50th Congress of SFSCMFCO

Received: 
20 February 2014 
 Periodontal management in orthognathic
Accepted: 
16 May 2014
Available online



surgery: Early screening of periodontal risk
10 July 2014 


and its current management for the


 optimization of orthodontic and surgical




treatments


 La prise en charge parodontale en chirurgie orthognathique :


 le dépistage précoce du risque parodontal et sa prise en charge

 actuelle pour une optimisation des traitements


 orthodontico-chirurgicaux


Available online at 
 B. Straub, P. Bouletreau*, P. Breton

ScienceDirect 
 Service de stomatologie de chirurgie maxillo-faciale et chirurgie plastique de la face, centre
www.sciencedirect.com hospitalier Lyon-Sud, 165, chemin du Grand-Revoyet, 69495 Pierre-Bénite cedex, France

Summary
Orthodontic preparation for orthognathic surgery requires correct-
ing mal-occlusions and coordination of arcades. In addition to
improving the aesthetics, these treatments can ensure the achie-
vement and sustainability of prosthetics and/or implants. Never-
theless, periodontal structures are easily damaged. Orthodontic
displacement can only be applied in the absence of inflammation
or weakened periodontal structure. An early detection of perio-
dontal risk should be achievable by prescribers of a surgical-
orthodontic treatment. Simplified periodontal examination, with
easily detectable warning signs, will help to identify the periodontal
risk. Although periodontal treatment follows current ‘‘non invasive’’
trend, some procedures remain necessary to prevent and/or remedy
periodontal defects or diseases, such as mineral periodontal rein-
forcement corticotomy. It is essential that the patient meets all the
practitioners to plan and assess the extent of the constraints
necessary to optimize results, before starting orthodontic treatment
combined with orthognathic surgery. Any periodontal complication
Résumé
La préparation orthodontique en vue d’une chirurgie orthognathique
nécessite la correction des malpositions dentaires et la coordination des
arcades. En plus de l’amélioration de l’esthétique, ces traitements
permettent d’assurer la réalisation et la pérennité de travaux prothé-
tiques et/ou implantaires. Néanmoins, les structures du parodonte sont
facilement dommageables. Les mouvements d’orthodontie qui la sol-
licitent doivent être appliqués en l’absence d’inflammation ou de
faiblesse d’attache. Le dépistage précoce du risque parodontal doit
être réalisable par tous les intervenants dans un traitement chirurgico-
orthodontique. L’examen parodontal simplifié, grâce à des
« clignotants » faciles à reconnaı̂tre,permettra de ciblerles « parodontes
à risque ». Bien que les traitements parodontaux suivent la mouvance
actuelle « non invasive », certains gestes restent indispensables pour
prévenir et/ou remédier aux pathologies parodontales comme le renfort
parodontal minéralisé basé sur les principes de la corticotomie. Avant
de débuter un traitement d’orthodontie associé à une chirurgie ortho-
gnathique, il est primordial que le patient rencontre tous les « acteurs »

* Corresponding author.
e-mail: pierre.bouletreau@chu-lyon.fr (P. Bouletreau).

http://dx.doi.org/10.1016/j.revsto.2014.06.001 Rev Stomatol Chir Maxillofac Chir Orale 2014;115:208-218

2213-6533/ß 2014 Elsevier Masson SAS. All rights reserved.

