Orthodontic movement and periodontal bone

defects: Rationale, timing, and clinical

implications
Daniele Cardaropoli,1,2 Lorena Gaveglio,1 and Ramzi V. Abou-Arraj3

Advanced periodontitis may be characterized by the formation of infrabony

pockets, infrabony defects, and possible pathologic tooth migration. An
interdisciplinary approach is often required in planning the treatment of
advanced periodontitis. Periodontal nonsurgical and surgical therapies
control the microbial infection whereas orthodontic therapy realigns the
migrated teeth. To avoid further periodontal breakdown, active orthodontic
movement must always follow proper periodontal therapy. Consequently,
orthodontic treatment is no longer a contraindication in patients with
controlled periodontal disease. Teeth can be moved into infrabony defects,
leading to defect closure, bone fill, and possibly new attachment formation.
Orthodontic stimulation at the periodontal ligament level has positive effects
on the quality of periodontal wound healing, especially when orthodontic
movement starts shortly after surgical periodontal treatment. When the
infrabony defects are subject to augmentation procedures, the graft material
does not impede orthodontic tooth movement that seems to enhance defect
healing. The present article describes the effects of orthodontic movement
into infrabony defects adjacent to pathologically migrated teeth. (Semin
Orthod 2014; 20:177–187.) & 2014 Elsevier Inc. All rights reserved.

Introduction lesions represent the anatomical sequelae to the

P
apical spread of periodontitis, and in particular,
eriodontitis is an infective disease primarily
they are related to the interplay between site-
caused by the dental biofilm, and its
specific progression and the local anatomy (deep
pathological manifestation is related to the host
pockets and furcation involvement).3 Most com-
response against the microbial challenge at the
monly, osseous defects are detected on conven-
tooth/gingival interface.1 Secondary etiological
tional periapical and bite-wing radiographs.
factors have been associated with periodontal
It is noteworthy to remember that 30–50% of
disease including systemic diseases and condi-
tissue destruction must occur before its radio-
tions (e.g., diabetes mellitus and unhealthy
graphic detection becomes possible. Another
lifestyle), environmental factors (e.g., genetics
limitation of conventional radiographs is the
and smoking), and local factors involving the
superimposition of three-dimensional structures
dentition.2 The progression of the periodontal
including alveolar bone, teeth, and soft tissue on
infection leads to connective tissue attachment
a two-dimensional image. Furthermore, even
loss, bone loss, and pocket formation. Osseous
advanced lesions may be masked by the presence
of superimposed structures.3 Nonetheless, a
1 radiographic examination usually allows distin-
PROED Institute for Professional Education in Dentistry,
Torino, Italy; 2Cardaropoli Dental Clinic, Torino, Italy; 3Department guishing the pattern of bone loss in addit-
of Periodontology, University of Alabama School of Dentistry, ion to the extent (localized or generalized)
Birmingham, AL. and severity (mild, moderate, or advanced).
Address correspondence to Daniele Cardaropoli, PROED Institute The pattern of bone loss is generally described
for Professional Education in Dentistry, corso Galileo Ferraris 148,
as either horizontal (i.e., even) or angular (i.e.,
10129 Torino, Italy. E-mail: dacardar@tin.it
infrabony or vertical), both of which may
& 2014 Elsevier Inc. All rights reserved.
1073-8746/12/1801-$30.00/0 present on different teeth in the same patient.
http://dx.doi.org/10.1053/j.sodo.2014.06.004 In the absence of periodontal therapy, sites

