The perio-ortho connection: 4 steps to aligning esthetics and periodontal health

In addition to enhanced appearance and self-esteem, correction of malocclusion may also benefit patients’ periodontal health.

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Nicole Smith, DDS

For patients with malocclusion, both general dentists and orthodontists typically consider the primary benefit of orthodontic treatment to be improved esthetics. However, in addition to enhanced appearance and self-esteem, correction of malocclusion can benefit patients’ periodontal health. Studies have shown that increased malocclusion is associated with increased severity of periodontal disease.1

The prevalence of periodontal disease is a multifactorial function of age, genetics, hygiene, and malocclusion. There are some malocclusions that can harm the periodontium. For example, crowding of anterior teeth has been shown to be a risk factor for caries, gingivitis, and periodontitis.2

By placing the dentition in an ideal position, clinicians can create stable, functional occlusion that results in improved periodontal health and a longer-lasting natural and restored dentition. Preventing gum disease and subsequent bone loss should include recommending proper tooth alignment. While there are different approaches to treatment planning, there are four main steps to treatment sequencing for patients needing multidisciplinary care to improve both tooth alignment and periodontal health. Let’s look at each of these steps in detail.

Disease control

First, it is critical to get any disease under control before beginning orthodontic treatment. This can include caries control, endodontic therapy, extractions, initial nonsurgical periodontal therapy (such as scaling and root planing), and initial restorative care (such as fillings or onlays).

It is clear that periodontal issues can be created by malocclusion. Crowding of as little as 3 mm in an arch has been shown to be a host factor for periodontal disease.2

However, orthodontic therapy to treat malocclusion can also present new periodontal issues. It is important that patients’ oral health is stable prior to beginning orthodontic treatment to ensure that any conditions do not worsen and optimal results are achieved.

Establishing proper occlusion

Second, present an orthodontic treatment plan based on patient preferences and oral health status. One main issue causing periodontal issues in patients is crowding. Crowding is caused by improper arch width (e.g., narrow palate), improper arch form (e.g., a V-shaped or omega-shaped arch), and buccolingual inclination. Relieving the crowding through orthodontic therapy can enable patients to clean areas better and prevent bacteria from accumulating in excess.

Orthodontic appliances on the dentition can also cause increased bacteria buildup and can be difficult to clean. Fixed appliances can create more periodontal challenges than removable appliances (such as clear aligners), which gives removable appliances a major advantage in patients who are at risk of periodontal problems.3

There are two major types of periodontal findings in orthodontic patients: mucogingival problems, including inadequate attached gingiva, and inflammatory lesions of the gingiva or periodontium. If using a removable appliance, these issues can be reduced due to increased hygiene ability. Patients should always be encouraged to follow the recommended periodontal maintenance protocol to ensure that the mouth remains healthy throughout orthodontic treatment.

Definitive periodontal treatment

Third, begin definitive periodontal treatment such as osseous surgery or tissue grafting if recommended for the patient. In some cases, orthodontic treatment can help improve gingival recession or prevent it from worsening.4 For example, teeth in traumatic occlusion due to horizontal forces from buccolingual inclination can be uprighted so that proper vertical forces are placed on the tooth, reducing risk for recession and abfractions. However, orthodontic treatment will not correct the gingival recession already present, and surgical intervention by a periodontist may be necessary.

Definitive restorations

Lastly, complete any definitive restorations needed for the patient, such as crowns or other esthetic restorations. The occlusal stability and elimination of traumatic occlusion gained from orthodontic treatment can result in longer retention of dental restorations.

To be comprehensive, dentists must look at orthodontia as more than just straightening teeth and realize that malocclusion can have severe repercussions on the dentition and periodontium. The World Health Organization has classified malocclusion as a disease due to its effects on the oral cavity.5 Recognizing and treating malocclusion with a sequenced protocol allows for patients’ dentition and restorative work to have fewer problems and last longer.


1. Bollen AM. Effects of malocclusions and orthodontics on periodontal health: evidence from a systematic review. J Dent Educ. 2008;72(8):912-918.

2. Staufer K, Landmesser H. Effects of crowding in the lower anterior segment—a risk evaluation depending upon the degree of crowding. J Orofac Orthop. 2004;65(1):13-25.

3. Karkhanechi M, Chow D, Sipkin J, Sherman D, Boylan RJ, Norman RG, Craig RG, Cisneros GJ. Periodontal status of adult patients treated with fixed buccal appliances and removable aligners over one year of active orthodontic therapy. Angle Orthod. 2013;83(1):146-151.

4. Jati AS, Furquim LZ, Consolaro A. Gingival recession: its causes and types, and the importance of orthodontic treatment. Dental Press J Orthod. 2016;21(3):18-29.

5. International Statistical Classification of Diseases and Related Health Problems, 10th Revision (ICD-10). World Health Organization website. Accessed October 12, 2018.

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Nicole Smith, DDS, is a graduate of the New York University College of Dentistry. She is an owner dentist supported by Pacific Dental Services, an Invisalign Preferred Provider, and a faculty member of the PDS University – Institute of Dentistry.

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