CASE REPORT

Management of Generalized Aggressive Periodontitis

Using Periodontal and Orthodontic Treatments
Lauren M. Syrowik,* Ana L. Janic,* and Leyvee C. Jacobs*

Introduction: This case report presents the use of periodontal therapy sequentially with orthodontics for the treatment
of generalized aggressive periodontitis (GAgP) and associated malocclusion.
Case Presentation: A female patient presented with GAgP. Non-surgical periodontal treatment and enamel matrix
derivative (EMD) therapy were completed while the patient was concurrently undergoing orthodontic treatment to correct
Class II malocclusion. Probing depths, free gingival margin, and clinical attachment level (CAL) were evaluated at baseline,
4 weeks, 3 and 6 months, and 1 year after treatment. CAL was the primary outcome variable. A 1-year postoperative visit
revealed that the patient’s periodontium had remained stable while still undergoing orthodontic treatment.
Conclusions: Sequential periodontal and orthodontic treatments improved this patient’s overall function, occlusion,
and esthetics. Regenerative therapy using EMD was effective in this case of GAgP, and results remained stable throughout
and after orthodontic treatment. Clin Adv Periodontics 2014;4:73-79.
Key Words: Aggressive periodontitis; enamel matrix proteins; regeneration.

Background Pathologic tooth migration (PTM) is an issue that often

must be addressed as a result of AgP. Frequently, the inci-
Aggressive periodontitis (AgP) is a form of periodontitis that in
sors will splay labially, creating more difficulty for the patient
general has three common characteristics: 1) despite having
functionally and hygienically.2,3 Orthodontic treatment, in
periodontitis, the patient is otherwise healthy; 2) there appears
addition to periodontal therapy, has been proven to be suc-
to be a rapid breakdown of tissue and bone despite a lack of
cessful in managing periodontitis with associated malocclu-
microbial plaque; and 3) there is often a familial aggregation.1
sion.4 Not only does orthodontic treatment help improve
Although not required, the disease does tend to affect patients
the function and esthetics of the dentition, but it can also help
younger than 30 years old. Clinically, AgP tends to localize at
the first molars and the incisors, but in a case of generalized AgP reduce inflammation and prevent more damage from occur-
ring to the periodontium by improving tooth alignment and
(GAgP), at least three other teeth in addition to the first molars
function.5
and incisors are affected by swift loss of hard and soft tissue.1
In this report, the management of a patient with GAgP us-
Because of the rapid attachment loss (AL) associated with
ing both periodontal and orthodontic treatments is examined.
GAgP, often pathologic movement or loss of teeth can occur.

* University of Detroit Mercy School of Dentistry, Department of Clinical Presentation

Periodontology and Dental Hygiene, Detroit, MI.
Submitted May 4, 2012; accepted for publication November 2, 2012
doi: 10.1902/cap.2012.120056
A 16-year-old female patient presented to the University of
Detroit Mercy (UDM) School of Dentistry for orthodontic
screening in July 2009 (Fig. 1) and was referred to the Grad-
uate Periodontics Department for a periodontal evaluation.

Clinical Advances in Periodontics, Vol. 4, No. 2, May 2014 73

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FIGURE 1a Patient presented for initial visit demonstrating PTM. 1b

Maxillary occlusal view at initial visit. 1c Right lateral view of patient’s
dentition at initial visit.

The patient was a non-smoker and demonstrated an O’Leary

plaque control record of 30%.6 She presented with a Class II
division 1 right malocclusion characterized by maxillary pro-
trusion and mandibular retrognathia, in addition to dentally
exhibiting an impinging anterior deep bite, severe overjet,
and maxillary and mandibular anterior spacing. The initial
periodontal examination revealed that all 31 teeth had
probing depths (PDs) of 3 to 10 mm with AL ranging from
1 to 10 mm associated with the incisors, first molars, teeth
#13 and #15, and the mandibular arch. The maxillary cen- FIGURE 2a Panoramic radiograph at initial visit. 2b Right vertical bitewing
tral incisors had Class I mobility. Radiographically, there radiograph at initial visit illustrating bone loss around the first molar regions.
2c Left vertical bitewing radiograph at initial visit illustrating bone loss
were localized vertical defects, impacted third molars, and around the first molar regions and Class II malocclusion. 2d through 2f
anterior spacing (Fig. 2a). Most notable vertical defects were Periapical radiographs of the anterior region at initial visit.

