|Year : 2015 | Volume
| Issue : 4 | Page : 261-264
Interdisciplinary approach for the treatment of pathologic migration in teeth with advanced periodontal disease
Pravesh Kumar Jhingta1, Kehar Singh Negi2, Deepak Sharma1, Vinay Kumar Bhardwaj3, Sanjeev Vaid2, Negi Nishant2
1 Department of Periodontology, H. P. Govt. Dental College and Hospital, Shimla-1, Himachal Pradesh, India
2 Department of Orthodontics and Dentofacial Orthopaedics, H. P. Govt. Dental College and Hospital, Shimla-1, Himachal Pradesh, India
3 Public Health Dentistry, H. P. Govt. Dental College and Hospital, Shimla-1, Himachal Pradesh, India
|Date of Web Publication||23-Nov-2015|
Pravesh Kumar Jhingta
Department of Periodontology, H. P. Govt. Dental College and Hospital, Shimla-1, Himachal Pradesh
Pathological migration of anterior teeth is an esthetic and functional problem that may be associated with advanced periodontal disease. It is defined as a change in tooth position resulting from disruption of the forces that maintain teeth in a normal position in relation to their arch. The disruption of the equilibrium in tooth position may be caused by several etiologic factors. These include periodontal attachment loss, pressure from inflamed tissues, occlusal factors, oral habits such as bruxism, tongue thrusting, and the playing of wind instruments, loss of teeth without replacement, a labial frenum, gingival enlargement and iatrogenic factors. However according to the literature, the destruction of tooth-supporting structures is the most relevant factor associated with pathologic migration. Unfortunately, pathologic tooth migration can be associated with esthetic damage of smile line, reducing patient's self-esteem. To solve both issues, therefore, a combination of orthodontic and periodontal treatment is often needed.
Keywords: Orthodontic treatment, pathological migration, periodontitis
|How to cite this article:|
Jhingta PK, Negi KS, Sharma D, Bhardwaj VK, Vaid S, Nishant N. Interdisciplinary approach for the treatment of pathologic migration in teeth with advanced periodontal disease. SRM J Res Dent Sci 2015;6:261-4
|How to cite this URL:|
Jhingta PK, Negi KS, Sharma D, Bhardwaj VK, Vaid S, Nishant N. Interdisciplinary approach for the treatment of pathologic migration in teeth with advanced periodontal disease. SRM J Res Dent Sci [serial online] 2015 [cited 2019 Dec 16];6:261-4. Available from: http://www.srmjrds.in/text.asp?2015/6/4/261/170286
| Introduction|| |
Pathological migration of anterior teeth is an esthetic and functional problem that may be associated with advanced periodontal disease.  It is defined as a change in tooth position resulting from disruption of the forces that maintain teeth in a normal position in relation to their arch. The disruption of the equilibrium in tooth position may be caused by several etiologic factors. These include periodontal attachment loss, pressure from inflamed tissues, occlusal factors, oral habits such as bruxism, tongue thrusting, and the playing of wind instruments, loss of teeth without replacement, a labial frenulum, gingival enlargement and iatrogenic factors. However according to the literature, the destruction of tooth-supporting structures is the most relevant factor associated with pathologic migration. , Unfortunately, pathologic tooth migration can be associated with esthetic damage of smile line, reducing patient's self-esteem. To solve both issues, therefore, a combination of orthodontic and periodontal treatment is often needed. 
Although some case reports have shown "spontaneous" repositioning of teeth following periodontal therapy alone, the treatment of severe cases of anterior spacing can be complex and time consuming, and a multidisciplinary approach is often required, including periodontic, orthodontic and restorative treatment.  The movement of teeth with reduced, but healthy periodontium has been studied in animal and clinical reports. These studies confirmed that the attachment is not damaged when inflammation is absent. However, in the presence of plaque-induced inflammation, orthodontic forces cause uncontrolled periodontal attachment loss. ,
Literature from two animal histologic studies suggest that the formation of new periodontal attachment is achievable with open flap debridement (OFD) plus orthodontic treatment. , In one of these studies, Geraci et al. created three-wall defects and treated them with OFD; they showed that it was possible to rebuilt lost periodontal support in conjugation with bodily tooth movement.  Moreover, Melsen et al. confirmed the capacity of OFD associated with orthodontic movement to result in new connective fiber formation over the deepest point of root instrumentation when intrusive tooth movement was performed. 
This paper describes the combined periodontal nonsurgical and surgical, and orthodontic treatment of a serious case of pathologic migration of maxillary and mandibular anterior teeth caused by severe periodontitis.
| Case report|| |
A 23-year-old, systemically healthy, nonsmoking female presented with the complaint of bleeding gums, mobility and increased space between upper and lower front teeth. She had undergone scaling of the teeth 3 years back. On intra-oral examination, there were composite restorations on mesial surfaces of maxillary central incisors [Figure 1]. A periodontal examination and charting was performed including assessment of probing depths (PDs), clinical attachment levels (CAL), full mouth bleeding (gingival bleeding index) and plaque scores (plaque control record). The measurements for PDs and CALs were performed at six sites per tooth (mesio-buccal, mid-buccal, disto-buccal, disto-lingual, mid-lingual and mesio-lingual). Generalized pocket depths and CAL ranged from 4 to 10 mm and 1-10 mm respectively with severe periodontal destruction in maxillary anterior. The occlusal examination revealed Class I molar relationship bilaterally for the first molars and canines. Overbite and overjet were 5 mm and 4 mm respectively, and the fremitus and tension tests were positive. The maxillary incisors showed pathologic migration and rotations. Radiographic examination showed generalized, moderate, horizontal bone loss in both arches [Figure 2]. A diagnosis of moderate to severe generalized chronic periodontitis was made. Treatment objectives were:
- Oral hygiene instructions, supragingival scaling, subgingival debridement and periodontal flap surgery to eliminate existing pockets and thus achieve a favorable periodontal environment for good oral hygiene with a regular follow-up.
