Periodontology 2000, Vol. 74, 2017, 140–157 © 2017 John Wiley & Sons A/S.

ley & Sons A/S. Published by John Wiley & Sons Ltd
Printed in Singapore. All rights reserved PERIODONTOLOGY 2000

Effect of orthodontic treatment

on the periodontal tissues
J O S E P H S. A N T O U N , L I M E I , K E L S I G I B B S & M A U R O F A R E L L A

An increasing number of adult patients are seeking The envelope of tooth movement
orthodontic treatment, many of whom are likely to
Moving teeth with orthodontic appliances is not with-
have some degree of periodontal disease (21). A
out limits. Several factors may influence the extent
reduction in periodontal support can be associated
(and stability) of orthodontic tooth movement, includ-
with labial flaring, extrusion, rotation, spacing and
ing the anatomy of the alveolar bone, pressures
drifting of the teeth (150). Such changes are believed
exerted by soft tissues, periodontal tissue attachment
to occur when the periodontal ligament is no longer
levels, neuromuscular forces and lip–tooth relation-
able to stabilize the teeth against external forces
ships (2, 110). It is commonly believed that the limits
(110). Maxillary incisors are particularly susceptible to
of tooth movement are defined by strict physiologic
pathological migration and over-eruption (25). These
and anatomic boundaries, which, if violated, can
acquired occlusal changes, along with any underlying
result in reduced periodontal and alveolar bone sup-
skeletal discrepancy, often result in a complex mal-
port. Accordingly, large movements of teeth beyond
occlusion that necessitates an interdisciplinary treat-
this so-called ‘envelope of discrepancy’ (Fig. 1) are
ment approach (30, 63).
only possible if favorable remodeling of the facial
Periodontal disease is not necessarily a contraindi-
skeleton is achieved or by orthognathic surgery (112).
cation to orthodontic treatment provided that the
It is unclear, however, how far these boundaries can
condition has been stabilized; however, loss of alveo-
be pushed before the health of the surrounding tissues
lar bone and soft-tissue architecture may pose con-
becomes adversely affected. This clinical dilemma is
siderable challenges to oral rehabilitation. It has been
particularly evident in borderline extraction cases with
suggested that adjunct orthodontic treatment may
reduced periodontal support. There is some anecdotal
play an important role in developing the optimal base
evidence to suggest that adult patients with severe
needed for re-establishing an esthetic and functional
crowding of the teeth and a reduced periodontium
dentition in these cases (86). Orthodontic extrusion of
may be successfully treated by moving the teeth
unrestorable teeth, for instance, may assist the peri-
beyond the envelope of the alveolar process, albeit
odontist and restorative team in harnessing alveolar
using well-controlled force systems (9). One likely rea-
bone and improving the soft-tissue architecture (150).
son for such favorable outcomes is variability in tissue
This adjunct treatment is particularly useful for
response to different treatment mechanics.
patients who require dental implants in esthetic
zones (71, 78).
Orthodontic therapy may also have detrimental
Tissue response to orthodontic forces
effects, including root resorption (11, 73) and bone
dehiscence (44). The introduction of fixed orthodon- When orthodontic forces are applied to teeth, both
tic appliances into the oral cavity also increases the compressive and tensile stresses develop in the sur-
amount of acidogenic biofilm, thus increasing the risk rounding tissues (134). Areas under tension have clas-
of gingivitis and caries (62, 149, 152). A critical issue in sically been described as sites of bone apposition,
the treatment planning of any patient revolves while those under compression undergo bone resorp-
around how much orthodontic movement the peri- tion. The net effect of this remodeling process is the
odontium can tolerate before it becomes adversely movement of teeth along the direction of the applied
affected. force and into the space created by the recently

