation can result from the increased bacterial load associated with ing in subsequent mild inflammation of the oral tissues. Professional
the fixed orthodontic appliances in highly susceptible patients, who check-up visits with a dental hygienist need to be performed every
often present at a young age. This scenario presents a special chal- 3 months and the time intervals between such visits should be de-
lenge to the orthodontist as she/he may be the first to detect signs creased according to the individual needs of the patient. The ortho-
of periodontitis and has the responsibility to refer the patient to a dontist should be aware of early-onset periodontitis, which may not
|

be present at initiation of OT but may develop in patients during or “We recommend that during OT the patient's peri-
after the course of therapy. For such patients, a periodontist should odontal status is closely monitored and managed,
be involved. ideally at each orthodontic appointment. If signs of
Disease progression in patients with periodontitis depends on periodontitis recurrence are detected, active OT
the extent and severity of the microbial biofilm challenge. Hence, should be interrupted, and the affected teeth should
to avoid increased tissue loss resulting from an unfavorable com- be maintained passively, while rendering proper
bination of periodontitis-associated inflammation with orthodonti- periodontal treatment and oral hygiene reinforce-
cally induced inflammation, periodontal disease needs to be under ment. Once periodontal health/stability has been re-
control before starting orthodontic treatment. During and after or- established, OT can be re-instituted. We recommend
thodontic tooth movements, stringent monitoring of all periodontal that after completion of OT, life-long supportive peri-
parameters, including biofilm control, must be performed because odontal care and life-long orthodontic retention are
an increased microbial load as a result of plaque accumulation provided tailored to the individual needs/risk profile
around orthodontic appliances can induce periodontal inflamma- of the patient.”
tion, which possibly may be followed by destruction of surrounding
tissues during tooth movement, depending on the individual suscep- Furthermore, to facilitate treatment planning and execution, and
tibility of the patient. To maintain the status of a successfully treated interdisciplinary cooperation between periodontists and orthodon-
periodontitis patient, 2 guidelines for periodontal care and follow-up tists, a treatment algorithm has been developed32 (Figure 7).
during OT are shown in (Table 2) and aim at achieving a plaque index In summary, OT can be safely performed in successfully treated
of <20%, periodontal probing depths of <5 mm, and absence of periodontitis patients with no detrimental effects on periodontal
bleeding on probing.3,66,88 tissues. However, conducting orthodontic tooth movements in pa-
To detect initial signs of deterioration, the periodontal status tients with undetected, untreated periodontitis and continuing OT
must be closely monitored by the hygienist/periodontist on a three despite periodontitis developing during treatment should be viewed
monthly basis and, in most patients, adjustment of oral hygiene tools as treatment errors. Most importantly, to avoid these treatment er-
becomes necessary. As routine, a complete periodontal examina- rors, periodontal health and adequate oral hygiene must be assured
tion should be performed every 6 months, and in the event of re- prior to starting OT and constantly monitored throughout treat-
current disease, both treatments need to be adjusted accordingly. ment. Failure to do so and failure to provide adequate supportive
Nonadherence to oral hygiene protocols requires a temporary halt therapy should be viewed as treatment errors.
of active tooth movements. In some patients, removal of appliances
should be considered until all signs of periodontal disease are re-
solved. In general, procedures initiating tooth movements should not 4 | OT I N R E L ATI O N TO M U CO G I N G I VA L
be performed until periodontal inflammation is controlled and the CO N D ITI O N
patient is able to perform personal meticulous oral hygiene measures
(Table 3). It has been known for a long time that mucogingival conditions can
89 90
Based on a randomized clinical trial and a systematic review, be affected by OT.91 Mucogingival conditions comprising gingival re-
as well as on expert opinion, the following expert consensus-based cessions and periodontal phenotypes have been newly defined by
recommendation (R7.7) was given in the new EFP S3 level clinical the 2018 World Workshop Classification of Periodontal Diseases
practice guideline32: and Conditions.1,12,92

TA B L E 2 Proposed guidelines for

Before Following
periodontal follow-up care during
orthodontic During orthodontic orthodontic
orthodontic therapy in patients
treatment treatment treatment
susceptible to periodontitis, based on
publications of Levin et al,88 Pini Prato and Plaque control + + +
Chambrone,66 and Herrera et al.32 Periodontal probing + + +
Every 6 months Once a year
Bitewings/parallel + + +
periapical radiographs Once a year unless there is Once a year
a pathological finding unless there is
a pathological
finding
Referral to a periodontist 1. In the event of pathologic periodontal pockets or radiographic
bone loss
2. In the event of doubt regarding the periodontal condition
|

TA B L E 3 Proposed actions required following different periodontal findings, based on Levin et al,88 Pini Prato and Chambrone,66 Sanz et
al3 and Herrera et al.32

Periodontal finding Action required

Probing depths >5 mm with no bleeding on probing Oral hygiene reinforcement; shorten interval between maintenance appointments to
4–6 weeks
Probing depths ≥5 mm with bleeding on probing Stop active orthodontic treatment; refer to a periodontist; only after resolution of the
periodontal inflammation continue orthodontic treatment with special care and
follow-up
Root resorption ≥3 mm apparent on radiographs Consider applying lighter forces; consider interruption of active tooth movement;
radiographic follow-up every 6 months

F I G U R E 7 Flowchart illustrating how orthodontic therapy (OT) of patients with stage IV periodontitis can be integrated into the overall
periodontal treatment plan with reference to recommendations R7.1–R7.8 of the S3-Level clinical practice guideline for the treatment of
stage IV periodontitis. The steps of periodontal therapy were as described in the S3-Level clinical practice guideline for the treatment of
periodontitis stages I–III.3 CAL, clinical attachment loss; PPD, probing pocket depth; BOP, bleeding on probing; RBL, radiographic bone loss;
4 w, 4 weeks; 6 m, 6 months; post-op, post-operative.32

4.1 | Gingival recession Gingival recession affects a large proportion (22–88%) of peo-
ple, with the proportion affected increasing with age.95 Among ana-
Gingival recession is defined as the apical shift of the gingival margin tomical variables, subjects with thin tissue and absence of attached
with respect to the CEJ; it leads to attachment loss and can be as- gingiva (thin gingival phenotype) tend to have a higher incidence of
sociated with various alterations of the root surface exposed to the gingival recession.12,92,96,121 Further risk factors are the shape of a
oral environment. The new classification considers the interproxi- tooth, the presence of dehiscence/fenestration, an aberrant path of
mal attachment level93 as well as the condition of the exposed root eruption, or thickness of the alveolar bone due to tooth position in
surface.94 the alveolar process.97,98
|

Gingival recession is associated with several clinical problems, increasing over time (Figure 8A). Mandibular incisors are the tooth
such as dentin hypersensitivity, the development of caries and non- type most commonly affected, followed by maxillary canines, pre-
carious cervical lesions on the exposed root surface, and impaired molars, and molars101 (Figure 8B).
esthetics, all of which are tooth-related conditions that concern the
patient and the clinician.12,99 A recent meta-analysis assessed the
long-term outcomes of untreated facial gingival recession defects. 4.2 | Periodontal phenotype
The authors concluded that facial gingival recession in subjects with
good oral hygiene is likely to result in an increase in the recession The new term “periodontal phenotype” was adopted to describe the
depth during long-term follow-up. In general, progression of gingival combination of gingival phenotype (gingival thickness, keratinized
100
recession does not seem to impair the long-term survival of teeth. tissue width) and bone morphotype (thickness of the buccal bone
Life expectancy is increasing, and people are retaining more plate).12 Gingival phenotype can be assessed by using a periodontal
teeth. Consequently, both gingival recession and the related damage probe to measure the gingival thickness observing visibility of the
to the root surface are likely to become more frequent. Therefore, it periodontal probe through gingival tissue after being inserted into
is important to define predisposing conditions or treatments that are the sulcus: (1) Probe visible: thin (≤1 mm); (2) Probe not visible: thick
associated with the occurrence of gingival recession. (>1 mm). Additional information on the three-dimensional gingival
Depending on the direction of orthodontic tooth movement, volume can be obtained by measuring the keratinized tissue width
gingival recession may develop or progress during or after OT. The from the gingival margin to the mucogingival junction. Bone mor-
prevalence of gingival recession varies from 5% to 12% at the end photypes have been measured radiographically using CBCT. There
of treatment, with the number of recessions (prevalence up to 47%) is evidence reporting a correlation between gingival thickness and

F I G U R E 8 A, Mean number of labial gingival recessions in patients treated with orthodontic therapy (cases) and in untreated controls.
Using the hurdle model, overall, the OR for cases compared with controls to have recessions is 4.48 (P < .001; 95% CI: 2.61–7.70). The OR
for the increase of age by 1 year to have recessions is 1.53 (P < .001; 95% CI: 1.38–1.70). For those estimated to have recessions, the mean
number of recessions for cases is estimated to be 142% higher than for controls (P = .013; 95% CI: 21–385). The estimated increase in
the number of recessions by increasing age, for those with recessions, was not statistically significant. This increase was estimated to be
10% (P = .231; 95% CI: 6–28). Adapted from Renkema et al.101 B, Frequencies (%) of gingival recessions per tooth at two time-points: T2
(at completion of orthodontic treatment) and T5 (5 years after completion of orthodontic treatment). Mandibular incisors seem to be the
tooth type most vulnerable to the development of gingival recessions, followed by maxillary canines, premolars, and molars. Adapted from
Renkema et al.102
|

buccal bone plate thickness.103,104 A thin gingival phenotype in- keratinized tissue before orthodontic treatment did not form new
creases the risk for gingival recession, and thin phenotypes are more keratinized tissue after the orthodontic treatment. An example of
prone to develop gingival recession of greater severity.12,100,105 a patient with lower incisors and canines affected is presented in
Figure 10.

