The Influence of Orthodontic Movement on

Periodontal Tissues Level

Daniele Cardaropoli and Lorena Gaveglio

Orthodontic forces are capable of reorganizing and remodeling the peri-

odontal ligament, to facilitate tooth movement. Optimal forces will pro-
duce favorable tissue responses, but whenever this balance is lost (as in
the case of high force magnitudes, or in the presence of reduced peri-
odontal support), the periodontal ligament may respond differently. This
review highlights the responses of the periodontal ligament reactions
when orthodontic forces— both normal and extreme—are applied. We
also attempt to discuss how orthodontic movement differs in patients
with good periodontal health and in those with periodontal disease.
(Semin Orthod 2007;13:234-245.) © 2007 Elsevier Inc. All rights reserved.

he question of whether orthodontic forces no or only clinically insignificant lesions in the

T may have negative effects on the periodon-
tal tissues has been evaluated through a number
of clinical and experimental studies.1 This issue
is of clinical relevance, since epidemiologic stud-
ies have shown that the worldwide prevalence of
gingival inflammation is high, and that 30% of
the population has advanced periodontal dis-
ease.2,3 It is also known that the prevalence of
periodontal disease in patients with a history of
gingivitis is high, as is susceptibility of certain
teeth.4 Thus, it is important to identify patients
who are susceptible to periodontal disease, and
to control their periodontal health before start-
ing orthodontic treatment.
The adult patient with periodontitis usually
presents with flaring of the anterior teeth,
spaces, rotations, and overeruption of the den-
tition. These changes in tooth position might
compromise the esthetics and function of the
dentition. In these situations orthodontic treat-
ment may be useful in bringing back better func-
tion and esthetics (Fig 1). When proper peri-
odontal health and oral hygiene are maintained
during the active phase of orthodontic therapy,
Private Practice, Torino, Italy.
Address correspondence to Dr. Daniele Cardaropoli, Via Balti-
mora 122, 10137 Torino, Italy. Phone: ⫹39.011.323683; E-mail:
dacardar@tin.it
© 2007 Elsevier Inc. All rights reserved.
1073-8746/07/1304-0$30.00/0
doi:10.1053/j.sodo.2007.08.005
supporting tissues will occur.5-9 However, if the
oral hygiene maintenance is less effective with
poor patient compliance and the presence of
established periodontal inflammation during
orthodontic treatment, the risk of a periodontal
breakdown is markedly increased.10-13 It should
be noted, however, that the majority of the clin-
ical studies evaluating the effect of orthodontic
movement on the periodontal tissues have been
performed in children or adolescents, who
rarely are affected by destructive periodontal
disease.14
The development of destructive periodontal
disease may result in the formation of suprabony
pockets, with inflamed connective tissue and the
dentogingival epithelium located coronal to the
alveolar bone crest, or in the formation of in-
frabony pockets, with the inflamed connective
tissue and the dentogingival epithelium located
apical to the alveolar bone crest.15 Experimental
studies involving histological analysis have re-
vealed that orthodontic forces per se are un-
likely to convert gingivitis into a destructive pe-
riodontitis.1,16 This finding may be related to
the fact that, in the case of gingivitis, the plaque-
induced inflammatory lesion is confined to the
supra-alveolar connective tissue, while the tissue
reactions occurring as a result of orthodontic
tooth movement are confined to the connective
tissue located between the root and the sur-
rounding alveolar bone.

234 Seminars in Orthodontics, Vol 13, No 4 (December), 2007: pp 234-245

 Orthodontic Forces and Periodontal Ligament 235

Figure 1. (A-D) Adult patient affected by a chronic periodontitis showing flaring of the anterior teeth due to loss
of bone support. After surgical periodontal treatment, orthodontic therapy was started to realign migrated teeth.
Note the esthetic improvement obtained at the end of treatment together with a healthy periodontal support.
(Color version of figure is available online.)

