An interdisciplinary treatment to manage pathologic tooth migration: A clinical report

Se-Lim Oh, DMD, MSa University of Maryland Dental School, Baltimore, Md

Pathologic tooth migration (PTM) is a common symptom of periodontal disease and a motivation for the patient to seek dental therapy. The primary factors causing PTM are periodontitis and occlusal trauma. Comprehensive treatment for managing a moderate degree of PTM, including periodontal, orthodontic and prosthodontic treatment is described. Increasing the occlusal vertical dimension (OVD) with provisional restorations was attempted to create space for retracting maxillary flared teeth. Retraction and intrusion of maxillary flared incisors were achieved by a sectional orthodontic appliance. Splinted crowns from maxillary right lateral incisor to left lateral incisor were fabricated and connected to posterior prostheses by means of attachments to prevent relapse and to provide long-term stability. (J Prosthet Dent 2011;106:153-158) Pathologic tooth migration (PTM) is defined as tooth displacement resulting when the balancing factors which maintain physiologic tooth position are disturbed by periodontal disease.1 The prevalence of PTM among periodontal patients ranges from 30% to 55.8%,2,3 and PTM is a common motivation for patients to seek periodontal therapy.3 The etiology of PTM appears to be multifactorial and includes periodontal bone loss and gingival inflammation,1 posterior overclosure,4 occlusal interferences,5 Angles Class II malocclusion,6 a shortened dental arch,7 and soft tissue pressure of the tongue, cheek, and lips.8 Maxillary anterior teeth, especially have a tendency to flare and elongate since they have no anteroposterior contacts resisting displacement,9 and may be traumatized by the opposing mandibular incisors during protrusive movement.10 Treatment of PTM often requires interdisciplinary approaches, including periodontal, orthodontic, and restorative treatment, depending on the periodontal involvement of flared teeth. While severe PTM is treated by extraction and restoration(s), spontaneous repositioning could be achieved after periodontal therapy in situations where light to moderate degrees of PTM (<1 mm) have recenta

ly developed and are associated with periodontal disease.11 The emphasis on orthodontic intrusion as an important part of treatment planning for managing moderate degrees of PTM is growing since the PTM of anterior teeth often involves extrusion of the affected teeth. Orthodontic movement of teeth with healthy periodontal tissues does not result in loss of connective tissue attachment.12,13 In the presence of inflammation, however, orthodontic movement could result in further periodontal breakdown. Orthodontic bodily tooth movement may enhance the rate of destruction of the connective tissue attachment for teeth with inflamed, infrabony pockets and increase the risk for additional attachment loss, particularly when the tooth is moved into the infrabony pocket.14 Further loss of the periodontal bone support may occur without professional dental prophylaxis.15 However, new connective tissue attachment formation was reported during the bodily intrusive movement of the periodontally involved teeth in monkeys when gingival infection was eliminated and the root surfaces were partially scaled.16 Clinical studies have demonstrated the possibility of correcting infrabony pockets with orthodontic intrusion, suggesting

that intrusive movement may have the potential to improve the periodontal condition by positively modifying the alveolar bone and the soft tissues around teeth.9,16-20 It was suggested that active orthodontic movements be initiated 7 to 10 days after periodontal surgery.19,20 The segmented arch techniques has been the treatment of choice to achieve intrusion of maxillary and mandibular incisors 21 because it allows teeth to combine into units: anterior, right buccal, and left buccal segments.22 Once teeth within segments are aligned, each segment is considered as one multirooted tooth. The segments are then assembled into a complete arch.22 Reportedly, the segmented arch technique can produce 1.5 mm of maxillary incisor intrusion in young adults21 and 1.35 mm vertical bone fills in patients with periodontal disease.20 This article presents an interdisciplinary treatment, including periodontal therapy, orthodontic treatment, and prosthodontic rehabilitation to manage PTM and spacing between maxillary incisors.

CLINICAL REPORT
A 48-year-old woman presented to the Department of Periodontics, Samsung Medical Center (SMC) Den-

Assistant Professor, Department of Oncology and Diagnostic Sciences.