140

Buccal
Palatal
A TRANSVERSE
Lingual Labial
B SAGITTAL
Orthodontics Only
Orthodontics + Orthopedics
Orthodontics + Surgery
Fig. 1. Conceptual illustration of the ‘envelope of discrep-
ancy’. Colored polygons represent the biologic boundaries
of tooth movement for orthodontic treatment only (green
zone), orthodontic treatment and dentofacial orthopedics
(blue zone) and orthodontic treatment and orthognathic
surgery (red zone). (A) Transverse tooth envelope for max-
illary posterior teeth. (B) Sagittal tooth envelope for
mandibular anterior teeth. Modified from Graber et al.
(49).
resorbed bone. It has recently been demonstrated,
however, that the distribution of compressive and
tensile strains in the periodontal tissues is more com-
plex than initially believed (27). Findings from experi-
ments in Beagle dogs indicate that different sections
of the periodontal ligament on the compression side
may appear either normal or disorganized (156). To
complicate matters further, small patches of hyalin-
ization are also reported to occur at tooth surfaces
that are not normally under compression (156).
The magnitude of the applied force is believed to
play a role in determining the pattern of stresses and
strains in the dento-alveolar tissues. It has also been
suggested that different force systems may determine
whether a tooth will move ‘through’ bone or ‘with’
bone (84–86). A tooth is thought to move through bone
when undermining resorption, rather than frontal
resorption, occurs in response to heavy orthodontic
forces (84). Such forces cause constriction of the
microvasculature and localized necrotic areas within
the periodontal ligament (hyalinization), which are
then removed by tartrate-resistant acid phosphatase-
positive macrophages and multinucleate giant cells
migrating from adjacent bone marrow sites (16, 22).
Undermining resorption is typically characterized by a
delay in tooth movement because no bone apposition
can occur on the tension side until the necrotic tissue
on the compression side has been removed (81, 132,
133). Under ideal conditions, it is thought that teeth
move with their alveolus when resorption occurs
Response of periodontal tissues to orthodontic treatment
directly at the alveolar–periodontal ligament interface
on the compression side, while bone apposition occurs
on the tension side and on the external surface of the
alveolar process (85, 86). The net outcome of this near-
simultaneous process is the movement of a tooth
beyond its original alveolar boundary (84).
Orthodontists have long been aware of the relation-
ship between force magnitude and the type of resorp-
tion that occurs on the pressure side ever since Carl
Sandstedt’s classical experiments on dogs in the early
1900s (16, 132, 133). Interestingly, in some experi-
ments on Beagle dogs, the use of light forces did not
seem to prevent hyalinization of the periodontal liga-
ment in the initial stages (155, 156) or influence the
rate of tooth movement (106). The use of light force
systems, however, may still prevent further hyaliniza-
tion from occurring after the initial period of tooth
movement (120).
The idea that orthodontic forces may contribute to a
differential tissue response in humans is rather appeal-
ing. From a clinical point of view, it provides clinicians
with a useful set of tools for the management of adult
patients with reduced periodontal support. Movement
of teeth through bone, for example, may be desirable in
cases where the clinician is interested in extruding a
root-fractured tooth without the accompanying bone
(86). On the other hand, movement of teeth with bone
may help augment bone as teeth are moved into sites
with atrophic alveolar ridges (86).
The purpose of the present review article was there-
fore to evaluate the clinical effects of various orthodon-
tic tooth movements on the surrounding hard and soft
tissues. Another objective was to identify important
patient and treatment-related factors that may influ-
ence the response of the periodontal tissue to specific
orthodontic treatments. Different types of orthodontic
movements are discussed, including expansion, extru-
sion, intrusion and the movement of teeth into edentu-
lous sites with limited alveolar bone.
Orthodontic space closure
One of the most challenging clinical problems in
orthodontics is the closure of large edentulous spaces
with severely resorbed alveolar ridges. These situa-
tions may arise following the loss of a deciduous
tooth with no permanent successor or after extraction
of an unrestorable tooth. In nongrowing patients, the
loss of a permanent molar often leads to progressive
tipping, rotation and lingual rolling of the adjacent
teeth (48, 96, 147). Over time, these uncontrolled
tooth movements can result in scissor bites,
141
Antoun et al.
nonworking side interferences, poor gingival con-
tours, deepening of the bite and over-eruption of the
opposing teeth (1, 48, 124). Pseudopockets may also
develop because of the bone’s tendency to follow the
inferiorly displaced cemento–enamel junction of
the tipped tooth (109). The orthodontic management
of lone standing molars often requires a combination
of uprighting and space closure. The uprighting of
tipped teeth usually results in apical migration of the
gingival margin and a decrease in the depth of the
periodontal pocket, which in turn helps to improve
plaque control and access to restorative margins (20,
113). Once a tooth has been uprighted, space closure
can be carried out to help establish occlusal contacts
and/or prepare the space for a prosthetic restoration.
There are several biomechanical and anatomic
challenges in closing long-standing edentulous
spaces with narrow ridges. Space closure is particu-
larly problematic in the mandible because of the den-
ser cortical plates (103) and greater susceptibility to
ridge resorption (7). Prosthetic tooth replacements
may not always be viable because of the limited
quantity and quality of bone available. Orthodontic
space closure may reduce costs for ridge augmenta-
tion and placement of implant-supported restora-
tions (131). Despite these potential benefits, most
orthodontists are often reluctant to close large eden-
tulous spaces (50, 61) because of the risk of localized
gingival dehiscence, poor root parallelism, incom-
plete space closure, increased treatment duration,
and relapse (53, 131). Reopening or incomplete
closure of these spaces can lead to further periodon-
tal breakdown if they result in open interproximal
contacts and food traps. In spite of these concerns,
only a few case reports and retrospective studies have
evaluated the effects of space closure on the adjacent
periodontal soft tissues and alveolar bone. Most of
these case reports have described complete or near-
complete space closure in the posterior mandible,
with only limited amounts of gingival recession and
loss of anterior anchorage (31, 131). Case reports,
however, represent the lowest level of evidence avail-
able for making clinical decisions (129).
Two retrospective human studies have investigated
the effect of space closure and found clinically signifi-
cant reductions in posterior space and moderate
increases in the width of the alveolar ridge (53, 143).
Both studies used small convenience samples and did
not report on any quantitative measurements of gin-
gival recession or attachment loss. In addition, the
thickness of the buccolingual bone around the test
teeth was assessed directly from the post-treatment
study casts, which provided little information about
142
the extent of bone apposition because large dehis-
cences may have been present. Despite these limita-
tions, two notable findings from these studies were
the slight loss of crestal bone height mesial to the
tooth being protracted (53) and the age-dependent
effect on the amount of increase in alveolar bone
width (143). With respect to the latter, new bone was
reported to follow the tooth as it moved through the
edentulous space in young growing individuals but
not necessarily in older patients (143).
The loss of crestal bone height reported in these
two studies may be related to the tipping movements
that occur when a tooth is moved along an arch-wire
(52). Tipping movements usually result in an unequal
distribution of stresses within the periodontal liga-
ment, with higher active forces (118) and levels of
compression found in the marginal tissues (119).
High levels of stress also normally occur in the mar-
ginal alveolar bone where the periodontal ligament
inserts (85). The large stresses occurring at the mar-
ginal tissues are likely to cause a negative remodeling
process, and thus net bone loss, at these sites. It is
noteworthy that the risk of bone loss at the alveolar
crest from excessive tipping movements may be
higher in adults (120). The benefits of closing edentu-
lous spaces in patients with significant vertical bone
loss should therefore be considered in light of these
potential risks. If space closure is necessary, bodily
movement of teeth may help to reduce these
unwanted effects at the marginal tissues (119).
The findings from these two human studies suggest
that bone apposition is possible under the correct cir-
cumstances. Some factors that may favor bone for-
mation include the magnitude of the applied force
and, accordingly, the level of strain in the surround-
ing tissues. According to Frost’s ‘mechanostat’ theory,
both low and excessive bone strains can cause
osteopenia and bone loss. On the other hand, strain
levels in the range of 1,500–3,000 microstrains tend to
favor a modeling process which is associated with
bone deposition (42, 43). The type of bone deposited
during this modeling process is thought to be depen-
dent on the amount of bone strain, with higher levels
resulting in the formation of woven bone (23). It is
noteworthy that those strain thresholds are not uni-
form between either individuals or bones (141).
Recent advancements in the fields of orthodontics
and periodontics have had a large impact on the
management of edentulous atrophic ridges. Skeletal
anchorage has been useful for uprighting tipped teeth
(115), facilitating bodily tooth movements during
space closure and reinforcing anchorage (57). The risk
of anchorage loss is particularly high in patients with

