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 man-
aging 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. Splint-
ed 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 re-
sulting when the balancing factors
which maintain physiologic tooth
position are disturbed by periodon-
tal 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 periodon-
tal bone loss and gingival inflamma-
tion,1 posterior overclosure,4 occlusal
interferences,5 Angles Class II maloc-
clusion,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 trauma-
tized by the opposing mandibular in-
cisors during protrusive movement.10
Treatment of PTM often requires
interdisciplinary approaches, includ-
ing 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 recent-
ly developed and are associated with
periodontal disease.11
The emphasis on orthodontic in-
trusion as an important part of treat-
ment planning for managing moder-
ate degrees of PTM is growing since
the PTM of anterior teeth often in-
volves extrusion of the affected teeth.
Orthodontic movement of teeth with
healthy periodontal tissues does not
result in loss of connective tissue at-
tachment.12,13 In the presence of
inflammation, however, orthodon-
tic movement could result in further
periodontal breakdown. Orthodontic
bodily tooth movement may enhance
the rate of destruction of the connec-
tive tissue attachment for teeth with
inflamed, infrabony pockets and in-
crease the risk for additional attach-
ment loss, particularly when the tooth
is moved into the infrabony pocket.14
Further loss of the periodontal bone
support may occur without profes-
sional 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 stud-
ies 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 peri-
odontal surgery.19,20 The segmented
arch techniques has been the treat-
ment 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 multi-
rooted tooth. The segments are then
assembled into a complete arch.22
Reportedly, the segmented arch tech-
nique can produce 1.5 mm of maxil-
lary incisor intrusion in young adults21
and 1.35 mm vertical bone fills in
patients with periodontal disease.20
This article presents an interdisciplin-
ary treatment, including periodontal
therapy, orthodontic treatment, and
prosthodontic rehabilitation to man-
age PTM and spacing between maxil-
lary 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.