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tal Clinic, Seoul, South Korea with spacing between the maxillary central and lateral incisors. The patient also had type 2 diabetes mellitus as a systemic contributory factor.23 Previously, the patient had visited the dental clinic due to severe gingival swelling and bleeding around the maxillary central and lateral incisors while hospitalized with diabetic shock at SMC. The mandibular incisors were impinging on the swollen palatal gingiva, and so gingival curettage was performed to diminish swelling. She was cared for by her physician on a regular basis after the diabetic shock episode. Her chief complaint was poor anterior esthetics, which had deteriorated due to spacing that developed 3 years prior. Clinical findings included a 2-mm space between maxillary central incisors and a 1-mm space between the maxillary left central and lateral incisors with 2 mm of gingival recession on the maxillary right central and lateral incisors (Fig. 1). Seven mm of vertical overlap and 7 mm of horizontal overlap were noted. Severe attrition of the maxillary left canine and first premolar was also found with extensive existing fixed prostheses, from the maxillary right second molar to the canine and from the maxillary left second premolar to the second molar. Moderate attrition on the mandibular incisors was found. All existing crowns and partial fixed dental prostheses had overextended margins (Fig. 2). The patient was wearing a mandibular partial removable dental prosthesis. The patient had an Angles Class II occlusal relationship. Occlusal contacts existed on all maxillary teeth except for the maxillary left second premolar and the second molar. Right lateral movement was guided by the maxillary right canine, and the lateral and central incisors. The maxillary left canine guided left lateral movement. Fremitus existed on the maxillary central and lateral incisors. Class II mobility24 was present on the maxillary right central incisor and the left first premolar. The maxillary left

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1 Preoperative condition. Note spacing between maxillary anterior teeth and large amount of vertical overlap.

2 Initial panoramic radiograph. first premolar had a circumferential infrabony defect on the palatal surface. The periodontal diagnosis was generalized moderate periodontitis with localized severe periodontitis on the maxillary right lateral and central incisors, and the maxillary left first premolar. Trauma from occlusion (TFO) and severe periodontitis likely contributed to flaring of the maxillary anterior teeth. Parafunctional habits (bruxism) likely contributed to attrition on the maxillary left canine and first premolar and mandibular incisors. The prognosis for the maxillary right lateral and central incisors was poor to questionable, and the prognosis for the maxillary left first premolar was determined as questionable to hopeless.25 Treatment options included 1) endodontic therapy for the maxillary right lateral and central incisors and fabrication of crowns for the maxillary incisors, and 2) extraction of the maxillary right lateral and central incisors and fabrication of a partial fixed dental prosthesis from the maxillary right canine to the left canine. However, those options were not chosen because the traumatic vertical overlap would not be corrected. Excessive traumatic vertical overlap could result in enhanced levels of inflammation and periodontal deterioration in the presence of plaque.26 Although the patient had posterior contact through extensive prostheses, the maxillary left canine and first premolar had severe attrition, which suggested that the patient might have experienced a subtle change in occlusion. Flaring of maxillary incisors could be induced by physiologic forces acting upon these teeth when there is a substantial loss of alveolar bone, even in situations

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dibular teeth since the maxillary teeth had more attachment loss and less favorable crown to root ratio than the mandibular teeth. While the patient was adjusting to the increased OVD, an apically positioned flap (APF) with osseous surgery was performed in the maxillary right quadrant. In addition, a free gingival graft (FGG) on the mandibular right quadrant and an FGG on the mandibular left first premolar were performed to augment keratinized gingiva. After periodontal reevaluation, the maxillary provisional restorations were cemented with zinc phosphate cement (ZPC; Benco Dental, Pittston, Pa) to improve the retention of the provisional restorations. A sectional orthodontic appliance (Mini-Twin Marking System; Ormco Corp, Orange, Calif ) was bonded directly to the teeth from the maxillary right canine to the left second premolar. Occlusal reduction of the maxillary left first premolar was performed to create the space for forced eruption to correct an infrabony defect27 before a Ni-Ti wire (.016 round; Ormco Corp) was engaged. An orthodontic power chain (Power Chain; Ormco Corp) was engaged to retract the maxillary incisors for 8 weeks after initial leveling. Intrusion of the maxillary right central incisor was attempted since there was no space available after retraction. A titanium-molybdenum alloy wire (.017 .025; Ormco Corp) was engaged with 2 closing loops for further space closure over 6 weeks (Fig. 4). A stainless steel wire (.017 .025; Ormco) was engaged for retention (Fig. 5). During the retention period, a periodontal evaluation was performed to determine the definitive prosthetic plan. The maxillary left first premolar was extracted due to a persisting 8 to 9 mm attachment loss and poor response to forced eruption. Splinted crowns on the maxillary incisors were planned since those teeth are susceptible to secondary and combined occlusal trauma,28,29 and definitive retention was needed especially after

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3 Increased OVD by using provisional restorations.

