Occlusal Reconstruction by Team Approach of a Skeletal Class III Patient with Severe Periodontitis: A Case Report

Recently, orthodontic treatment is often carried out as part of the total periodontal therapy. The treatment goal is not only to improve the esthetic appearance, but to establish a functional and easy-to-care dentition that would not cause trauma from occlusion. When skeletal disorders play a major role in the progress of periodontal disease, surgical orthodontics may be indicated to attain an optimal outcome. This report deals with a skeletal class III patient with severe periodontitis. His mandible was asymmetric, and probably due to the loss of left molars, he suffered from pain in his left temporo-mandibular joint. Since the faulty jaw-to-jaw relationship had to be corrected by means of surgery, we assembled a team composed of an endodontist and periodontist, an orthodontist, two oral surgeons and a prosthodontist to manipulate the complicated problems. First, intensive periodontal therapy took place starting with oral hygiene instruction and extraction of a hopeless tooth. The remaining teeth were thoroughly planed and underwent periodontal surgery (flap operation) except for a few that showed good healing after root planing. In parallel with the course, endodontic treatment was conducted and provisional restorations were installed. The patient was a highly-motivated complier, and the response of his periodontal tissue was rapid and satisfactory. Under the supportive periodontal therapy, orthodontic treatment started 19 months after the first visit. The leveling and alignment of the teeth was accomplished by using multi-bracket appliances and the patient received intraoral vertical ramus osteotomy. During retention, the periodontal therapy was enhanced as the teeth became loosened by slight gingivitis. It was 4 years since the first visit when the permanent restorations and partial dentures were installed to provide a firm and functional vertical stop. By this multidisciplinary approach, the patient's profile has been esthetically improved, and the initially poor periodontal support is now stable. Also, the temporo-mandibular joint-related symptoms, such as clicking, pain in the left joint and headache on the left side, have all disappeared. The result suggests that an accurate diagnosis based upon detailed analysis along with elaborate planning is essential for resolution of complex cases such as those with skeletal disorders. J. Jpn. Soc. Periodontol., 41: 43-51, 1999.