reduced periodontal support. The relatively apical
position of miniscrews is also useful for applying
orthodontic forces closer to a tooth’s center of resis-
tance, thus reducing the likelihood of unwanted tip-
ping movements (57). Despite the potential
advantages of skeletal anchorage systems, there is still
a lack of high-quality evidence regarding their clinical
efficacy. Another important development has been
the application of periodontal regeneration therapies
during orthodontic treatment. The clinical outcomes
of this combined approach are promising, with
increased connective tissue attachment levels
reported in selected cases (94). A recent review of the
literature, however, identified significant method-
ological heterogeneity and a lack of high-quality stud-
ies in this area (116). Encouragingly, the use of bone
substitutes to treat localized periodontal defects and
augment atrophied alveolar ridges does not seem to
have an adverse effect on orthodontic tooth move-
ment in animals (136). The potential for those techni-
ques to improve the efficacy of orthodontic space
closure in patients with reduced alveolar bone sup-
port requires further investigation.
Considerations for tipped teeth with
infrabony defects
Infrabony pockets are often associated with peri-
odontally compromised teeth or severely tipped teeth
adjacent to edentulous spans. Some authors have
warned that orthodontic movements can aggravate
the periodontal issues and lead to widening of the
defect (61). An important consideration in these treat-
ments is therefore the response of infrabony pockets
to orthodontic tooth movement.
The response of periodontal tissues to orthodontic
tooth movement has been investigated in dogs with
poor oral hygiene and experimentally induced infra-
bony pockets (163). In contrast to the maxillary
control teeth, bodily movement of the mandibular
test teeth resulted in a significant increase in pocket
depth and loss of connective tissue attachment, espe-
cially when the teeth were moved toward the infra-
bony defects. One probable reason for the continued
destruction of the periodontal tissues and the persis-
tence of infrabony pockets in these situations is the
apical displacement of the adjacent supragingival
plaque into subgingival sites (38).
Other studies, however, have reported improved
healing of infrabony defects when good oral-hygiene
measures were implemented. In a similar study to
that of Wennstro € m et al. (160), infrabony pockets
were experimentally produced around the incisors of
Response of periodontal tissues to orthodontic treatment
four Rhesus monkeys and the effect of tooth move-
ment into these defects was investigated (107). Histo-
logic findings from that study showed the potential
for complete resolution of these defects in the pres-
ence of reduced, but healthy, periodontal tissues.
These results are consistent with the findings of some
studies (95, 154) but not of others (29). Using a rat
model, Vardimon et al. (154) performed a histomor-
phometric analysis on 62 decalcified hemimaxillary
blocks following the movement of teeth into surgi-
cally created bony defects. Although a 6.5-fold
increase in the total area of bone apposition was
reported in the experimental group, this increase was
not statistically significant. Another similar study in
dogs found no changes in the level of connective tis-
sue attachment and the extent of epithelial migration
following the movement of roots into surgically cre-
ated defects, although coronal bone apposition was
significantly reduced in the experimental group (29).
Unfortunately, it is difficult to make meaningful com-
parisons between these studies because of method-
ological differences in the type of animals used, the
size of surgical defect, the type of tooth movement
performed and retention periods. One common fea-
ture of these studies, however, was the large individ-
ual variation reported in the experimental group (29,
154). This increased variability is likely to reflect dif-
ferences in the regenerative capacity of the periodon-
tal tissues following the movement of teeth into
osseous defects. The findings of these studies should
also be interpreted with caution because experimen-
tally induced osseous defects in animals may not
completely resemble those found in humans (154).
Osseous defects are usually created in animals using
traumatic surgical techniques, whereas those found
in humans are a result of chronic pathological pro-
cesses. On the other hand, animal models are ideal
for investigating attachment-level changes using his-
tologic techniques (87). For obvious ethical consider-
ations these ‘gold standard’ analytic techniques are
seldom possible in human samples. Interestingly, one
human study involved the removal of teeth in block
sections following molar uprighting, although no sub-
sequent histologic analysis was reported (20). It is
noteworthy, however, that uprighted molars in that
study showed a 2.5 mm clinical reduction in pocket
depth in comparison with controls. This reduction,
however, may be the result of recession, rather than
gain in attachment. An important clinical implication
from both animal and human studies is the need to
maintain healthy periodontal tissues throughout the
process of uprighting and space closure. Regular
monitoring of oral health should therefore be carried
143
Antoun et al.
out throughout the course of orthodontic treatment
(117).
Considerations for dental implants
Space closure can often be challenging in patients
with severe Class II or Class III malocclusions unless
the underlying skeletal discrepancy is corrected. Sin-
gle dental implants are useful in these cases provided
there is adequate bone at the recipient site. Unfortu-
nately, absence or extraction of teeth can lead to sig-
nificant reductions in the width and height of the
alveolar ridge over time (145). Several methods have
been advocated for preparing future implant sites,
including bone grafting, guided tissue regeneration
and the use of prerestorative orthodontics (140).
Strategic repositioning of teeth in the arch can
result in extensive regeneration of the alveolar bone
and supporting tissues (Figs 2 and 3). The develop-
ment of the alveolar bone using this technique may
be particularly useful in patients with congenitally
missing lateral incisors. In these cases, the alveolar
ridge of the lateral incisors can be prepared for receiv-
ing future implants by allowing the canines to erupt
adjacent to the central incisors and then distalizing
them back to their normal positions within the arch
(68, 140). Following treatment, bone deposition
would be expected to occur on the mesial aspect of
the distalized canine because this represents a site of
tension.
Use of this particular treatment protocol has been
reported to result in adequate alveolar bone width,
which is relatively stable up to 4 years after treatment
(67, 140). Similar findings were recently reported in a
larger retrospective study of 80 patients with 128
missing lateral incisors (98). Over the study’s 5-year
retention period, the width and height of the alveolar
bone were reduced by only 2% and 0.4 mm, respec-
tively. Interestingly, a recent systematic review found
that horizontal and vertical bone loss, 6 months after
tooth extraction, were somewhere in the region of
29–63% and 11–22%, respectively (145). Despite these
encouraging findings, prospective randomized con-
trolled trials are still needed to compare the efficacy
of this treatment modality with other types of ridge-
augmentation techniques.
A similar treatment protocol has been recom-
mended for managing congenitally missing second
premolars (140). Although a healthy primary tooth can
be expected to last for a considerable period of time,
these teeth may occasionally be lost as a result of
extensive root resorption, dental caries or infraocclu-
sion (17, 139). The late removal of ankylotic primary
144
molars may result in significant ridge resorption and
vertical bone defects, prohibiting the placement of
dental implants in an optimal position (69). Instead, a
dental implant may be placed at the site of the first
premolar tooth after it has been distalized into the sec-
ond premolar space (69, 140). An important considera-
tion in these situations is the potential effects of
moving teeth into areas with reduced alveolar bone.
This is a common scenario in older patients, in whom
approximately 25% reduction in the width of the alve-
olar ridge has been shown to occur during the first
3 years following extraction of a deciduous molar
(100). The findings of an experimental study involving
Beagle dogs suggest that no change in connective tis-
sue levels occurs following the movement of teeth into
edentulous areas with reduced bone height (75).
Summary
The management of large edentulous spaces is an
important part of oral rehabilitation. Despite the
limited evidence available, sagittal movement of
teeth into longstanding edentulous sites seems to be
a viable method for closing residual spaces and
redeveloping variable amounts of alveolar bone.
Several treatment factors may also help to reduce
the risk of marginal tissue breakdown during space
closure, including the use of light forces, bodily
tooth movement, absence of inflammatory peri-
odontal disease and the maintenance of good oral
hygiene throughout treatment. Nonetheless, the risk
of gingival recession and attachment loss should be
carefully assessed in individual patients before clos-
ing residual spaces.
Orthodontic intrusion
Orthodontic intrusion may be a useful treatment
adjunct in a wide range of cases, including the
management of elongated incisors and traumatic
deep-bite (88), and the restoration of severely worn
incisors (13).
Intrusion of flared and elongated teeth
Flaring and elongation of the incisor teeth is com-
monly seen in patients with advanced periodontal
disease (114, 150). One consequence of these
unwanted occlusal changes is the development of a
traumatic deep-bite, which can cause significant
soft-tissue and hard-tissue trauma (93). In adults,
severe skeletal deep-bites are often treated using a
 Response of periodontal tissues to orthodontic treatment