208

(even minor) will be considered as a failure, regardless of good
aesthetic and functional results.
ß 2014 Elsevier Masson SAS. All rights reserved.
Keywords: Periodontium, Orthodontics, Orthognatic surgery
‘‘O
rthognathic surgery is a teamwork! The imple-
mentation of an orthodontic-surgical protocol
may require the intervention of many practi-
tioners, and their coordination often determines the quality of
the final result’’ [1]. Orthodontic treatments are no longer
considered as likely to worsen or induce periodontal lesions;
likewise, orthognathic procedures are no longer restricted to
treatment of major dysmorphism. Indeed, many authors have
demonstrated that dental alignment facilitates plaque
control and prevents the aggravation of a periodontal disease.
Likewise, coordination of arcades with orthognathic surgery
decreases displacements and duration of orthodontic treat-
ment. The authors of a retrospective study demonstrated that
some major mal-occlusions could induce and/or worsen perio-
dontal diseases: corticotomy allows obtaining 2 to 4 times
faster results for the active phases of treatment, and a great
stability of results by thickening of the cortical bone [2].
Whatever the type of treatment, orthodontic treatments
can only be performed on healthy or treated, thick or rein-
forced periodontium.
The periodontal pre-orthodontic treatment diagnosis is a
mandatory clinical step. Two types of periodontal diseases
may be diagnosed: inflammatory diseases of bacterial origin
and tissue defects (osseous or mucous). The initial consulta-
tion will determine the whole treatment: the active participa-
tion of the patient is essential for treatment success in
periodontology.
The aim of our article was to determine a periodontal
approach for orthodontic-surgical treatment in a rational,
simplified, but global manner. We will first consider the
periodontal examination and the new therapeutics, and then
define the management according to the age of patients with
different diseases, motivations, and expectations.
The initial consultation
This is the ‘‘meeting’’ between 2 strangers who will have to
work together on a more or less complex journey for a various
length of time. The global and local history must be taken to
screen for aggravating factors; but it is also necessary to
dedicate time to understand the patient’s motivation for a
treatment lasting more than 2 years and to make sure all the
information is given.
Periodontal management in orthognathic surgery
intervenants, afin de planifier et d’apprécier l’ampleur des contraintes
nécessaires pour optimiser les résultats. Toute complication parodon-
tale (même minime) sera vécue comme un échec, indépendamment
d’une occlusion fonctionnelle et d’une harmonie faciale.
ß 2014 Elsevier Masson SAS. Tous droits réservés.
Mots clés : Parodonte, Orthodontie, Chirurgie orthognathique
Simplified periodontal examination
The periodontium is usually divided in 2 interdependent parts:
the superficial periodontium and the deep periodontium
(table I). Any deterioration of one part will impact the other
[2]. The periodontium includes all the tissues supporting the
teeth: the alveolar bone, the periodontal or dentoalveolar
ligament, the attached gums which are solidly anchored on
the maxilla and on teeth, the cementum that is the external
layer of the tooth roots. The tissue characteristics are deter-
mined genetically but may be influenced by other factors such
as the size and position of teeth, or by physiological factors
such as growth or aging. The periodontium is a very important
factor in orthodontics because it must be healthy and resis-
tant to allow multiple dental displacements in the course of
treatment. Its structures are fragile and easily damaged if
inadequate forces are used. A bad oral hygiene (difficulty to
eliminate plaque because of orthodontic material) may
induce inflammation that can destroy its components and
make dental displacements iatrogenic [3].
Table I
Simplified periodontal examination. If there is 1 yes in the
answers: pretreatment periodontal consultation is mandatory.
Yes No
Global history
Tobacco
Diabetes
Intra-oral examination
Plaque, tartar
Gingival bleeding
Edema, suppuration
Gingival necrosis
Modification buds
Dental mobility
> 0.5 mm
Alveolysis
Horizontal vertical
Gingival hypertrophy
Thin periodontium
Iatrogenic bridles
Gingival recession
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B. Straub et al. Rev Stomatol Chir Maxillofac Chir Orale 2014;115:208-218

Intra-oral examination

Examination of the superficial periodontium

Color: light pink (healthy) or red (inflammatory vasodilata-
tion).
Texture: firm and dimpled ‘‘orange skin’’, pathognomonic sign
of a healthy periodontium (insertions of collagen fibers); any
inflammation will destroy these fibers and the gums, then
become soft and smooth (pitting edema).
Contours: architecture following cemento-enamel junction
(excess by hypertrophy or insufficiency by necrosis or reces-
sion). Presence of plaque and tartar.
The interproximal papillae (figs. 1 and 2) is the main diagnostic
element: this is where inflammation begins; its loss (irrever- Figure 2. Multiple recessions: patient with TCA (eating behavioral
sible) is the result of definitive underlying bone lysis and its disorder) and iatrogenic brushing. Thin periodontium and presence of
interdental papillae (arrow), hence, covering of roots possible by
presence in case of recession allows a possible total covering of
gingivoplasty.
roots by gingival grafts. It is thus the key structure to examine.