4.2.1 | Gingival thickness

4.2.3 | Bony envelope
The assumption that the direction of tooth movements and the
buccolingual thickness of the gingiva may play an important role A histological study in experimental animals demonstrated that the
in soft tissue alteration during orthodontic treatment was system- movement of teeth to positions outside the labial or lingual alveo-
atically reviewed.106 The authors concluded that there is a higher lar plate could result in thinning of the alveolar plate or even dehis-
probability of recession during tooth movement in areas with thin cence formation.111 This observation was confirmed by a systematic
gingiva and that gingival augmentation can be indicated before review of clinical studies showing a higher occurrence or increased
the initiation of orthodontic treatment in such areas. Furthermore, severity of gingival recession in more proclined teeth compared with
studies have demonstrated a correlation between labial movement, less proclined or untreated teeth. The authors concluded that move-
post-treatment proclination, and a thin periodontal phenotype of ment of incisors out of the osseous envelope of the alveolar pro-
mandibular incisors with tooth surface exposure during and after cess can be associated with a higher tendency for development of
106–109
orthodontic treatment. gingival recessions.112 Recent cone beam CBCT studies confirm a
Thus, the occurrence of gingival recession—in particular at man- higher incidence of bony dehiscence and gingival recession in teeth
dibular incisors with post-treatment proclination—has to be viewed exposed to orthodontic forces that result in movement of teeth out-
as a common side effect/complication of OT. If post-orthodontically side the bony housing, for example, after arch expansion.113 Clearly,
a recession defect almost reaches the apex, the risk of tooth loss such outcomes should be considered at least as treatment compli-
cannot be disregarded (Figure 9). Failure to monitor patients regu- cations if not as treatment errors. Examples of patients before and
larly and not intervening when there is an increase of recession and after orthodontic arch expansion are shown in Figures 11 and 12.
loss of the attached gingiva apical to the recession should be re-
garded as a treatment error.
4.3 | Postorthodontic treatment changes in
tooth position
4.2.2 | Keratinized tissue width
Changes in tooth position that are related to orthodontic tooth
A retrospective study on the effects of OT examined the width of movement but occur during the retention phase, after comple-
keratinized tissue in young patients.110 A greater incidence of com- tion of active treatment, can also have unfavorable effects on
plete loss of keratinized tissue was found after OT on teeth with mucogingival conditions. Many clinicians use fixed flexible spiral
<2 mm of width of keratinized tissue (6.1% loss) than on teeth with wire retainers in the anterior regions of the maxilla and mandible
>2 mm width of keratinized tissue (0.1% loss). Teeth with a lack of but there is limited evidence regarding stability of orthodontic

F I G U R E 9 A 20-year-old
postorthodontic patient presenting with a
very advanced recession defect reaching
the apex. The risk of tooth loss cannot be
disregarded.
|

C
F I G U R E 1 1 A, Clinical situation of a 16-year-old healthy female
patient practicing good oral hygiene. Thin gingival tissues, narrow
gingival width, and gingival recessions already present before
orthodontic treatment. B, Five years after arch expansion, the
patient presented with generalized gingival recessions, in spite of
the extraction of four premolars in the course of the treatment.

related to the bonding failures of the retainer. In six (2.7%) pa-

tients, unexpected post-t reatment complications (torque differ-
ences of the incisors, increased buccal canine inclination) were
observed. These unexpected findings are confirmed by another
F I G U R E 1 0 A, Clinical situation of a 12-year-old healthy male
publication115 from the same group and are attributed to an active
patient before orthodontic treatment, with anterior crowding in
the mandibular front. Thin gingival tissues with an inadequate zone component of the wire due to either an elastic deflection caused
of marginal gingiva (width of keratinized tissue less than 2 mm) by the clinician or a mechanical deformation from masticatory
are present locally at the lower central incisors and canines. B, forces because the complications observed after orthodontic
Situation at the age of 17. C, Distinct gingival recessions at the treatment were not present before this treatment was started.
lower central incisors and canines at the age of 18 after debonding;
Forces generated by lingual fixed retainer wires were assessed
the patient is now complaining about hypersensitivity. Orthodontic
therapy can influence the development of gingival recessions in vitro and recorded during simulated intrusion–e xtrusion and
during orthodontic therapy involving teeth that have an inadequate buccal–lingual movements. High forces that exceed 1 N might
zone of the marginal gingiva (width of keratinized tissue less than be generated, and such forces are large enough to produce un-
2 mm) present locally at the lower central incisors and canines. wanted tooth movement during retention. Accordingly, gingival
recession with root exposure might occur as a consequence of a
root position outside the bony envelope.116 This “wire syndrome”
alignment of the mandibular anterior teeth retained using these may present in different degrees of severity and depends on the
canine-to-c anine lingual retainers. Therefore, Renkema114 as- amount of incisor inclination and torque differences.117 Reported
sessed the long-term effectiveness of mandibular canine-to- prevalence rates are up to 30%.118
canine wire retainers bonded to all six teeth in a large consecutive These unwanted adverse effects of OT in the retention phase
group of patients; they found that at 5 years post-t reatment, should be viewed at least as complications and if left unnoticed and/
alignment of the mandibular anterior teeth was stable in 90.5% or unaddressed in their early stages should be considered as treat-
of the patients, whereas 9.5% experienced an increase in the ment errors. Various solutions, including removal of the bonded lin-
main irregularity index. The increase of irregularity was strongly gual retainer,119 may be necessary (Figures 13 and 14).
|

F I G U R E 1 2 A, Clinical situation of
a 45-year-old healthy female patient
who reported difficulty in cleaning her
crowded lower incisors and problems
with food impaction; tooth #41 shows
minimal recession. B, After orthodontic
tooth alignment (arch expansion) for
oral hygiene improvement. Proclination
of tooth #41 and alignment was
accompanied by a distinct increase of
recession and loss of attached gingiva.

F I G U R E 1 3 Four clinical situations (A-D) of “Wire syndrome” characterized by an increased buccal inclination of incisors and movement
of mandibular canines. Irregularity can be graded according to differences in position of the root tip and/or coronal third of the root inside/
outside the bony envelope. A, Incisor 31 root tip within the bony envelope, coronal third 1 mm outside the bony envelope, and 3 mm of soft
tissue dehiscence: 100% root coverage possible without orthodontics. B, Incisor 41 root tip within the bony envelope, coronal third 2 mm
outside the bony envelope, and 5 mm of soft tissue dehiscence: partial root coverage possible without orthodontics. C, Incisor 31 with root
tip and coronal third >2 mm visible and outside the bony envelope: root coverage without orthodontics impossible. D, Hopeless lower incisor
31: root tip and coronal third visible on the mesial aspect, completely outside the bony and soft tissue envelope. A, B, C : Recession coverage
by Karin Jepsen; D: Extraction of the root by Anton Sculean.
|

F I G U R E 1 4 Clinical situation of the lower sextant in a 29-year-old healthy female patient undergoing orthodontics for the third time in
her life. A, Frontal view. B, Occlusal view. The reason for referral was a progressive, severe recession in the lower anterior sextant. Repeated
acute infections had occurred as a result of inadequate oral hygiene. After comprehensive examination it became evident that tooth #41
had become nonvital and was diagnosed as nonmaintainable. Orthodontic space closure after extraction of tooth #41 was not considered
because of missing bone and an anticipated unfavorable anterior occlusal relationship (Case courtesy of Giles de Quincey—Department of
Periodontology, University of Bern, Switzerland). C, After an initial phase involving scaling and root planing, and oral hygiene instructions,
planned surgical treatment was scheduled. Tooth #41 was removed. D, The residual socket was de-epithelialized and sealed using a root-
shaped, partially epithelialized connective tissue graft from the tuberosity. Within the same procedure, a palatal subepithelial connective
tissue graft was harvested from region #32–42 (using the MCAT (modified coronally advance tunnel)-/LCT (LCT, laterally closed tunnel)
technique) (E) for subsequent use in a modified coronally/laterally advanced tunneling technique, with the aim to provide root coverage (F)
and gingival augmentation (G). H, Root debridement and EDTA-conditioning was followed by the application of amelogenins to the rinsed
and dried root surfaces of teeth #31–32. The root-formed, partially epithelialized connective tissue graft was then sutured in place to the
lingual gingiva using resorbable 6-0 sutures. The subepithelial connective tissue graft was inserted into the tunnel (J) and sutured using
resorbable and non-resorbable 5-0/6-0 sutures sutures (K, L). M, N, Tooth #41 was temporarily replaced by attaching the autogenous crown
to the orthodontic appliance. A nonsteroidal anti-inflammatory drug and chlorhexidine rinse were prescribed postoperatively. Healing
was uneventful at 1 week (O) and 8 weeks (P), with limited morbidity at the palatal donor site. Q, Long-term replacement of tooth #41 was
achieved by using the autogenous crown as an adhesive bridge combined with a lingual wire retainer. Orthodontic treatment was continued
and, 13 months after surgery, tooth #41 was converted to a semi-permanent autogenous adhesive bridge, attached to the orthodontic wire
retainer from teeth #33 to 43 and—to prevent rotation—a second wire retainer from teeth #31–42.