4 TMA (titanium-molybdenum alloy) wire engaged with 2 closing

5 SS (stainless steel) wire engaged for retention after space closure. where no loss or a subtle loss of occlusal vertical dimension (OVD) occurs.4 Thus, orthodontic treatment was planned along with an increase in the OVD through provisional restorations to create the adequate space for the retraction of the maxillary incisors. The OVD was increased approximately 2 mm using provisional restorations (Alike; GC America, Alsip, Ill) after full mouth scaling and root planing was completed (Fig. 3). Preparation and provisional restoration of the maxillary left canine were also performed to increase OVD and to protect the tooth from further attrition. While the provisional restorations were being fabricated, acrylic resin (GC America) was added to increase the clinical crown length of the man-

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orthodontic intrusion.30-33 Secondary occlusal trauma is injury caused by normal occlusal forces applied to teeth with inadequate periodontal support.29 Combined occlusal trauma is injury resulting from abnormal occlusal forces applied to teeth with inadequate periodontal support.29 The splinted crowns allowed for a more favorable distribution of forces on the maxillary incisors.28 Extracoronal or intracoronal composite resin splint options were excluded because there was not enough space on the lingual surfaces of the maxillary incisors and those options could not have solved the interdental gingival voids between the maxillary incisors. A mandibular partial removable dental prosthesis was planned. The success rate of implants in diabetes mellitus patients may be less favorable,34 and a bone graft procedure would be needed to place implants due to inadequate bone width in the edentulous area. Furthermore, the patient experienced no discomfort with her existing mandibular partial removable dental prosthesis. Splinted metal ceramic crowns on the maxillary central and lateral incisors were connected to posterior metal ceramic partial fixed dental prostheses using semiprecision attachments (Tube Lock; Sterngold, Attleboro, Mass). Splinting incisors with reduced bone support would not achieve adequate resistance against anterior vectors of force that could cause future migration of the entire segment. Resistance to anterior vectors of force and stabilization of the anterior segment could be further enhanced by extending the splint posteriorly.35 Splinted metal ceramic crowns on the mandibular left first premolar and canine and splinted metal ceramic and cast metal crowns on the mandibular right second premolar, first and second molars were fabricated to compensate for the increased crown to root ratios and cemented with resin-modified glass ionomer luting cement (Fuji-CEM Automix; GC America) (Figs. 6, 7) Cast metal crowns were cho-

6 Definitive prostheses.

7 Postoperative panoramic radiograph.

B
8 A, Initial radiographs from maxillary right canine to maxillary left second premolar before the treatments. B, Post operative radiographs 5 months after treatment.

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sen for molars since attrition on the provisional restorations developed during orthodontic treatment. A mandibular partial removable dental prosthesis with rests seats on the mandibular left first premolar, left canine, right first premolar, and right second molar clasping the mandibular left first premolar and right second molar was fabricated. Radiographs (Fig. 8) demonstrate the condition of the maxillary incisors before treatment and 5 months after insertion of the definitive prostheses. The 2 to 4 mm of clinical attachment gain achieved by the end of the orthodontic movement resulted from decreased gingival recession and diminished periodontal probing depths on maxillary central incisors. Intrusion of the maxillary right central incisor also resulted in reducing clinical crown length (Fig. 5). The patient maintained excellent oral hygiene, and no complications were observed at the 8-month recall evaluation. Studies have reported a tendency to relapse ranging from 17% to 60%, especially in Angles Class II situations corrected with intrusion mechanics.31-33 The provisional restorations remained in place for 10 months. It was observed that attrition developed on the provisional restorations. Acrylic resin has poor resistance to wear when compared to definitive restorations especially in patients with a history of parafunctional habits. Close monitoring of the provisional restorations and occlusion was accomplished throughout the treatment to prevent occlusal trauma of the maxillary anterior teeth and reduction of the OVD. Acrylic resin (GC America, Alsip, Ill) was added to the occlusal surfaces as needed. Definitive retention with splinted crowns was used to prevent secondary occlusal trauma. An occlusal device was fabricated at the end of the treatment to help alleviate the effects of parafunctional habits and combined occlusal trauma. The interdental gingival voids between the maxillary incisors, which became noticeable at the end of orthodontic treatment, could be also improved through the use of splinted metal ceramic crowns. The time and cost involved in interdisciplinary treatments would be a limitation of the treatment described in this report. Stringent periodontal maintenance must be performed to avoid any complications. Oral prophylaxis was performed at 4-week intervals during orthodontic treatment, and at a 3-month interval after finishing the definitive prostheses for this patient. sequence should be used to manage periodontal disease, occlusion, and tooth movement. After completing orthodontic movement, semi-definitive or definitive retention should be considered to prevent occlusal trauma and relapse.