Examination of the deep periodontium

The junction between gums and teeth (junctional epithelium)
is a fragile, non-keratinizing zone: its sealing determines the
integrity of periodontal structures; its apical migration may be
consecutive to a bacterial or traumatic pathology.
Periodontal bone sounding can allow detecting the migration
of the junctional epithelium. It is performed with a round tip
probe introduced softly along the root. Bleeding reveals
inflammation (active site) and scaling determines the depth
of the periodontal pocket, sign of alveolysis (fig. 3). The
examination of the deep periodontium should be completed
by imaging (panoramic or retro-alveolar view) to determine
the extent and the type of alveolysis (horizontal, vertical,
localized, or generalized). A vitality test should be performed
to screen for any endo-periodontal lesion that should be
treated first.
mobility: ankylosis; I: physiological mobility felt with the
fingertip and not visible to the naked eye; II: transversal
mobility visible to the naked eye and < 1 mm; III: transversal
mobility visible to the naked eye and > 1 mm; IV: axial
mobility.
‘‘Mobility does not reflect a pathology but the result of
adaptation to a clinical state. Its evolution is important and
not its intrinsic character’’ [3]. It reflects an enlargement of the
alveolodental ligament. This ligament connects the alveolar
bone to the root cementum. It is the site of permanent bone
and cementum changes, maintaining a balance of and
absorbing micro-displacements. The adaptive capacity of
bone remodeling allows phases of resorption and apposition

Tooth mobility
It is tested between 2 instruments, or between a finger and an
instrument. Mobility indices: ARPA international [3]. 0: no

Figure 3. Consultation for secondary migrations. Probing a 7 mm deep

Figure 1. Advanced periodontitis, gum recessions consecutive to alveolysis. pocket, purplish vestibular color of tooth 12: sign of a very inflammatory
Bacterial plaque and definitive loss of interdental papillae (arrow). deep pocket; tartar and plaque on the mandible.