a

Oh
154 Volume 106 Issue 3
tal Clinic, Seoul, South Korea with
spacing between the maxillary central
and lateral incisors. The patient also
had type 2 diabetes mellitus as a sys-
temic contributory factor.23 Previous-
ly, the patient had visited the dental
clinic due to severe gingival swelling
and bleeding around the maxillary
central and lateral incisors while hos-
pitalized with diabetic shock at SMC.
The mandibular incisors were imping-
ing on the swollen palatal gingiva,
and so gingival curettage was per-
formed to diminish swelling. She was
cared for by her physician on a regular 1 Preoperative condition. Note spacing between maxillary
anterior teeth and large amount of vertical overlap.
basis after the diabetic shock episode.
Her chief complaint was poor an-
terior esthetics, which had deterio-
rated due to spacing that developed 3
years prior. Clinical findings included
a 2-mm space between maxillary cen-
tral incisors and a 1-mm space be-
tween the maxillary left central and
lateral incisors with 2 mm of gingival
recession on the maxillary right cen-
tral 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 prosthe- 2 Initial panoramic radiograph.
ses, from the maxillary right second
molar to the canine and from the first premolar had a circumferential fabrication of crowns for the maxil-
maxillary left second premolar to the infrabony defect on the palatal sur- lary incisors, and 2) extraction of the
second molar. Moderate attrition on face. The periodontal diagnosis was maxillary right lateral and central inci-
the mandibular incisors was found. generalized moderate periodontitis sors and fabrication of a partial fixed
All existing crowns and partial fixed with localized severe periodontitis on dental prosthesis from the maxillary
dental prostheses had overextended the maxillary right lateral and central right canine to the left canine. How-
margins (Fig. 2). The patient was incisors, and the maxillary left first ever, those options were not chosen
wearing a mandibular partial remov- premolar. Trauma from occlusion because the traumatic vertical over-
able dental prosthesis. (TFO) and severe periodontitis likely lap would not be corrected. Excessive
The patient had an Angles Class contributed to flaring of the maxillary traumatic vertical overlap could result
II occlusal relationship. Occlusal con- anterior teeth. Parafunctional habits in enhanced levels of inflammation
tacts existed on all maxillary teeth (bruxism) likely contributed to attri- and periodontal deterioration in the
except for the maxillary left second tion on the maxillary left canine and presence of plaque.26 Although the
premolar and the second molar. Right first premolar and mandibular inci- patient had posterior contact through
lateral movement was guided by the sors. The prognosis for the maxillary extensive prostheses, the maxillary
maxillary right canine, and the lat- right lateral and central incisors was left canine and first premolar had se-
eral and central incisors. The max- poor to questionable, and the prog- vere attrition, which suggested that
illary left canine guided left lateral nosis for the maxillary left first premo- the patient might have experienced a
movement. Fremitus existed on the lar was determined as questionable to subtle change in occlusion. Flaring of
maxillary central and lateral incisors. hopeless.25 maxillary incisors could be induced by
Class II mobility24 was present on the Treatment options included 1) physiologic forces acting upon these
maxillary right central incisor and the endodontic therapy for the maxillary teeth when there is a substantial loss
left first premolar. The maxillary left right lateral and central incisors and of alveolar bone, even in situations
The Journal of Prosthetic Dentistry Oh
September 2011
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 occlu-
sal 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 approxi-
mately 2 mm using provisional res-
torations (Alike; GC America, Alsip,
Oh
Ill) after full mouth scaling and root
planing was completed (Fig. 3). Prep-
aration and provisional restoration of
the maxillary left canine were also per-
formed to increase OVD and to pro-
tect 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-
155
dibular teeth since the maxillary teeth
had more attachment loss and less fa-
vorable 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 ad-
dition, 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 provi-
sional restorations. A sectional orth-
odontic appliance (Mini-Twin Mark-
ing 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 en-
gaged 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 re-
traction. A titanium-molybdenum al-
loy 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 re-
tention (Fig. 5).
During the retention period, a peri-
odontal evaluation was performed to
determine the definitive prosthetic
plan. The maxillary left first premo-
lar 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 sus-
ceptible to secondary and combined
occlusal trauma,28,29 and definitive
retention was needed especially after
156 Volume 106 Issue 3
orthodontic intrusion.30-33 Second-
ary occlusal trauma is injury caused
by normal occlusal forces applied to
teeth with inadequate periodontal
support.29 Combined occlusal trau-
ma 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 Extracoro-
nal or intracoronal composite resin
splint options were excluded because
there was not enough space on the
6 Definitive prostheses. lingual surfaces of the maxillary in-
cisors and those options could not
have solved the interdental gingival
voids between the maxillary incisors.
A mandibular partial removable den-
tal prosthesis was planned. The suc-
cess rate of implants in diabetes mel-
litus patients may be less favorable,34
and a bone graft procedure would be
needed to place implants due to inad-
equate bone width in the edentulous
area. Furthermore, the patient experi-
enced no discomfort with her existing
mandibular partial removable dental
prosthesis.
7 Postoperative panoramic radiograph.
Splinted metal ceramic crowns
on the maxillary central and lateral
incisors were connected to posterior
metal ceramic partial fixed dental
prostheses using semiprecision at-
tachments (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
A entire segment. Resistance to ante-
rior vectors of force and stabilization
of the anterior segment could be fur-
ther 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 premo-
lar, first and second molars were fabri-
B cated to compensate for the increased
8 A, Initial radiographs from maxillary right canine to maxillary left second crown to root ratios and cemented with
premolar before the treatments. B, Post operative radiographs 5 months after resin-modified glass ionomer luting ce-
treatment. ment (Fuji-CEM Automix; GC America)
(Figs. 6, 7) Cast metal crowns were cho-
The Journal of Prosthetic Dentistry Oh
September 2011
sen for molars since attrition on the pro-
visional 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 mo-
lar 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 orth-
odontic movement resulted from de-
creased gingival recession and dimin-
ished 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 main-
tained excellent oral hygiene, and no
complications were observed at the
8-month recall evaluation.
DISCUSSION
The use of orthodontic intru-
sion in periodontally compromised
patients remains controversial since
there is no histologic evidence in
humans that orthodontic intrusion
produces new attachment. While ex-
trusion is recommended to improve
periodontal conditions,28 it is not the
best option as PTM involves the ex-
trusion of teeth which already have
long clinical crowns. Therefore, orth-
odontic 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 radio-
graphs (Figs. 7 and 8B).
The definitive prosthetic plan was
determined to provide retention of
intruded maxillary incisors, to pre-
vent 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
Oh
Studies have reported a tendency to
relapse ranging from 17% to 60%, es-
pecially in Angles Class II situations
corrected with intrusion mechan-
ics.31-33 The provisional restorations
remained in place for 10 months. It
was observed that attrition developed
on the provisional restorations. Acryl-
ic resin has poor resistance to wear
when compared to definitive restora-
tions especially in patients with a his-
tory of parafunctional habits. Close
monitoring of the provisional resto-
rations and occlusion was accom-
plished throughout the treatment to
prevent occlusal trauma of the max-
illary anterior teeth and reduction of
the OVD. Acrylic resin (GC America,
Alsip, Ill) was added to the occlusal
surfaces as needed. Definitive reten-
tion with splinted crowns was used to
prevent secondary occlusal trauma.
An occlusal device was fabricated at
the end of the treatment to help al-
leviate the effects of parafunctional
habits and combined occlusal trau-
ma. The interdental gingival voids
between the maxillary incisors, which
became noticeable at the end of orth-
odontic treatment, could be also im-
proved through the use of splinted
metal ceramic crowns.
The time and cost involved in in-
terdisciplinary treatments would be a
limitation of the treatment described
in this report. Stringent periodontal
maintenance must be performed to
avoid any complications. Oral pro-
phylaxis was performed at 4-week in-
tervals during orthodontic treatment,
and at a 3-month interval after finish-
ing the definitive prostheses for this
patient.
SUMMARY
This clinical procedure with a
short-term follow-up demonstrated
that orthodontic treatment of peri-
odontally compromised teeth could
improve their clinical attachment
levels by reducing gingival recession.
The etiology causing PTM must be
determined before initiating treat-
ment. The appropriate treatment
157
sequence should be used to manage
periodontal disease, occlusion, and
tooth movement. After completing
orthodontic movement, semi-defini-
tive or definitive retention should be
considered to prevent occlusal trauma
and relapse.
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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 con-
flicts of interest related to this case report.
Copyright 2011 by the Editorial Council for
The Journal of Prosthetic Dentistry.

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