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Original Article

Determinants of pathological tooth migration

Leelarani Moka, Ramanarayana Boyapati1, Shyam S. Salavadhi1, Srikanth Chintalapani1,
Kotya Naik Maloth2, Kirankumar Nagubandi1
Department of Periodontics, G S L College of Dental Sciences, Rajahmundry, Andhra Pradesh, 1Departments of
Periodontics and 2Oral Medicine and Radiology, Mamata Dental College, Khammam, Telangana, India

ABSTRACT
Objective: Pathological tooth migration (PTM) is an esthetic and functional problem that may be associated with multiple
etiological factors. The purpose of this cross‑sectional epidemiological study is to determine prevalence of PTM among
periodontitis patients and investigate the association of various contributing factors such as tongue thrusting, missing posteriors,
trauma from occlusion, class II malocclusion, and aberrant frenum.
Materials and Methods: A cross‑sectional study was conducted with a total of 445 participants (age of 25–65 years) with
chronic periodontitis.
Results: Comparison of categorical values was done using Chi‑square test and continuous variables were done using
independent‑sample t‑test. Statistically significant results were seen in patients with tongue thrusting  (P < 0.002), missing
posteriors (P < 0.032), trauma from occlusion (P < 0.007). The results are not statistically significant with abnormal frenum,
class II malocclusion.
Conclusion: We conclude that tongue thrusting, missing posteriors, and trauma from occlusion are associated with PTM in
periodontitis patients. Though class II malocclussion and aberrant frenum are seen in patients with pathological migration,
significant association is not present.

Key words: Diastema, facial flaring, pathological migration, periodontitis

INTRODUCTION be addressed by creating awareness towards early

Chronic periodontitis results in inflammation within
the supporting tissues of the teeth that causes
attachment loss, periodontal pocket formation,
bone loss, mobility, and may be associated with
pathological tooth migration  (PTM). PTM is defined
as a “Change in tooth position that occurs when there
is disruption of forces that maintain teeth in a normal
relationship.”[1] PTM is of more concern in dentofacial
aesthetics as its impact is more in adults; it needs to
Address for correspondence:
Dr. Ramanarayna Boyapati,
Department of Periodontics, Mamata Dental College,
Khammam, Telangana, India.
E-mail: dr.ramanarayana@gmail.com
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diagnosis instead of a challenge to treat psychological
destruction and its effects.
Teeth position relies on two factors; health, normal
height of the periodontium, and the forces exerted on
the teeth. Imbalance among the factors that maintain
physiological tooth position result in PTM.[2] The
prevalence of PTM among periodontitis patients
is 30.03–55.8%. [3] Equilibrium in tooth position
may become disrupted by several factors such as
periodontal attachment loss, pressure from inflamed
tissue, occlusal factors, unreplaced missing posteriors,
abnormal frenal attachment, and oral habits such
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DOI: How to cite this article: Moka L, Boyapati R, Salavadhi SS,

Chintalapani S, Maloth KN, Nagubandi K. Determinants of pathological
10.4103/JDRNTRUHS.JDRNTRUHS_52_17
tooth migration. J NTR Univ Health Sci 2018;7:89-93.

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Moka, et al.: Pathological tooth migration

as tongue thrusting, digit sucking, playing of wind
instruments.[4]
PTM is a sign caused by complex and multiple
factors, and its treatment in advanced stage is
complex, expensive, time consuming, and requires
interdisciplinary approach. Importance of complete
periodontal examination along with dental examination
should be emphasized upon for timely detection and
intervention. PTM associated with parafunctional
habits, occlusal factors, and aberrant frenum requires
correction of respective anomalies apart from
periodontal treatment alone. Hence, a clinician
should focus on thorough examination of oral
cavity pertaining to correct diagnosis and eliminate
the etiologic factors.[5] The aim of this study is to
determine the various factors contributing to PTM in
patients with chronic periodontitis.
of the tongue through the anterior spacing’s while
swallowing. Trauma from occlusion was determined
through fremitus test “a palpable or visible movement
of a tooth when subjected to occlusal forces.” The
location of alveolar attachment of abnormal high
frenum is observed by “blanching test.” Clinical
parameters were assessed considering cementoenamel
junction  (CEJ) as the reference point. Pocket
depth  (PD) was measured from gingival margin  (GM)
to the base of the sulcus. Clinical attachment level
was calculated from PD and gingival recession.
Further, bone loss was evaluated using intraoral
periapical radiographs obtained through paralleling
angle technique. Bone loss was calculated from the
CEJ to the alveolar bone crest. Clinical examination
was done by a single operator to prevent bias.
RESULTS