Fig. 2. Large osseous defect associ-

ated with three missing mandibular
B incisors. (A) The alveolar bone level
was at the apical third of the root of
the mandibular right lateral incisor
(tooth 42). Gingival recession was
also pronounced, especially on the
mesiobuccal aspect of that tooth. (B)
Tooth 42 was moved mesially along
the alveolar ridge using fixed appli-
ances. Both the clinical appearance
and periapical radiograph show sig-
C nificant bone formation distal to
tooth 42 (yellow arrows). (C) The
final implant-supported restoration.
Gingival inflammation around tooth
42 has resolved, with no significant
change in connective tissue attach-
ment. Clinical photographs and
intra-oral radiographs courtesy of Dr
Alberto Laino (Naples, Italy).

Fig. 3. Alveolar bone formation fol-

lowing space closure in the posterior
maxilla. (A) The maxillary right sec-
ond molar (tooth 17) was moved
mesially following removal of the
first molar. Note the limited space
available for eruption of the third
B molar and the close proximity of the
second molar roots to the maxillary
sinus. (B) Complete space closure
was accompanied by successful
eruption of the third molar and a
significant amount of bone forma-
tion distal to tooth 17. Note the
extensive remodeling of the maxil-
lary sinus floor – no clinical signs or
symptoms of a sinus perforation
were noted. Clinical photographs
and intra-oral radiographs courtesy
of Dr Alberto Laino (Naples, Italy).

joint surgical–orthodontic approach (12), although intruding elongated incisor teeth are the improve-
intrusion of the anterior teeth is also possible in ment in smile esthetics and reduction in soft-tissue
some cases (24). Two important advantages of trauma.

145
Antoun et al.
The intrusion of teeth has a number of important
effects on the periodontal tissues (33). Bone deposi-
tion occurs along the stretched periodontal ligament
fibers in the middle and coronal thirds of the root
(18). The intensity and direction of the intrusive force,
however, seem to play an important role in influenc-
ing the responses of these tissues. Light forces are
likely to reduce stresses in the marginal part of the
periodontal ligament, while forces directed through
the long axis of a tooth favor bodily intrusion and
limit the extent of hyalinization (87). Force magnitude
also affects the reaction of the tissues at an apical
level, with heavy intrusive forces associated with a
higher degree of root resorption (18, 33).
The clinical effects of intrusion have been exten-
sively investigated in both animals and humans (18,
26, 33, 39, 41, 83, 87, 88). In one animal study, the use
of light and continuous forces resulted in pure intru-
sion without any loss of marginal bone (87). Follow-
ing surgical debridement, the intruded teeth in the
five Macaca fascicularis monkeys had greater attach-
ment levels, which were attributed to coronal migra-
tion of the periodontal ligament cells. In teeth with
poor oral hygiene, however, osteoclastic activity was
noted at the marginal bone level (87). As mentioned
earlier, one plausible cause of the breakdown of mar-
ginal tissues is the inflammatory response that occurs
as a result of the displacement of supragingival pla-
que below the gingival margin (38). On the other
hand, meticulous periodontal therapy during intru-
sion exposes the root surface to the periodontal liga-
ment cells and increases the likelihood for connective
tissue regeneration (88). This seems consistent with
the findings of an experimental study, which found
that teeth intruded in the presence of good oral
hygiene had shallower pockets and relatively stable
marginal bone levels compared with those exposed to
poor oral hygiene (83).
The effects of intrusion are not limited to the mar-
ginal tissues, with bone deposition reported on the
labial and palatal surfaces of the alveolar process and
near the root apices (18, 83). The formation of new
bone in these areas is reported to result in a small
increase in the buccolingual width of the alveolar pro-
cess. It has been hypothesized that this new bone
forms in response to the negative loading created by
the intrusive forces on the adjacent structures (18,
83). Similar findings have also been reported in a
sample of deep-bite adult patients with horizontal
bone loss (88). In that study, following intrusion, bony
support increased and clinical crown length
decreased by approximately 7% and 1.1 mm, respec-
tively. A large number of patients experienced little or
146
no change in either bony support or clinical crown
length, although individual variability was high for
both clinical parameters. Extrapolation of these
results to other periodontal patients should be carried
out with caution, however, as the severity of pretreat-
ment bone loss in the sample varied greatly, with
some patients experiencing up to 60% horizontal
bone loss, while others had virtually normal bone
levels. Nonetheless, these findings are consistent with
another human study that used a similar intrusive
appliance and found reduced clinical crown heights
of the mandibular incisors (39). No predictors of tis-
sue response could be identified, presumably because
of the limited sample size and heterogeneity of the
malocclusions and treatment effects included. How-
ever, even in larger studies, no associations were
found between bone-level changes and age, gender,
treatment time, amount of intrusion and pretreat-
ment bone level (13).
Although orthodontic intrusion has been shown
to improve periodontal support under optimal con-
ditions, careful consideration should still be given to
some of the adverse side effects that may occur as a
result of this tooth movement, especially root
resorption and shortening (33, 34). Findings from
both animal models and human samples suggest
that force magnitude plays an important role in the
extent of tissue loss, with heavier forces associated
with a higher degree of root resorption (18, 33, 41,
142). Interestingly, the magnitude of the intrusive
force seems to play a more important role in the
development of root resorption than does the
amount of tooth displacement (33). It is important
to note that other factors, such as genetic suscepti-
bility and history of previous trauma, may also
increase the risk of root resorption in some patients
(160). Fortunately, most of the resorption lacunae
undergo repair once the intrusive force is termi-
nated and healing is permitted (83).
Intrusion of worn incisors
Long-term incisal wear is typically associated with
over-eruption, reduction in clinical crown length,
uneven gingival margin heights and a ‘gummy’ smile
(13, 66). The gingival tissues of fractured or severely
worn teeth often migrate coronally if these teeth are
allowed to continue erupting (70). In addition to clini-
cal crown-lengthening surgery, orthodontic intrusion
may be a viable option for displacing the bone and
soft tissues in an apical direction. During intrusion,
the gingival tissues typically follow the path of the
teeth, although to a lesser extent (39, 92). Following