210

to move teeth, during orthodontic displacements. The equili-
brium is disrupted, if the stimuli last too long or are too
strong, and recession may appear progressively and lead to
tooth mobility [3]. The apposition and resorption phases of
the alveolar bone are influenced by hormones liberated to let
the body maintain its phosphocalcium homeostasis. An
appropriate periodontal treatment must be initiated before
beginning orthodontic treatment in case of inflammation,
bleeding, mobility, gingival hypertrophy, suppuration, or bone
loss (table I).
Complementary examinations
A phase contrast microscope analysis of the pathogenic flora
or enzymatic tests may contribute to the diagnosis and to
raising the patient’s awareness. The microbiological tests by
DNA probes or by culture with or without any antibiogram
may also contribute to the diagnosis, help guide treatment
and assess its effectiveness, and allow monitoring the evolu-
tion of sites during periodontal maintenance. These tests
should be restricted to patients at risk, at the end of perio-
dontal sanitizing before the implant-prosthetic phase, or for
some cases of ‘‘resistant’’ periodontitis, i.e. not responding to
the initial treatment [4].
Teaching oral hygiene (OH)
The objective of the initial consultation is to teach the patient
adequate plaque control for a healthy and non-iatrogenic
periodontium. Often not enough time is dedicated to this
teaching because it requires a great investment from the
practitioner, all the more so that hygiene habits are very
difficult to change (especially for adults). Furthermore, to
obtain long-term observance, the patient must be shown
how to use OH material and given clear instructions. The
patient must be explained, during the initial consultation,
that the orthodontic treatment will be effective only if he
totally and regularly eliminates the biofilm at home. The need
to disrupt the bacterial biofilm before using an antiseptic
treatment is evident, as stressed by Brecx et al. [5].
Dental hygiene is more difficult if orthodontic braces and
vestibular or lingual arches are present. Dental floss or other
complementary means will have to be used. Interdental
brushes can also be used to clean between braces and in
some cases, the larger interdental gaps. Irrigation devices will
eliminate the larger food deposits but not plaque. The patient
should go back home with all the necessary information and
tools to begin the etiologic anti-bacterial phase; at the next
appointment, the practitioner should be able to check the
level of observance, mandatory to lead the orthodontic-sur-
gical treatment to its term without any complications.
The pathogenic sub-gingival flora will have to be eliminated
by non-surgical and/or surgical treatment, depending on the
severity of the periodontal disease, to control the inflam-
mation. The most effective antiseptic is chlorhexidine as
Periodontal management in orthognathic surgery
mouthwash, gel, and spray, or triclosan as toothpaste. The
effectiveness of antiseptic agents is limited by the bacterial
load in the biofilm, by the bacterial mechanisms of resistan-
ces, and by the difficulty of agents to penetrate into the
biofilm. The sub-gingival flora is made-up of mobile gram-
negative rods. The most virulent of these species are:
A. actinomycetemcomitans, P. gingivalis, T. forsythia, and
T. denticola. Some bacterial complexes were defined accord-
ing to the virulence and pathogenic power of bacteria [6].
Hydrogen peroxide may be used as mouthwash or as a local
application mixed with sodium hydrogen carbonate that
potentiates its activity. This combination is especially recom-
mended for the initial treatment of very inflammatory pre-
sentations. Recent data indicates that using antibiotics should
be restricted to aggressive presentations, of rapid evolution,
involving a very pathogenic flora [7].
AFSAPS (French Agency for the safety of Health Products) 2011
recommendations: ‘‘Using antibiotics cannot compensate an
inadequate oral hygiene, or replace universal hygiene rules
and the asepsis expected for any kind of care’’.
Necrotizing periodontal diseases: metronidazole: 1500 mg/D
in 2 or 3 intakes for 7 days.
Aggressive localized periodontitis: doxycyclin: 200 mg/D in 1
intake for 14 days.
Aggressive localized or generalized periodontitis: amoxicillin
1500 mg/D in 3 intakes (or 2000 mg in 2 intakes) for 7 days
and metronidazole: 1500 mg/D in 2 or 3 intakes for 7 days.
In case of allergy to penicillins: metronidazole: 1500 mg/D for
7 days.
If inflammation is observed at the initial
consultation
Initial phase: periodontal sanitizing
Lindhe [8] demonstrated that if constraints alone cannot
generate periodontal pockets, the combination of constraints
and bacterial inflammation aggravates tissue destruction,
leading to loss of attachment, bone lysis, and gingival reces-
sion. The non-surgical periodontal treatment relies on radi-
cular descaling and surfacing (RDS). This initial periodontal
treatment has for objective to decrease the bacterial load by
disrupting the pathogenic biofilm to come back to a normal
commensal flora, to make radicular surfaces compatibles with
a healthy periodontium, and to control the patient’s local and
general risk factors. Various instruments are available to
ensure mechanical debridement of radicular surfaces. Accord-
ing to the American Academy of Periodontology (AAP), an
ultrasonic system with micro-inserts is the fastest and chea-
pest non-surgical treatment for the elimination of supra or