MATERIALS AND METHODS
A cross‑sectional study is conducted on chronic
periodontitis patients during 2015–2016,
with age group of 25–65  years. A  total of
445 participants  (249  females and 196  males) were
selected among patients attending the department of
periodontics. An informed consent form was obtained
from the patient after thorough explanation of the
study. The study was conducted after obtaining an
institutional ethical committee clearance.
All the analysis was done using SPSS version
18.0 IBM SPSS (IBM Inc. Chicago). A  P  value
of  <0.05 was considered statistically significant.
Comparison of categorical variables was done using
Chi‑square test and continuous variable was done
using independent‑sample t‑test. This study included
445 participants  (249  females and 196  males); their
distribution and prevalence is presented in Table  1 and
Chart 1. They fall under the age group of 25–65  years,
with a mean age of 48.93  years. Age distribution is
displayed in Table  2 and Chart 2. In the present study,

Patients with chronic periodontitis, systemically healthy, TABLE 1: COMPARISON AND GENDER DISTRIBUTION
nonsmokers, have not undergone periodontal therapy W I T H A N D W I T H O U T PAT H O L O G I C A L T O O T H
MIGRATION
previously, probing depth  >3  mm, CAL  >3  mm were
Total Subjects P
included in the study. All participants were examined
No PTM PTM
clinically for any manifestations of PTM, i.e.,  flaring,
n % n %
diastema, rotation, extrusion, and tipping of teeth. Sex
Possible contributing factors such as occlusal factors, Female 120 56.9 129 55.1 0.711; NS
parafunctional habits such as digit sucking lip sucking, Male 91 43.1 105 44.9
tongue thrusting, placing coins between teeth, anatomic Chi‑square test
anomalies such as aberrant frenum, and absence of
replacement of missing posteriors other than third 60.00% 56.90% 55.10%
molars were also assessed. Parafunctional habits 50.00% 43.10% 44.90%
contributing to PTM were assessed using a thorough 40.00%
questionnaire in the interview. 30.00% Absent
Present
20.00%
The questionnaire includes type of parafunctional 10.00%
habits and the duration of association with the habit. 0.00%
The tongue thrust was determined through lingual Female Male

interposition, examination of swallow pattern, teeth Chart 1: Comparison and Gender distribution with and without
indentations on tongue, and popping out of the tip pathological tooth migration

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Moka, et al.: Pathological tooth migration

