Periodontal surgeries & Orthodontic treatment

	Periodontal treatment before orthodontic treatment
	Treatment of periodontal diseases occur during orthodontic treatment
	Soft tissue graft
	Frenectomy (removal of attachment of the lip or check to the gingiva)
	Exposure of impacted teeth for orthodontic treatment
	Mini implants and dental implants for orthodontic anchorage
	Periodontal cosmetic surgeries after orthodontic treatment
	Corticotomy and bone graft before orthodontic treatment

Periodontal treatment before orthodontic treatment

Examination of the gingiva and its treatment in case of any inflammation is very important before orthodontic treatment. Ignoring this step may worsen the periodontal condition and increase teeth mobility during orthodontic treatment due to difficulty in cleaning the teeth. Orthodontic treatment for periodontally compromised tooth without periodontal treatment and follow up may lead to loss of this tooth.

Treatment of periodontal diseases occur during orthodontic treatment

During orthodontic treatment, teeth cleaning becomes more difficult which may lead to periodontal inflammation and formation of periodontal pockets. Periodic periodontal examination and early treatment is important during orthodontic treatment.

Soft tissue graft

During orthodontic treatment, teeth cleaning becomes more difficult which may cause gingival recession. In case of gingival recession or if the gingiva is thin, soft tissue graft should be done to treat the recession and increase the gingival tissue resistance to inflammation.

Frenectomy (removal of attachment of the lip or check to the gingiva)

This surgery is usually done after completion of orthodontic, but sometimes before or during orthodontic treatment if the orthodontist request that. It is very simple surgery which takes 10 about minutes

Frenectomy (removal of attachment of the lip or check to the gingiva)       Very high thick frenum causing recession in upper right central incisor and deep pocket         After frenectomy and suturing
Before		After

	Impacted canine before exposure

	Flap design

	Flap was reflected and bone over the crown is removed

	After bone removal (osteoplasty & ostectomy)

	Flap was sutured appically

	The canine after two weeks of surgical exposure

	The canine after two weeks of surgical exposure

Before		After

Mini implants and dental implants for orthodontic anchorage :

When there are no molars that can be used for orthodontic anchorage to pull other teeth, or when the teeth that should be used for anchorage are mobile or periodontally compromised, mini-implants can be used for orthodontic anchorage

	The impacted canine can be seen in the x-ray, but adjacent teeth cannot be used to pull it out

	The canine was exposed and mini-implant was placed according to orthodontist advice to be used for pulling the canine

	The gingiva become enlarged in some patients during orthodontic treatment, which makes cleaning difficult. To solve this problem gingivectomy (removal of enlarged tissue) can be done to carve the gingiva to its original position. This surgery can be done during treatment if orthodontic treatment will take time to finish the case or postponed to after orthodontic treatment if the case is close to finish.
	Also if the patient has short teeth or gummy smile after finishing orthodontic treatment, esthetic crown lengthening can be done to solve this problem and provide better esthetics. (we should understand that orthodontic treatment can arrange and move teeth only, it cannot change shape of the teeth or the gingiva. To change the shape of the teeth, crowns or veneers can be done, and to change the shape of the gingiva, esthetic periodontal procedures should be done)

	Gingival enlargement in orthodontic patient makes teeth cleaning difficult and causing inflammation

	After gingivectomy (removal of enlarged tissue)

	Gummy smile with short teeth and the gingiva can be seen above all teeth

	Intra-oral picture before periodontal surgery

	After gingival recontouring for the right side

	After gingival recontouring for all teeth form # 16-26

	After osteoplasty and ostectomy

	The patient has high frenum attachment, Frenectomy is indicated

	After crown lengthening and frenectomy

	After finishing orthodontic treatment

	This patient does not need veneers or crown because the shape and color of teeth is acceptable

	Corticotomy is one of the modern non-invasive techniques that can be done before orthodontic treatment to speed the treatment. It is simply a surgery to thin the bone around the roots by removing only 0.5mm of bone around the roots. This surgery is usually combined with bone graft especially in arch expansion cases to increase the bone volume around the teeth and prevent root exposure.
	Doing this procedure improperly or without knowledge or experience may have a negative effect on the teeth and bone surrounding it.
	Also after doing this surgery, orthodontic treatment should be done by experienced orthodontist who is familiar with this technique.
	This technique is not applicable to all cases, case selection and treatment plan is important for excellent results
	The case selection for treatment by this technique is done by periodontist and orthodontist together

	Minimizing orthodontic treatment time to one third (e.g. cases that need 18 months of treatment can be finished in 6 months using this technique).
	Increase bone volume around the root, so expansion can be done without dehiscence of bone around the roots.
	Soft tissue graft during the same surgery in case of gingival recession.
	Cosmetic periodontal surgery when needed during the same surgery.

	This patient needs expansion of the posterior upper teeth and she has short teeth

	Full arch flap was reflected

	The flap was reflected beyond the root of the teeth

	Corticotomy grooves were made within the cortical bone (0.5 – 1.0 mm deep). The cortical penetrations were done with a small round bur for good blood supply to the graft

	Bone graft was placed to cove the decorticated area

	The flap was sutured in place

	After one week of corticotomy, bone graft, and crown lengthening. (Excellent healing)

	After finishing orthodontic treatment

	One of the difficult cases that I treated with orthodontic consultant without extraction of teeth. As you see, there is severe crowding of teeth, severe recession in the upper right canine, and moderate recession in upper right premolars and first molar

	Full arch flap was reflected and corticotomy grooves were made within the cortical bone (0.5 – 1.0 mm deep). The cortical penetrations were done with a small round bur for good blood supply to the graft

	Bone graft was placed to cove the decorticated area and soft tissue graft (AlloDerm) was used to cover the recession

	After 2 weeks of corticotomy and bone graft for all upper arch, and soft tissue graft for upper right side and upper left canine

	After 12 months, all teeth which had the recession are completely covered except the upper right canine which had about 60% coverage