sub-gingival tartar. High-level clinical studies focusing on
laser treatment for periodontology are still lacking, and do
not allow recommending this treatment.
211
B. Straub et al.
Global disinfection
Quirynen et al. [9] developed the concept of global disinfec-
tion in 1995. 2 complete RDS sessions are performed, 24 hours
apart, the tongue is brushed with chlorhexidine gel at 1% for
1 minute, the mouth is washed with a chlorhexidine solution
at 0.2% for 2 minutes, and all sub-gingival pockets are irriga-
ted with a chlorhexidine solution at 1%; chlorhexidine mouth-
wash at 0.2% is prescribed for 2 weeks.
The conclusions of the workshop in periodontology (2008) do
not allow recommending any of the 2 RDS protocols. Hand
curettes are ‘‘aggressive’’, and eliminate a great quantity of
dental tissue, whereas ultrasounds have a ‘‘softer’’ action on
the root surface.
A new approach: the photodynamic therapy relying on dis-
infection with an LAD pen associated to a gel and probiotic
tablets for 3 months was promising but scientific evidence of
its effectiveness versus conventional treatment is still lacking.
Some authors have reported immediate benefit compared to
conventional treatment [10]; others have reported longer-
term benefit (to 1 year) [11].
Sanitizing procedures
These are indicated when there is a persistence of pockets (or
furcation lesion) after a non-surgical treatment as well as to
perform bone filling. They allow debriding gingival or bone
lesions. The ANAES (French National Agency for Accreditation
and Evaluation of Heath Care) mentions a minimum depth of
6 mm as reference for pockets requiring surgery but this
remains discussed. The breakthroughs in tissue engineering
allow regenerating (in a limited way) periodontal structures
destroyed by the disease. The membranes used for guided
tissue regeneration have currently been left aside because of
gingival pain and risks of exposure (inducing failures) to
biomaterials associated or not with proteins derived from
the enamel. These regeneration techniques are very effective
and give optimized results for the usual treatment of advan-
ced periodontitis, but some authors have reported that in the
course of orthodontic treatment, there is no difference with
the usual pocket surgery [12]. When can orthodontic activa-
tion be initiated after periodontal preparation? The resolution
of inflammation indicated that orthodontic displacements
will not be iatrogenic and can begin.
Gingivectomy
Gingival growth may be due to the combination of bacterial
factor and orthodontic displacements. The previously medio-
cre hygiene becomes even worse. After controlling OH, gin-
givoplasty by gingivectomy should allow better controlling
plaque. Nevertheless relapse is frequent; the patient’s coo-
peration for OH is mandatory. Chlorhexidine-based non alco-
holic mouthwash (preventing alteration of taste) should be
prescribed and should allow acquiring a flora compatible with
a healthy periodontium, thus delaying any relapse [13].
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Rev Stomatol Chir Maxillofac Chir Orale 2014;115:208-218
Supportive therapy
These are mandatory steps during periodontal treatment to
screen for any relapse but also to prevent the patient from
losing motivation and to remind him of the rules that are
sometimes overlooked. During these consultations, every 2 to
3 months, OH will be assessed, as well as inflammation by
probing the pockets (or even furcations), or with radiogra-
phies if needed; and professional prophylactic cleaning with
ultrasounds should be performed. The delay between 2
appointments will have to be shortened for risk treatments
such as aggressive periodontitis (addressed later in the part
concerning teenagers), tobacco abuse, and diabetes. Fluoride
application may be used to prevent possible root caries.
If no inflammation is observed at the
initial consultation
Examination of the superficial periodontium should allow
determining the periodontal biotype to prevent recession
(or control it). Four clinical indices should be assessed: gum
thickness, height of attached gums, presence of gum reces-
sion and iatrogenic bridles. This examination determines the
patient’s periodontal thick or thin biotype (to risk) [14]. This
examination can also be performed with a periodontal probe.
Height and thickness of attached gums
There should be at least 3 mm of attached gum height [8] (fig.
4).
Recession and bridles
Iatrogenic bridles can be demonstrated by vertical mobiliza-
tion of mucosal zones towards the crown.
Periodontium thickness
A ‘‘thick’’ periodontium should normally be more resistant,
but in case of periodontal inflammation, pockets may form by
underlying alveolysis [8]. A smaller height of attached gums
does not systematically require surgery. Monitoring the
superficial periodontium may be sufficient, especially in case
of good OH. It should be reinforced if orthodontic displace-
ments at risk must be performed. Various biotypes may be
observed in a single patient.
Marginal tissue recession
Marginal tissue recession is defined as a partial denudation of
the root surface due to the apical migration of marginal gums
(fig. 5). This is different from (as mentioned in the first
paragraph) gum retraction consecutive to peri-dental alveo-
lysis following an inflammatory periodontal disease whether
active or stabilized.
It usually includes: apical migration of marginal gums from
the cemento-enamel junction, partial or total absence of