Seminars in Orthodontics, Vol 20, No 3 (September), 2014: pp 177–187 177

178 Cardaropoli et al

with angular bony defects present a signifi-
cantly higher risk of additional bone and
tooth loss when compared to horizontal bone
defects.4
Moderate or advanced bone and connective
tissue attachment loss can be complicated by
migration of the involved tooth or teeth, espe-
cially in the presence of unfavorable occlusal
forces. When present in the adult patient with
advanced periodontitis, pathological tooth
migration is characterized by newly formed dia-
stemata, increased tooth mobility, rotation, and
supraeruption of the dentition, and it com-
promises the patient's esthetics and function. In
these situations, an interdisciplinary approach
involving periodontal and orthodontic therapies
to restore periodontal health and reestablish
function and esthetics is warranted. The aim of
this article is to describe the relationship between
periodontal disease and tooth migration and the
rationale for performing adjunctive orthodontic
treatment. The optimal sequence of treatments,
possibilities to resolve infrabony defects, and
control of the magnitude of orthodontic forces
will also be discussed.
Pathologic tooth migration
Pathologic tooth migration (PTM) is defined as a
change in tooth position that occurs when there
is disruption of forces that maintain teeth in a
normal relationship.5 PTM is considered a
frequent finding in patients with advanced
periodontitis. Martinez-Canut et al.6 examined
852 patients in a private periodontal practice and
reported a PTM prevalence of 55.8%. In these
patients, PTM was associated with a developing
diastema in the maxillary anterior sextant, which
was not previously present or had already existed
and increased.6 Towfighi et al.7 analyzed the
prevalence of PTM in 343 patients with moderate
to severe periodontitis before treatment. PTM of
anterior teeth was self-reported after asking
patients if they were aware of anterior tooth
migration in the past 5 years, and its prevalence
was found to be 30.03%.7 The difference in PTM
prevalence between these two studies might be
explained by the exclusion of diastemata present
since birth in the latter study.8 PTM is often a
motivational factor for patients seeking
periodontal and orthodontic therapies as it can
result in severe dental disfiguration and devastate
the patient's self-esteem (Fig. 1).
PTM can be caused by a variety of factors, most
of which play an influential role in tooth position.
Periodontal tissues; soft tissues of the cheeks,
tongue, and lips; occlusal forces; and a number of
oral habits are the major factors affecting tooth
position.8,11,12 Of interest, periodontal inflam-
mation and tissue destruction have been shown
to be significantly associated with PTM, as shown
in the following two studies.6. 7 Martinez-Canut
et al.6 found that PTM was statistically associated
with bone loss, tooth loss, and gingival inflam-
mation. The probability of having PTM was
almost three times higher as bone loss
increased on affected teeth.6 They concluded
that no single factor was clearly associated with
PTM, but they recognized that the primary factor
related to PTM was periodontal bone loss,
followed by tooth loss and gingival inflam-
mation.6 Following the evaluation of 150

Figure 1. A 38-year-old female patient with generalized aggressive periodontitis: (A) pathological tooth migration
of anterior maxillary teeth due to loss of periodontal support is complicated by deepening of the bite, opening of a
median diastema, and extrusion of maxillary right lateral incisor and (B) the radiographic image shows severe
generalized horizontal bone loss with infrabony defects and furcation involvements.
 Orthodontic movement and periodontal bone defects 179

contralateral teeth (75 migrated versus 75 Orthodontic therapy in periodontal

non-migrated teeth) in 44 patients with
advanced periodontitis, Towfighi et al.7 found
migrated teeth to have a significantly greater
clinical attachment loss (4.79 ⫾ 0.28 mm) in
comparison to contralateral non-migrated teeth
(3.21 ⫾ 0.18 mm).
In case of advanced periodontitis, tooth
migration may occur since the disease creates an
inflammatory tension into the periodontal liga-
ment and the teeth move away from the defect,
thus if the defect is mesial, the tooth migrates
distally (Fig. 2). The pressure of inflammatory
tissue in periodontal pockets caused by an
increase in capillary filtration and interstitial
fluid pressure is theorized to cause tooth
displacement.11,13
The importance of PTM prevention is mag-
nified when the significant psychological effects
as well as the lengthy and costly treatments are
considered. It has been suggested that control of
periodontal disease probably offers the single
most effective method to prevent PTM.8 While
early tooth displacement leading to small
diastemata (r1 mm) was shown to be rever-
sible with periodontal therapy alone in one
study,10 spontaneous correction of tooth
migration in periodontal patients was consi-
dered unpredictable in another report.9
patients: Treatment sequence
The question whether orthodontic treatment is
detrimental for periodontal tissues in patients
with periodontitis has been a widely debated
topic over the years. Epidemiologic studies sug-
gest that the worldwide prevalence of gingival
inflammation is high and advanced periodontal
disease affects a percentage of the population up
to 30%.14–16 The following presents a summary of
relevant articles investigating the influence of
orthodontic forces on the periodontium in the
presence of health and disease.
According to Ericsson et al.,17 active orthodontic
therapy did not cause any significant lesions to
periodontal tissues when proper periodontal
health and dental plaque control were main-
tained. On the contrary, when dental plaque
control was less effective in the presence of
established periodontal inflammation during
orthodontic treatment, there was an increased
risk for periodontal breakdown.18 Experimental
studies involving histological analysis have revealed
that orthodontic forces per se are unlikely to
convert gingivitis into a destructive periodontitis.19
This may be related to the fact that, in a case of
gingivitis, the plaque-induced inflammatory lesion
is confined to the supra-alveolar connective tissue,
while the tissue reactions occurring as a result of