4.4 | Periodontal phenotype modification for These studies were unable to provide a definitive answer as to when
patients receiving orthodontic treatment it is best to perform hard and soft tissue augmentation—before, dur-
ing, or after orthodontic treatment. It would be reasonable to sug-
In light of the reported risk for recessions in patients undergoing OT, gest augmentation before any labial tooth movement, especially in
an American Academy of Periodontology best-evidence consensus the presence of a thin phenotype or when there is less than 2 mm
statement120 focused on the question: “Is periodontal phenotype width of keratinized tissue.96
modification therapy beneficial for patients receiving orthodontic Examples of phenotype modification involving hard and soft tis-
treatment?” Based on a best-evidence review of the literature,96 the sue augmentation are presented in Figures 15 and 16. A procedure
authors concluded that periodontal phenotype modification involv- for phenotype modification using soft tissue augmentation before
ing hard and/or soft tissue augmentation may provide clinical bene- orthodontic treatment is described in Figure 17.
fits to patients undergoing orthodontic treatment. They emphasized Alternatively, a novel interdisciplinary orthodontic–mucogingival
that the evidence is still limited and based on only a few studies. approach for isolated gingival recession defects affecting
|

F I G U R E 1 5 This patient is presenting

with a thin periodontal phenotype
accompanied by a space-closure problem
after the loss of a deciduous molar (regio
#35). Corticotomy-assisted orthodontic
therapy combined with simultaneous
bone and soft tissue augmentation
(for modification of the periodontal
phenotype) was performed to prevent
attachment loss/recession. A, Occlusal
view showing a splace closure problem
in area #35, which is more distinct in
the left than in the right quadrant. B, A
narrow bony architecture of the collapsed
alveolar process is visible in a three-
dimensional image of the occlusal view.
C, Situation at baseline, occlusal view.
D, Situation at baseline, buccal view. E,
Postextraction site, 9 mm wide; bone
fenestration, 9 mm deep. F, After partial
decortication on the mesial aspect of
tooth #34 and to the distal aspect of
tooth #36 using a deproteinized bovine
bone mineral (BioOss®; Geistlich,
Wollhusen, Switzerland) to enhance the
bony architecture. G, A collagen matrix
(Mucograft®; Geistlich) was placed to
enhance the soft tissue volume. H, Flap
closure. I, Within 3 months, tooth #36
could be moved to close the gap with no
loss of periodontal attachment (frontal
view). K, Occlusal view (Periodontal
surgery: Karin Jepsen; orthodontic
therapy: Nikolaos Daratsianos).

mandibular incisors with a labially displaced root has been proposed. cleft formation in a 23-year-old pre-orthodontic patient with an ex-
This includes selective correction of tooth malposition and subse- traction space #13 to be closed is shown in Figure 18.
quent surgical recession coverage with coronally advanced flap and
connective tissue graft. In a case series of 20 patients, favorable 1-
year results were reported.122 4.6 | Loss of interdental papilla

Gingival recession can also be a consequence of periodontal therapy

4.5 | Gingival clefts as a result of the shrinkage of soft tissues during the resolution of in-
flammation. The pattern of interdental tissue support can have a major
Gingival clefts develop frequently during orthodontic space closure esthetic effect and may also influence the outcome of periodontal at-
and may compromise the treatment outcome. A randomized trial123 tachment regeneration. The appearance of so-called “black triangles”
indicated that the time-point when orthodontic space closure is is generally considered to be esthetically unacceptable because these
initiated after permanent tooth extraction affects the incidence of are undesirable in an esthetic smile.124 The absence of an interdental
gingival cleft development and that development of a gingival cleft papilla is one of the most challenging and troubling dilemmas in the
seems to occur more frequently following early initiation of tooth treatment of periodontal disease. Besides esthetics, patients com-
movement and in “fast movers”. The development of gingival clefts plain about functional and phonetic problems, leading to difficulties
should be considered as a complication. A severe case of gingival in personal relationships, self-esteem, and self-perception.125
|

F I G U R E 1 6 A, Typical example of a progressive recession with gingival inflammation following retainer-enhanced plaque accumulation:
recession is labial and mesial, frenum attachment, bony dehiscence is present between incisors, and the patient has a thin gingival
phenotype. All images in (A) show the situation after repeated oral hygiene instructions and professional tooth cleaning. B, Surgical
procedures, including lateral bone augmentation between the central incisors using a deproteinized bovine bone mineral (BioOss®;
Geistlich), application of enamel matrix derivative (Emdogain®; Straumann, Basel, Switzerland), and positioning of a connective tissue graft
(CTG) underneath a coronally positioned flap, were performed C, One year result: images show complete coverage after coronal positioning
of the flap (Periodontal surgery: Karin Jepsen).

F I G U R E 1 7 A, Smile line of a 30-year-

old female patient. She was more worried
about a prominent lower right canine from
an esthetic point of view than about the
severe recession. B, Severe recessions up
to 8 mm deep were present on the lower
right canine (tooth #43). C, Situation
after phenotype conversion before the
initiation of orthodontic therapy. Active
tooth movements started 1 year after
recession coverage procedures. D, Five
years after debonding (Orthodontic
therapy: Christoph Reichert. Periodontal
surgery: Karin Jepsen).
|

F I G U R E 1 8 Clinical situation of a 23-year-old healthy female patient with a missing canine tooth (extraction space #13). Having been
severely displaced, the tooth had to be removed surgically. A, Situation immediately after removal of the retained and displaced canine.
B, During movement of tooth #14 toward the right segment, an invagination became evident in the middle of the gap. C, Situation before
periodontal surgery; a buccopalatal through-and-through cleft-like defect was present. D, Full-thickness flap with maximal soft tissue
preservation, a vertical incision was made on the distal aspect of tooth #14 for access. E, Bony defect visible on the mesial aspect. F,
Placement of a collagen matrix and a bone substitute (BioGide®, BioOss®; Geistlich). G, Wound closure. H, Two weeks postoperatively. I, Six
months postoperatively. The space had almost closed and there was no additional periodontal damage (Periodontal surgery: Karin Jepsen;
orthodontic therapy: Nikolaos Daratsianos).

F I G U R E 1 9 A, Clinical situation after a 23-year-old female patient with the diagnosis periodontitis stage IV, grade C, presenting with
a complete loss of the papilla, class 3, between the maxillary central incisors, underwent nonsurgical therapy. Tunnel preparation (B) and
placement of a subepithelial connective tissue graft (C). D, Microporous, monofilament suture (Goretex 5-0; W. L. Gore & Associates,
Flagstaff, AZ, USA). E, Tooth intrusion and mesial torquing movements. F, In addition to the previous treatments, interdental stripping
reduces the bone crest—contact point distance. G, Clinical situation 1 year after debonding, demonstrating that the soft tissues adapted to
the new emergence profiles of the teeth as the interproximal spaces were reduced (Periodontal surgery: Karin Jepsen; orthodontic therapy:
Andreas Jäger).