Orthodontic movement creates clinical, cel-
lular, and molecular level changes in the alve-
olar bone. In periodontal pressure sites, bone
resorption occurs by osteoclasts, while in the
periodontal tension sites, bone apposition oc-
curs by osteoblasts. Orthodontically generated
dental movement thus is strictly related to phys-
iological processes of cellular activity, both in
the soft connective tissue and in the alveolar
bone compartments.17
This article will review experimental and clin-
ical reports that may be helpful in trying to
understand the effect of orthodontic movement
on periodontal tissue levels, and to determine
when abnormal force application can create a
risk for further periodontal breakdown.
Periodontal Responses to Orthodontic
Force Application
Classically, when an orthodontic force is ap-
plied, tooth movement will occur in the direc-
tion of the force, by narrowing the periodontal
ligament (PDL) at the site of compression, with
subsequent bending and resorption of the alve-
olar bone. In this way teeth can be moved a small
distance, until the resisting bone stops the move-
ment. This resistance is eventually overcome by
the ensuing resorption of the bone opposite the
compressed PDL. At sites of force-induced ten-
sion in the PDL, a concomitant apposition of
bone will occur, until the PDL has regained its
normal width. Thus, tooth movement occurs as a
direct outcome of force-induced tissue remodel-
ing around the dental root. Such a remodeling
requires the presence of cells capable of resorb-
ing and forming the extracellular matrix (ECM)
of the PDL and alveolar bone. When this mech-
anism is kept under control, initial anatomic
limitations such as sinuses, sutures, or cortical
barriers can be exceeded, and tooth movement
can be performed even through the maxillary
sinus.18
236 Cardaropoli and Gaveglio

When orthodontic treatment is commenced, the teeth are deflected in the PDL space. After
a force system should be planned to reach the an additional 3 to 5 seconds, this fluid leaks out
proposed objectives. Increasing or decreasing of the ligament, which generates compression
force levels, are always associated with a tissue and pain, leading to a cessation of any damaging
reaction. Under normal conditions, chewing force. However, the pattern of the tissue re-
and phonetic forces act on teeth surfaces, but no sponse to orthodontic forces differs and can be
dental movement results, since teeth are placed related to the intensity of the applied force. It
in a so-called neutral zone. Moreover, this equi- differs in accordance with the magnitude of the
librium is also maintained by means of an active applied orthodontic force, whether light or
stabilization, mediated by the metabolic activity heavy. When light forces are used, a deforma-
of the PDL. To overcome this equilibrium and tion of the alveolar bone develops within 1 sec-
move a tooth, a minimal force of 5 to 10 g/cm2 ond, since the PDL fluids cannot be com-
is required.19 Dental movements can be classi- pressed. After 1 to 2 seconds, the fluids leak out
fied as movement “with the bone” or “through of the ligament, allowing the tooth to move in
the bone.” To achieve “with the bone” move- the ligament space. After 3 to 5 seconds the PDL
ment, frontal (direct) resorption of the bone in blood vessels will be compressed in pressure sites
the direction of the movement should occur, and stretched in tension sites. Within a few min-
with a balance between resorption and apposi- utes, a decrease of the Po2 (partial pressure of
tion. With excessive force application, indirect oxygen) will develop, along with an increase in
resorption occurs in areas surrounding the com- the concentrations of prostaglandins and cyto-
pressed, necrotic (hyalinized) PDL, and tooth
movement will be of “through the bone” type,
with only small amounts of bone apposition.20,21
However, once the bony barrier is dissolved, the
tooth moves rapidly in the direction of the force,
while the PDL in the tension sites is stretched,
and bone apposition proceeds vigorously.
When an orthodontic force is applied, a cas-
cade of events initiated by mechanical deforma-
tion of cells and ECM takes place. The mechan-
ical deformation of cells, their change in shape
(ovoid or round), and the release of arachidonic
acid from the cell surface and its metabolism
through either the lipooxygenase or cyclooxy-
genase pathway leads to release of first messen-
gers (prostaglandins and leukotrienes), which in
turn activate or stimulate the release of second
messengers (cyclic AMP, inositol phosphate, dia-
cyl glycerol, and mitogen-activated tyrosine ki-
nases). These second messengers evoke cellular
reactions, such as bone and PDL remodeling. In
addition, pressure generated in the PDL alters
the vascular support, contributing to the cellular
reactions and remodeling changes.
In the presence of heavy and intermittent
forces, as are produced during mastication, a
dental response is completed within a few sec-
onds. These heavy intermittent forces cause an
instantaneous microdeformation of the alveolar
Figure 2. Cat maxillary canine after 7 days of orthodon-
bone since the fluid component of the PDL tic treatment showing compressed PDL and undermin-
cannot be compressed. After 1 to 2 seconds, ing resorption. Tissue section stained with hematoxylin
fluid leaks out of the periodontal ligament and and eosin. (Color version of figure is available online.)
 Orthodontic Forces and Periodontal Ligament 237