Figure 2. A 72-year-old male patient with localized severe chronic periodontitis: (A) extrusion of the maxillary
right central incisor, with opening of the diastema, apical shift of the free gingival margin at the facial aspect, and
loss of the interdental papilla; (B) a deep infrabony defect on the mesial side of the central incisor is evident on the
periapical radiograph; and (C) intrasurgical image shows the anatomy of the infrabony defect. Severe bone loss is
evident on the mesial and facial aspects of the root surface. The inflammation of the periodontal tissues on the
mesial-apical side of the tooth is thought to contribute to the pathological tooth movement in a coronal and distal
direction.
180 Cardaropoli et al

orthodontic tooth movement are confined to the
connective tissue located between the root and the
surrounding alveolar bone. Orthodontic move-
ment creates clinical, cellular, and molecular level
changes in the alveolar bone. Orthodontically
generated dental movement is strictly related to a
physiological process of cellular activity in both the
connective and alveolar bone compartments.20
Experimental studies have demonstrated an aggra-
vating effect on the progression of periodontal
disease when trauma, caused by jiggling forces, was
superimposed on periodontal lesions associated
with angular bony defects.18,21 This may indicate
an increased risk for progression of plaque-
associated periodontal disease when orthodontic
movement is applied to teeth with angular bony
defects in the lack of proper periodontal treat-
ment.18,21 The combination of inflammation with
occlusal trauma or tooth movement will likely
produce a more rapid destruction of the perio-
dontal apparatus.20
As a consequence to periodontal bone loss,
the center of resistance is apically displaced on
the involved teeth, which complicates the bodily
movement mechanics. The subsequent effect is
that involved teeth become more prone to tip-
ping.22,23 Besides these mechanical difficulties,
the formation of a hyalinized zone adjacent to a
periodontally compromised tooth can be dele-
terious since regeneration of the periodontal
ligament does not occur when inflammation is
present, resulting in greater amount of bone loss.
An experiment carried out in dogs clearly
demonstrated that intrusive orthodontic forces
are prone to shift supra-gingival plaque into a
sub-gingival position and thereby result in the
formation of an infrabony pocket.17 However,
provided that gingival health is achieved and
maintained with periodontal therapy, intrusion
of teeth with well-calibrated and low-magnitude
orthodontic forces can be considered. In fact, it
has been shown that intrusion of teeth with
periodontal bone loss was possible without fur-
ther bone loss, and it conversely led to a certain
gain in connective tissue attachment in the
presence of adequate plaque control.24,25 Thus,
in case of advanced periodontal involvement,
teeth should only be moved after periodontal
therapy has been performed and infection has
been controlled.26,27
As a proper sequence of treatment plan,
periodontal therapy should always precede
orthodontic movement. A convenient decision
tree regarding the management of patients with
periodontitis seeking orthodontic treatment
typically includes three phases of treatment.
Following diagnosis of periodontal disease, the
first therapeutic phase should involve an ade-
quate cause-related therapy including oral
hygiene instructions, scaling and root planing,
and improving the patient’s compliance and
motivation. In the second phase, re-evaluation of
the cause-related therapy is performed, and only
in case of positive outcomes (i.e., reduction of
probing pocket depths, bleeding on probing, and
plaque index), surgical therapy should be per-
formed for pocket reduction or correction of
bone defects, if needed. The third phase involves
active orthodontic therapy after control of
periodontal inflammation.