Nordland and Tarnow126 described a classification for papilla in 98% of cases; this dropped to 56% and 27% when the distance
loss that was based on three identifiable anatomical landmarks. from the bone crest to the contact point was 6 and 7 mm, respec-
Tarnow et al127 found that when the distance between the bone tively. Wu et al128 reached a similar conclusion. In general, this
crest and the contact point was 5 mm or less, a papilla was present means that the shorter the distance between the interproximal
|

contact and the bone crest, the less likely it is that a papilla will ORCID
be missing. Karin Jepsen https://orcid.org/0000-0002-1015-3145
Adjunctive orthodontic tooth movement can be beneficial in Anton Sculean https://orcid.org/0000-0003-2836-5477
reducing interdental papilla loss. Closing the interdental contacts Søren Jepsen https://orcid.org/0000-0002-4160-5837
by conventional orthodontic movement, with or without inter-
dental stripping, reduces the bone crest—contact point distance. REFERENCES
However, the length of treatment, the need for appliances, and 1. Caton JG, Armitage G, Berglundh T, et al. A new classification
cost are limiting factors. Burke et al129 recommended bringing the scheme for periodontal and peri-implant diseases and conditions
-introduction and key changes from the 1999 classification. J Clin
roots closer using a mesial torquing movement in an attempt to
Periodontol. 2018;45:S1-S8.
compensate for missing papillae. In conjunction with orthodon- 2. Chapple ILC, Mealey BL, Van Dyke TE, et al. Periodontal health and
tic treatment, proximal enamel can be recontoured to change gingival diseases and conditions on an intact and a reduced peri-
the contact area to a broader surface, along with relocating the odontium: consensus report of Workgroup 1 of the 2017 World
Workshop on the classification of periodontal and peri-implant
contact more apically. Cardaropoli et al130 presented a study
diseases and conditions. J Clin Periodontol. 2018;45:S68-S77.
evaluating a combined approach of orthodontic and periodontal 3. Sanz M, Herrera D, Kebschull M, et al. Treatment of stage I-III
treatment to reconstruct the interdental papillae between upper periodontitis-the EFP S3 level clinical practice guideline. J Clin
central incisors, demonstrating that the soft tissues adapted to the Periodontol. 2020;47:4-60.
4. Mucha JN. Orthodontic finishing: ten steps to success. APOS
new emergence profiles during intrusion of the teeth as the inter-
Trends Orthodontics. 2018;8:184-199.
proximal spaces were reduced. A clinical example of a combined 5. Chung CH, Tadlock LP, Barone N, et al. Common errors observed
periodontal-orthodontic approach, including proximal enamel re- at the American Board of Orthodontics clinical examination. Am J
shaping together with soft tissue augmentation and orthodontic Orthod Dentofacial Orthop. 2017;152:139-142.
tooth approximation, is presented in Figure 19. 6. Lang NP, Bartold PM. Periodontal health. J Clin Periodontol.
2018;45:S9-S16.
In summary, OT can have adverse effects on mucogingival
7. Sabane A, Patil A, Swami V, Nagarajan P. Biology of tooth move-
conditions. Especially in situations with a thin gingival phenotype, ment. Br J Med Med Res. 2016;16:1-10.
labial tooth movement—in particular of mandibular incisors with 8. Polson A, Subtelny JD, Meitner SW. Long-term periodontal sta-
proclination—c an result in recession defects. This should be re- tus after orthodontic treatment. Am J Orthod Dentofacial Orthop.
1988;93:51-58.
garded as a common complication of which the patient needs to
9. Gomes SC, Varela CC, da Veiga SL, Rosing CK, Oppermann RV.
be informed prior to therapy and preventive phenotype modifica- Periodontal conditions in subjects following orthodontic therapy.
tions considered. Advanced recession defects resulting from tooth A preliminary study. Eur J Orthod. 2007;29:477-481.
movements outside the bony envelope—often associated with 10. van Gastel J, Quirynen M, Teughels W, Coucke W, Carels C.
Longitudinal changes in microbiology and clinical periodontal
rapid arch expansions—may be considered as treatment errors.
parameters after removal of fixed orthodontic appliances. Eur J
Postorthodontic changes of tooth position can occur as a result Orthod. 2011;33:15-21.
of the use of nonpassive retention devices leading to increasing 11. Fan J, Caton JG. Occlusal trauma and excessive occlusal forces:
recession defects/root exposure (“wire syndrome”). These ad- narrative review, case definitions, and diagnostic considerations. J
Periodontol. 2018;89:S214-S222.
verse events should be considered at least as complications, but,
12. Jepsen S, Caton JG, Albandar JM, et al. Periodontal manifestations
if left unnoticed and/or unaddressed, as treatment errors. The de- of systemic diseases and developmental and acquired conditions:
velopment of gingival clefts following orthodontic space closure consensus report of workgroup 3 of the 2017 world workshop
occurs frequently and is viewed as a common complication. By on the classification of periodontal and Peri-implant diseases and
conditions. J Clin Periodontol. 2018;45:S219-S229.
contrast, orthodontic tooth movement can facilitate treatment of
13. Bollen A-M, Cunha-Cruz J, Bakko DW, Huang GJ, Hujoel PP. The
the “loss of interdental papilla” through a combined periodontal– effects of orthodontic therapy on periodontal health. J Am Dent
orthodontic approach. Assoc. 2008;139:413-422.
In conclusion, the present review has identified several areas 14. Chhibber A, Agarwal S, Yadav S, Kuo CL, Upadhyay M. Which or-
of concern, in which OT can have unwanted adverse effects on thodontic appliance is best for oral hygiene? A randomized clinical
trial. Am J Orthod Dentofacial Orthop. 2018;153:175-183.
periodontal/mucogingival conditions, but also areas with great
15. Huser MC, Baehni PC, Lang R. Effects oforthodontic bands on
potential for synergies between orthodontic and periodontal microbiologic and clinical parameters. Am J Orthod Dentofacial
therapy. Orthop. 1990;97:213-218.
Altogether, these call for close consultation and offer excellent 16. Lucchese A, Bondemark L, Marcolina M, Manuelli M. Changes in
oral microbiota due to orthodontic appliances: a systematic re-
opportunities for cooperation between the two specialties for the
view. J Oral Microbiol. 2018;10:1476645.
benefit of patients affected by tooth malpositioning and periodontal 17. van Gastel J, Quirynen M, Teughels W, Coucke W, Carels C.
or mucogingival problems. Influence of bracket design on microbial and periodontal param-
eters in vivo. J Clin Periodontol. 2007;34:423-431.
18. Papageorgiou SN, Papadelli AA, Eliades T. Effect of orthodontic
AC K N OW L E D G M E N T
treatment on periodontal clinical attachment: a systematic review
Open Access funding enabled and organized by Projekt DEAL. and meta-analysis. Eur J Orthod. 2018;40:176-194.
|