- Alignment and leveling of both arches,
- To achieve optimal facial esthetics, and to obtain an optimal over jet-over bite relationship,
- Finishing and detailing.
|Figure 2: Radiographic examination showed generalized, moderate, horizontal bone loss in both arches modified papilla preservation technique used|
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Gingival inflammation, plaque scores and periodontal pocket depths improved after nonsurgical periodontal therapy. The modified papilla preservation surgical flap technique was selected when the inter-dental space was wider than 2 mm; the simplified papilla preservation surgical flap technique was performed where the space was >2 mm [Figure 3]. A full-thickness flap was elevated to allow adequate visualization at the treatment site [Figure 4]. To reduce postoperative complications, including pain and swelling patient received antibiotic therapy (amoxicillin 1.5 g/day for 6 days), and rinsed twice a day for 15 days with chlorhexidine 0.2%, sutures were removed after 7 days. Chlorhexidine is antiplaque, antigingivitis and antiplaque agent. It may be used postoperatively since it offers the advantage of reducing the bacterial load in the oral cavity and preventing plaque formation at a time when mechanical cleansing may be difficult because of discomfort.  The patient was enrolled in a recall system that included professional tooth cleaning and reinforcement of oral hygiene maintenance for 1-year after periodontal treatment [Figure 5]. Orthodontic treatment started 1-year after surgery. Patient underwent different types of movement according to the clinical need to realign the dental arch: Intrusion and bodily movement that included movement away from the defect (tension side) and movement into the defect (pressure side). Orthodontic treatment was performed with the goal to obtain movement that would not impair the newly regenerated attachment. Straight-wire preadjusted brackets with thermo-active nickel arch wire(3M MBT 0.22-inch victory system) manufatured by Victory 3M UNITECK were used to achieve well-controlled repositioning. The clinician selected an appropriate fixed retention device after active therapy. This long-term retention was used to prevent relapse, to decrease tooth mobility, and to improve chewing comfort. Following orthodontic treatment, functionally stable occlusion and improved aesthetics were achieved [Figure 6].
| Discussion|| |
Advanced periodontal disease is primarily characterized as severe attachment loss and a reduction of alveolar bone support, and the periodontal condition is usually characterized by tooth mobility, migration, spacing and marginal gingival recession. In the maxillary anterior region, functional discomfort is usually accompanied by compromised esthetics. Orthodontic treatment for realignment of migrated periodontally involved teeth is initiated only after control of the periodontal inflammation has been achieved. If the patient is reasonably motivated and responds well to the initial periodontal therapy, adult orthodontic treatment has a role in providing complete rehabilitation in terms of both function and appearance, with a satisfactory long-term prognosis. 
The key element in orthodontic management of adult patients with periodontal complications is to eliminate or reduce plaque accumulation and gingival inflammation.  Systematic periodontal treatment is typically carried out in the preorthodontic phase to eliminate periodontal infection, with nonsurgical treatment, followed by a surgical regenerative procedure.  Several studies have demonstrated that teeth with reduced but healthy periodontium can be moved without attachment loss, whereas both intrusion and bodily movement may cause conversion of supragingival plaque into subgingival plaque, resulting in intra-bony pocket formation in cases of uncontrolled periodontal inflammation or in absence of good patient compliance. In the presence of deep infrabony defects, periodontal regeneration seems to be the only way to re-create periodontal support as shown by clinical, histologic, and long-term survival studies. 
However histologic findings by Melsen et al.  and Geraci et al.  have shown the possibility to rebuild lost attachment only with OFD and earlier orthodontic movement, probably as a consequence of the mitotic activity on the ligament cells. Unfortunately, other studies have not been able to replicate this result.  Some clinical studies in which nonregenerative surgical therapy was performed in association with orthodontic movement presented the possibility to correct pathologic tooth migration after severe periodontal attachment loss. , The true goal of this therapy should be to stop disease progression and regenerate lost periodontium, thereby changing the long-term prognosis of the teeth. The choice of regenerative surgery for periodontal therapy seems to be safer and more predictable. 
The loss of attachment and alveolar bone support of the dentition, due to periodontal disease, directly influences the biomechanics of any such treatment. Centers of resistance and moment-to-force ratios must be adjusted to compensate for the biologic restrictions of the situation, as well as the magnitudes of forces applied to the teeth.  Thus, two issues seem to be very delicate during the orthodontic phase: The correct application of biomechanical apparatus that is appropriate for each patient and the monitoring of oral hygiene. The correct sequence of biomechanics is intended to reduce the risk of root resorption, gingival recession and further bone loss. In the postorthodontic phase, permanent retention is performed, so that remineralization can be completed without the risk of relapse and to eliminate secondary occlusal trauma thereby improving patient comfort. Realignment of flaring teeth with a combined orthodontic-periodontal approach is an essential contribution to esthetic dentistry. 
Although the ability to draw conclusions from the present study is limited, this study presents one way to combine orthodontic and periodontal therapy effectively and safely. This therapy resulted in improved probing pocket depths and CAL provided by tissue regeneration, and no detrimental effect to the new apparatus was seen during the orthodontic phase, in which general improvement of esthetic parameters took place.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]