Figure 3. A 33-year-old male patient with aggressive generalized periodontitis. (A) Pathological tooth migration
and diastema formation caused an esthetic concern that motivated the patient to seek treatment. (B) Intraoral
frontal image at baseline showing inflammation of the marginal periodontal tissues, with anterior deep bite, right
posterior cross bite, flaring of the maxillary right central incisor, and diastema between the right central and lateral
incisors. (C) Panoramic radiograph at baseline showing mild to moderate horizontal reduction of the marginal
bone level, partial or complete impaction of the left canines, maxillary left second molar, and all four third molars.
(D) Clinical image at the re-evaluation of the cause-related periodontal therapy including scaling and root planing
and oral hygiene instructions. Reduction in inflammatory signs and good patient compliance were noted. (E)
Orthodontic therapy started after improvement of periodontal status and control of inflammation. Both
segmented arch technique and straight-wire technique were used on both arches. The maxillary right central
incisor was repositioned using negative torque mechanics, the deep bite was reduced, the mandibular anterior
teeth were intruded, the posterior cross bite was corrected, and the impacted left canines were repositioned. (F)
Final intraoral frontal view: good esthetic and functional results maintained at 1 year after debonding. Final teeth
position was maintained with the delivery of Maryland splints from canine to canine in both arches to avoid relapse.
(G) Clinical presentation at 6-year follow-up: stability of the periodontal status and tooth positions were noted. The
patient demonstrated good compliance with regular supportive periodontal care every 4 months. (H) Panoramic
radiograph at 7 years post-treatment. Maintenance of the marginal bone levels with no additional bone loss and
absence of infrabony defects. A good remineralization of the cortical bone at the alveolar crest level can also be
observed. The maxillary third molars and left second molar were extracted.
 Orthodontic movement and periodontal bone defects 181

