King Saud University Journal of Dental Sciences (2013) 4, 9194

King Saud University

King Saud University Journal of Dental Sciences

www.ksu.edu.sa
www.sciencedirect.com

CASE REPORT

Periodontium biotype modication prior to

an orthodontic therapy: Case report
Hassan A. Alhulaimi
a
b

a,*

, Fatin A. Awartani

Head of Periodontic Department, Alhassa Dental Center, MOH, Saudi Arabia

Professor at Periodontic and Community Department, College of Dentistry, KSU, Saudi Arabia

Received 29 May 2012; revised 25 February 2013; accepted 29 April 2013

Available online 19 June 2013

KEYWORDS
Collagen membrane;
Alloderm;
Periodontium biotype;
Orthodontic treatment

Abstract Introduction: Thin periodontium is frequently characterized by osseous defects and dehiscence; moreover, it exhibits pathological changes like gingival recession when subjected to traumatic
surgical insults or orthodontic force more than thick periodontium. Therefore, this case report aimed
to validate the need for bio-modication of thin periodontium before an orthodontic treatment.
Case description: A 30-year old female patient who had started on orthodontic treatment which was
not completed because of hypermobility of the anterior teeth. Periodontal diagnosis revealed a localized chronic slight periodontitis and severe crowding in the anterior mandibular arch and ridge defects
(Siebert class I) at the sites of missing maxillary lateral incisors. The patient was prepared for periodontal surgery by scaling and root planning. Periodontal surgery included frenectomy and simultaneous bone augmentation using GBR procedure which was done using 0.5 mg of BioOss and
20 30 mm size/GBR membrane (AlloDerm) then 625 mg Augmentin TID and 400 Ibuprofen
TID, were prescribed for 7 days.
Results: The patient responded well to the surgical treatment and neither bleeding pockets nor probing depth exceeding 4 mm was detected at the follow-up examinations. The mobility of Teeth #11 and
#21 reduced from grade II to almost normal status. The soft tissues were well adapted and the defects
in the sites of the missing maxillary lateral incisors disappeared. One year later the orthodontic therapy
was restarted.
Conclusions: The outcomes of this case treatment showed that the thickening of the soft tissues,
before an orthodontic treatment has a clinical positive effect. Moreover; transferring the case from
thin periodontium to thick periodontium would have reduced the possibility of future breakdown
of the periodontium during the orthodontic therapy.
2013 Production and hosting by Elsevier B.V. on behalf of King Saud University.
Open access under CC BY-NC-ND license.

* Corresponding author.
E-mail addresses: halhulaimi@hotmail.com (H.A. Alhulaimi),
fawartani@me.com (F.A. Awartani).
Peer review under responsibility of King Saud University.

Production and hosting by Elsevier

1. Introduction
Orthodontic therapy is a common dental treatment serving
nowadays all the age groups. The orthodontists usually deal
with variable cases having different periodontal situations in
which the periodontal health is crucial for the orthodontic

2210-8157 2013 Production and hosting by Elsevier B.V. on behalf of King Saud University. Open access under CC BY-NC-ND license.
http://dx.doi.org/10.1016/j.ksujds.2013.04.002

92
therapy. They use different appliances with variable force magnitudes in different directions.6,13 Experimental studies demonstrated that when a tooth is moved bodily in a labial direction
toward the cortical plate of the alveolar bone, no bone formation will occur. In addition, bone thinning and dehiscence
might take place as well. Such cortical plate perforation can
occur during an orthodontic treatment in some unavoidable
situations especially with thin periodontium which may lead
to gingival recession and root exposure.11,12,15
There are two periodontium biotypes in general: thick periodontium (Prevalence: 85%) and thin periodontium (Prevalence: 15%) while there are few cases which have features of
both thick and thin types.9 Thick periodontium is characterized by thick gingival tissue which is probably the image most
associated with periodontal health. The tissue is dense in
appearance with a fairly large zone of attachment. The gingival
topography is relatively at with the suggestion of a thick
underlying bony architecture.3,8 Surgical evaluation of these
areas often reveals relatively thick underlying osseous forms.
On the other hand, thin gingival tissue tends to be delicate
and almost translucent in appearance (Fig. 1a and b). The tissue appears friable with a minimal zone of the attached gingivae. The soft tissue is highly accentuated and often suggestive
of thin or minimal bone over the roots labialy. Moreover, thin
gingival tissues are frequently characterized by osseous defects
like fenestration and dehiscence.9 Moreover, thin periodontium usually exhibits pathological changes like gingival recession when subjected to inammatory, traumatic or surgical
insults. Scientic reports found that an orthodontic force
and appliances may cause gingival recession in cases of thin
periodontium7. Therefore; preparatory periodontal therapy is
needed to prevent periodontal tissue breakdown during an
orthodontic treatment.4,5 The periodontal treatment includes
non-surgical periodontal therapy and/or surgical correction
of any soft tissue or bone defects. Surgical corrective therapy
includes different interventions like frenectomy, soft tissue