74 Clinical Advances in Periodontics, Vol. 4, No. 2, May 2014 Periodontal and Orthodontic Treatments in Generalized Aggressive Periodontitis

FIGURE 3a Fibrotic tissue between teeth #25 and #26. 3b Four-week
postoperative view of gingivectomy between teeth #25 and #26.
found between the maxillary central incisors and around
tooth #30 (Figs. 2b through 2f). Tooth #30 also exhibited
furcation involvement. The diagnosis was GAgP, and the
general prognosis was favorable with a locally question-
able prognosis for teeth #3, #7 through #10, #14, #19,
#23 through #26, and #30.
Case Management
The periodontal treatment objectives were as follows: 1) re-
duce inflammation; 2) repair and regenerate damaged hard
and soft tissue; and 3) create an environment conducive to
good oral hygiene.
In September 2009, following verbal consent from the
patient’s mother, the patient underwent initial periodontal
therapy that involved patient education, oral hygiene instruc-
tions, and four quadrants of scaling and root planing (SRP)
in conjunction with 250 mg metronidazole and 250 mg
amoxicillin. Four weeks later, periodontal reevaluation
was performed. PDs were generally 3 to 4 mm, with 5
mm noted in teeth #8, #9, #18, #19, #22, #23, #25, #26,
and #30. Clinical attachment levels (CALs) ranged from
1 to 9 mm. There was noticeable reduction in PDs that ranged
from 1 to 5 mm and minimal change in the CALs that ranged
from 1 to 2 mm. Because of fibrotic gingival tissue on the
labial of teeth #25 and #26 (Fig. 3a), a gingivectomy was
Syrowik, Janic, Jacobs
C A S E R E P O R T
also performed after the reevaluation. The patient was then
cleared to begin orthodontic treatment.
The tissue associated with the gingivectomy healed
uneventfully with adequate keratinized tissue remaining
(Fig. 3b). Maintenance was delivered 3 months after ini-
tial SRP. At this time, local antibiotic delivery (LAD)† was
placed on the mesial and distal aspect of tooth #30, in
which PDs of 9 mm on the mesio-lingual, 7 mm on the
mesio-buccal, and 6 mm disto-lingual were noted. At this
time, teeth #2, #3, #9, #14, #15, #18, #19, and #31 had
PDs of 4 to 5 mm. The remainder of the dentition had PDs
of <3 mm. CALs were similar to records taken during
reevaluation after initial SRP.
The patient presented 1 month after LAD placement for
reevaluation of tooth #30. All areas were probed, with the
deepest PD being 7 mm on the mesio-lingual aspect of tooth
#30. All other areas were deemed stable based on consis-
tent PDs and CALs taken during the last maintenance.
In April 2010, 9 months after non-surgical treatment, it
was decided that osseous surgery with enamel matrix deriv-
ative (EMD)‡ would be necessary to regenerate periodontal
tissues surrounding tooth #30 based on the careful risk anal-
ysis and determination of defect morphology.7 During the
surgery, sulcular incisions were made from the distal line an-
gle of tooth #31 to the distal line angle of tooth #27 on the
buccal aspect and on the midline of the same teeth on the lin-
gual aspect. The full-thickness flaps were reflected, and the
area was debrided and degranulated (Figs. 4a through 4d).
EMD was placed in the mesial and distal vertical bony de-
fects of tooth #30 and in the lingual Class II furcation of tooth
#30. Single interrupted polyglactin 910 4-0 suturesx were
placed interproximally (Fig. 4e).
The patient returned for 1- and 2-week postoperative visits.
At the 2-week postoperative visit, the polyglactin 910 sutures
were removed, and the site was healing uneventfully.
At the 2- and 4-week visits after the osseous surgery, ex-
tractions of teeth #1, #16, #17, and #32 were performed at
the UDM Oral Surgery Department. At the 4-week postop-
erative visit, all surgical sites appeared to be healing well.
Clinical Outcomes
At 1 year after the osseous surgery, while the patient was
still undergoing orthodontic treatment, a clinical examina-
tion was performed and radiographs were taken. There
was significant reduction in PDs, improved CALs, and lack
of clinical bleeding on probing. PDs and CALs at this time
ranged from 2 to 4 mm and 1 to 5 mm, respectively, which
represented a 1- to 5-mm change in PDs and 1- to 6-mm gain
in CALs compared with the initial findings. Updated in-
traoral radiographs revealed excellent improvement in
the area of tooth #30 suggestive of bone fill (Figs. 5a and
5b). Bone levels in the anterior appeared to have remained
the same throughout orthodontic treatment (Figs. 2d
through 2f and 5c through 5e).
†
Arestin, OraPharma, Horsham, PA.
‡
Emdogain, Straumann, Basel, Switzerland.
x
