Ortodoncia Valencia: The patient with hyperplasia gingival induced by orthodontic movement and poor oral hygiene will undergo a gingivectomy before orthognathic surgery to correct her gummy smile and intermaxillary positioning. 

Gummy smile, gingivectomy, gingival hyperplasia, orthodontic movement, orthognathic surgery, metal brackets braces.

Referral

The patient was attended in a private clinic in (Sarpsborg, Norway).

Patient Complaint

« Her orthodontist referred the patient to remove her wisdom teeth and treat her periodontal disease. »

History of presenting complaints

The patient attends the consultation gingivitis, generalised by biofilm induced and due to local risk factors as brackets(Caton et al., 2018).

She associates the growth of her gums with her gummy smile, diagnosed by her maxillofacial surgeon as a bone excess case which needs surgery.

Her teeth have always been small, but since she got braces, her teeth have gotten smaller. 

 

Social history

Age: 26 years old

Occupation: Student.

Medical History:

Alcohol intake: She drinks on the weekends, four glasses of wine per week.

Family conditions: Her mother is originally from Africa, Cameroon. She has fluid retention problems and osteoarthritis(Sacitharan, 2019) in her hands and feet.

 

Dental history

Oral hygiene: She brushes her teeth but does not floss or superfloss.

However, on the first few consultations, she was taught to use superfloss (Wong & Wade, 1985).

Dental visits: Frequent.

Evaluation:

 1. Health

2. Function

3. Aesthetics

The maximum aperture was 42 mm in the anterior zone.

Attitudes Towards Previous Treatment

Good attitude.

 

Systematic orofacial examination

The face:

1. Black woman with brachyfacial features.

2. She has a convex profile that lacks a lip seal. Her lips have hypermobility and an anterior open bite.

Periodontal Treatments 

phase one

1. The first step in therapy is to guide behaviour change by successfully motivating the patient to remove supragingival dental biofilm and risk factor control.

To achieve this first step, it is necessary to do the following:

• Supragingival dental biofilm control and develop skills in dental biofilm removal. 

• Interventions to improve the effectiveness of oral hygiene motivation and instructions.

• Adjunctive therapies for gingival inflammation 

• Interventions aimed at removing supragingival plaque and calculus, as well as possible plaque-retentive factors that impair oral hygiene practices.

• Risk factor control includes all the behavioural health change interventions eliminating/mitigating the recognised risk factors for periodontitis onset and progression (smoking cessation, improved metabolic control of diabetes, and dietary counselling and weight loss).

I reevaluated the patient after six weeks to continue building motivation and adherence or exploring other alternatives to overcome the barriers.

Treatments

1. Cleaning and applying airflow are carried out.

2. Radiological diagnostic method: Periapical radiographs and orthopantomography were performed to assess periodontal health.

3. Perio chart shows the deep pockets and soft tissue conditions:

A. The probing deep generalised was 7 mm. In the periodogram obtained from the OPUS program, we observe that the patient presents large periodontal pockets because there is a generalised overgrowth of the gum on the enamel-cemental line.

B. The gingival margin of teeth with brackets is above the Enamel-cementum line, an average of 4 mm., which is related to orthodontic treatment and biofilm-induced, producing gingival hyperplasia.

C. CAL values were 3 mm in general.

D. Bleeding and plaque generalised.

E. Thick biotype.

F. Generalised gingival hyperplasia in superior and inferior teeth with brackets.

G. The patient has gingivitis, generalised by biofilm induced and due to local risk factors as brackets(Caton et al., 2018).

H. The CPITN code was 2 for the majority of her teeth.

F. At the sevens level, when this periodogram was performed, she did not have orthodontic bands; she did not present bleeding or gingival hyperplasia in these molars, which helps diagnose gingival hyperplasia due to orthodontic treatment and biofilm.

4. The patient was taught the instructions and good brushing and flossing techniques. An electric toothbrush is recommended since, according to Ccahuana-Vasquez et al. (Ccahuana-Vasquez et al., 2019), 2019 reduces plaque and gingivitis compared to the manual toothbrush.

5. To control plaque levels in the patients, it was recommended to use some tablets to detect plaque after brushing. Thus, they would know if the plaque is being removed and where they need to brush better.

6. The patient was inculcated with motivation and education about the harmful effects of tobacco and alcohol on health. It was recommended to visit pages such as the Slutta.no page, created by Helsenorge.no, for more information on quitting smoking. Pinto-Filho et al. 2018(Pinto-Filho et al., 2018) conducted a cross-sectional study about alcohol and tooth loss. They found that Alcohol dependence increased 2.5 times the risk of tooth loss.