orthodontic treatment, however, mucogingival sur-
gery may still be needed to increase clinical crown
heights and eliminate pockets that develop from the
stretching of the gingival fibers (92).
Summary
Several animal and human studies have investigated
the effect of orthodontic intrusion on the periodontal
soft tissues and alveolar bone, although direct com-
parison between studies is generally difficult because
of differences in appliance design, force levels, oral-
hygiene care and treatment durations. Of these
different treatment factors, the maintenance of
healthy gingival tissues throughout intrusion appears
to reduce the risk of marginal bone breakdown. In
order to facilitate oral hygiene, surgical periodontal
debridement may be needed in some patients to
reduce the depth of existing periodontal pockets.
Orthodontic intrusion may be useful for the intru-
sion of elongated and flared incisors, management
of traumatic deep-bites and the intrusion of over-
erupted worn or fractured incisors. Posterior teeth
may also be successfully intruded for receiving pros-
thetic restorations, managing open-bites and cor-
recting occlusal plane discrepancies. The decision to
use intrusive forces in patients with advanced peri-
odontal disease should take into account the risk of
root resorption because this may create an unfavor-
able crown-to-root ratio. In these cases, light forces
should be used in order to reduce this risk.
Orthodontic extrusion
The extrusion of teeth has been advocated as an
effective method for managing one- and two-wall
infra-osseous defects (55). Numerous case reports
have been published to illustrate the potential bene-
fits of tooth extrusion on the adjacent soft and hard
tissues (55, 56, 108, 144, 165). Some of these reports
have found favorable effects on pre-existing peri-
odontal pockets, including a reduction in pocket
depth, an increased zone of attached gingiva and cre-
stal bone apposition (56). Although some of these
changes have been attributed to the regular peridon-
tal maintenance often implemented during treatment
(55), it seems biologically reasonable that stretching
of the periodontal ligament fibers would induce some
bone apposition at the alveolar crest (49). Interest-
ingly, a similar tissue response has also been
observed when teeth are allowed to erupt naturally
(99). One situation where orthodontic extrusion may
Response of periodontal tissues to orthodontic treatment
be particularly useful is in implant site development
(Fig. 4).
Implant site development
The extrusion of hopeless teeth can help develop the
investing soft and hard tissues before implant place-
ment (4, 19, 166). The effect of orthodontic extrusion
on the alveolar bone has been studied using various
animal models. In Rhesus monkeys, significant
amounts of bone apposition were found on the lin-
gual, interproximal and apical surfaces following
spontaneous extrusion of the mandibular incisors
(10). Although the distance between the cemento–
enamel junction and alveolar crest had slightly
decreased at the three sites (by 1 mm or less), this
was considered to be minimal given that the teeth
had undergone nearly 5 mm of extrusion. These find-
ings are consistent with those of another study in
which extrusion of premolars in three Beagle dogs
resulted in a similar pattern of bone apposition
within 2 weeks of starting treatment (138). After
7 weeks, mature bone was found at the crestal sur-
face and the periodontal fibers had assumed a similar
orientation to controls.
The effect of orthodontic extrusion on the adjacent
tissues has been studied in Beagle dogs with a signifi-
cantly reduced periodontium and poor oral hygiene
(153). Using light forces, ranging from 20 to 25 g,
hemisected premolar teeth were gradually extruded
to the point of extraction and then stabilized for a
period of 3 weeks. Following retention, new-bone
formation was radiographically and histologically
detected coronal to the marginal bone level, as well
as apical to the root apices. Similar findings have also
been reported in a small sample of patients in whom
the average ratio of bone-to-tooth displacement was
70% and soft tissue-to-tooth displacement was 65%
(4). By extruding teeth approximately 6 mm (to the
point of extrusion), the authors were able to achieve
nearly 4 mm of bone and soft-tissue augmentation.
Interestingly, no soft-tissue migration occurred in any
of the patients with established periodontal pockets.
Several characteristic soft-tissue responses have
also been described when teeth are extruded to the
point of extraction (77). Initially, the gingival margin
exhibits a red-collar appearance; pocket depth also
tends to decrease during the extrusion process. With
continued extrusion, a nonkeratinized red patch may
appear coronal to the free gingival margin. This thin
tissue, which later becomes keratinized to resemble
the surrounding gingival tissues, is formed from ever-
sion of the pocket lining (20). It is noteworthy,
147
Antoun et al.
Fig. 4. Patient with chronic periodontal disease who pre-
sented with an elongated and mobile maxillary right cen-
tral incisor. A lingual retainer supported the tooth at the
time of presentation. (A) The tooth was deemed to have a
poor prognosis and a decision was made to replace it with
an implant, following orthodontic extrusion. Esthetics was
compromised by the unfavorable shape of the tooth and
gingival recession. (B) Intra-oral photographs showing
stepwise extrusion of the tooth with a preadjusted
148
edgewise appliance. The tooth was root filled during treat-
ment, and the occlusal surface was gradually reduced as
the tooth was extruded. (C) Periapical radiographs of tooth
11 before treatment, during orthodontic extrusion and
after implant placement. Note the angular bony defects
present before treatment. Some bone apposition can be
seen at the crestal ridge during extrusion (yellow arrows)
and following treatment. (D) Extra- and intraoral pho-
tographs of the final implant-supported restoration.