VICRYL, Ethicon, Johnson & Johnson, Somerville, NJ.
Clinical Advances in Periodontics, Vol. 4, No. 2, May 2014 75
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FIGURE 4a Preoperative buccal view of tooth #30 before osseous surgery. 4b Preoperative lingual view of tooth #30 before osseous surgery.
4c Surgical (buccal) view of mesial and distal vertical defects of tooth #30. 4d Surgical view of mesial and distal vertical defects and furcation involvement in
tooth #30. 4e View of the surgical site sutured.
Orthodontic treatment included banding and bonding
teeth #2 through #15 and #18 through #31. Total treat-
ment time in the maxilla was 12 months, followed by a
Hawley retainer. Total treatment time in the mandible was
18 months, followed by a bonded retainer for teeth #22
through #27. Overjet and overbite were corrected to ac-
ceptable limits per the patient’s desires, although full cor-
rection of the Class II malocclusion was not achieved in
this non-extraction non-surgical approach (Fig. 6).
Discussion
The American Academy of Periodontology (AAP) de-
scribes GAgP as generalized interproximal AL affecting
at least three permanent teeth other than the first molars
and incisors.1 Furthermore, the patient must present as oth-
erwise healthy, younger than 35 years old, and have break-
down of the periodontium that is inconsistent with the
amount of microbial plaque.8 The case presented included
AgP not only in the molars and incisors but also in areas of
the premolars and the canines, making it consistent with
the AAP description of GAgP.1
In this case, a frequent clinical manifestation of AgP was
evident: PTM. Although the etiology of PTM appears to be
multifactorial, it has yet to be clarified. Because PTM often
occurs in the anterior region and compromises esthetics, it
is the main reason periodontally involved patients seek
dental treatment.9 The labial inclination of the patient’s in-
cisors made it difficult for her to close her lips around her
teeth. Furthermore, the patient exhibited a drifting of her
midline to the right and a cross-bite on her left side attribut-
able to the buccal positioning of tooth #15.
Timing for orthodontic treatment is critical to its effec-
tiveness. Without periodontal therapy, inflammation is not
controlled and thus can hinder bone deposition and influence
the resorption of bone.10-12 Thus, orthodontic treatment may
76 Clinical Advances in Periodontics, Vol. 4, No. 2, May 2014
cause more damage than was originally present.9 It is neces-
sary to consider performing periodontal treatment before
proceeding with orthodontic treatment to limit inflamma-
tion in the oral cavity and reduce the potential for additional
bone loss during orthodontic treatment. Despite this, it
should be noted that current research does not consider se-
vere periodontitis to be a contraindication to orthodontic
treatment but rather suggests that it can restore a patient’s
dentition and allow the teeth to be retained.13
An example of this is using orthodontics to address
PTM. Orthodontic treatment not only moves the incisors
into an esthetic position but also, using retrusive and intru-
sive forces, can increase CAL for anterior teeth that may
have been moved outside of the alveolar bone as a result
of PTM.12 In fact, intrusion with low continuous forces
on periodontally healthy teeth can decrease clinical crown
height and increase the alveolus.14 This outcome is highly
desirable in patients with reduced periodontium because it
can improve esthetics and function. The present case report
is a good example of this, wherein the application of retru-
sive and intrusive light forces improved the patient’s peri-
odontal condition, occlusion, and overall appearance.
Another significant issue in orthodontics relates to the
potential alteration in the soft-tissue dimension. There is
evidence that plaque-induced inflammation while a patient
is undergoing orthodontic treatment can lead to gingival
recession.15-20 However, if plaque control is good, it is pos-
sible to maintain the soft tissue even with forces that are
extrusive and labial.15-17 In fact, Batenhorst et al.16 demon-
strated that, with these forces, there was an increase in the
width of the keratinized gingiva and bone apposition on the
lingual if the patient maintained good plaque control.
These effects demonstrate that home care is of the utmost
importance for orthodontic patients, especially those with
a compromised periodontium. In the present case report,
Periodontal and Orthodontic Treatments in Generalized Aggressive Periodontitis