Figure 3. Cat maxillary canine after 7 days of orthodontic treatment showing PDL tension site and beginning
of new alveolar bone formation. Tissue section stained with hematoxylin and eosin. (Color version of figure is
available online.)

kines. After a few hours, metabolic alterations
will increase the incidence and rate of cellular
differentiation, and after 2 days, noticeable ini-
tiation of tooth movement can be found. This
process occurs predominantly due to the load-
induced bone remodeling performed by a com-
bined activity of both osteoclasts and osteoblasts.
This kind of tissue reaction will generate a direct
bone resorption (Fig 2), with a synchronization
of tissue resorption and apposition in PDL pres-
sure and tension sites (Fig 3), respectively.
In contrast, when heavy forces are applied to
teeth, alveolar bone deformation will develop
within 1 second, since the PDL fluids cannot be
compressed. After 2 seconds, the fluids leak out
of the ligament, allowing the teeth to move in
the ligament space. After 3 to 5 seconds, the
PDL blood vessels will be occluded, and within
few minutes, the blood supply to compressed
areas of the ligament will stop altogether. Within
a few hours, signs of cellular death will appear in
these zones, with the development of necrosis,
which resembles the appearance of hyaline car-
tilage when viewed with a microscope (the so-
called hyalinized zone). After 3 to 5 days, new
cellular differentiation starts, along with the be-
ginning of indirect bone resorption in all areas
surrounding the hyalinized zone (Fig 4). One to
2 weeks later, the lamina dura will be removed,
facilitating tooth movement.
Based on these findings, it can be concluded
that light forces are more efficient in developing
continuous tooth movement, preserving both
bone and PDL from necrosis. With light forces,
tooth movement begins after about 2 days of
treatment, and this early movement can some-
times exceed 0.5 mm. The movement then con-
tinues, and if an appropriate system of force
application is continued, a 2-mm space change
may be detected after about 3 weeks. In contrast,
tooth movement with heavy forces will not be
continuous, but will occur with alternating peri-
ods of movement and a break, because of the
need for resorption of the necrotic areas. How-
ever, it is difficult to quantify the amount of
force delivered to each tooth, and to determine
whether it should be categorized as “light,” since
such quantification may depend on various pa-
238 Cardaropoli and Gaveglio
Figure 4. Cat maxillary canine after 7 days of orth-
odontic treatment showing compressed PDL and di-
rect alveolar bone resorption. Tissue section stained
with hematoxylin and eosin. (Color version of figure
is available online.)
rameters, such as root surface area, tooth anat-
omy, and the extent of periodontal support
height. In the case of periodontal disease with loss
of attachment, a “normal” force may be “excessive”
in relation to the existing support of the teeth,
which often leads to tissue hyalinization, excessive
bone resorption, and further periodontal break-
down. It is obvious that in the case of severe peri-
odontal disease, this scenario could even lead to
tooth loss. To provide a numeric quantification
useful for the clinician, it is suggested that a force
not greater than 10 to 15 g should be applied to a
maxillary incisor with loss of periodontal support,
to minimize further tissue breakdown.19
Tooth movement in regions outside the alve-
olar process is undesirable and may occur due to
an altered and poorly designed force system.
Force distribution in tissues surrounding dental
roots is controlled by the force magnitude, and
by the moment/force ratio at the center of re-
sistance of the root. The force magnitude, espe-
cially at the onset of treatment and in adult
patients, should be very low, to avoid areas of
hyalinization and to promote proliferation of
periodontal cells,22 while the moment/force ra-
tio should be high,23 to achieve a good distribu-
tion of the forces along the PDL. Adult age per
se is not a contraindication for therapy, even
though tissue response to orthodontic forces,
including cell mobilization, activation, and re-
sponses, is slow when compared with those of
children. This difference can be attributed to
reduced cellular activity with tissues rich in col-
lagen in adult subjects. In adults, hyalinized
zones can form readily in pressure sites, tempo-
rarily preventing the tooth from moving in the
intended direction.23 Eventually, these necrotic
zones are eliminated through resorption by os-
teoclasts and macrophages derived from the ad-
jacent marrow spaces, followed by regeneration
of the PDL.24
In summary, when strong/heavy forces are
applied, the compressed PDL is crushed, result-
ing in local ischemia and hyalinization, which
delay tooth movement. When even moderate
forces are applied, the PDL may become stran-
gulated, resulting in a delay in bone resorption.
However, light forces will produce only a partial
PDL ischemia, along with direct bone resorp-
tion, resulting in a continuous tooth movement.
Orthodontic Movement of Teeth with
Loss of Periodontal Support
Periodontitis is a multifactorial disease, which
develops as a result of bacterial infection, super-
imposed on a genetic predisposition. Orthodon-
tic forces per se are unlikely to convert gingivitis
into a destructive periodontitis, but poorly exe-
cuted orthodontic therapy in patients with peri-
odontitis can easily lead to further periodontal
breakdown (Fig 5). The combination of inflam-
mation with occlusal trauma or dental move-
ment will produce a rapid destruction of the
support apparatus. The loss of alveolar bone in
periodontitis patients results in an apical dis-
placement of the center of resistance of the
involved teeth, making bodily movement (trans-
lation) very difficult. The subsequent effect is
that the teeth become prone to tipping. In ad-
dition to these mechanical difficulties, the for-
mation of a hyalinized zone adjacent to a peri-
 Orthodontic Forces and Periodontal Ligament 239