60 Absent
48.93 25.0% 23.1% Present occlussion
50 47.3

20.0%
40 17.5%

30 15.0% 13.2%
Absent 11.8%
20 10.4%
Present 10.0% 8.5%
10
5.7% 5.2%
5.0% 3.8%
0
1.9%
Age
0.0%
Tongue Missing Trauma from Class 2 Abnormal
Chart 2: Comparison of mean age in patients with and without thrusting posteriors malocclusion frenum
pathological tooth migration
Chart 3: Prevalence and risk factors in patients with and without
pathological tooth migration
the association of factors such as tongue thrusting,
missing posteriors other than third molars, trauma from TABLE 2: COMPARISON OF MEAN AGE IN PATIENTS
occlusion, class  II malocclusion, and aberrant frenum W I T H A N D W I T H O U T PAT H O L O G I C A L T O O T H
with PTM in periodontitis patients was examined. MIGRATION
Analysis of the contributing factors is presented in Total Subjects P
Table  3 and depicted in Chart 3. No PTM Group PTM Group
Mean SD Mean SD
Age 47.30 11.20 48.93 8.13 0.082; NS
Among 445 participants, the chronic association of
Independent sample t‑test
tongue thrusting was seen in 54 participants with
PTM which contributes to 23.11%; 48 participants TABLE 3: PREVALANCE AND RISK FACTORS IN
had nonreplaced missing teeth comprising 20.51%. PATIENTS WITH AND WITHOUT PATHOLOGICAL
Trauma from occlusion is seen in 16.6% of the TOOTH MIGRATION
studied group, 8.5% of participants with class  II PTM P
malocclusion and aberrant frenum is seen in 3.8% 0 1
of participants with PTM. Periodontitis patients with n % n %
Tongue thrusting
PTM with no other contributing factor were seen in
0 186 88.2% 180 76.9% 0.002; Sig
32.47% participants. PTM set out in different forms 1 25 11.8% 54 23.1%
are presented in Table  4. Missing posteriors
0 189 89.6% 193 82.5% 0.032;Sig
DISCUSSION 1 22 10.4% 41 17.5%
Trauma from occlusion
0 199 94.3% 203 86.8% 0.007; Sig
Successful treatment of PTM depends upon accurate
1 12 5.7% 31 13.2%
diagnosis and early intervention. A  differential Class 2 malocclusion
diagnosis needs to be made regarding the etiology of 0 200 94.8% 214 91.5% 0.168; NS
the condition to propose a proper treatment plan. The 1 11 5.2% 20 8.5%
clinician must identify different forces causing tooth Abnormal frenum
movement to reposition tooth to their proper location. 0 207 98.1% 225 96.2% 0.222; NS
Kim et al.  (2012)[6] observed that, except periodontal 1 4 1.9% 9 3.8%