19. Papageorgiou SN, Xavier GM, Cobourne MT, Eliades T. Effect 38. Feller L, Khammissa RA, Thomadakis G, Fourie J, Lemmer J. Apical
of orthodontic treatment on the subgingival microbiota: a external root resorption and repair in orthodontic tooth move-
systematic review and meta-analysis. Orthod Craniofac Res. ment: biological events. Biomed Res Int. 2016;2016:4864195.
2018;21:175-185. 39. Maues CP, do Nascimento RR, Vilella Ode V. Severe root resorp-
20. Guo R, Lin Y, Zheng Y, Li W. The microbial changes in subgingival tion resulting from orthodontic treatment: prevalence and risk
plaques of orthodontic patients: a systematic review and meta- factors. Dental Press J Orthod. 2015;20:52-58.
analysis of clinical trials. BMC Oral Health. 2017;17:90. 40. Bayir F, Bolat GE. External apical root resorption after orthodontic
21. Kado I, Hisatsune J, Tsuruda K, Tanimoto K, Sugai M. The impact treatment: incidence, severity and risk factors. J Dent Res Dent Clin
of fixed orthodontic appliances on oral microbiome dynamics in Dent Prospects. 2021;15:100-105.
Japanese patients. Sci Rep. 2020;10:21989. 41. Tieu LD, Saltaji H, Normando D, Flores-Mir C. Radiologically deter-
22. Campobasso A, Lo Muzio E, Battista G, Ciavarella D, Crincoli V, mined orthodontically induced external apical root resorption in
Lo ML. Taxonomic analysis of oral microbiome during orthodontic incisors after non-surgical orthodontic treatment of class II divi-
treatment. Int J Dent. 2021;2021:8275181. sion 1 malocclusion: a systematic review. Prog Orthod. 2014;15:48.
23. Koopman JE, van der Kaaij NC, Buijs MJ, et al. The effect of fixed 42. Bellini-Pereira SA, Aliaga-Del Castillo A, Vilanova L, et al. Sagittal,
orthodontic appliances and fluoride mouthwash on the oral micro- rotational and transverse changes with three intraoral distalization
biome of adolescents -a randomized controlled clinical trial. PLoS force systems: jones jig, distal jet and first class. J Clin Exp Dent.
One. 2015;10:e0137318. 2021;13:e455-e 462.
24. Karkhanechi M, Chow D, Sipkin J, et al. Periodontal status of adult 43. Sameshima GT, Sinclair PM. Predicting and preventing root resorp-
patients treated with fixed buccal appliances and removable align- tion: part II. Treatment factors. Am J Orthod Dentofacial Orthop.
ers over one year of active orthodontic therapy. Angle Orthod. 2001;119:511-515.
2013;83:146-151. 44. Sameshima GT, Sinclair PM. Predicting and preventing root resorp-
25. Zachrisson B. Gingival condition associated with orthodontic tion: part I. Diagnostic factors. Am J Orthod Dentofacial Orthop.
treatment. Angle Orthod. 1972;42:353-357. 2001;119:505-510.
26. Eid HA, Assiri HA, Kandyala R, Togoo RA, Turakhia VS. Gingival 45. Motokawa M, Sasamoto T, Kaku M, et al. Association between
enlargement in different age groups during fixed orthodontic root resorption incident to orthodontic treatment and treatment
treatment. J Int Oral Health. 2014;6:1-4. factors. Eur J Orthod. 2012;34:350-356.
27. Zanatta FB, Ardenghi TM, Antoniazzi RP, Pinto TM, Rosing CK. 46. Roscoe MG, Meira JB, Cattaneo PM. Association of orthodontic
Association between gingivitis and anterior gingival enlargement force system and root resorption: a systematic review. Am J Orthod
in subjects undergoing fixed orthodontic treatment. Dental Press J Dentofacial Orthop. 2015;147:610-626.
Orthod. 2014;19:59-66. 47. Sharab LY, Morford LA, Dempsey J, et al. Genetic and treatment-
28. Pinto AS, Alves LS, Zenkner J, Zanatta FB, Maltz M. Gingival en- related risk factors associated with external apical root resorp-
largement in orthodontic patients: effect of treatment duration. tion (EARR) concurrent with orthodontia. Orthod Craniofac Res.
Am J Orthod Dentofacial Orthop. 2017;152:477-482. 2015;18:71-82.
29. Trackman PC, Kantarci A. Connective tissue metabolism and gingi- 48. Yassir YA, McIntyre GT, Bearn DR. Orthodontic treatment and
val overgrowth. Crit Rev Oral Biol Med. 2004;15:165-175. root resorption: an overview of systematic reviews. Eur J Orthod.
30. Ghijselings E, Coucke W, Verdonck A, et al. Long-term changes 2021;43:442-456.
in microbiology and clinical periodontal variables after com- 49. Samandara A, Papageorgiou SN, Ioannidou-Marathiotou I,
pletion of fixed orthodontic appliances. Orthod Craniofac Res. Kavvadia-Tsatala S, Papadopoulos MA. Evaluation of orthodon-
2014;17:49-59. tically induced external root resorption following orthodontic
31. Martin C, Celis B, Ambrosio N, Bollain J, Antonoglou GN, Figuero treatment using cone beam computed tomography (CBCT): a sys-
E. Effect of orthodontic therapy in periodontitis and non- tematic review and meta-analysis. Eur J Orthod. 2019;41:67-79.
periodontitis patients: a systematic review with meta-analysis. J 50. Sondeijker CFW, Lamberts AA, Beckmann SH, et al. Development
Clin Periodontol. 2021;49:72-101. of a clinical practice guideline for orthodontically induced exter-
32. Herrera D, Sanz M, Kebschull M, et al. Treatment of stage IV nal apical root resorption. Eur J Orthod. 2020;42:115-124.
periodontitis: the EFP S3 level clinical practice guideline. J Clin 51. Weltman B, Vig KW, Fields HW, Shanker S, Kaizar EE. Root resorp-
Periodontol. 2022;49(suppl 24):4-71. tion associated with orthodontic tooth movement: a systematic
33. Lund H, Grondahl K, Grondahl HG. Cone beam computed tomog- review. Am J Orthod Dentofacial Orthop. 2010;137:462-476; dis-
raphy evaluations of marginal alveolar bone before and after or- cussion 12A.
thodontic treatment combined with premolar extractions. Eur J 52. Hirschfeld J, Reichardt E, Sharma P, et al. Interest in orthodon-
Oral Sci. 2012;120:201-211. tic tooth alignment in adult patients affected by periodontitis: a
34. Castro LO, Castro IO, de Alencar AH, Valladares-Neto J, Estrela questionnaire-based cross-sectional pilot study. J Periodontol.
C. Cone beam computed tomography evaluation of distance from 2019;90:957-965.
cementoenamel junction to alveolar crest before and after nonex- 53. Towfighi PP, Brunsvold MA, Storey AT, Arnold RM, Willman
traction orthodontic treatment. Angle Orthod. 2016;86:543-549. DE, McMahan CA. Pathologic migration of anterior teeth in
35. Jager F, Mah JK, Bumann A. Peridental bone changes after ortho- patients with moderate to severe periodontitis. J Periodontol.
dontic tooth movement with fixed appliances: a cone-beam com- 1997;68:967-972.
puted tomographic study. Angle Orthod. 2017;87:672-680. 54. Cardaropoli D, Gaveglio L. The influence of orthodontic movement
36. Garlock DT, Buschang PH, Araujo EA, Behrents RG, Kim KB. on periodontal tissues level. Semin Orthod. 2007;13:234-245.
Evaluation of marginal alveolar bone in the anterior mandi- 55. Ericsson I, Thilander B, Lindhe J, Okamoto H. The effect of or-
ble with pretreatment and posttreatment computed tomogra- thodontic tilting movements on the periodontal tissues of in-
phy in nonextraction patients. Am J Orthod Dentofacial Orthop. fected and non-infected dentitions in dogs. J Clin Periodontol.
2016;149:192-201. 1977;4:278-293.
37. Brezniak N, Wasserstein A. Orthodontically induced inflamma- 56. Wennstrom JL, Stokland BL, Nyman S, Thilander B. Periodontal
tory root resorption. Part II: the clinical aspects. Angle Orthod. tissue response to orthodontic movement of teeth with infrabony
2002;72:180-184. pockets. Am J Orthod Dentofacial Orthop. 1993;103:313-319.
|