however, that these tissue reactions are subject to
individual variation and to the intensity and extent of
extrusion.
Extrusion of teeth has a number of desirable
effects on the position of the gingival margin, pocket
depth and width of attached gingiva. The gingival
margin normally follows the direction of tooth dis-
placement, but to a variable extent (4). In teeth with
deep periodontal pockets, for example, the coronal
displacement of the soft tissues lags behind that of
the hard tissues (77). In general, however, extrusion
of teeth causes the attached fiber bundle to be dis-
placed coronal to the epithelial attachment, thereby
inverting the periodontal pocket and reducing its
depth (20, 77). The width of the attached gingiva also
increases because the free gingival margin is dis-
placed more coronal than the mucogingival margin
(4). This clinical observation has been confirmed in
animal studies, which used tattoo marks as an objec-
tive record of the position of the mucogingival
margin (10, 59).
Considerations for the direction of tooth
extrusion
There is some controversy regarding the ideal angle
and direction of extrusion when preparing implant
sites. In general, teeth may either be extruded along
their long axis (4), or with progressive application of
labial root torque (166). In the presence of an angular
defect, gradual mesiodistal tipping of the teeth
toward the defect may also be considered (151). Each
method has a number of advantages and disadvan-
tages. When extruding teeth with labial root torque,
the marginal tissues are believed to follow the root
apex as it moves both buccally and coronally (166).
This scenario may be particularly useful in cases with
severely resorbed labial bone plates. On the other
hand, excessive application of root torque in cases
with reduced, but intact, labial plates is likely to com-
promise the integrity of the remaining buccal bone
and create unwanted bony dehiscences/fenestra-
tions. In such cases, it would seem more reasonable
and less destructive to extrude teeth along their long
axis so that the entire periodontium is displaced coro-
nally.
Despite these theoretical considerations, there is
still a lack of evidence supporting the use of each
method in different clinical situations. Future studies
are needed to evaluate and compare the efficacy of
different extrusion techniques. Until then, the deci-
sion to use one of these techniques should be based
on the amount and architecture of the existing hard
Response of periodontal tissues to orthodontic treatment
and soft tissues. Regardless of the method used, how-
ever, extrusion should be carried out using light and
controlled forces, and in the absence of deep peri-
odontal pockets (4, 166). Moreover, a short stabiliza-
tion period following extrusion is recommended to
allow the new bone to mineralize and mature (4).
Summary
Although most orthodontists are aware of the poten-
tial to develop prospective implant sites through
tooth extrusion, data on the efficacy of this technique
are lacking. Most of the evidence in this area origi-
nates from case series and small experimental stud-
ies. Based on the evidence available, however,
orthodontic extrusion seems to be an effective
method for developing the investing soft tissues and
alveolar bone. During orthodontic extrusion, the alve-
olar bone and soft tissues are displaced coronally,
along with the cemento–enamel junction. There is
some evidence that elimination or reduction of peri-
odontal pockets, before extrusion, increases the likeli-
hood of soft-tissue migration. In general, orthodontic
extrusion may offer an effective and less-invasive
method for developing prospective implant sites,
especially if orthodontic treatment is already
indicated.
Orthodontic expansion and incisor
proclination
There is an increasing trend toward nonextraction
treatment in orthodontics (111), whereby crowding is
managed by increasing the arch length. Lateral expan-
sion of the buccal segments, and labial advancement
of the incisors, can theoretically provide a variable
amount of additional space for the alignment of dis-
placed teeth (64, 65). Proclination and advancement
of the mandibular incisors has been suggested as a
viable alternative to extractions and orthognathic
surgery in adult patients with increased overjets and
moderate-to-severe crowding (3, 89). Nonetheless,
there is still some controversy regarding the risks of
nonextraction treatment, especially in patients with
significant arch-length discrepancies. One important
concern is the effect of orthodontic expansion on the
gingival tissues and alveolar bone.
Transverse expansion
Both maxillary and mandibular arches undergo a sig-
nificant amount of transverse development during
149
Antoun et al.
normal growth (14, 72, 76, 79). In addition to these
growth-related changes, arch expansion can be
achieved using a number of orthodontic appliances,
including arch-wires, removable plates, fixed expan-
ders and orthognathic surgery. Several animal and
human studies have investigated the relationship
between arch expansion and gingival recession,
attachment loss and bony dehiscence. The effect of
maxillary expansion on the thickness and height of
buccal alveolar bone has mostly been investigated
using clinical examination (51), computed tomogra-
phy and cone-beam computed tomography (46, 47,
128). Although these studies have mainly been limited
to young patients with a healthy periodontium, their
findings provide some useful insights into the effect
of arch expansion on the periodontal tissues.
Rapid maxillary expansion has been shown to
cause significant changes in alveolar bone thickness
following treatment (46, 128). Recently, a comparison
between pre- and post-treatment spiral computed
tomography images in a small sample of adolescents
receiving rapid maxillary expansion identified several
areas of bony dehiscence and a 0.6–0.9 mm reduction
in buccal bone plate thickness of the banded teeth
(46). Interestingly, the presence of thinner buccal
bone plates at the onset of treatment was associated
with greater changes in crestal bone levels and the
occurrence of a bony dehiscence following expansion.
A similar relationship between buccal bone changes
and initial buccal bone thickness has been reported
elsewhere (126). It is noteworthy, however, that these
findings reflect the status of the alveolar bone shortly
after treatment and do not necessarily account for
any long-term changes that may occur as a result of
bone remodeling.
A few studies have investigated the effects of maxil-
lary expansion on the long-term health of the peri-
odontal tissues. In one such study, which included
young patients, the prevalence of gingival recession
on one or more teeth in the rapid maxillary expansion
and fixed appliance groups were 20% and 6%, respec-
tively (49). In contrast, other studies have demon-
strated clinically significant increases in intra-arch
width, without any detrimental medium-term/long-
term effects on the periodontal tissues (8, 51). Some
of these findings, however, may be related to the
techniques used to measure buccal bone changes fol-
lowing maxillary expansion. For instance, Ballanti
et al. (8) measured bone thickness from computed
tomography scans at the level of the root furcation
and did not account for the relatively thinner mar-
ginal regions in which periodontal breakdown would
be expected to occur during tooth movement.
150
Surgically assisted rapid maxillary expansion is
often used to manage transverse skeletal discrepan-
cies in adult patients. The effect of surgically assisted
rapid maxillary expansion on the periodontal tissues
seems less detrimental, with minimal change in
attachment levels reported (47). Nonetheless, some
reduction in buccal alveolar bone thickness and cre-
stal bone level can still be expected in these patients
(47). One reason for the more pronounced effects of
conventional rapid maxillary expansion on the peri-
odontal tissues may be related to the heavy forces
delivered by these appliances to the supporting peri-
odontium. During rapid maxillary expansion, heavy
forces are usually needed to induce hyalinization of
the periodontal ligament around the anchor teeth
and thus halt initial tooth movement (46). During this
rather slow process of undermining resorption, the
forces acting on the anchor teeth are used to expand
the two maxillae laterally. Once the orthopedic effect
has been attained and the undermining resorption
process completed, the residual forces will act to
move the anchor teeth through the alveolar process
(46). The extent to which these teeth move will ulti-
mately depend on the amount of orthopedic expan-
sion achieved, with more favorable and predictable
outcomes usually found in growing patients (15). The
heavy forces produced by rapid maxillary expansion
appliances, along with the diminished orthopedic
response found in some patients, may therefore pre-
dispose to a reduction in buccal bone dimensions.
The adverse effects of heavy forces on the support-
ing periodontium have fueled interest into the use of
light-force appliances, which may theoretically favor
the movement of teeth ‘with bone’. Self-ligation
brackets are reported to produce low friction, which
permits light forces to be delivered to the teeth (80).
Although conflicting data exist regarding the light
force properties of self-ligating brackets (101, 102),
their role in developing labial and buccal bone has
recently been investigated (28). Using a well-designed
randomized clinical trial, the changes in buccal bone
were assessed following transverse expansion with
self-ligating brackets. Transverse expansion was
found to occur mainly as a result of buccal tipping,
rather than by true translation of the teeth ‘with’ buc-
cal bone. Interestingly, the buccal tipping produced
by these self-ligating bracket systems was similar to
that reported in studies using rapid maxillary expan-
sion (128). The bone area on the buccal aspect of the
second premolar was also reduced following expan-
sion, although similar data were not provided for the
canine or molar teeth. Unlike the other tooth move-
ments discussed previously, it is plausible that bone