Figure 4. Various periodontal biotypes: thick, normal, and thin [6].
attached gums (which will disrupt the cemento-enamel junc-
tion line; called ‘‘short attachment’’, in case of partial absence,
or ‘‘rupture of attachment’’, in case of total absence), exposed
radicular cementum, concomitant loss of alveolar bone and
periodontal ligament. The width is the most important crite-
rion for the prognosis. Recessions are considered as wide
when 3 mm in size or more. Dome-shaped teeth presenting
with an increased vestibular and lingual diameter are more
likely to be next to thin cortical bone, causing dehiscence or
fenestration. The etiologies are multifactorial and often rela-
ted.
Predisposing factors
These are sites of eruption and malposition, histogenesis (the
cemento-enamel junction may be more or less well-establis-
hed), aging.
Figure 5. Multiple recessions, possible etiologies: iatrogenic brushing
associated to orthodontic treatment without extractions. The patients
experience this state as failure despite satisfactory facial and occlusal
equilibrium.
Periodontal management in orthognathic surgery
Aggravating factors
These are frenulum, bridles and shallow vestibule, inflamma-
tion, occlusal factors, iatrogenic factors, tartar, tobacco, and
chewing Betel, nail biting, piercings, etc.
In orthodontics
There is a risk of recession when displacements are too rapid,
outside of bone bases inducing dehiscence or fenestration, or
when too strong constraints are applied; the recession is more
severe in case of inflammation. ‘‘The prevalence of gum
recession after orthodontic treatment is 10.3%; skeletal class
III and retro-alveolar mandibular incisors can cause more
severe gum recessions.’’ [15]. Gum recession gingival can also
occur in case of vertical incision next to the osteotomy line. It
may be involuntarily in the course of surgical preparation.
Periodontal plastic surgery
Gingivoplasty should be considered if vestibular orthodontic
displacements are planned on a thin periodontium, and
especially if there are already gum recessions. Preventive
periodontal plastic surgery is meant to increase the quantity
of gingival and/or osseous tissue: indeed, it is easier and
especially more predictable to prevent the occurrence or
aggravation of recession.
Frenectomy and vestibular deepening
Cold-blade or laser scalpel section allows suppressing the
iatrogenic tensions observed during the examination. This
is often sufficient to prevent the occurrence of recession.
Vanarsdall, in 1991 [16], also recommended the section of chin
213
B. Straub et al.
muscles and eventually completing vestibular deepening by
an epithelial-connective tissue graft.
Epithelial-connective tissue grafts (ECG)
The procedure consists in placing an epithelial-connective
tissue graft (harvested from the palate) on the zone to treat
(fig. 6). The epithelial-connective tissue grafts thicken pro-
gressively and take a nacreous aspect due to the specificity
and tissue induction. They become very unsightly; they often
look like a ‘‘patch’’. Furthermore, their success rate is uneven;
they require 2 operative sites with a high rate of morbidity
because of the secondary intention palate wound healing.
They are nevertheless very useful for reinforcement because
they increase keratinized tissue height and thickness [17].
Figure 6. Periodontium reinforced by 2 sub-epithelial connective tissue
grafts before surgical and orthodontic treatment. Very satisfactory but
unsightly gingival reinforcement.
Inlay connective tissue graft (ICG) [17]
This technique consists in harvesting sub-epithelial connec-
tive tissue from inside the palatine mucosa and inserting it
under a gingival flap. Several bi-layer variants can be used:
tunnel, lateral flaps, coronary flap, etc. The sub-epithelial
connective tissue grafts give very good results for periodontal
covering and reinforcement (estimated from 80 to 100%). The
esthetic results acquired from 1 to 3 months are excellent.
These rapid results are due to the fact that the sub-epithelial
connective tissue graft is vascularized by 2 sources, the flap
and the periosteum and/or the underlying connective tissue.
The healing of the harvesting site is much less painful than for
an ECG because it is performed in first intention. Neverthe-
less, the sub-epithelial connective tissue graft also requires 2
operative sites.
Periodontal mineral reinforcement (PMR)
[18]
Wilcko et al. [19] described in 2001 an orthodontic treatment
basedonalveolarcorticotomyassociatedtograftaugmentation,
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Rev Stomatol Chir Maxillofac Chir Orale 2014;115:208-218
according to the principles of a regional
acceleratory phenomenon (RAP) described by
Frost in 1989 [20] (fig. 7a–d). This was
performed to increase the thickness of the
alveolar bone to maintain results acquired after
dental displacement and to prevent relapses.
The principle is to alter the alveolar bone (by
piezocision or with a bone drill) so as to
provide vascularization and osteogenic cells
and place a biomaterial graft in contact with
the bone. ‘‘Bone has the unique potential to
restore its original structure. Any bone lesion
will induce osteoinduction. The bone cells or
the neighboring cells release growth factors
and bone induction factors such as morphoge-
nic bone proteins’’ [21]. Wilcko et al. 2011 [22]
call this ‘‘Accelerated osteogenic orthodon-
tics’’. PMR is applied before orthodontic-
surgical treatment according to Frost and
Wilcko’s principles.
Orthodontic treatments accelerated by alveolar
corticotomy
They allow accelerating of dental displacements, and, some-
times avoiding orthognathic surgery. The principles are those
of RAP described by Frost. Wilcko et al. demonstrated that
accelerated osteogenic orthodontics by osteogenic periodon-
tium stimulation (AOOOPS) were 300 to 400% higher than by
the conventional technique [22].
In 2011, a group of Korean and American researchers, Kim et al.
[23] used Wilcko idea and technique. They tried to obtain a
rapid dental displacement with corticotomy, and a thickening
of the alveolar bone for a thin periodontium (as with PMR),
with the apposition of biomaterials, allowing rapid orthodon-
tic displacements and preventing feared post-treatment
periodontal complications. The corticotomy could allow molar
ingression, correction of previous anterior gaps by posterior
maxillary ingression, a more rapid traction of impacted cus-
pids, and a faster alignment and leveling.
These techniques are still experimental and EBM studies are
needed to confirm scientifically their advantages and draw-
backs [24].
Management of the teenager
Announcing an orthodontic-surgical treatment to a teenager
and his parents is not an easy task for the orthodontist and
the maxillo-facial surgeon: if first a periodontal management
is necessary, it increases the treatment ‘‘burden’’. Neverthe-
less, preventive periodontal procedures (often simple) may
help prevent any aggravation (or onset) of periodontal patho-
logies. These preventive procedures lead to better results than
repairing lesions at the end of treatment.
 Periodontal management in orthognathic surgery

