Orthodontic Management in Relation to Other Disciplines

By Dr. Christine R. Climaco-Bejasa

APO General Meeting
Fiscal Year 2013-2014
June 5, 2013 Wednesday
Grand Ballroom 4

A very early Wednesday morning found us orthodontists at the Solaire Grand Ballroom 4.  Much as it was a temptation to try our luck and enrich our pockets, we were there to enrich our minds and refresh our knowledge of other disciplines, such as Orthognathic Surgery and Periodontal Considerations in relation to Orthodontics.  This was organized by the Manila 2 Cell Group with Dr. Glenn Gonzales as Master of Ceremonies who is incidentally also the Cell Group Leader.

The meeting began with the registration and a lovely sitdown breakfast, giving us a chance to catch up with our friends.  Dr. Frances Tamayo soon after delivered the invocation and led the National Anthem.  Our president Dr. Laarni P. Serraon discussed some APO matters and gave updates as to upcoming lectures and encouraged us to plan ahead for our upcoming APO Regional Congress to be held in Bohol.  Dr. Lally Gogna delivered the Membership Committee Report and reminded us to update our information for the APO Directory.  We are also encouraged to provide a ‘Lifeline’ or a contact who is enabled to touch base with each one of us for purposes of information dissemination. After all APO matters and concerns have been discussed, we then proceeded with the lectures.

We were given the honor and pleasure to listen to Dr. Charles P. Sia and Dr. Antolin P. Serraon who shared their expertise in Orthognathic Surgery and Periodontics, respectively.  Dr. Charles P. Sia is a specialist in Oral and Maxillofacial Surgery.  He purports that corrective jaw surgery is done to correct a wide range of skeletal and dental irregularities. A patient’s appearance may be dramatically enhanced as a result of their surgery.  He answers the question of when to refer to an orthognathic surgeon by providing some indications which include, but not limited to, unbalanced facial appearance, protruding jaw, receding chin, difficulty chewing, open bites, chronic mouth breathing and sleep apnea.

Dr. Sia also presented some of the common osteotomies, namely: Le Fort I (maxilla), Sagittal Split (mandible advancement), Vertical Ramus, Hofer/Block Sub-Apical, Surgically-Assisted Rapid Palatal Expansion or SARPE, Surgically-Assisted Rapid Mandibular Expansion.  It would also be of importance to know the possible consequences/complications after surgery such as: edema, subacute infection, compromised post-operative airway, TMD, orthognathic relapse, trismus, gingival recession (common in mouth segment osteotomies), dental trauma/avulsion, soft tissue trauma, unfavorable fractures (common in ramus surgery), avascular necrosis, persistent neurosensory deficit and undesirable aesthetics. Thus, it cannot be emphasized enough that a thorough work-up is necessary. The patient works closely with the Orthognathic Surgeon and the Orthodontist in preparation for the surgery. They should have an open communication. The patient should be referred and evaluated by several specialists including a General Dentist, Periodontist, Prosthodontist, Implantologist to assess the status of the oral cavity and plan other procedures necessary for pre- and post-treatment.  Other necessary preparations include evaluating the psychological and social health status of the patient.

Treatment course follows a Preparation Phase, Presurgical Orthodontic Phase (9-18 months: Level and Align, Decompensation), Surgical Phase (with Healing and Recovery of 4-6 weeks), Post-Surgical Phase (done 4-6 months after surgery: Refine Alignment, Final Occlusion, Retention).

In the Philippines, Orthognathic Surgery is an elective not commonly underataken. In a few of the statictics provided by Dr. Sia, the University of Singapore is able to do 3-5 cases a month, while the University of Wales does 1-3 cases a month.  In the Philippines, it is even lower.

Our second lecturer, Dr. Antolin P. Serraon, is a founding member of the Philippine Society of Periodontology and is the current Head of the Oral Medicine Section at the UP College of Dentistry. He presented the periodontal problems associated with orthodontic treatment. These include: gingivitis, periodontitis, tooth mobility, fenestration, dehiscence and gingival recession. He also mentioned the significant changes occurring in pregnancy and puberty. The gingiva is said to have receptors for both estrogen and progesterone. These hormones increase during both pregnancy and puberty.  The effect is that there is an increase in capillary permeability and increase in tooth mobility. Prevention is the key in maintaining gingival health. OHI is instituted and the patient is motivated. Adjunctive oral care measures is recommended for the patient.  He also reminds us that elastics are “attractors” of plaque.

It is important to evaluate the periodontium of the patient.  Use a probe and measure pocket depths. A measurement of 1.5-2 mm is normal, 2-4 millimeters shows gingival inflammation, greater than 4mm shows attachment loss. Assess tooth mobility, as well, determine the degree of tooth mobility and fremitus. Third degree mobility, which is horizontal and vertical movement, is visible when grinding. Trauma from occlusion during orthodontic treatment cannot induce periodontal tissue breakdown. It may result to resorption of alveolar bone but will regenerate to original bone height when placed in a physiologic position.

Movement of bone towards alveolar bone in orthodontic tooth movement constitutes favorable tooth movement. There should be no need for pre-orthodontic gingival augmentation. With favorable tooth movement, surgical procedures will have a higher predictability of success after orthodontic treatment. However, the type of bone must also be considered. Individuals with thin bone biotype may have no periodontal pockets but have periodontal disease.  Recessions may be manifested.

Unfavorable tooth movement is the movement of teeth beyond the genetically determined envelope of alveolar bone. Before any orthodontic tooth movement is initiated, one should check for thickness of bone and tissues on the pressure side of all teeth. Careful and adequate plaque control measures should be instituted before, during and after treatment to reduce the risk of the recession. Tooth movement into compromised bone area is possible as long as periodontal status is stable, light forces should be employed, patient has developed excellent oral hygiene and avoid moving into very constricted bone.

In a study by Boyd, et.al. (1989), the findings showed that healthy periodontium did not result into further breakdown and tooth loss while unhealthy periodontium resulted into further breakdown and tooth loss. Needless to say, a healthy a peridontium pre-orthodontically is the key to maintaining the periodontal health post-treatment.

The most important treatment consideration is to reduce plaque accumulation by modifications in appliance design such as avoiding loops, hooks, elastic rings and the use of bondable tubes rather than bands. The use of well-controlled forces is necessary. For periodontally-compromised patients, use half of the normal force.

To be effective orthodontists, we should know and exhaust all possible options that are available to us. It is always good to have a team working together should the case require it. It is with gratitude that Drs. Sia and Serraon have refreshed our knowledge and updated us on  the disciplines of Orthgnathic Surgery and Periodontics.