apposition does not accompany transverse and sagit-
tal tooth movements to the same extent because the
overlying cortical plate in this direction is far too thin
for the osteogenic progenitor cells to form new bone
(5). While a small amount of bone may be formed by
periosteal apposition, excessive tooth movements are
likely to cause the periodontal ligament to fuse with
the adjacent periosteum, thus creating a bony dehis-
cence (45). This theory seems to be well supported by
the unexpected, but highly interesting, work of Baten-
horst et al. (10), who found distinctive tissue changes
when teeth were both extruded and advanced labi-
ally. During these tooth movements, the alveolar
bone and epithelial attachment increased at the lin-
gual, interproximal and apical sides of the experimen-
tal teeth. On the labial aspect, however, bony
dehiscence was noted and the epithelial attachment
was located more apically.
An important limitation of these human studies is
that most have not evaluated the long-term response
of the periodontal soft tissues and alveolar bone in
teeth that have been expanded and retained outside
the cortical bone. Although some recovery of buccal
bone thickness has been reported after a 6-month
retention period in patients treated with rapid maxil-
lary expansion, these changes have been small and
mostly insignificant (8). The effect of retaining the
apices of premolar teeth outside the cortical plate has
also been studied in a small group of Macaca speciosa
monkeys (157). Histologic analysis of the premolar
teeth, immediately after expansion, revealed thinning
of the buccal cortical plate, lack of bone over the root
apex and disorganization of the periodontal ligament.
There was also a lack of hyalinization in the speci-
mens, although this was attributed to the lag period
between activation of the appliance and histological
analysis. In the other phase of the study, retention
of the premolar apices outside the bone for a period
of 4 months resulted in osteogenesis around the
exposed root apices and some improvement in the
orientation of the periodontal ligament fibers. Unfor-
tunately, the limited study period did not permit the
authors to determine whether complete bony repair
was possible.
Given the short follow-up period of most studies,
the potential for complete recovery of buccal bone
thickness and height following transverse expansion
is unclear. It has been suggested that thinning out of
the buccal tissues during expansion may predispose
to long-term gingival recession as a result of mechan-
ical trauma and/or periodontitis (51). Previous stud-
ies, however, have not found any clinically significant
changes in gingival recession and connective tissue
Response of periodontal tissues to orthodontic treatment
attachment levels following lateral expansion (47).
One possible explanation for this finding is the fact
that gingival and periodontal tissue changes may not
be detectable at the time of appliance removal or
even after a short period of retention (51). Indeed,
long-term evaluation of the periodontal tissues indi-
cates that adult patients undergoing rapid maxillary
expansion have significantly greater clinical crown
heights than either controls or those who receive sur-
gically assisted expansion (97).
Sagittal expansion
The ideal position of the mandibular incisors has long
been the subject of intense debate. Significant
changes in the pretreatment position of the mandibu-
lar incisors are associated with a greater risk of
relapse (54, 90), which makes it an important factor
to consider when planning orthodontic cases. Still, a
more pressing issue is often the effect of incisor pro-
clination on the health of the periodontal soft tissues
and alveolar bone. Clearly, a significant amount of
arch space can be gained by proclining the incisors
(64), but at what expense?
The effect of incisor position on the adjacent alve-
olar bone has been studied both in dogs (60, 143)
and in monkeys (10, 37, 141, 162). Nearly all of these
animal studies have found a consistent reduction in
the level of the alveolar bone following incisor tip-
ping or bodily displacement. Interestingly, marginal
bone levels increased and experimentally induced
fenestrations/dehiscences resolved following the
repositioning of previously expanded teeth within
the alveolus (37, 143, 154). However, that eruption
of the incisors during this repositioning process may
also have influenced the level of the marginal bone
in these studies, as the alveolar crest migrates coro-
nally to maintain its relationship with the cemento–
enamel junction (125). Buccal bone regeneration
has also been reported in a patient following the
repositioning of a displaced canine tooth back
within the alveolus (104).
Alveolar bone defects may also occur in the
absence of any deliberate attempt to protrude the
teeth outside the cortical plate. In a rare postmortem
report of a deceased adult patient undergoing
orthodontic treatment, the roots of the mandibular
incisors were found to have perforated the lingual
plate (159). It is noteworthy that the mandibular sym-
physis in this patient was both narrow and high, with
only a thin amount of alveolar bone supporting the
incisors. The presence of bony dehiscence and fenes-
trations were also confirmed in the maxilla of this
151
Antoun et al.
patient using histological techniques (158). Although
these findings must be interpreted with caution, they
suggest that specific morphological features may play
an important role in the development and extent of
bony dehiscence and fenestrations. Patients with
hyperdivergent skeletal patterns, for instance, are
reported to have a thinner alveolus and this may pre-
dispose them to a greater risk of developing bony
dehiscence (130). Interestingly, facial type per se does
not seem to be associated with a higher frequency of
bony dehiscence and fenestration in untreated indi-
viduals (40). Prospective studies with adequate sam-
ple sizes are clearly needed to investigate the
relationship between morphologic features and the
occurrence of bony defects during orthodontic treat-
ment.
In addition to the development of a bony dehis-
cence or fenestration, labial advancement of the
mandibular incisors is reported to cause tension at
the free gingival margin, which reduces its apico-
coronal height and buccolingual thickness (161,
164). Several predisposing factors have been
reported, including patient age (122), gingival bio-
type (89, 164) and width of the attached gingiva
(36). The extent of incisor proclination and the pres-
ence of visible plaque have also been linked with
gingival recession (6, 89, 164). In particular, a thin
gingival biotypes, coupled with excessive proclina-
tion of the incisors, can render the gingival tissues
less resistant to plaque-induced inflammation and
traumatic toothbrushing (164). As indefinite reten-
tion of the incisors is often required in patients with
severely expanded dental arches, it is likely that the
risk of gingival recession would be particularly pro-
longed in these cases. However, the association
between gingival recession and sagittal expansion/
incisor proclination is not consistent throughout the
literature (3, 35, 123, 127).
A recent systematic review in this area described
the current level of evidence as low and highlighted a
number of methodological weaknesses, including the
use of retrospective study designs, inadequate clinical
records and lack of follow-up data (58). The standard
of oral hygiene is often not accounted for in these
studies. These limitations highlight the need for
well-designed prospective studies to investigate the
factors that predispose to gingival recession during
orthodontic treatment.
Summary
Based on the data available, it would seem prudent to
maintain the position of the teeth within the alveolar
152
process. Excessive bodily advancement or proclination
of the teeth for the purpose of gaining additional arch
space may adversely affect the health of the periodon-
tal tissues, especially in the presence of specific trig-
gering factors, such as overzealous toothbrushing (86).
There may be some cases, such as dentoalveolar retru-
sion, where the incisors can be advanced with less risk
of recession (5). Careful evaluation of the periodontal
tissues, oral hygiene, underlying skeletal structures
and magnitude of tooth movement is therefore recom-
mended for individual patients.
Limitations of current research
There is considerable heterogeneity in the quality and
type of studies investigating the effects of orthodontic
treatment on the periodontal tissues and alveolar
bone. A large proportion of the research in this area
has been based on animal models. In comparison
with human studies, experimental models have a
number of important advantages, including the stan-
dardization of testing conditions and the use of pow-
erful, but invasive, analytic techniques. Nonetheless,
several authors have warned that findings from ani-
mal models may not necessarily be valid and/or
reproducible in human populations (82, 86, 105).
There are a number of important differences in the
behavior of human and animal tissue during tooth
movement. In comparison with humans, the labial
and lingual alveolar walls of dogs and rats are denser
and contain fewer marrow spaces (121). Other differ-
ences have also been noted between species in the
occurrence of hyalinization zones, structural content
of the roots, surface texture of the alveolar bone and
the porosity of the lamina dura (32, 121). Given these
biologic differences and the inherent variability of
treatment responses in humans, it possible that ani-
mal models may not fully predict the tissue response
achieved in clinical practice (135). Therefore, it is
important that findings from experimental models
are supported by well-designed human studies when-
ever possible.
Even in human studies, however, there are a num-
ber of methodological issues that deserve some con-
sideration. Previous studies, for example, have
assessed the structure and dimensions of the alveolar
bone using a wide range of imaging modalities,
including conventional two-dimensional radiography
(88) and computed tomography (8, 46, 103). An
increasing number of studies are also currently using
cone-beam computed tomography for assessing alve-
olar bone changes following orthodontic treatment