Figure 7. Patient 23 years after first orthodontic treatment. Surgical class III before orthodontic and surgical treatment (January 2011): a: rather thin
periodontium and recessions on teeth 11 and 21; b: June 2011. Recession on teeth 11 and 21 corrected by gingivoplasty and ongoing orthodontic treatment.
Mediocre OH: sub mucosal radicular protrusion while decompensation is not finished; c: mandibular PMR at D + 15; d: end of treatment (July 2013).
Satisfactory periodontium thickness, slight retraction of inferior interdental papillae, stable graft for teeth 11 and 21.

Bacterial pathology
School constraints, teenage crisis, early tobacco abuse make it
very difficult to change OH habits if these are inadequate to
complete surgical and orthodontic treatment successfully.
Gingival hypertrophy may appear, associated or not to enamel
demineralization. Giving advice for OH is crucial for prevention.
RDS sessions should be performed if inflammation persists.
Screening for aggressive periodontitis
Juvenile periodontitis, in the old classification, is characterized
by its early onset, by its rapid evolution, and by the impor-
tance of tissue loss as well as by frequent relapse. The
bacteriology of this type of periodontitis [6] has been demons-
trated (even if sometimes some bacterial tests may be non-
significant, in case of major clinical symptoms). The virulence
factors associated to a lack of host response (defective che-
motactism of polymorphonuclears) in this bacterial aggres-
sion may lead to a rapid loss of teeth if they are mobilized
without previous sanitizing. The treatment is local and gene-
ral (antibiotic therapy combining amoxicillin and metronida-
zole, Afssaps 2011) and frequent follow-up. The siblings should
be seen in consultation.
Early screening is crucial; here are some significant ‘‘warning
signs’’:
 good or very good OH;
 few or no caries and/or obturation;
 important localized vertical alveolysis, sometimes only 1 or
2 sites, often ‘‘mirror’’ images in the premolar, molar, and
incisor areas;
 female/male ratio: 3/1;
 main ethnic origin (African and Asian).
Mucosal and gingival pathology: screening for
frenula and bridles
It is crucial to identify a mucosal anomaly, in this age range,
which can be treated by simple procedures (cf. previous
chapter). The anomaly is usually located next to the mandi-
bular incisors, in case of congestion. The patient should be
screened preventively for pathological frenula and bridles.
Bridles and absence of vestibule are very frequently observed
in the lateral and superior canine areas, in patients presenting
with a cleft palate. It is crucial to treat the condition as early as
possible, especially before inserting implants (agenesis of
lateral incisors). These are patients managed from birth

