Spontaneous correction of pathologically migrated teeth with periodontal therapy alone.

Pathological tooth migration is a characteristic sign of an advanced form of chronic periodontitis. The etiology of pathological tooth migration is complex and multifactorial. Usually treatment of pathological migration includes a multidisciplinary approach. However, in some cases, spontaneous repositioning of the pathologically migrated teeth has been reported following periodontal therapy alone. In the present report, following periodontal surgery, there was a spontaneous repositioning of the migrated teeth and restoration of dento-facial esthetics. The treatment options in cases of pathological tooth migration, based on the severity, are also discussed.

INTRODUCTION

Chronic periodontitis results in inflammation within the supporting tissues of the teeth, progressive attachment loss, periodontal pocket formation, bone loss, mobility, and may be associated with pathological tooth migration (PTM).[1] Periodontitis can be an extremely disfiguring disease when associated with the pathological migration of anterior teeth.[2] PTM refers to tooth displacement that results when the balance among the factors that maintain physiological tooth position is disturbed by periodontal disease. PTM may be manifested in the form of diastema formation, facial flaring, rotation, extrusion, tipping into the edentulous spaces, and a combination of the above. Its prevalence ranges from 30.03 to 55.8%.[2] Although there is an awareness of pathological migration, there is little information available concerning this widespread complication, and thus, there has been little advancement in the diagnosis, prevention, and treatment of the problem.

The etiology of PTM is complex and multifactorial. Several etiological factors have been suggested for PTM, which include periodontal attachment loss, pressure from the inflamed tissue, occlusal factors like trauma from occlusion, habits (like bruxism, mouth breathing, tongue thrusting, lip habits, sucking habits, pipe smoking, and playing of wind instruments), abnormal labial frenum, non-replacement of missing teeth, gingival overgrowth, and iatrogenic factors.[13] However, no scientific data has been collected to validate these etiological factors or determine their relative importance. Treatment of PTM is mainly focused upon the etiological factors and the severity of involvement. In some cases, the treatment may be complicated and time consuming. However, the commonly used procedures to treat PTM involve the multidisciplinary approach, which includes periodontal (non-surgical/surgical) therapy, orthodontic therapy, and restorative therapy.[4] There are few case reports in the dental literature showing spontaneous repositioning of the migrated teeth after the periodontal therapy, without the institution of any orthodontic or restorative therapy.[3] In the present report such a case of PTM has been described, which was treated successfully by periodontal therapy alone, to achieve self-correction.

CASE REPORT

A 27-year-old female patient reported with the chief complaint of increasing spacing between her upper front teeth since the last nine months. There was no history of previous dental treatment. Her family and medical history were noncontributory. The patient provided a history that there was no spacing between the maxillary central incisors two years back. A gradual increase in spacing was noticed between the maxillary central incisors over the last nine months. On intraoral examination, other than a poor oral hygiene status, a 9 mm deep periodontal pocket was noticed between the maxillary central incisors. Both the teeth were showing Miller's Grade I mobility. There was high labial frenum attachment and a 2 mm diastema was present between the two central incisors [Figure 1]. Functional occlusal evaluation was done, which revealed an increased overbite that could be traumatic to the opposing maxillary teeth. An intraoral periapical radiograph revealed horizontal bone loss in between #11 and #21 [Figure 2].

Figure 1

Clinical image showing 2 mm wide diastema between teeth #11 and #21

Figure 2

Preoperative intraoral periapical radiograph of horizontal bone loss in between teeth #11 and #21

After the completion of Phase-1 therapy, the patient was re-evaluated, during which the pocket depth was reduced to 7 mm. There was no gingival recession around the involved teeth. Occlusal equilibration was done to relieve the occlusal interference in the maxillary and mandibular anterior teeth. Periodontal flap surgery, along with excision of the high frenum attachment was planned, explained to the patient, and informed consent was obtained from the patient. Under local anesthesia, frenectomy was performed and a full-thickness mucoperiosteal (papilla preservation) flap was reflected [Figure 3]. Thorough degranulation was followed by root planing and saline irrigation. Black silk was used for suturing and simple interrupted sutures were placed [Figure 4]. Periodontal dressing was also done. The patient was discharged after giving postoperative instructions and prescribing antibiotics and analgesics/anti-inflammatory drugs. After one week, the periodontal dressing and sutures were removed and the area was thoroughly irrigated with saline. Three months postoperatively, there was complete closure of the diastema [Figure 5] and both the teeth showed no signs of clinical mobility. Intraoral periapical radiographs showed bone gain between the two maxillary central incisors [Figure 6]. At three months, the periodontal probing depth was 3 mm and a gingival recession of 2 mm was noticed around both the maxillary central incisors. The patient was explained the importance of maintenance therapy and also the chances of a relapse of pathological migration in case of recurrence of periodontal disease. The patient was provided the option of a retainer to maintain the tooth in position, which the patient declined. The patient is being followed with no signs of recurrence of pathological migration.