57. Re S, Corrente G, Abundo R, Cardaropoli D. Orthodontic treat- 77. Nibali L, Koidou VP, Nieri M, Barbato L, Pagliaro U, Cairo F.
ment in periodontally compromised patients: 12-year report. Int J Regenerative surgery versus access flap for the treatment of intra-
Periodontics Restorative Dent. 2000;20:31-39. bony periodontal defects: a systematic review and meta-analysis.
58. Gkantidis N, Christou P, Topouzelis N. The orthodontic-periodontic J Clin Periodontol. 2020;47(suppl 22):320-351.
interrelationship in integrated treatment challenges: a systematic 78. Jepsen K, Jaeger A, Jepsen S. Esthetic and functional rehabil-
review. J Oral Rehabil. 2010;37:377-390. itation of a severely compromised central incisor: an interdisci-
59. Cardaropoli D, Gaveglio L, Abou-Arraj RV. Orthodontic movement plinary approach. Int J Periodontics Restorative Dent. 2015;35:
and periodontal bone defects: rationale, timing, and clinical impli- e35-e 43.
cations. Semin Orthod. 2014;20:177-187. 79. Aimetti M, Garbo D, Ercoli E, Grigorie MM, Citterio F, Romano
60. Sanz M, Martin C. Tooth movement in the periodontally com- F. Long-term prognosis of severely compromised teeth following
promised patient. In: Lindhe NPLJ, ed. Clinical Periodontology and combined periodontal and orthodontic treatment: a retrospective
Implant Dentistry. Vol 2. 6th ed. Wiley Blackwell; 2015:1297-1324. study. Int J Periodontics Restorative Dent. 2020;40:95-102.
61. Gorbunkova A, Pagni G, Brizhak A, Farronato G, Rasperini G. Impact 80. Cardaropoli D, Re S, Manuzzi W, Gaveglio L, Cardaropoli G. Bio-
of orthodontic treatment on periodontal tissues: a narrative review Oss collagen and orthodontic movement for the treatment of in-
of multidisciplinary literature. Int J Dent. 2016;2016:4723589. frabony defects in the esthetic zone. Int J Periodontics Restorative
62. Zasciurinskiene E, Lindsten R, Slotte C, Bjerklin K. Orthodontic Dent. 2006;26:553-559.
treatment in periodontitis-susceptible subjects: a systematic liter- 81. Ogihara S, Wang HL. Periodontal regeneration with or without
ature review. Clin Exp Dent Res. 2016;2:162-173. limited orthodontics for the treatment of 2- or 3-wall infrabony
63. Papageorgiou SN, Antonoglou GN, Michelogiannakis D, Kakali L, defects. J Periodontol. 2010;81:1734-1742.
Eliades T, Madianos P. Effect of periodontal-orthodontic treat- 82. Attia MS, Shoreibah EA, Ibrahim SA, Nassar HA. Regenerative
ment of teeth with pathological tooth flaring, drifting, and elonga- therapy of osseous defects combined with orthodontic tooth
tion in patients with severe periodontitis: a systematic review with movement. J Int Acad Periodontol. 2012;14:17-25.
meta-analysis. J Clin Periodontol. 2021;49:102-120. 83. Ghezzi C, Viganò VM, Francinetti P, Zanotti G, Masiero S.
64. Eliasson LA, Hugoson A, Kurol J, Siwe H. The effects of ortho- Orthodontic treatment after induced periodontal regeneration in
dontic treatment on periodontal tissues in patients with reduced deep Infrabony defects. Clin Adv Periodontics. 2013;3:24-31.
periodontal support. Eur J Orthod. 1982;4:1-9. 84. Tietmann C, Broseler F, Axelrad T, Jepsen K, Jepsen S. Regenerative
65. Boyd RL, Leggott PJ, Quinn RS, Eakle WS, Chambers D. Periodontal periodontal surgery and orthodontic tooth movement in stage IV
implications of orthodontic treatment in adults with reduced or periodontitis: a retrospective practice-based cohort study. J Clin
Normal periodontal tissues versus those of adolescents. Am J Periodontol. 2021;48:668-678.
Orthod Dentofacial Orthop. 1989;96:191-198. 85. Jepsen K, Tietmann C, Kutschera E, et al. The effect of timing of
66. Pini Prato GP, Chambrone L. Orthodontic treatment in periodontal orthodontic therapy on the outcomes of regenerative periodontal
patients: the use of periodontal gold standards to overcome the surgery in patients with stage IV periodontitis: a multicenter ran-
“grey zone”. J Periodontol. 2020;91:437-4 41. domized trial. J Clin Periodontol. 2021;48:1282-1292.
67. Zasciurinskiene E, Baseviciene N, Lindsten R, Slotte C, Jansson H, 86. Kloukos D, Roccuzzo A, Stähli A, Sculean A, Katsaros C, Salvi G.
Bjerklin K. Orthodontic treatment simultaneous to or after peri- Effect of combined periodontal and orthodontic treatment of
odontal cause-related treatment in periodontitis susceptible pa- tilted molars, and of teeth with intrabony and furcation defects
tients. Part I: clinical outcome. A randomized clinical trial. J Clin in stage IV periodontitis patients. A systematic review. J Clin
Periodontol. 2018;45:213-224. Periodontol. 2021;49:121-148.
68. Engelking G, Zachrisson BU. Effects of incisor repositioning on 87. Papapanou PN, Sanz M, Buduneli N, et al. Periodontitis: consensus
monkey periodontium after expansion through the cortical plate. report of workgroup 2 of the 2017 world workshop on the classi-
Am J Orthod Dentofacial Orthop. 1982;82:23-32. fication of periodontal and Peri-implant diseases and conditions. J
69. Cardaropoli D, Re S, Corrente G, Abundo R. Intrusion of migrated Periodontol. 2018;89:S173-S182.
incisors with infrabony defects in adult periodontal patients. Am J 88. Levin L, Einy S, Zigdon-Giladi H, Aizenbud D, Machtei EE.
Orthod Dentofacial Orthop. 2001;120:671-675; quiz 677. Guidelines for periodontal care and follow-up during orthodon-
70. Corrente G, Abundo RR, Cardaropoli D, Cardaropoli G. tic treatment in adolecents and young adults. J Appl Oral Sci.
Orthodontic movement into Infrabony defects in patients with 2012;20:399-4 03.
advanced periodontal disease: a clinical and radiological study. J 89. Jiang C, Fan C, Yu X, et al. Comparison of the efficacy of differ-
Periodontol. 2003;73:1104-1109. ent periodic periodontal scaling protocols for oral hygiene in ad-
71. Boyer S, Fontanel F, Danan M, Olivier M, Bouter D, Brion M. olescents with fixed orthodontic appliances: a prospective cohort
Severe periodontitis and orthodontics: evaluation of long-term study. Am J Orthod Dentofacial Orthop. 2021;159:435-4 42.
results. Int Orthod. 2011;9:259-273. 90. Arn ML, Dritsas K, Pandis N, Kloukos D. The effects of fixed or-
72. Ghezzi C, Silvestri M, Rasperini G. Orthodontic treatment of peri- thodontic retainers on periodontal health: a systematic review. Am
odontally involved teeth after tissue regeneration. Int J Periodontics J Orthod Dentofacial Orthop. 2020;157:156-164.e17.
Restorative Dent. 2008;28:560-567. 91. Wennstrom JL. Mucogingival considerations in orthodontic treat-
73. Roccuzzo M, Marchese S, Dalmasso P, Roccuzzo A. Periodontal ment. Semin Orthod. 1996;2:46-54.
regeneration and orthodontic treatment of severely periodontally 92. Cortellini P, Bissada NF. Mucogingival conditions in the natural
compromised teeth: 10-year results of a prospective study. Int J dentition: narrative review, case definitions, and diagnostic con-
Periodontics Restorative Dent. 2018;38:801-8 09. siderations. J Clin Periodontol. 2018;45:S190-S198.
74. Cortellini P, Tonetti MS. Clinical concepts for regenerative therapy 93. Cairo F, Nieri M, Cincinelli S, Mervelt J, Pagliaro U. The interprox-
in intrabony defects. Periodontol 2000. 2000;2015(68):282-3 07. imal clinical attachment level to classify gingival recessions and
75. Badersten A, Nilveus R, Egelberg J. Effect of nonsurgical periodon- predict root coverage outcomes: an explorative and reliability
tal therapy. II. Severely advanced periodontitis. J Clin Periodontol. study. J Clin Periodontol. 2011;38:661-666.
1984;11:63-76. 94. Pini-Prato G, Franceschi D, Cairo F, Nieri M, Rotundo R.
76. Brunsvold DMA. Pathologic tooth migration. J Periodontol. Classification of dental surface defects in areas of gingival reces-
2005;76:859-866. sion. J Periodontol. 2010;81:885-890.
|