FIGURE 5a Periapical radiograph of tooth #30 at initial visit. 5b Vertical bitewing radiograph of tooth #30 1 year after surgery. 5c through 5e Periapical
radiographs of anterior teeth 1 year after initial therapy.
FIGURE 6a through 6d Clinical images at time of orthodontic appliance removal. 6e Panoramic radiograph at the time of orthodontic appliance removal.
the patient consistently demonstrated good home care, help-
ing to maintain periodontal stability after initial therapy.
Periodontal treatment for the patient included SRP, an
antibiotic regimen, open-flap debridement (OFD), and re-
generative therapy using EMD. SRP and open-flap curet-
tage with antibiotics have been long-standing treatment
options for reducing the inflammation associated with
periodontal disease.21 Regenerative options such as EMD
have had their efficacy proven in situations with surgical ac-
cess and root surface conditioning.7,22 The clinician’s experi-
ence and patient compliance also contribute to its outcome.7
Regular maintenance appointments were performed after
initial treatment to maintain periodontal stability and rein-
force good oral hygiene. Moreover, while undergoing ortho-
dontic treatment, the patient received EMD surrounding
tooth #30, which had a distal bone defect. Assessment of
#30 after evaluation and continued orthodontic treatment
revealed a decrease in the bone defect.
This finding was consistent with past literature.23,24 It
has been shown that OFD followed by EMD application
has led to significantly higher attachment gains compared
with OFD alone.17 Additionally, a reported clinical benefit
Syrowik, Janic, Jacobs
C A S E R E P O R T
of using EMD is the improvement of wound stability to di-
minish the possibility of soft-tissue recession.25
EMD has had its efficacy proven in well-documented,
longitudinal studies indicating that stability over the long-term
is similar to that obtained with guided tissue regeneration.26
However, there are good sources of evidence to suggest that
treatment with OFD and EMD does not provide significant
advantages over OFD alone.27
Unfortunately, there is very little literature regarding
concurrent orthodontic and periodontal treatment. The lit-
erature available points to stability after orthodontic treat-
ment.4,11,23 Although there are reports of orthodontic and
periodontal treatment in cases of GAgP, to the best of the
authors’ knowledge, there are none that include surgical
management of defects while the patient is undergoing or-
thodontic treatment. This case report demonstrates that it
is possible to use an interdisciplinary approach to create an
environment of overall oral health even in a young patient
with a generally compromised periodontium. Additional
studies need to be conducted on a larger scale to determine
the positive effects of using periodontal and orthodontic
treatments sequentially. n
Clinical Advances in Periodontics, Vol. 4, No. 2, May 2014 77
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Summary
Why is this case new information? j Demonstrates that it is possible to successfully perform EMD therapy
on a patient with GAgP while the patient is simultaneously undergoing
orthodontic treatment

What are the keys to successful j Careful selection of defects (i.e., deep, narrow 2- or 3-wall intrabony
management of this case? defects; mandibular Class II buccal recessions)
j Careful selection of patients (i.e., good plaque control, non-smoker)
j Stabilizing the periodontium before beginning orthodontic treatment

What are the primary limitations to j No additional available data demonstrating efficacy of combined
success in this case? orthodontic and periodontal treatment of patients with GAgP

Acknowledgments CORRESPONDENCE:
Dr. Lauren Syrowik, 200 First Street SW, Rochester, MN 55905. E-mail:
The authors acknowledge the following individuals for lmfrizzo@gmail.com.
their help in the project: Mr. Eric Jacobs, University of
Detroit Mercy Dental Media Specialist, Detroit, Michigan,
and Mr. Nathan Blume, Instructional Designer and Web
Developer/Designer, Detroit, Michigan, for their assistance
with the images. Special thanks to Dr. Richard Kulbersh,
University of Detroit Mercy School of Dentistry Ortho-
dontics Chair and Program Director, for his help with
the organization and production of this manuscript. The
authors report no conflicts of interest related to this case
report.

78 Clinical Advances in Periodontics, Vol. 4, No. 2, May 2014 Periodontal and Orthodontic Treatments in Generalized Aggressive Periodontitis

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