(28, 47, 128). Although the estimation of bone thick-
ness/height using cone-beam computed tomography
appears to correlate rather well with direct bone mea-
surements (148), the evaluation of bony dehiscence
and fenestrations using three-dimensional rendering
software can often overestimate the occurrence of
these defects (resulting in a false-positive diagnosis),
even if conservative thresholds are used (74).
Overall, three-dimensional imaging modalities
have been useful for detecting changes in the
dimensions of the alveolar bone following orthodon-
tic treatment. However, more work is needed to
improve the positive predictive value of bony dehis-
cence and fenestrations (74). Studies intending to
measure small changes in buccal bone thickness
should also use standardized image settings, carry
out sample-size calculations and include suitable
control groups (91).
Conclusions
In general, the controlled movement of teeth seems
to have a positive, but highly variable, effect on the
supporting tissues. The correction of some orthodon-
tic problems, such as excessively tipped molars, trau-
matic deep-bites and flared and spaced incisors, may
be particularly beneficial in periodontally compro-
mised patients who are motivated to undergo treat-
ment and demonstrate stable periodontal conditions.
Specific tooth movements can also help develop
alveolar bone sites for placing dental implants. How-
ever, several factors may contribute to a harmful peri-
odontal response including the use of heavy forces,
inappropriate force systems and poor oral hygiene.
Excessive and unrealistic tooth movements are also
likely to result in reduced alveolar bone thickness,
especially in patients with thin cortical plates. On the
other hand, the response of the soft tissues is less pre-
dictable and likely to be influenced by multiple fac-
tors. Well-designed long-term prospective studies are
therefore needed to identify these patient and/or
treatment factors.
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