Figure 5. (A-D) Detrimental effects of a poorly executed treatment. Patient presented with tooth migration and
space opening due to periodontal disease. Orthodontic treatment has been performed without proper elimi-
nation of the periodontal infection and adequate plaque control. Note the deepened periodontal pocket after
tooth alignment. Surgical opening of the site showed severe bone loss resulting in further periodontal break-
down and esthetic complications. (Color version of figure is available online.)

odontally compromised tooth can be deleterious,
since regeneration of the PDL does not occur
in the presence of a bacterial infection, resulting in
extensive loss of alveolar bone (Fig 6). Thus, in
case of a deep periodontal infection, teeth
should be moved only after proper periodontal
therapy has been performed, and deep infection
has been eliminated.25,26
From a clinical point of view, in many patients
with a periodontally involved dentition the mi-
gration of the anterior teeth leads to spacing
and eruption, resulting in serious functional and
esthetic problems. In these cases, orthodontics
can be a reliable therapeutic treatment, because
it does not result in a decrease of the marginal
bone level, provided gingival inflammation is
controlled (Fig 7). Proper and timely combina-
tion of orthodontic and periodontal treatment
has been shown to improve reduced periodontal
conditions, suggesting the possibility for a long-
term success.25 Best results are obtained when
orthodontic movements are performed with
light forces, and the line of action of the force
passing close to the center of resistance.26 The
central point for the effectiveness of such treat-
ments is in the ability of the procedure used to
remove subgingival plaque and calculus from
the root surface. Following these guidelines
orthodontic treatment is no longer contraindi-
cated when major marginal bone loss has oc-
curred due to periodontal disease. The treat-
ment of patients with severe periodontal disease
is now being performed with interdisciplinary
teamwork between the orthodontist and the pe-
riodontist, to improve the possibilities of saving
and restoring a deteriorated dentition.
The Influence of Orthodontic Forces on
the Inflamed Periodontal Ligament
The development of destructive periodontal dis-
ease may result in the formation of infrabony
240 Cardaropoli and Gaveglio