This treatment sequence has demonstrated
validity and efficacy in 267 adult periodontal
patients treated and maintained up to 12 years.27
All patients were affected by severe periodontal
disease with pathological migration of anterior
teeth. According to their baseline probing
depth measurements, 129 patients were as-
signed to have surgical periodontal treatment
whereas 128 patients received nonsurgical
treatment. Fixed appliances were inserted with-
in 1 week after completion of the periodontal
procedures in both groups. Mean orthodontic
182 Cardaropoli et al
treatment time was 10 ⫾ 3.04 months. To
evaluate the effectiveness of the proposed
combined orthodontic–periodontal treatment,
all migrated and orthodontically realigned
teeth were analyzed. For each patient, the
mean value of probing depth and the rate of
positive bleeding on probing of the teeth
involved in the orthodontic movement were
registered at the start of the periodontal
treatment, at the end of the orthodontic
treatment, and at the follow-up evaluation. The
authors reported that all patients maintained
their natural dentition (only two teeth were
extracted during the treatment period because of
their periodontal status), finishing with proper
occlusal relationships, good masticatory function,
and improved esthetics. It was concluded that in
reduced but healthy periodontal tissue support,
orthodontic forces and tooth movement within
biological limits do not cause periodontal
breakdown. The combination of a proper
orthodontic and periodontal treatment has been
shown to improve reduced periodontal con-
ditions. Both surgical and nonsurgical proce-
dures can be effective in the treatment of
periodontal disease in association with ortho-
dontics (Fig. 3).
Orthodontic movement into infrabony
defects: Biological basis
The presence of an infrabony defect increases
the risk for tooth loss,4 and therefore, requires
immediate periodontal therapy. It has been
shown that periodontal conservative surgery
(i.e., open flap debridement) usually leads to
minimal or no bone fill and the formation of a
long junctional epithelium in the treatment of
infrabony defects.28 A slight gain of clinical
attachment level may also be expected. On the
contrary, the application of guided tissue
regeneration (GTR) procedures to treat infra-
bony defects has a significantly higher potential
to heal via the formation of new cementum, new
periodontal ligament, and new alveolar bone,
with a considerable gain of clinical attachment
level.29
Whether orthodontic therapy is able to pos-
itively influence the healing of infrabony defects
is still a matter of debate. Common orthodontic
movements have been reported as adjunctive
therapy in the interdisciplinary management of
infrabony defects and they include extrusion,
bodily movement and tipping into the defect,
and intrusion.
Extrusive movements seem to improve osseous
defects if the alveolar bone follows the tooth in its
displacement.30 However, endodontic and pros-
thetic considerations have to be taken in account
as the extruded tooth has to be progressively
shortened to maintain proper dimensions and
relationship with the opposing dentition.
Alternatively, extrusion can be performed as
means of implant site preparation where the
extruded tooth is orthodontically extracted while
bone tissue is being progressively deposited
apical to it.31 Bodily tooth movement into
infrabony defects has the potential to reestab-
lish a healthy and well-functioning dentition with
favorable psychological and esthetic results.32
However, if orthodontic movement into infra-
bony defects is performed within an inflamed
periodontium, further periodontal breakdown
will occur as shown by Wennstrom et al.33 After
surgically creating angular bony defects in beagle
dogs, plaque was allowed to accumulate and
teeth were moved into and through these
infrabony defects. As a result, additional loss of
connective tissue attachment with undermining
resorption was noticed after 6 months of follow-
up.33 In a rhesus monkey model, Polson et al.34
artificially created localized infrabony defects
around isolated incisors, root planed the
involved root surfaces, and orthodontically
moved the experimental teeth into and
through the infrabony defects. This resulted in
a resolution of the angular defect, the formation
of a long junctional epithelium on the root
surface, and unchanged levels of connective
tissue attachment.34 It is noteworthy that other
studies could not confirm the same results.
Histologic evidence of new attachment forma-
tion was reported by Geraci et al.35 following
proper periodontal therapy and adjunctive
bodily movement of teeth into infrabony
defects in a monkey model. In addition,
orthodontic tipping movement has been shown
to achieve bone fill in surgically created
infrabony defects in rats and theorized to
guide the direction (corono-apical versus apico-
coronal) of bone repair within the defects.36
Intrusion is yet another orthodontic
approach, specifically advantageous in the
treatment of pathological tooth migration.
 Orthodontic movement and periodontal bone defects
Intrusion has been shown to affect the perio-
dontal status of the involved tooth on a cellular
level by decreasing the thickness of the perio-
dontal ligament, increasing the cellular density,
increasing the number of mitosis and peri-
radicular cells, and stimulating the formation of
cellular cementum.37–39 Multiple animal and
human studies were performed to investigate the
effects of intrusion on periodontal infrabony
defects.24,40,41 Following experimental perio-
dontitis, periodontal treatment, and orthodontic
intrusion, histological evidence of new attach-
ment formation was demonstrated in monkeys,40
and clinical reduction in probing depth and gain
in attachment levels were achieved in dogs.41 The
first human study regarding orthodontic intru-
sion in adult periodontal patients was carried out
by Melsen et al.24 They reported clinical
attachment level gain and clinical crown length
decrease after performing periodontal surgeries
(modified Widman flaps) and intrusion of
maxillary incisors in 30 patients. Cardaropoli
et al.25 evaluated 10 adult patients affected by
chronic periodontitis, presenting with pathologic
tooth migration of a maxillary central incisor with
an infrabony defect on the mesial side. Following
periodontal conservative surgery, affected teeth
were orthodontically intruded and followed for 1
year. Significant probing pocket depth reduction
(mean of 4.35 mm), decrease of the clinical
crown length (mean of 1.05 mm), and radio-
graphic bone fill were observed. Two years later,
a mean clinical attachment level gain of 5.5 mm
was reported on the same patient population.42
The above studies demonstrate the efficacy of a
combined periodontal–orthodontic approach in
the treatment of pathologically extruded teeth
with periodontal disease and infrabony defects.
Early orthodontic movement after
periodontal therapy
In the absence of tooth movement, it has been
accepted that complete histological healing of
the periodontal wound could be observed at 3–6
months following conservative surgical therapy,28
and at 12 months following regenerative surgical
therapy.29 However, biology seems to prove that
orthodontic treatment may have positive effects
on the periodontal wound healing in the absence
of inflammation, as previously described.
183
In an experimental study on monkeys studying
the biologic aspects of vertical movement of
teeth, orthodontic movement began 1 week after
periodontal surgery.43 In another study,
experimental periodontitis with horizontal
bone loss was created in mongrel dogs, and
orthodontic movement was initiated 8 weeks
after a periodontal flap operation.41 In both
cases, no detrimental effect of early orthodontic
movement on the periodontium was reported,
while new attachment was found to occur.
The potential benefits of orthodontic move-
ment beginning shortly after periodontal therapy
have been highlighted by Nemcovsky et al.44,45 In
experimental studies on Wistar rats, bony defects
were surgically created and orthodontic move-
ment started just 1 week after the surgery. The
authors evaluated the effect on probing depth,
bone healing, and the level of the junctional
epithelium. Conclusions were that orthodontic
tooth movement had favorable effects on
restraining epithelial apical down-growth and
decreasing pocket depth, whereas bony defects
showed enhanced bone healing.44,45
Based on the above reported results, it can be
suggested that orthodontic movement, if started
shortly after periodontal surgery or before the
complete healing of the periodontal wound, has
no negative effects on the periodontium. During
an adjunctive orthodontic treatment, the mag-
nitude of orthodontic forces is controlled and
limited in time.20 The beneficial effects of
orthodontic forces at the periodontal ligament
level37–39 may explain the inhibition of epithelial
down-growth and the favorable effects on the
new attachment formation.35,40
A number of human studies reported clinical
protocols where orthodontic therapy was ini-
tiated 7–10 days after periodontal therapy and
demonstrated successful outcomes.25,46,47 In 28
adult patients with chronic periodontitis and
angular bony defects, Re et al.46 started ortho-
dontic treatment after 7–10 days from open flap
debridement on pathologically migrated maxil-
lary central incisors. A mean gingival recession
decrease of 0.79 mm was reported irrespective of
soft tissue biotype (thin or thick) at the end of
treatment and remained stable at the 1-year
evaluation visits. In the same patient population,
Cardaropoli et al.47 evaluated the effect of this
combined interdisciplinary therapy on perio-
dontal health and interdental papillary level.
184 Cardaropoli et al