H.A. Alhulaimi, F.A. Awartani

augmentation and bone augmentation.4,5 Both soft tissues
and bone augmentations have been reported to have high success rate if the case was cautiously selected.1,14 It is possible to
modify the thin periodontal tissues by using these surgical
techniques before or during an orthodontic therapy to avoid
tissue collapse.
One of the key factors for the successful treatment of patients with orthodontic problems is the interdisciplinary intervention, which involves teamwork approach to achieve an
optimal result. Only few clinical reports presented such situation which shows the importance to prepare the case before
an orthodontic therapy. Therefore, this case report aimed to
present a clinical evidence for the need in some cases, to modify
the periodontal tissue biotype prior to an orthodontic therapy.
2. Case presentation
The patient is a 30-year-old, well-educated woman in good general health; she had started the orthodontic therapy on February 2009, for teeth arrangement. The patient had been seeing
her orthodontist monthly for follow-up. The orthodontist
was notied by the patient about the hypermobility of upper
teeth during the treatment about 56 months later. The orthodontist had referred the patient to the periodontal clinic in Alhassa dental center for periodontal assessment and care since
then. The patient was thoroughly examined, and investigated.
Periodontal examination showed a shallow pocket formation
in general, with no gingival recession, but a grade II mobility
of maxillary central incisors, with thin gingival tissues and the
root shadow were clearly seen at anterior segments of both arches (Fig. 1a and b). Periodontal diagnosis revealed a localized
chronic slight periodontitis and severe crowding in the anterior
mandibular arch and ridge defects (Siebert class I) at the sites of
missing maxillary lateral incisors (Fig. 1a and b). Moreover, the
patient was worried and apprehensive about her situation,
therefore; the orthodontist was advised to delay the orthodontic treatment. Agreement was done with the patient to start
periodontal therapy before an orthodontic teeth alignment.
Periodontal treatment plan included full mouth scaling and
root planning then periodontal surgery at the area of maxillary
anterior sites to correct the ridge defect, and to augment the
thin gingivae.
3. Treatment

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

from canine to canine are translucent in appearance. The tissues
are friable with a minimal zone of attached gingivae which suggest
thin or minimal bone over the root labial as well.

The periodontal therapy was initiated, which included patient

education, oral hygiene instructions, supragingival/subgingival
scaling and root planning of the entire dentition. One month
later, the patient was booked for surgical correction. The surgery was started by frenectomy which was done to relieve tissue tension and to enhance future teeth alignment. Suturing
was done at the frenectomy site. Facial mucoperiosteal ap
was reected from distal site to distal site of teeth #13 and
#23. Exploration of the surgery sites showed osseous defects
at both sites of missing teeth #12 and #22. Dehiscences at teeth
#11 and #21, and bone fenestrations at tooth #13 were detected. Curettage of granulation tissues was done using surgical curette. Bone augmentation was started by decortication
using round surgical bur at defect sites. Bone granules of
0.5 gm (BioOss) were used to ll the defects, and to thicken
the cortical plate, and to cover the fenestration (Fig. 2a and b).