7. Every four months until she got the surgical operation, systematic revaluation was recommended to check the periodontal evolution in the supportive periodontal care phase.

  Perio-Chart

Up:

  Down:

 

 O.P.G

 

  Intraoral Photos

 

 

 

 

 

 

 

 Diagnosis

1. The patient has gingivitis induced by biofilm due to local risk factors such as brackets(Caton et al., 2018).

2. She presents a gummy bone smile and gingival hyperplasia associated with orthodontic treatment with nickel brackets(Gursoy et al., 2007) and poor oral hygiene. 

3. She has an altered passive eruption type 1 subtype A. See image 1.

  Image 1.

The image is taken from the article by Mele et al. 2018(Mele et al., 2018).

Differential diagnosis

1. Gingival hyperplasia of idiopathic origin.

2. Gingival hyperplasia caused by drugs such as cyclosporine (Sánchez López, Cariati and Rodríguez, 2019) and nifedipine.

Once phase one was completed, making the patient understand why her gums were bleeding and the importance of controlling the plaque, we began phase two of the treatment.

Phase two

The second therapy step aims to control (reduce/eliminate) the subgingival biofilm and calculus (subgingival instrumentation). In addition to this, the following interventions may be included:

• Use of adjunctive physical or chemical agents • Use of adjunctive host-modulating agents (local or systemic) • Use of adjunctive subgingival locally delivered antimicrobials • Use of adjunctive systemic antimicrobials(Sanz et al., 2020)

1. Scaling and root planning were performed. The aims of this treatment are:

A. To reduce bleeding and the level of plaque to £25%.

B. To reduce the depth level of the pocket under 4 mm plus BOP and any PPD> 6 mm.

C. Keep the horizontal defect under 2-3 mm in the furcation.

D. To prevent pain or bad smell.

E. To evaluate other techniques such as regenerative or resective surgery or re-scaling and root planning again if this treatment is not successful in the periodontal revaluation carried out after six weeks.

2. The patient was inculcated with motivation and education about the harmful effects of tobacco and alcohol on health. It was recommended to visit pages such as the Slutta.no page, created by Helsenorge.no, for more information on quitting smoking. Pinto-Filho et al. 2018(Pinto-Filho et al., 2018) conducted a cross-sectional study about alcohol and tooth loss. They found that Alcohol dependence increased 2.5 times the risk of tooth loss.

1. Periodontal re-evaluation

The aims of therapy:

 No periodontal pockets >4 mm with bleeding on probing or no deep periodontal pockets ≥6 mm. 

If this is not done, in that case, the third step of therapy should be considered. Some specific situations follow directly to phase three, such as tooth mobility with no antagonist.

If the treatment successfully achieves the therapy endpoints, patients should be placed in supportive periodontal care (SPC) programme.(Herrera et al., 2022).

1. After scaling and root planning, indicating the brushing and flossing technique to the patient, the patient was summoned for a review two weeks later.

2. The results were unfavourable; the gingiva was still bloody and showed gingival hyperplasia.

Teeth prognosis (Mac Guire, 1991)

Her teeth have a good prognosis since when a gingivectomy is performed, they can be cleaned better, less plaque will accumulate, and they will bleed less. Therefore, their prognosis is good.

Once the orthognathic surgery has been performed, a new prognosis should be made because this type of surgery often involves root resorption or dental mobility.

In this case, after phase two of her periodontal treatment, it was decided to move the patient to phase three Since we needed to carry out a new treatment plan that included a gingivectomy to eliminate the size of the periodontal pockets and allow the patient to have better hygiene, her orthodontist could better visualise the size of the clinical crowns, to place them in a perfect position the brackets.

Phase three

If the endpoints of therapy: 

No periodontal pockets >4 mm with bleeding on probing or deep pockets ≥6 mm have not been achieved. The third therapy step should be implemented(Sanz et al., 2020).

to gain further access to subgingival instrumentation or aim at regenerating or resecting those lesions that add complexity in managing periodontitis (intra-bony and furcation lesions). It may include the following interventions(Sanz et al., 2020):

• Repeated subgingival instrumentation with or without adjunctive therapies

• Access flap periodontal surgery • Resective periodontal surgery • Regenerative periodontal surgery.

When there is an indication for surgical interventions, these should be subject to additional patient consent, and specific evaluation of risk factors or medical contraindications should be considered. In addition, the individual response to the third therapy step should be re-assessed (periodontal re-evaluation)(Sanz et al., 2020).