bone loss, no other single factor was associated with

PTM. Similarly, Rohatgi et al.  (2011)[7] concluded TABLE 4: DISTRIBUTION OF DIFFERENT FORMS OF
MOVEMENTS
in his study that a direct relationship exists between
Specific form of movement No of sites Involved Prevalence
PTM and clinical attachment loss as well as gingival
Facial Flaring 642 87.1
inflammation. Oh in 2011 stated that adjacent teeth Diastema 597 81
are held by the transeptal fibers that may play a Rotation 530 72
very important role in PTM.[8] In fact, these fibers Extrusion 332 45.04
form a chain from one tooth to another and are Tipping 89 12.07
considered helpful in maintaining contact between
teeth throughout arch. If the continuity of this chain combination with the occlusal factors, imbalance in
is broken due to periodontal infection alone or in forces arise which may displace the teeth. The present
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Moka, et al.: Pathological tooth migration
study aims at targeting the contributing factors for
PTM in patients with chronic periodontitis.[9]
In the present study, smokers were excluded as
smoking aggravates the loss of alveolar bone. [2]
Sutton  (1985)[10] proposed a theory affirming within
the blood vessels and inflamed tissue in the
periodontal pockets the hydrodynamic and hydrostatic
forces may account for abnormal teeth migration.
In the present study, the chronic association of
occlusal factors, such as class  II malocclusion, short
dental arches, i.e.,  missing posteriors other than third
molars, trauma from occlusion, oral habits such as
tongue thrusting, digit sucking, and anatomic factors
such as aberrant frenum were studied. Among the
234 periodontitis patients with PTM, tongue thrusting
was seen in 23.11%, which is in accordance to
previous studies by Profit (1978),[11] who reported
that forces from tongue, cheek, and lips together with
the forces of the periodontal tissues are important
factors that maintain tooth position. Emslie  (1964)[12]
reporrted that the pressure from adjacent muscular
organs  –  tongue, cheek, and lips  –  determine tooth
position. Seki et al.  (2010)[13] emphasized the role of
oral musculature of the lips, cheek, and tongue on the
movement of the migrated teeth.
In the present study, the association of trauma
from occlusion is approximately 13.2%, which is
a statistically significant result. According to the
literature review, TFO may cause a shift in tooth
position either by itself or in combination with
inflammatory periodontal disease [1] as a result of
trauma to the maxillary anterior teeth from the
mandibular antagonists; the maxillary anterior incline
forwardly, resulting in an increased circumference
of upper arch. Occlusal disharmony created by the
altered tooth positions may traumatize the supporting
tissues of the periodontium, reducing the periodontal
support, and leading to further migration of teeth.[2]
Among the 234 participants, missing molars were
seen in 17.5% of the patients with PTM, showing
statistically significant association between the two.
This  is in accordance to Sarita Paulo et al.  (2010),[14]
conducted a study, the results of which affirm that
the extreme shortened dental arches had significant
more interdental spacing’s, occlusal contacts of
incisors, and vertical overlap compared to complete
dental arches. The occlusion and its effect on the
periodontium have been reported in the literature as
early as 1970s. Posterior bite collapse and occlusal
92 Journal of Dr. NTR University of Health Sciences | Volume 7 | Issue 2 | April-June 2018
interferences have been implicated as a common
cause of PTM.
In the present study, the association of PTM
with class  II malocclusion is seen in 8.5% of
the participants. This association is supported
by studies of Craddock and Youngson  (2004) [15]
and Fujita et al.  (2010) [16] who reported PTM as
having association with factors such as occlusion.
Selwyn  (1973) [17] conducted a study, stating that
a class  II skeletal pattern was more common in
patients with migrated incisors.[2] Absence of lip seal
associated with angles class  II division I and direct
trauma to the gingiva by mandibular anterior in angles
class  II division II have been an aggravating factor in
developing periodontal diseases,[8] which potentiates
tooth migration. However, the results obtained in the
present study are not statistically significant in causing
PTM.
Most researchers such as Angle et al. reported
that high labial frenal attachment causes midline
diastema.[18] In this study, the association of aberrant
frenum with PTM is seen in approximately 3.8% of
the study sample. This is not a statistically significant
result. Ceremello  (1933) [19] found no correlation
between frenum attachment and diastema width,
between frenum width and diastema, or between
frenum height and frenum width. High frenal
attachment and muscle pull have been considered
deleterious to periodontal health as it pulls away
the gingival margin, contributing to accumulation
of plaque and calculus, leading to periodontitis.
Hirschfield  (1939) [20] is a pioneer who called to
attention the marginal attachment of the frenum
as a causative factor in periodontal disease and
recommended its excision. Periodontitis alone as an
etiological factor is seen in 234 participants  (32.47%),
showing that inflammatory granulation tissue
and bone loss are major contributing factors to
tooth migration. According to studies by Towfighi
et al.  (1997),[3] most common form of manifestation
of teeth migration is facial flaring which accounts to
approximately 90.9  ±  4.4%, diastema 88.6  ±  4.8%,
rotation 72.7  ±  6.8%, extrusion 68.2  ±  7.1%, tipping
13.6  ±  5.2%. Similar results are seen in the present
study with facial flaring amounting to 87.1%,
diastema about 81%, rotation 72%, extrusion 45.04%,
and tipping 12.07%. Finally, after knowing the