Periodontium biotype modication prior to an orthodontic therapy: Case report

93

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

used to cover the augmented sites. Resorbable suture was used to
x the membrane in situ, and then the aps were repositioned and
sutured to completely cover the wound.

patient was advised to rinse with a 0.2% chlorhexidine gluconate mouthwash twice daily for 21 days.
Figure 2 Mucoperiosteal ap reection from distal site to distal
site of teeth #13 and #23. The surgery sites showed osseous defects
at both sites of missing teeth #12 and #22. Dehiscences at teeth
#11 and #21, and bone fenestrations at tooth #13 were detected.

GBR membrane (AlloDerm) of 20 30 mm size/was used to

cover the augmented sites. Resorbable suture was used to x
the membrane in situ (Figs. 3 and 4). The aps were repositioned and sutured to completely cover the wound and then
a periodontal dressing was used. 625 mg Augmentin TID
and 400 Ibuprofen TID, were prescribed for 7 days. The

4. Treatment evaluation
The patient was reviewed after 2 weeks from the day of surgery
for initial healing assessment and suture removal. The healing of
soft tissues showed good tissue adaptation with minimum gingival margin inammation and no complications were detected.
The sutures were removed under normal saline irrigation. The
patient was instructed to continue on mouthwash for two more
weeks then to resume the oral hygiene practice. The patient was
followed after 2 months from the surgery then put on recall supporting periodontal therapy every 2 months for one year.
The patient responded well to the treatment and neither
bleeding pockets nor probing depth exceeding 4 mm was detected at the follow-up examinations. Mobility of Teeth #11
and #21 reduced from grade II to almost normal status. The
soft tissues were well adapted and tissue thickness increased
in the sites of missing teeth #12 and #22 (Fig. 5). One year later
the orthodontic therapy was restarted (Fig. 6a, b and c).
5. Discussion

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

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

Figure 5
#22.

In this case; the regular periodontal visits before the surgical

intervention revealed that the patient had a great interest in
having a healthier dentition to urge the orthodontic therapy.

Six months after surgery, the soft tissues were well adapted and tissue thickness increased in the sites of missing teeth #12 and

94

H.A. Alhulaimi, F.A. Awartani

morphology (a three-wall defect will heal with more bone ll
than a two-wall or one-wall defect). Tooth mobility, ap coverage of the defect, operator skill, and of course the level of patient compliance are other important factors. However, clinical
and histomorphometric studies, demonstrated that the
combination of Bio-Oss with collagen membranes or GBR
AlloDerm could be used successfully for alveolar ridge
augmentation.2,4
The outcomes of the short term follow ups of this case
showed that the thickening of the tissues, before or during
an orthodontic treatment has a clinical positive effect. Moreover, transferring the case from thin periodontium to thick
periodontium would have reduced the possibility of future
breakdown of the periodontium during an orthodontic therapy. In addition, better soft tissue adaptation over the anterior
teeth which was clearly observed could give better gingival
appearance that increased the patient satisfaction.
References

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

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

Patient observation of the front teeth in the maxilla had proclined and big diastema (3 mm) with missing lateral incisors
and mobility underscores her higher aesthetic consciousness.
However the patient and her orthodontist were not fully aware
of the partially periodontal breakdown and osseous defects at
the sites of missing teeth #12 and #22 which was scored as class
I ridge defect according to Seibert classication 10. As a prerequisite, a thorough periodontal treatment then followed by surgical correction was carried out. Surgical therapy aimed to ll
the defects at the sites of missing maxillary lateral incisors
and to thicken the tissues over central incisors. The defect correction gave better soft tissue adaptation at the sites of missing
lateral incisors. Moreover; it gave better tissue adaptation over
central incisors as well. Although the patient had missing maxillary lateral incisors, proclined central incisors and big diastema, good periodontal healing with bone ll at the defects
and tissue thickening enhanced the aesthetic results obtained.
This issue was revealed by the response of the patient where
she had a feeling of better lip ll after the surgery being done.
The presented treatment is in the scope of periodontal surgical modalities although predictability of ridge defects healing
with this amount of bone ll is always scarce. However; horizontal ridge augmentation has been used successfully.4 Many
factors can interfere with the healing response: e.g. the defect

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