Figure 6. (A-D) Adult patient with malocclusion who underwent orthodontic therapy without a proper peri-
odontal and mucogingival evaluation. After the alignment of the two lower central incisors, a deep recession
developed, which can be attributed to uncontrolled labial movement. The intrasurgical view show the hard tissue
level, with the bone dehiscence. The situation was partly improved by the combination of guided tissue
regeneration and connective tissue graft. (Color version of figure is available online.)

pockets, that is, angular bony defects with the
inflamed connective tissue and the dentogingi-
val epithelium located apical to the crest of the
alveolar bone. Furthermore, infrabony pockets
may be created by orthodontic tipping or intrud-
ing movements of teeth harboring bacterial
plaque, or both.27 Experimental studies have
demonstrated an aggravating effect on the pro-
gression of periodontal disease when trauma,
caused by “jiggling” forces, was superimposed on
periodontal lesions associated with angular bony
defects. This effect may indicate an increased

Figure 7. (A-C) Interdisciplinary treatment of an adult patient with chronic periodontitis. After proper non-
surgical periodontal treatment, osseointegrated implants were inserted in the posterior areas to replace the
missing teeth and orthodontic treatment was performed to align the migrated dentition. At the end of therapy,
anterior teeth were splinted by means of resin-bonded Maryland-type bridges. (Color version of figure is available
online.)
 Orthodontic Forces and Periodontal Ligament
risk for progression of plaque-associated peri-
odontal disease, when orthodontic mechanics is
applied to a tooth, which already has angular
defects.28,29 However, a similar study performed
in monkeys failed to demonstrate additional loss
of connective tissue attachment when jiggling
trauma was superimposed on periodontally dis-
eased sites.30
The effect of bodily movement of teeth into
infrabony periodontal defects has been evalu-
ated in an experimental study in monkeys.31 The
study reported that no deleterious effect was
observed on the level of the connective tissue
attachment. The angular defect was eliminated
by the orthodontic treatment but no gain in
attachment level was obtained. There remained
only a thin epithelial lining covering the root
surface. However, in this study periodontal treat-
ment was performed before the orthodontic
tooth movement was instituted, and the animals
were subjected to plaque control measures dur-
ing the entire course of the experiment.31 In
another study performed in 4 beagle dogs, an-
gular bony defects were prepared at the mesial
aspect of the third premolars and an experimen-
tal periodontitis was induced. Orthodontic tooth
movement was performed, to move one premo-
lar into and through the angular bony defect.
Clinical, radiographic, and histological evalua-
tions revealed that it was possible to establish
and maintain an infrabony pocket with a subcr-
estal, plaque-induced inflammatory lesion dur-
ing the entire course of the study. While the
control teeth had maintained their attachment
levels, the orthodontically moved teeth did show
additional loss of attachment. It was concluded
that orthodontic therapy involving bodily tooth
movement may enhance the rate of destruction
of the connective tissue attachment in teeth with
inflamed, infrabony pockets. The risk for addi-
tional attachment loss is particularly evident
when the tooth is moved into the infrabony
pocket.32 In another experimental study on
monkeys, in which bodily movement of teeth
into infrabony lesions was performed, results in-
dicated the possibility to obtain reattachment of
the periodontium after tooth movement.33
Clinical studies that have examined the effect
of orthodontic movement in periodontal pa-
tients with infrabony defects also abound in the
literature. A combined therapy, made of open
flap surgery and orthodontic intrusion, resulted
241
in the realignment of the treated teeth with
radiological bone fill, gain in clinical attach-
ment level and probing pocket depth reduc-
tion, confirming the possibility of achieving a
final healthy periodontium. These clinical stud-
ies demonstrated that it is possible to perform
tooth movement into infrabony defects in pa-
tients with advanced periodontal disease, but
emphasizing the importance of preorthodontic
periodontal therapy.34,35
A common problem in adult patients who
have periodontal disease is the migration, overe-
ruption, and spacing of incisors. These posi-
tional changes can be the result of the lack of
equilibrium between the periodontal support
and the forces acting on the teeth. Anterior
teeth are specifically prone to overeruption,
since they are not protected by occlusal forces
and have no anteroposterior contacts inhibiting
migration. Moreover, masticatory forces are pre-
dominantly directed anterolaterally and there
exists little resistance, particularly in cases of
increased overjet. With progressive bone loss,
the center of resistance moves more apically,
and the forces acting on the crowns generate a
progressive displacement. From a functional
and esthetic point of view, the intrusion of these
teeth seems to be the logical solution34 even if
orthodontic treatment, involving intrusive move-
ments, does include a risk for an aggravation
of the periodontal condition.36 These types of
movements might have some beneficial effect on
clinical crown lengths and marginal bone levels
(Fig 8).34 Furthermore, histological investiga-
tions suggest that orthodontic intrusion may
lead to new attachment formation: an experi-
mental study on monkeys demonstrated new
connective tissue attachment formed during the
intrusion of periodontally involved teeth. It is
possible that once the gingival infection is elim-
inated and the root surfaces are thoroughly
scaled, it is possible for a new cementum layer to
form on the former infected root surface.37 In
another study, performed with the help of met-
ric and histological analyses in monkeys, it was
found that only about 60% of the distance
moved is covered by the gingiva when the teeth
are intruded with a continuous force of 80 to
100 g.38
In contrast to the latter, an experiment per-
formed on dogs demonstrated that intrusive
orthodontic forces are prone to shift supragin-
242 Cardaropoli and Gaveglio