95. Albandar JM, Kingman A. Gingival recession, gingival bleeding, 114. Renkema AM, Renkema A, Bronkhorst E, Katsaros C. Long-term
and dental calculus in adults 30 years of age and older in the effectiveness of canine-to-c anine bonded flexible spiral wire lin-
United States, 1988–1994. J Periodontol. 1999;70:30-43. gual retainers. Am J Orthod Dentofacial Orthop. 2011;139:614-621.
96. Wang CW, Yu SH, Mandelaris GA, Wang HL. Is periodontal pheno- 115. Katsaros C, Livas C, Renkema AM. Unexpected complications
type modification therapy beneficial for patients receiving ortho- of bonded mandibular lingual retainers. Am J Orthod Dentofacial
dontic treatment? An American Academy of periodontology best Orthop. 2007;132:838-8 41.
evidence review. J Periodontol. 2020;91:299-310. 116. Sifakakis I, Pandis N, Eliades T, Makou M, Katsaros C, Bourauel C.
97. Kassab MM, Cohen RE. The etiology and prevalence of gingival In-vitro assessment of the forces generated by lingual fixed retain-
recession. J Am Dent Assoc. 2003;134:220-225. ers. Am J Orthod Dentofacial Orthop. 2011;139:44-48.
98. Maroso FB, Gaio EJ, Rösing CK, Fernandes MI. Correlation be- 117. Charavet C, Vives F, Aroca S, Dridi SM. “Wire syndrome” following
tween gingival thickness and gingival recession in humans. Acta bonded orthodontic retainers: a systematic review of the litera-
Odontol Latinoam. 2015;28:162-166. ture. Healthcare (Basel). 2022;10:1003-1009.
99. Tonetti MS, Jepsen S, Working Group 2 of the European 118. Wolf M, Schulte U, Kupper K, et al. Post-treatment changes in per-
Workshop on Periodontology. Clinical efficacy of periodontal manent retention. J Orofac Orthop. 2016;77:446-453.
plastic surgery procedures: consensus report of group 2 of the 119. Beitlitum I, Barzilay V, Rayyan F, Sebaoun A, Sarig R. Post-
10th European workshop on periodontology. J Clin Periodontol. orthodontic lower incisors recessions: combined periodon-
2014;41:S36-S 43. tic and orthodontic approach. Int J Environ Res Public Health.
100. Chambrone L, Tatakis DN. Long-term outcomes of untreated buc- 2020;17:8060.
cal gingival recessions: a systematic review and meta-analysis. J 120. Kao RT, Curtis DA, Kim DM, et al. American Academy of periodon-
Periodontol. 2016;87:796-8 08. tology best evidence consensus statement on modifying peri-
101. Renkema AM, Fudalej PS, Renkema AA, Abbas F, Bronkhorst E, odontal phenotype in preparation for orthodontic and restorative
Katsaros C. Gingival labial recessions in orthodontically treated treatment. J Periodontol. 2020;91:289-298.
and untreated individuals: a case–control study. J Clin Periodontol. 121. Mehta L, Tewari S, Sharma R, Sharma RK, Tanwar N, Arora R.
2013;40:631-637. Assessment of the effect of orthodontic treatment on the sta-
102. Renkema AM, Fudalej PS, Renkema A, Kiekens R, Katsaros C. bility of pre-orthodontic recession coverage by connective tis-
Development of labial gingival recessions in orthodontically treated sue graft: a randomized controlled clinical trial. Quintessence Int.
patients. Am J Orthod Dentofacial Orthop. 2013;143:206-212. 2022;53:236-248.
103. Zweers J, Thomas RZ, Slot DE, Weisgold AS, Van der Weijden 122. Fadda M, Stefanini M, Rendon A, Sangiorgi M, Tavelli L, Zucchelli
FG. Characteristics of periodontal biotype, its dimensions, asso- G. Treatment of deep isolated gingival recession defects affect-
ciations and prevalence: a systematic review. J Clin Periodontol. ing mandibular incisors: a novel interdisciplinary orthodontic-
2014;41:958-971. Mucogingival approach. Int J Periodontics Restorative Dent.
104. Ghassemian M, Lajolo C, Semeraro V, et al. Relationship between 2022;42:25-33.
biotype and bone morphology in the lower anterior mandible: an 123. Bertl K, Neuner H, Meran A, et al. Does the time-point of ortho-
observational study. J Periodontol. 2016;87:680-689. dontic space closure initiation after tooth extraction affect the
105. Agudio G, Cortellini P, Buti J, Pini PG. Periodontal conditions of incidence of gingival cleft development? A randomized controlled
sites treated with gingival augmentation surgery compared with clinical trial. J Periodontol. 2020;91:572-581.
untreated contralateral homologous sites: an 18-to 35-year long- 124. Ziahosseini P, Hussain F, Millar BJ. Management of gingival black
term study. J Periodontol. 2016;87:1371-1378. triangles. Br Dent J. 2014;217:559-563.
106. Kim DM, Neiva R. Periodontal soft tissue non-root coverage pro- 125. Bonetti GA, Alberti A, Sartini C, Parenti SI. Patients' self-
cedures: a systematic review from the AAP regeneration work- perception of dentofacial attractiveness before and after expo-
shop. J Periodontol. 2015;86:S56-S72. sure to facial photographs. Angle Orthod. 2011;81:517-524.
107. Aziz T, Flores-Mir C. A systematic review of the association be- 126. Nordland WP, Tarnow DP. A classification system for loss of papil-
tween appliance-induced labial movement of mandibular incisors lary height. J Periodontol. 1998;69:1124-1126.
and gingival recession. Aust Orthod J. 2011;27:33-39. 127. Tarnow DP, Magner AW, Fletcher P. The effect of the distance from
108. Renkema AM, Navratilova Z, Mazurova K, Katsaros C, Fudalej PS. the contact point to the crest of bone on the presence or absence
Gingival labial recessions and the post-treatment proclination of of the interproximal dental papilla. J Periodontol. 1992;63:995-996.
mandibular incisors. Eur J Orthod. 2015;37:508-513. 128. Wu YJ, Tu YK, Huang SM, Chan CP. The influence of the distance
109. Rasperini G, Acunzo R, Cannalire P, Farronato G. Influence of from the contact point to the crest of bone on the presence of the
periodontal biotype on root surface exposure during orthodontic interproximal dental papilla. Chang Gung Med J. 2003;26:822-828.
treatment: a preliminary study. Int J Periodontics Restorative Dent. 129. Burke S, Burch JG, Tetz JA. Incidence and size of pretreatment
2015;35:665-675. overlap and posttreatment gingival embrasure space between
110. Coatoam GW, Behrents RG, Bissada NF. The width of keratinized maxillary central incisors. Am J Orthod Dentofacial Orthop.
gingiva during orthodontic treatment: its significance and impact 1994;105:506-511.
on periodontal status. J Periodontol. 1981;52:307-313. 130. Cardaropoli D, Re S, Corrente G. The papilla presence index
111. Wennstrom JL, Lindhe J, Sinclair F, Thilander B. Some periodon- (PPI):a new system to assess interproximal papillary levels. Int J
tal tissue reactions to orthodontic tooth nnovement in monkeys. J Periodontics Restorative Dent. 2004;24:488-492.
Clin Periodontol. 1987;3:121-129.
112. Joss-Vassalli I, Grebenstein C, Topcuoglu N, Sculean A, Katsaros C.
Orthodontic therapy and gingival recession: a systematic review.
Orthod Craniofac Res. 2010;13:127-141.
How to cite this article: Jepsen K, Sculean A, Jepsen S.
113. Mandelaris GA, Neiva R, Chambrone L. Cone-beam computed to-
mography and interdisciplinary dentofacial therapy: an American Complications and treatment errors involving periodontal
Academy of periodontology best evidence review focusing on tissues related to orthodontic therapy. Periodontol 2000.
risk assessment of the dentoalveolar bone changes influenced by 2023;92:135-158. doi:10.1111/prd.12484
tooth movement. J Periodontol. 2017;88:960-977.