At the 1-year evaluation, the authors reported
2.64 mm of mean probing depth reduction and
3.54 mm of mean clinical attachment gain. Mean
papilla presence index (according to Nordland
and Tarnow48) improved from a value of 1.57
(baseline) to 0.68 (1-year), whereas complete
interdental papilla fill was noted in 10 inter-
proximal sites. On average, interdental papillae
were repositioned coronally to the interproximal
levels of the cemento–enamel junctions of
migrated teeth at the end of this combination
therapy, regardless of soft tissue biotype.47 These
findings have a great clinical impact in the
treatment of patients with esthetic discrepan-
cies in association with their periodontal disease
and anterior tooth displacement (Fig. 4).
Orthodontic movement and periodontal
regenerative procedures
Treatment of periodontal deep angular defects
on pathologically migrated teeth often requires a
combination of a periodontal regenerative pro-
cedure and orthodontic therapy. Periodontal
regeneration aims to reconstruct tissues dam-
aged by periodontal disease, namely the alveolar
bone, cementum, and periodontal ligament to
their original levels.
The outcomes of orthodontic movement into
infrabony pockets filled with bone grafts have
been investigated. Hossain et al.49 moved the
maxillary incisors of dogs into native bone or
surgically created bone defects and augmented
with autogenous bone grafts or beta-tricalcium
phosphate. They showed similar adaptive changes
of the grafted defects to native bone when
subjected to orthodontic tooth movement.49
Diedrich et al.50 performed GTR in combi-
nation with enamel matrix derivative in three-
wall angular bony defects, created at the first and
second premolars of four foxhounds. One month
after surgery, premolars were moved into the
defects with orthodontic intrusion. At the end of
experiment, extensive periodontal regeneration
was noted histologically at the tension side of
intruded teeth, as evidenced by 70–80% of new
cementum and bone formation.50
Bone grafts have also been shown not to impede
tooth movement in other studies. Araújo et al.51
investigated orthodontic tooth movement in
extraction sockets grafted with bovine bone
mineral graft in five beagle dogs. Not only tooth
movement was possible in all cases but also the
rates of bone graft degradation and bone turnover
were accelerated due to orthodontic stimulation.
In contrast, grafted sockets displayed minimal bone
turnover and maintenance of graft content where
there was no orthodontic tooth movement.51
These positive outcomes reported by animal
studies were confirmed by a human clinical re-
entry report,52 where maxillary incisors were
orthodontically moved into infrabony defects
filled with bovine bone mineral. Surgical re-
entry was performed 12 months after ortho-
dontic movement and revealed complete fill of
the bony defect with bone-like hard tissue, in
addition to a clinical reduction in probing depth
and gingival recession (Fig. 5). Furthermore, the
combination of orthodontics with periodontal
regenerative surgery has been shown to
enhance esthetics and function in the treatment
of extruded maxillary incisors with deep infrabony