Figure 3

Clinical image after mucoperiosteal flap elevation and debridement

Figure 4

Clinical image after placement of sutures

Figure 5

Clinical image showing closure of diastema after three months following periodontal therapy

Figure 6

Postoperative intraoral periapical radiograph showing bone gain between the maxillary central incisors and closure of the diastema

DISCUSSION

Pathological tooth migration is one of the most undesirable esthetic complications of chronic periodontitis. It is more common in the anterior region and so creates a major esthetic concern and psychosomatic problems to the patient. Some patients may even develop an inferiority complex and be reluctant to go to their work places or attend any social gatherings. PTM alone may motivate the patient to visit the dentist and seek treatment for this dento-facial esthetic problem.

Although the etiology of PTM is multifactorial (Table 1 lists out the most common causes of pathological tooth migration), microbial plaque-induced periodontal infection is considered to be the most common causative factor. Kim et al.,in 2012, observed that no single factor is associated with PTM, but the primary factor is periodontal bone loss.[4] Similarly, Rohatgi et al., conducted a study on the etiology of pathological tooth migration and concluded that a direct relationship exists between pathological tooth migration and clinical attachment loss as well as gingival inflammation.[5] On the other hand, Oh SL, in 2011, suggested that the transseptal fibers that hold the adjacent teeth may play a very important role in pathological migration.[6] In fact, these fibers form a chain from tooth to tooth and are considered to be helpful in maintaining contact between the teeth throughout the arch. In case, the continuity of this chain is broken or weakened due to periodontal infection alone or in combination with the occlusal factors, the balance of forces is upset and displacement (pathological migration) of teeth may occur.

Table 1

Causes for pathological migration of teeth[3]

The treatment of pathological tooth migration is usually planned and executed through a multidisciplinary approach involving the periodontal, orthodontic and restorative treatments. (Table 2 enumerates the signs and symptoms of various types of pathological tooth migration and their corresponding treatment). Treatment planning for pathologically migrated teeth is important and is based on the severity of the pathological migration. Mild cases of pathological migration can be successfully treated with periodontal therapy alone, while moderate cases require a combination of periodontal and minor orthodontic treatment. Teeth with a severe variety of PTM usually cannot be saved and are best replaced with prosthodontic therapy. Few cases have been reported in dental literature, wherein there has been spontaneous repositioning of the migrated teeth after periodontal (nonsurgical/surgical) therapy alone.[3] Kumar et al., have reported cases of spontaneous correction of PTM following routine nonsurgical periodontal therapy without orthodontic treatment.[7] Later, a new terminology, ‘reactive positioning,’ was used in periodontal literature to describe this phenomenon, and it claimed that diastema closure could be possible with periodontal therapy alone, without providing any orthodontic treatment.[7]

Table 2

Treatment plan based on severity of pathological migration[4]

Hirschfeld believed that while treating PTM with periodontal therapy alone, it may result in resolution of inflammation and shrinkage of periodontal tissues.[7] Furthermore, there is contraction of the healing connective tissue resulting into the spontaneous repositioning of teeth and closure of the diastema. On the other hand, Seki et al., emphasized the role of the oral musculature of the lips, cheek, and tongue on the movement of the migrated teeth during normal function, after periodontal therapy alone.[8] However, no scientific evidence is present to validate this theory.[8]

Periodontal treatment along with orthodontic clear aligners has been successfully used in the treatment of pathological tooth migration.[9] A clear aligner is an effective appliance to move teeth, as it costs little in terms of expense and time. In addition, it wraps whole crowns, providing advantages to deal with crowding, spacing, and size of the arch. In short, a clear aligner may be a useful treatment option for a PTM patient, as it provides decreased probing depth, gingival recession, clinical attachment level, mobility, and esthetical restoration.[9]

In the present report, the patient was subjected to Phase-I (nonsurgical) therapy followed by surgical treatment. Along with the flap surgery, frenectomy was also performed, to eliminate the forces applied on the maxillary central incisors by the fibrous frenum. No orthodontic or restorative treatments were considered. Postoperative results showed spontaneous repositioning of the migrated central incisors and complete closure of the diastema. Also, there was reduction in the pocket depth, improved attachment level, and decreased mobility. Hence, the present report supports the view that there is spontaneous repositioning of the migrated teeth even if only periodontal therapy is instituted, in cases of pathological tooth migration of a mild variety.