different contributing factors of PTM, considerations
have to be made with the different concepts of
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Moka, et al.: Pathological tooth migration
repositioning the migrated teeth. Many studies by
Kumar et al.  (2009) [21] support the spontaneous
repositioning of teeth. Gaumet et al.  (1999)[22] also
support the role of wound contraction in spontaneous
repositioning. Following periodontal therapy, there
is decrement of inflammatory cell infiltrate resulting
in diminution in edema and soft tissue shrinkage.
Healthy collagen fibers replace the inflammatory cell
infiltrate and may contribute to the re‑establishment
of a normal equilibrium of forces, leading to reactive
movement of migrated teeth to its position. In case
of shortened dental arches, the missing teeth are
to be replaced. Extreme forces can cause tooth
movement when their duration is approximately
50% of time even though the magnitude is very
low. Deleterious habits need to be corrected by habit
breaking appliances and by psychological approaches.
Failure to consider occlusal factors can lead to
fruitless treatment; hence, occlusion correction should
me made prior to specific treatment modality. With
adequate orthoperio treatment approaches, a healthy
and well functioning dentition with good occlusion,
sufficient masticatory function, and satisfactory
esthetics that will improve psychological status of the
patient can be re‑established.
CONCLUSION
In the present study, tongue thrusting, missing
posteriors, and trauma from occlusion showed
significant association with pathological migration
in periodontitis patients. These results conclude the
multifactorial etiology of pathological migration,
which emphasize the importance of differential
diagnosis so that the actual cause of diastema rather
than the space alone can be treated.
Limitations of the study
In this study, the number of missing teeth is not
quantified and the duration since the teeth are missing
is not considered. Duration of the deleterious habits
is recorded based on questionnaire given to subjects.
Hence, patient’s subjective perception may lead to
exaggeration of the real prevalence of pathological
migration which could be confounding. Individual factor
without periodontitis is not studied. Limited data may
reduce the impact of conclusions made. Further studies
are required emphasizing all the associated factors
causing PTM and to corroborate the study results.
Journal of Dr. NTR University of Health Sciences | Volume 7 | Issue 2 | April-June 2018
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
REFERENCES
1. Agrawal N, Siddani PS. Reactive positioning of pathologically
migrated tooth following non‑surgical periodontal therapy. Indian J
Dent Res 2011;22:591‑3.
2. Carranza, Newman, Takei, Klokevold. Clinical Periodontology‑10th ed.
p. 474.
3. Towfighi PP, Brunsvold MA, Storey AT, Arnold RM, Willmann DE,
Mc Mahan CA. Pathologic migration of anterior teeth in patients with
moderate to severe periodontitis. J Periodontol 1997;68;967‑72.
4. 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.
5. Rohatgi  S, Narula  SC, Sharma  RK, Tewari  S, Bansal  P. Clinical
evaluation of correction of pathologic migration with periodontal
therapy. Quintessence Int 2011;42:22‑30.
6. Kim  YI, Kim  MJ, Choi  JI, Park  SB. A  multidisciplinary approach
for the management of pathologic tooth migration in a patient
with moderately advanced periodontal disease. Int J Periodontics
Restorative Dent 2012;32:225‑30.
7. Rohatgi S, Narula  SC, Sharma RK, Tewari S, Bansal P. A study on
clinical attachment loss and gingival inflammation as etiologic factors
in pathologic tooth migration. Niger J Clin Pract 2011;14:449‑53.
8. Oh SL. An interdisciplinary treatment to manage pathologic tooth
migration: A clinical report. J Prosthet Dent 2011;106:153‑8.
9. Dadlani H, Ramachandra SS, Mehta DS. Spontaneous correction of
pathologically migrated teeth with periodontal therapy alone. J Indian
Soc Periodontol 2013;17:531‑4.
10. Sutton PR, Graze HR. The blood‑vessel thrust theory of tooth eruption
and migration. Med Hypotheses 1985;18:289‑95.
11. Profit WR. Equilibrium theory revisited: Factors influencing position
of the teeth. Angle Orthod 1978;48:175‑86.
12. Emslie RD. Migration of teeth in periodontal disease. Proc R Soc Med
1976;69:319‑23.
13. Seki K, Sato S, Asano Y, Akutagawa H, Ito K. Improved pathologic
teeth migration following gingivectomy in a case of idiopathic gingival
fibromatosis. Quintessence Int 2010;41:543‑5.
14. Sarita PT, Kreulen CM, Witter DJ, van’t Hof M, Creugers NH. A study
on occlusal stability in shortened dental arches. Int J Prosthodont
2003;16:375‑80.
15. Craddock HL, Youngson CC. A study of the incidence of over eruption
and occlusal interferences in unopposed posterior teeth. Br Dent J
2004;196:341‑8.
16. Fujita T, Montet X, Tanne K, Kiliaridis S. Overeruption of periodontally
affected unopposed molars in adult rats. J Periodontal Res
2010;45:271‑6.
17. Selwyn SL. An assessment of patients with periodontally involved
migrated incisors. J Dent 1973;31:153‑7.
18. Abraham R, Kamath G. Midline diastema and its etiology‑A review.
Dent Update 2014;41:457‑64.
19. Ceremello PJ. The superior labial frenum and the midlin diastema
and their relation to growth and development of the oral structures.
Am J Orthodont 1933;39:120‑39.
20. Hirschfield  I. The dynamic relationship between pathologically
migrating teeth and inflammatory tissue in periodontal pockets:
A clinical study. J Periodontol 1933;4:35‑47.
21. Kumar  VS, Thomas  CM. Reactive repositioning of pathologically
migrated teeth following periodontal therapy. Quintessence Int
2009;40:355‑8.
22. Gaumet PE, Brunsvold MI, McMahan CA. Spontaneous repositioning
of pathologically migrated teeth. J Periodontol 1999;70:1177‑84.
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