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REFERENCES
1. Martinez-Canut P, Carrasquer A, Magn R, Lorca A. A study on factors associated with pathologic tooth migration. J Clin Periodontol 1997;24:492-7. 2. Towfighi PP, Brunsvold MA, Storey AT, Arnold RM, Willman DE, McMahan CA. Pathologic migration of anterior teeth in patients with moderate to severe periodontitis. J Periodontol 1997;68:967-72. 3. Brunsvold MA. Pathologic tooth migration. J Periodontol 2005;76:859-66. 4. Shifman A, Laufer BZ, Chweidan H. Posterior bite collapse--revisited. J Oral Rehabil 1998;25:376-85. 5. Watkinson AC, Hathorn IS. Occlusion in the aetiology and management of upper anterior tooth migration. Restorative Dent 1986;2:56, 58, 60-1. 6. Selwyn SL. An assessment of patients with periodontally involved migrated incisors. J Dent 1973;1:153-7. 7. Witter DJ, Creugers NH, Kreulen CM, de Haan AF. Occlusal stability in shortened dental arches. J Dent Res 2001;80:432-6. 8. Proffit WR. Equilibrium theory revisited: Factors influencing position of the teeth. Angle Orthod 1978;48:175-86. 9. Melsen B, Agerbaek N, Markenstam G. Intrusion of incisors in adult patients with marginal bone loss. Am J Orthod Dentofacial Orthop 1989;96:232-41. 10.Stern N, Brayer L. Collapse of the occlusion--aetiology, symptomatology and treatment. J Oral Rehabil 1975;2:1-19. 11.Gaumet PE, Brunsvold MI, McMahan CA. Spontaneous repositioning of pathologically migrated teeth. J Periodontol 1999;70:1177-84. 12.Ericsson I, Thilander B. Orthodontic forces and recurrence of periodontal disease. an experimental study in the dog. Am J Orthod 1978;74:41-50. 13.Polson A, Caton J, Polson AP, Nyman S, Novak J, Reed B. Periodontal response after tooth movement into intrabony defects. J Periodontol 1984;55:197-202. 14.Wennstrm JL, Stokland BL, Nyman S, Thilander B. Periodontal tissue response to orthodontic movement of teeth with infrabony pockets. Am J Orthod Dentofacial Orthop 1993;103:313-9. 15.Artun J, Urbye KS. The effect of orthodontic treatment on periodontal bone support in patients with advanced loss of marginal periodontium. Am J Orthod Dentofacial Orthop 1988;93:143-8. 16.Melsen B, Agerbaek N, Eriksen J, Terp S. New attachment through periodontal treatment and orthodontic intrusion. Am J Orthod Dentofacial Orthop 1988;94:104-16.

DISCUSSION
The use of orthodontic intrusion in periodontally compromised patients remains controversial since there is no histologic evidence in humans that orthodontic intrusion produces new attachment. While extrusion is recommended to improve periodontal conditions,28 it is not the best option as PTM involves the extrusion of teeth which already have long clinical crowns. Therefore, orthodontic retraction and intrusion was planned for this patient. The gingival recession was decreased at the end of treatments. No bony destruction occurred as evidenced by the radiographs (Figs. 7 and 8B). The definitive prosthetic plan was determined to provide retention of intruded maxillary incisors, to prevent occlusal trauma, and to restore the esthetics of the maxillary incisors. Dentitions with reduced periodontal support show a marked tendency to return to their pretreatment position following active appliance therapy.30