Figure 4. A 63-year-old patient with pathologic tooth migration of the upper left central incisor: (A) extrusion of
the maxillary left central incisor along with gingival recession, diastema formation, and loss of interdental papilla
due to periodontal disease; (B) active orthodontic therapy started shortly after periodontal therapy and aimed to
realign the tooth, with a combination of intrusive and mesial movement; and (C) after 1 year of interdisciplinary
treatment, a significant reduction of the gingival recession and reconstruction of the interdental papilla were
achieved. Overall improvement of esthetics was noted.
 Orthodontic movement and periodontal bone defects 185

Figure 5. A 58-year-old female patient with chronic periodontitis: (A) pathologic tooth migration of the maxillary
central incisors; (B) periapical radiograph presents a deep infrabony defect on the mesial aspect of the right
central incisor; (C) intrasurgical view of the deep narrow defect on the mesial aspect of the right central incisor;
(D) occlusal view of the periodontal defect after debridement and root planning; (E) the defect was filled with a
mixture of bovine bone mineral with 10% collagen biomaterial; (F) 2 weeks after periodontal surgery, orthodontic
therapy was initiated; (G) final evaluation at the end of orthodontic treatment: tooth repositioning was achieved in
a healthy periodontium; and (H) final periapical radiograph shows the radiographic bone fill of the infrabony
defect.
186 Cardaropoli et al
defects and diastemata.53,54 In this case, bovine
bone mineral was the grafting material and the
orthodontic movement started 2 weeks after the
periodontal surgery. This combined approach
resulted in a complete interdental papillary fill,
probing depth reduction, radiographic bone fill,
realignment of teeth, and improved esthetics. The
authors attribute these positive outcomes to the
role of orthodontic movement as an adjunct to the
periodontal therapy. They hypothesize that tooth
realignment in the early phase of wound healing
achieves an anatomical environment that is more
favorable for hard and soft tissue healing. Closure
of diastemata and intrusion of teeth can reposi-
tion the interproximal contact points closer to the
alveolar bone crest and lead to a significant
interdental papillary fill. In addition, orthodontic
intrusion shortens the clinical crown of the tooth,
thus enhances its emergence profile and allows
the soft tissues to better adapt at the gingival
margin level and in the embrasure space, leading
to optimized esthetics.
Conclusions
Orthodontic treatment is a reliable therapeutic
protocol in case of pathologic tooth migration in
periodontal patients. Active orthodontic therapy
must always be preceded by a proper periodontal
initial therapy. In such conditions long-term sta-
bility of the periodontal health can be achieved,
with reduction of probing depth and bleeding on
probing. Orthodontic movement starting shortly
after periodontal surgical therapy seems to
enhance the wound healing and achieve esthetics
in terms of gingival recession reduction and
interdental papilla reconstruction. The combi-
nation of periodontal regenerative procedures
and orthodontic movement probably represents
the gold standard for the treatment of infrabony
defects adjacent to pathologically migrated teeth.
The presence of regenerative materials in
infrabony defects does not seem to impede
orthodontic tooth movement, nor does the latter
have any detrimental effects on the regenerative
procedure, in the absence of inflammation.
Acknowledgments
Authors wish to thanks Dr. Stefania Re for the ortho-
dontic treatment of the clinical case described in Fig. 3.
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