Figure 8. (A and B) Adult patient with pathologic tooth extrusion of a maxillary central incisor. After a
nonsurgical periodontal therapy, orthodontic treatment was initiated using light and continuous forces, which
helped in reintrusion of the tooth, with a perfect realignment, esthetic harmony, and clinical crown length
reduction with a physiologic sulcus. (Color version of figure is available online.)

gival plaque into a subgingival position, and
thereby result in formation of an infrabony
pocket.27 However, contraindication of intrusive
movement should not be a major concern if a
meticulous oral hygiene and a healthy gingival
status are maintained. Once the periodontal
treatment leads to a healthy gingival condition
and susceptibility is controlled, and if the ap-
plied orthodontic forces are well calibrated, it is
possible to intrude teeth with periodontal bone
loss. This intrusion may lead to a certain gain in
connective tissue attachment.34,36,37
The orthodontically induced extrusion of
teeth can be indicated to increase the clinical
crown length of teeth, or to reduce differences
in alveolar bone levels. The so called forced
eruption has been described for the treatment
of infrabony pockets, in which the extrusive
movement leads to a coronal positioning of
intact connective tissue attachment, to shallow
out the bony defect.39 One contraindication to
this technique is that, following the extrusion,
the teeth will be in supraocclusion and the
crown will need to be shortened, often requiring
endodontic therapy and prosthetic restoration
(Fig 9 A-F).
Depending on the different clinical situa-
tions, on occasion it may be desirable to have the
periodontium follow the tooth in the extrusive
movement, while in other situations it may be
desirable to move a tooth out of the periodontal
support. An experimental study on monkeys re-
vealed that free gingiva moved about 90% and
attached gingiva about 80% of the extruded dis-
tance. The width of the attached gingiva and the
clinical crown length increased significantly,
while the position of the mucogingival junction
was unchanged.40 Therefore, the extrusion of a
single tooth that would be extracted at a later
time can be a reliable method to improve the
marginal bone levels, when implant placement is
a treatment option. The supporting soft tissues
will move vertically with the corresponding tooth
during the forced eruption, so as to create the
ideal conditions for implant placement.41 On
the other hand, in teeth with crown-root frac-
ture at a subgingival level, the target of the treat-
ment may be to force the tooth to erupt out of
the periodontium to perform a prosthetic reha-
bilitation. In the latter situation, the extrusive
movement should be combined with gingival
fiberotomy. This excision of the coronal portion
of the fiber attachment around the tooth should
be performed once every 14 days, so that the
tooth can be moved out of the bone without
affecting the bony and gingival levels of the
neighboring teeth.42,43
Orthodontic Movement and Anatomic
Limitations
Orthodontic treatment may on occasion be per-
formed in adult patients who have partially
edentulous dentitions (as the result of agenesis
or previous extractions), and in these circum-
stances there may be anatomic limitations that
can complicate tooth movement. Atrophic bone
ridges, with a reduction of the horizontal volume,
are not a limit to orthodontic tooth movement if
direct bone resorption is obtained. Clinical and
 Orthodontic Forces and Periodontal Ligament 243