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who need to ‘‘undergo’’ many procedures, often including
orthognathic surgery.
Dental retainer. It is usually made of an extra-coronal
maxillary and mandibular bonded wire retainer and a Hawley
plate to improve intercuspidation. Non-individualized conten-
tion (type ‘‘tooth positioner’’) is strictly contra-indicated in
case of a thin periodontium. It could induce major gum
recessions.
Management of the young adult
There are 2 populations of patients in this age range: those
who have never undergone orthodontic treatment and pre-
senting with major dysmorphism, and those who have under-
gone an inadequate treatment or presenting with evolutive
dysmorphism leading to relapse (fig. 8a and b). The manage-
ment should be made according to their active and affective
life (availability, economic constraints, esthetic constraints,
stress, tobacco use, etc.) but also according to dental and
gingival pathologies already present.
Bacterial pathology
These patients already have ‘‘periodontal history’’ with gin-
givitis or periodontitis aggravated by the tobacco, stress,
parafunctions, etc. They often present with major gum reces-
sions, either due to excessive brushing associated to malpo-
sitioned teeth, or to previous orthodontic treatments
(expansion of arcades beyond biological limitations). The
multiple appointments are difficult to integrate in an early
active life, not withstanding the important financial cost
because of non-registered procedures. These conditions make
it mandatory to hold a multidisciplinary consultation so that
all healthcare professionals involved can inform the patient
about the treatment burden and the need to consider it
before beginning. Any periodontal complication not mentio-
ned initially will be considered as a failure.
Figure 8. Young adult patient with major dysmorphism and periodontitis: a: pre-orthodontic-surgical treatment consultation. Mediocre OH and important
gingival inflammation. Recession on tooth 41; b: periodontal maintenance session 12 months after inferior frenectomy, vestibular deepening, and
periodontal sanitizing. Absence of inflammation, and satisfactory periodontium for teeth 41 and 31.
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Rev Stomatol Chir Maxillofac Chir Orale 2014;115:208-218
Dental retainer. The choice among extra-coronal bonded wire
retainer, a Hawley plate, and intra-coronal splint will depend
on the extent of alveolysis.
Management of the adult
The main reason for consulting in adults is the migration of
incisors by loss of bone support consecutive to periodontitis
and often associated to loss of anchorage. Prosthetic or
implant rehabilitation is difficult or impossible when skeletal
dysmorphism is present. A ‘‘minimal’’ orthodontic treatment
is often impossible. The condition may be aggravated by long-
term tobacco abuse, or associated pathologies such as: type II
diabetes, osteoporosis, etc.
The surgical and orthodontic treatment will require a great
motivation from the patient if the demand is mostly esthetic
(hoping for rapid results).
The scheme will begin with periodontal treatment and teach-
ing of OH, RDS, reevaluation at 8 weeks. The orthodontic
treatment can begin when the inflammation has resolved and
if there are no pockets deeper than 6 mm. Supportive therapy
will be necessary before each activation, then every 4 months,
then life-long. The observed recessions will have to be treated
with gingival grafts to prevent their aggravation, but the
covering will often be partial because of a periodontal patho-
logy having induced marginal alveolysis. Great care should be
taken to avoid worsening bone loss.
Stutzmann and Petrovic [25] stated that the life-long persi-
stence of significant alveolar bone renewal and the possibility
to increase it with orthodontics made it possible to perform
therapeutic dental displacement at any age. The loss of ancho-
rage due to tooth loss may require using mini-screws, or even
plates or implants after periodontal sanitizing. Whatever the
initial periodontal status and the indication of treatment, tissue
inflammation should be strictly controlled during all the dis-
placement stage, because in adult patients having presented

with a periodontal disease, the inflammatory reaction imme-
diately results in relapse and aggravation of bone lesions.
Permanent retainers are recommended in adults, so as to
ensure stable results by supporting tissue reorganization
and in preventing relapses, especially in case of a thin
periodontium. Splints allow distributing forces by decreasing
transversal constraints. Obtaining occlusal balance at the end
of treatment is mandatory to ensure permanent results.
Supportive therapy, also mandatory for permanent results,
requires among other things, the active participation of the
patient, and as suggested by its name, the physician’s invest-
ment. This is a part of the periodontal treatment in which the
patient’s attention and the demonstration of advice for OH
are as, if not more important than any office procedure.
Nevertheless, it is time-consuming, repetitive, and often
neglected.
Conclusion
To summarize, orthodontic-surgical treatment implies several
conditions.
Psychological: the patient’s motivations should be well-asses-
sed to ensure his active participation.
Anatomic: the periodontium should be initially sanitized and
reinforced.
Mechanic: the forces applied should be light and continuous.
The various problems will have to be identified at the initial
consultation so as to explain to the patient how to act for
everything to be planned. Periodontal sanitizing with the
current minimally invasive technique and recurrent suppor-
tive therapy should allow preventing complications during
the treatment and ensuring permanent results. Ultrasonic
instrumentation is the best technique for debridement of
radicular surfaces. But the laser still requires more testing for
non-surgical treatment in periodontology. Alveolysis (even
important) consecutive to stabilized periodontitis is not a
contra-indication for orthodontic treatment: the forces
applied should be appropriate for the residual periodontium.
But monitoring for any inflammatory relapse is mandatory
and should be performed regularly. Orthognathic surgery may
be of interest by limiting dental displacements and harmo-
nizing arcades.
A weak attachment does not systematically require an inter-
vention, especially in case of a good OH. Regular monitoring
should allow screening for and correcting the occurrence of
complications during the treatment. Periodontal reinforce-
ment by gingival grafts (often unsightly) only masks the
underlying bone defect whereas PMR should allow bone
control in the areas where teeth must be vestibulated by
maintaining alveolar bone thickness and respecting perio-
dontal environment during the treatment [18,23,26].
Nevertheless, these new technique require more feedback
data to assess the true benefits. The current breakthroughs
Periodontal management in orthognathic surgery
allow pushing back the limits of secondary adverse effects,
and with a pluridisciplinary management, we should be able
to offer a treatment protocol that will optimize the results
and be in phase with the personal investment and the
expectations of our patients.
Disclosure of interest
The authors declare that they have no conflicts of interest
concerning this article.
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