Periodontology 2000 - 2023 - Jepsen - Complications and Treatment Errors Involving Periodontal Tissues Related To
No ratings yet
Periodontology 2000 - 2023 - Jepsen - Complications and Treatment Errors Involving Periodontal Tissues Related To
24 pages
Periodontology 2000 - 2023 - Jepsen - Complications and Treatment Errors Involving Periodontal Tissues Related To
No ratings yet
Periodontology 2000 - 2023 - Jepsen - Complications and Treatment Errors Involving Periodontal Tissues Related To
24 pages
Wjarr 2023 0689
No ratings yet
Wjarr 2023 0689
10 pages
An Update On Periodontic Orthodontic.15
No ratings yet
An Update On Periodontic Orthodontic.15
6 pages
Ortho-Perio Relation: A Review: Deepthi PK, Arun Kumar P, Esther Nalini H, Renuka Devi
No ratings yet
Ortho-Perio Relation: A Review: Deepthi PK, Arun Kumar P, Esther Nalini H, Renuka Devi
5 pages
Noticias 1368018543 PDF
No ratings yet
Noticias 1368018543 PDF
14 pages
Ortho Perio New
No ratings yet
Ortho Perio New
5 pages
An Update On Periodontic-Orthodontic Interrelationships
No ratings yet
An Update On Periodontic-Orthodontic Interrelationships
7 pages
Ortho-Perio Synergy - A Review: Crimson Publishers
No ratings yet
Ortho-Perio Synergy - A Review: Crimson Publishers
8 pages
Periodontology 2000 - 2025 - Chackartchi - Orthodontic Treatment in Periodontitis Patients
No ratings yet
Periodontology 2000 - 2025 - Chackartchi - Orthodontic Treatment in Periodontitis Patients
10 pages
Ortho Perio Interrelationships
83% (6)
Ortho Perio Interrelationships
59 pages
Biomechanical and Biological Multidisciplinary Strategies in The Orthodontic Treatment of Patients With Periodontal Diseases A Review of The Literature
No ratings yet
Biomechanical and Biological Multidisciplinary Strategies in The Orthodontic Treatment of Patients With Periodontal Diseases A Review of The Literature
14 pages
J of Oral Rehabilitation - 2010 - GKANTIDIS - The Orthodontic Periodontic Interrelationship in Integrated Treatment
No ratings yet
J of Oral Rehabilitation - 2010 - GKANTIDIS - The Orthodontic Periodontic Interrelationship in Integrated Treatment
14 pages
#1 Ortho Periodontal Health Dental Journal12-00112
No ratings yet
#1 Ortho Periodontal Health Dental Journal12-00112
16 pages
Dentistry 2828303
No ratings yet
Dentistry 2828303
14 pages
Davis 2014
No ratings yet
Davis 2014
11 pages
Orthodontics & Periodontics Synergy
No ratings yet
Orthodontics & Periodontics Synergy
5 pages
1 s2.0 S1073874624000124 Main
No ratings yet
1 s2.0 S1073874624000124 Main
9 pages
Ortho Perio Interdisciplinary Procedure
No ratings yet
Ortho Perio Interdisciplinary Procedure
64 pages
Impacts of Orthodontic Treatment On Peri
No ratings yet
Impacts of Orthodontic Treatment On Peri
10 pages
Mariyam Zehra PG 1St Year Department of Orthodontics
75% (4)
Mariyam Zehra PG 1St Year Department of Orthodontics
101 pages
The Orthodontics-Periodontics Challenges in
No ratings yet
The Orthodontics-Periodontics Challenges in
10 pages
15 Ortho Perio Interrelationships
No ratings yet
15 Ortho Perio Interrelationships
117 pages
Orthodontic Periodontics Interdisciplinary.5
No ratings yet
Orthodontic Periodontics Interdisciplinary.5
1 page
Perio Ortho
No ratings yet
Perio Ortho
9 pages
Orthodontic Treatment of Periodontal Patients Chal
No ratings yet
Orthodontic Treatment of Periodontal Patients Chal
38 pages
Periodontal Considerations During Orthodontic Intrusion and Extrusion in Healthy and Reduced Periodontium
No ratings yet
Periodontal Considerations During Orthodontic Intrusion and Extrusion in Healthy and Reduced Periodontium
25 pages
Flow Chart Perio Ortho 1-S2.0-S1761722721001431-Main PDF
No ratings yet
Flow Chart Perio Ortho 1-S2.0-S1761722721001431-Main PDF
14 pages
Interdisciplinary Orthodontics - A Review
100% (1)
Interdisciplinary Orthodontics - A Review
5 pages
32 V PDF
No ratings yet
32 V PDF
7 pages
Ortho Perio Article
No ratings yet
Ortho Perio Article
18 pages
The Effects of Orthodontic Therapy PDF
No ratings yet
The Effects of Orthodontic Therapy PDF
11 pages
Kjod 52 6 439
No ratings yet
Kjod 52 6 439
12 pages
10.21307 - Aoj 2020 101
No ratings yet
10.21307 - Aoj 2020 101
16 pages
Lyons Et Al-2017-Periodontology 2000
No ratings yet
Lyons Et Al-2017-Periodontology 2000
4 pages
Odfen 2009121 P 17
No ratings yet
Odfen 2009121 P 17
13 pages
Perio-Ortho Symbiosis: A Review Article: Dr. Apeksha Ghai and Dr. Mayur Kaushik
No ratings yet
Perio-Ortho Symbiosis: A Review Article: Dr. Apeksha Ghai and Dr. Mayur Kaushik
3 pages
Clark Seminars in Orthodontics Perio Considerations Dec 7 09
No ratings yet
Clark Seminars in Orthodontics Perio Considerations Dec 7 09
55 pages
Jurnall 1
No ratings yet
Jurnall 1
8 pages
Interdisciplinary Approach in Periodontal Therapy
92% (13)
Interdisciplinary Approach in Periodontal Therapy
100 pages
Exploring The Symbiotic Relationship Between Orthodontics and Periodontics
No ratings yet
Exploring The Symbiotic Relationship Between Orthodontics and Periodontics
3 pages
Diedrich
No ratings yet
Diedrich
16 pages
Car 50
No ratings yet
Car 50
2 pages
J Esthet Restor Dent - 2023 - Han - Precautions and Possibilities in Orthodontic Treatment of Periodontally Compromised
No ratings yet
J Esthet Restor Dent - 2023 - Han - Precautions and Possibilities in Orthodontic Treatment of Periodontally Compromised
11 pages
Orthodontic Treatment and The Compromised Periodontal Patient European Journal of Dentistry
No ratings yet
Orthodontic Treatment and The Compromised Periodontal Patient European Journal of Dentistry
2 pages
Tratamiento Ortodontico en Estadio 4 Pacientes Con Periodontitis Tiempo, Manejo y Ppronostico
No ratings yet
Tratamiento Ortodontico en Estadio 4 Pacientes Con Periodontitis Tiempo, Manejo y Ppronostico
10 pages
Pini Prato and Chambrone 2019-Journal - of - Periodontology
No ratings yet
Pini Prato and Chambrone 2019-Journal - of - Periodontology
5 pages
Pini Prato and Chambrone 2019-Journal - of - Periodontology PDF
No ratings yet
Pini Prato and Chambrone 2019-Journal - of - Periodontology PDF
5 pages
34
No ratings yet
34
58 pages
9
No ratings yet
9
11 pages
The Influence of Orthodontic Movement On Periodontal Tissues Level
No ratings yet
The Influence of Orthodontic Movement On Periodontal Tissues Level
12 pages
Ortho-Perio Interrelationship - A Review
No ratings yet
Ortho-Perio Interrelationship - A Review
4 pages
Displacement and Stress Distribution of Mandibular
No ratings yet
Displacement and Stress Distribution of Mandibular
10 pages
Interrelationships Between Orthodontics and Periodontics: Hillcrest Heights, MD
No ratings yet
Interrelationships Between Orthodontics and Periodontics: Hillcrest Heights, MD
19 pages
Orthodontic Considerations in The Evaluation and Treatment of Dentofacial Deformities
No ratings yet
Orthodontic Considerations in The Evaluation and Treatment of Dentofacial Deformities
36 pages
3rd Year MCQ 1st Term 2022 - Watermark
No ratings yet
3rd Year MCQ 1st Term 2022 - Watermark
17 pages
Seats Matrix Govt
No ratings yet
Seats Matrix Govt
9 pages
Major Connectors in Dental Prosthetics
No ratings yet
Major Connectors in Dental Prosthetics
3 pages
Principles and Design of Removable Orthodontic Appliances 1
No ratings yet
Principles and Design of Removable Orthodontic Appliances 1
134 pages
Orthodontic of Expansion Screws
No ratings yet
Orthodontic of Expansion Screws
6 pages
Bracket Positioning
No ratings yet
Bracket Positioning
16 pages
Chapter 060 LO
No ratings yet
Chapter 060 LO
59 pages
Test Bank For Dental Materials 11th Edition by Powersdownload
100% (21)
Test Bank For Dental Materials 11th Edition by Powersdownload
53 pages
Lingual Orthodontics
No ratings yet
Lingual Orthodontics
95 pages
Textbook of Complete Dentures 6th Edition by Arthur Rahn, John Ivanhoe, Kevin Plummer ISBN 1607950251 9781607950257 Download
No ratings yet
Textbook of Complete Dentures 6th Edition by Arthur Rahn, John Ivanhoe, Kevin Plummer ISBN 1607950251 9781607950257 Download
75 pages
Twenty Keys To Achieve Long-Term Stable Functional Occlusion in Orthodontics, An Evidence Based Approach
No ratings yet
Twenty Keys To Achieve Long-Term Stable Functional Occlusion in Orthodontics, An Evidence Based Approach
25 pages
Removable Orthodontic Appliances Guide
No ratings yet
Removable Orthodontic Appliances Guide
13 pages
Over Denture
No ratings yet
Over Denture
19 pages
J Esthet Restor Dent - 2006 - KOKICH - Managing Congenitally Missing Lateral Incisors Part I Canine Substitution
No ratings yet
J Esthet Restor Dent - 2006 - KOKICH - Managing Congenitally Missing Lateral Incisors Part I Canine Substitution
6 pages
Neuroclusal Rehabilitation With Planas Direct Tracks in The Treatment of Anterior Crossbite - Literature Review
No ratings yet
Neuroclusal Rehabilitation With Planas Direct Tracks in The Treatment of Anterior Crossbite - Literature Review
5 pages
Ce360 1
No ratings yet
Ce360 1
1 page
Skeletal Anchorage System Miniplates An
No ratings yet
Skeletal Anchorage System Miniplates An
9 pages
Ifu Rodin Sculpture Resin
No ratings yet
Ifu Rodin Sculpture Resin
5 pages
نموذج استرشادي مادة الاستعاضة الصناعية رابعه قديم
No ratings yet
نموذج استرشادي مادة الاستعاضة الصناعية رابعه قديم
3 pages
4th Year Weekly Timetable
No ratings yet
4th Year Weekly Timetable
2 pages
Dental Anatomy and Nomenclature For The Radiologist
No ratings yet
Dental Anatomy and Nomenclature For The Radiologist
11 pages
SAC Assessment v2 2025 05 07
No ratings yet
SAC Assessment v2 2025 05 07
3 pages
Lingualized Occlusion Guide
No ratings yet
Lingualized Occlusion Guide
2 pages
Robbins Ovate
No ratings yet
Robbins Ovate
5 pages
Periodontitis Case Study
No ratings yet
Periodontitis Case Study
4 pages
Brava Hands-On Training - Cochin, Lucknow-2
No ratings yet
Brava Hands-On Training - Cochin, Lucknow-2
2 pages
JCDR 10 ZD04
No ratings yet
JCDR 10 ZD04
3 pages
Assignment Guide For Tooth Carving
No ratings yet
Assignment Guide For Tooth Carving
3 pages
Management of Periodontally Weak Tooth
No ratings yet
Management of Periodontally Weak Tooth
75 pages
Enamel Interproximal Reduction and Periodontal Health
No ratings yet
Enamel Interproximal Reduction and Periodontal Health
4 pages

Periodontology 2000 - 2023 - Jepsen - Complications and Treatment Errors Involving Periodontal Tissues Related To

Uploaded by

Periodontology 2000 - 2023 - Jepsen - Complications and Treatment Errors Involving Periodontal Tissues Related To

Uploaded by

Received: 28 June 2022 | Revised: 25 October 2022 | Accepted: 4 January 2023

Complications and treatment errors involving periodontal

Karin Jepsen1 | Anton Sculean2 | Søren Jepsen1

1 | I NTRO D U C TI O N Orthodontics continue to see consistent problems, including lack of

Periodontology 2000. 2023;92:135–158. ﻿ wileyonlinelibrary.com/journal/prd | 135

2.2 | Gingival inflammation and overgrowth/

2.4 | Root resorption

TA B L E 2 Proposed guidelines for

Periodontal finding Action required

4.2.1 | Gingival thickness

related to the bonding failures of the retainer. In six (2.7%) pa-

F I G U R E 1 5 This patient is presenting

Gingival recession can also be a consequence of periodontal therapy

F I G U R E 1 7 A, Smile line of a 30-­year-­

You might also like

Periodontology 2000. 2023;92:135–158. wileyonlinelibrary.com/journal/prd | 135

F I G U R E 1 7 A, Smile line of a 30-year-