Pathologic tooth migration (PTM) is a common complication of moderate-to-severe periodontitis.1,2 The prevalence of PTM among periodontal patients has been reported to range from 30.03% to 55.8%. It occurs most frequently in the anterior region, but posterior teeth can also be affected. There are many types of pathologic tooth migration: diastema, extrusion, rotation, facial flaring, and drifting into edentulous spaces. Some of the important factors are poor periodontal support as the result of periodontal disease and the eventual loss of teeth, which changes the forces exerted on the remaining dentition. Later, if the missing teeth are not replaced, especially the first molars, the maxillary incisors are forced labially and laterally, which leads to the extrusion of the anterior teeth and the resulting diastema. Teeth mobility increases, and the second and third molars tilt mesially, which results in a reduced vertical dimension. This can also lead to an anterior overbite, and the mandibular incisors occlude near or on the palatal gingival margin of the maxillary anterior dentition.
PTM is caused by several factors, and one or more teeth can be involved. The treatment of most cases may require a multidisciplinary approach. In addition to periodontal therapy, orthodontic tooth movement can be beneficial. Replacing missing teeth with implants can stabilize the occlusion and reduce the trauma on the anterior dentition
The following is a case that involves the multidisciplinary approach. A 56-year-old female patient was referred for periodontal treatment. The general dentist had diagnosed periodontal involvement with deep pocket formation and increased tooth mobility. He was willing to place a bridge to replace the missing teeth #29 and 30 and asked an assessment of the prognosis of tooth #31.
The patient visited the dentist once a year for routine recall therapy. The most recent oral prophylaxis was performed 10 days before the first periodontal visit. The oral hygiene regimen included toothbrushing with a manual toothbrush, once a day. The patient was not using any other hygiene instruments or mouthwashes. She had a negative history of previous periodontal or orthodontic treatment.
Her overall oral hygiene status was poor with abundant bacterial plaque present, especially around the distal and lingual surfaces. There were no visible supragingival calculus deposits because the patient had a dental appointment a few days earlier. However, subgingival calculus was present throughout. The patient did not present any pathologic lesions and was not aware of oral malodor.
There were symptoms of PTM in the anterior region (Supplement A Figure 51-1). Diastemas were present between the maxillary incisors, as well as the mandibular dentition. The patient confirmed that in the past the position of her anterior teeth was normal and that her teeth “were all touching.” The maxillary and mandibular incisors displayed extrusion, rotation, and facial flaring. There was a pronounced anterior overbite.
In the posterior region, several teeth had been missing for many years. The most prominent missing teeth were the mandibular first molars. Only teeth #5 and 13 were replaced. The patient was able to function bilaterally even though the first molars were missing.
To assess the extent of the periodontal disease, a full periodontal examination was accomplished. The examination included pocket probing and evaluation of gingival recession and tooth mobility. Supplement A Figure 51-2 indicates the extensive periodontal involvement of the maxillary arch. Periodontal pockets that involved the interdental and lingual areas ranged from 4 to 6 mm. The majority of the anterior teeth presented recession that measured 2 mm. Increased mobility was noted for most teeth, especially tooth #31. Most of the furcations were class I.