Once it was verified that the previous requirements were met, a treatment plan was designed to perform the following:

1. Gingivectomy went from the cementoenamel line to the incisal, plus a gingival peeling to reduce the gum’s thickness.

1. Gingival peeling eliminates melanin pigmentations(Taher et al., 2020). It is indisputable that she has a bony, gummy smile. However, in this case, the gingivectomy will help the surgeon know exactly where the termination of the crown is and allow the orthodontist to reposition the brackets if deemed necessary.

Differential treatment to make the gingivectomy

Authors Dolt AH 3rd & Robbins JW 1997(Dolt et al., 3rd, & Robbins, 1997) suggested sitting in front of the patient and using an acrylic resin or resin composite stent as a surgical guide.

This technique is quite good, but it is more challenging to position a surgical guide splint with brackets.

Treatment

1. In this case, the peeling is performed with a round bur and a scalpel; the idea was to thin the keratinised gum and eliminate melanin pigmentation. After two weeks, the ideal smile design was made, the teeth were measured from the enamel-cemental line to incisal, three points were created with the periodontal probe, and then these points were joined with a scalpel.

1. A 1-2 and 5-6 curette was used to remove the excess tissue.

1. A round bur was used to improve the gingival profile of each tooth. 

1. Chlorhexidine at 0,12% was applied to rinse the gingiva, and maintenance chlorhexidine was prescribed for one week. Ibuprofen 400 mg was named during the first day every 8 hours.

1. Given the possible gingival bleeding, Cyklokaprom was prescribed to control the bleeding. 

 

Options (conveniences- inconveniences)

conveniences

1. It is a treatment shown in numerous articles that it works. It is known that the gingival peeling(Taher et al., 2020) recurs, the patient is informed.

2. Gingivectomy with a scalpel blade is a treatment that requires much agility to make it look good(Inchingolo et al., 2010); however, it is a treatment studied in several articles.

Inconveniences

1. Today, more advanced techniques exist than the scalpel, such as the YAG laser(Inchingolo et al., 2010). 

1. To control bleeding, using an electric scalpel makes things much more manageable.

 

Photos of gingivectomy and peeling

Re-evaluation

Periodontal re-evaluation

The aims of therapy:

 No periodontal pockets >4 mm with bleeding on probing or no deep periodontal pockets ≥6 mm. 

In the upper part, it is fulfilled; now, we must start at the bottom.

Once the objectives were met, the patient was recommended to continue in phase four of periodontal treatment; an agreement was reached that it would be done every four months until orthognathic surgery was performed.

Photo after gingivectomy in the maxilla and starting of the mandible

Phase four

It aims to maintain periodontal stability in all treated periodontitis patients by combining preventive and therapeutic interventions defined in therapy’s first and second steps. It is realised from three to six months after phases one, two or three, depending on the severity of the condition, age, and cooperation.

The must be rechecked risk factors, do the perio chart again.

• Register of dental biofilm.
• PPD.
• Furcations invoice exam.
• Mobility.
• X-rays if there are clinic changes or pain.

Scaling and root planning and polish restorations in specific points:

A. To reduce bleeding and the level of plaque to £25%.

B. To reduce the depth level of the pocket to under 5 mm.

C. Keep the horizontal defect under 2-3 mm in the furcation involved.

D. To prevent pain or bad smell.

If everything is controlled and there are no periodontal pockets >4 mm with bleeding on probing or no deep periodontal pockets ≥6 mm, the control appointment will be the first year every four months and the second year every six months; This must be agreed upon with the patient, his cooperation, and financial conditions.

1. The patient was continuously motivated and educated on the harmful effects of tobacco and alcohol on health. It was recommended to visit pages such as the Slutta.no page, created by Helsenorge.no, for more information on quitting smoking. Pinto-Filho et al. 2018(Pinto-Filho et al., 2018) conducted a cross-sectional study about alcohol and tooth loss. They found that Alcohol dependence increased 2.5 times the risk of tooth loss.
2. Systematic revaluation was recommended after four months to recheck the periodontal evolution.

The depth level of the periodontal pockets decreased because the distance from the bone level to the enamel line diminished. This occurred by increasing the size of the clinical crown(Marzadori et al., 2018). 

 

Periapical X-rays

Teeth prognosis (Mac Guire, 1991)

Her level of plaque and hygiene improvement has been incredible. Even though she has braces, she handles the water pick and super floss very well.

Reviewing the periapical ones, she has lost some interproximal bone due to orthodontic movements. It must be remembered that the patient is an adult woman.

The general prognosis for her teeth is good until she has orthognathic surgery, which must be done again.

Evolution

As of February 2023, she has not yet undergone orthognathic surgery. Her orthodontic treatment has slowed down. Her third molars were extracted at the indication of her orthodontist.

On March 17, he told us that he would live in another city and would not be able to continue with his treatment. He was given the journal and all the relevant information on the patient.