SUMMARY
This clinical procedure with a short-term follow-up demonstrated that orthodontic treatment of periodontally compromised teeth could improve their clinical attachment levels by reducing gingival recession. The etiology causing PTM must be determined before initiating treatment. The appropriate treatment

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17.Steffensen B, Storey AT. Orthodontic intrusive forces in the treatment of periodontally compromised incisors: A case report. Int J Periodontics Restorative Dent 1993;13:433-41. 18.Cardaropoli D, Re S, Corrente G, Abundo R. Intrusion of migrated incisors with infrabony defects in adult periodontal patients. Am J Orthod Dentofacial Orthop 2001;120:671-5. 19.Re S, Corrente G, Abundo R, Cardaropoli D. The use of orthodontic intrusive movement to reduce infrabony pockets in adult periodontal patients: A case report. Int J Periodontics Restorative Dent 2002;22:365-71. 20.Corrente G, Abundo R, Re S, Cardaropoli D, Cardaropoli G. Orthodontic movement into infrabony defects in patients with advanced periodontal disease: A clinical and radiological study. J Periodontol 2003;74:1104-9. 21.Ng J, Major PW, Heo G, Flores-Mir C. True incisor intrusion attained during orthodontic treatment: A systematic review and meta-analysis. Am J Orthod Dentofacial Orthop 2005;128:212-9. 22.Shroff B, Lindauer SJ, Burstone CJ, Leiss JB. Segmented approach to simultaneous intrusion and space closure: biomechanics of the three-piece base arch appliance. Am J Orthod Dentofacial Orthop 1995;107:136-43. 23.Mealey BL, Ocampo GL. Diabetes mellitus and periodontal disease. Periodontol 2000 2007;44:127-53. 24.Miller SC. Textbook of Periodontia. 2nd ed. Philadelphia: Blakiston;1943. p.103. 25.McGuire MK. Prognosis vs outcome: Predicting tooth survival. Compend Contin Educ Dent 2000;21:217-20, 222, 224 passim. 26.Ross IF, DOnofrio ED, Roman JS. Occlusal contacts and tooth mobility. females, aged 18-30. J Periodontol 1972;43:760-4. 27.Ingber JS. Forced eruption. I. A method of treating isolated one and two wall infrabony osseous defects-rationale and case report. J Periodontol 1974;45:199-206. 28.Greenstein G, Cavallaro J, Scharf D, Tarnow D. Differential diagnosis and management of flared maxillary anterior teeth. J Am Dent Assoc 2008;139:715-23. 29.Hallmon WW. Occlusal trauma: effect and impact on the periodontium. Ann Periodontol 1999;4:102-8. 30.Ericsson I, Thilander B. Orthodontic relapse in dentitions with reduced periodontal support: An experimental study in dogs. Eur J Orthod 1980;2:51-7. 31.Sadowsky C, Schneider BJ, BeGole EA, Tahir E. Long-term stability after orthodontic treatment: Nonextraction with prolonged retention. Am J Orthod Dentofacial Orthop 1994;106:243-9. 32.Fidler BC, Artun J, Joondeph DR, Little RM. Long-term stability of angle class II, division 1 malocclusions with successful occlusal results at end of active treatment. Am J Orthod Dentofacial Orthop 1995;107:276-85.

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33.Al-Buraiki H, Sadowsky C, Schneider B. The effectiveness and long-term stability of overbite correction with incisor intrusion mechanics. Am J Orthod Dentofacial Orthop 2005;127:47-55. 34.Klokkevold PR, Han TJ. How do smoking, diabetes, and periodontitis affect outcomes of implant treatment? Int J Oral Maxillofac Implants 2007;22:173-202. 35.Nyman SR, Lang NP. Tooth mobility and the biological rationale for splinting teeth. Periodontol 2000 1994;4:15-22. Corresponding author: Dr Se-Lim Oh University of Maryland Dental School 650 West Baltimore Street, Room 3215 Baltimore, MD 21201 Fax: 410-706-7745 E-mail: soh@umaryland.edu Acknowledgments The author thanks Dr Kwan-Woo Lee for all his restorative work and Dr Radi M. Masri for his critical reading. The author reports no conflicts of interest related to this case report. Copyright 2011 by the Editorial Council for The Journal of Prosthetic Dentistry.

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