histological observations have confirmed that if
light forces are applied and teeth are moved
more bodily into an area of reduced bone
height, a thin bone plate is recreated ahead of
the moving teeth.44 The same conclusions can
be reached regarding the possibility of moving a
tooth through anatomic limitations such as si-
nus, suture, or cortical barriers. Limitation of
tooth movement in regions outside the alveolar
process, as the maxillary sinus, is the result of an
“abnormal force system,” but if a proper distri-
bution of the forces along the periodontal liga-
ment can be obtained, the limitations of the
cortical bone of the alveolar process or the max-
illary sinus can be overcome.
A clinical study in humans has demonstrated
the movement of a premolar into the maxillary
sinus. After 6 months of active orthodontics, the
radiographic evaluation of the displacement re-
vealed that bodily movement was achieved, with
the translation of the root in the distal direction,
without any vertical displacement. Direct resorp-
tion allowed the movement even if the sinus
floor seemed to set a limit to it. After the distal
movement, the direct remodeling caused a dis-
placement of the lamina dura, leading to a com-
plete remodeling of the sinus contours. The
tooth maintained normal vital response to pulp
testing during this period. It seems that the
tooth did not fall into the sinus but moved with
its supporting bone, without experiencing loss
of connective tissue attachment. Moreover, this
controlled movement left the bone necessary for
implant insertion into the alveolus of the dis-
placed tooth.45 Hence, based on the findings in
the studies referred to, it seems reasonable to
assume that a tooth moved through the maxil-
lary sinus will maintain the original height of the

Figure 9. (A-F) Patient presenting crown-root fracture at a subgingival level. A gold-alloy post was cemented into
the root canal and orthodontic extrusion initiated performing circumferential fiberotomy every 2 weeks. At the
end of treatment a permanent ceramic crown was inserted. (Color version of figure is available online.)
244 Cardaropoli and Gaveglio
supporting apparatus, the connective tissue at-
tachment, and the alveolar bone height.
Conclusions
The orthodontic treatment of patients with de-
teriorated dentitions requires an interdiscipli-
nary team approach that involves different den-
tal specialties to obtain satisfactory functional
and esthetic outcome. Orthodontic therapy is
based on the principle of displacing teeth by
applying mechanical forces and remodeling the
PDL and alveolar bone. Clinical and histological
evidence support the need for using light con-
tinuous forces during orthodontic treatment.
Light forces evoke direct bone resorption, a so-
called with-the-bone resorption, in the direction
of the movement, with a balance between re-
sorption and apposition. In contrast, heavy
forces create blood vessel strangulation with sub-
sequent necrosis (hyalinization) in PDL com-
pression zones. This kind of tissue reaction will
delay tooth displacement and increase the risk
for bone loss. In the presence of a periodontally
involved dentition, a risk for further periodontal
breakdown is unacceptable since it may lead to
tooth loss. On the other hand, orthodontic ther-
apy performed with well-calibrated forces and
applying appropriate force systems can be useful
in realigning migrated teeth in adult patients
with periodontal disease following elimination
of the periodontal infection.
An understanding of the basic clinical and
biological principles of orthodontic tooth dis-
placement is an essential requirement for the
implementation of a successful therapeutic reg-
imen in patients of all age groups with normal as
well as compromised periodontal tissues.
Acknowledgment
The authors thank Drs. Stefania Re, Giuseppe Corrente, and
William Manuzzi for their contribution in the clinical treat-
ment. The authors also express their sincere gratitude to Dr.
Ze’ev Davidovitch for providing histologic figures as well as
with a critical review and revision of the manuscript.
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