Pathological Migration Of Anterior Teeth In Patients Choosing Orthodontic Treatment - A Retrospective Study

Keywords

Orthodontic Treatment; Pathological Migration; Esthetic; Periodontal Ligament; Periodontal Therapy.

Introduction

Pathological migration of anterior teeth is a functional and esthetic problem that may be associated with the destruction of supporting structures of the periodontal ligament [1]. It is defined as a change in the tooth position that occurs as a result of disruption of the maintenance of normal position of the tooth in their arch [2]. This disruption can be caused by various etiological factors such as gingivitis, occlusal factors, iatrogenic factors, oral habits like bruxism, tongue thrusting, mouth breathing, lip forces, loss of teeth without replacement, sucking habits, gingival enlargement etc. However destruction of the periodontal ligament fibres are the most relevant factor associated with pathological migration [3]. Forced orthodontic eruption of the tooth will result in sound tooth structure occlusal to the gingival margin and help preserve the junctional epithelium [4].

Although case reports have shown that repositioning of these teeth by appropriate orthodontic movement may restore the healthy and stable relationship improving the patient’s Dentofacial esthetics [5]. Orthodontic treatment should be initiated after periodontal disease is brought under control [6]. Anterior teeth are especially prone to elongation and displacement as they are not protected by occlusal forces and have no antero–posterior contacts to inhibit tooth migration. To ensure a good clinical outcome, excellent coordination care must be taken between orthodontic and periodontal discipline [7]. The point of force application lies apical to the center of resistance of the maxillary anterior teeth [8]. The force delivered from auxiliaries is commonly calibrated using Dontrix tension gauge and Correx gauge in clinical situations [9]. The cortical bone present in the mandible would receive larger stress while orthodontic forces were owing to the higher elastic modulus of the cortical bone compared with that of the spongy bone in the maxilla [10]. These interactions are mutually beneficial, allowing the diseased periodontium to be significantly improved and permitting tooth movement.

The fundamentals of orthodontic treatment is that teeth move through the alveolar bone when adequate forces are delivered [11]. Successful orthodontic management of a tooth depends on the degree of the tooth’s vertical position, and the maturity of the tooth apex [12]. Indian population has been largely divided into seven ethnic groups based on their anthropometric measurements, skin colour and language. The food, dietary habits and language differ and hence prevalence of malocclusion. Chennai, the capital of Tamil Nadu in India, is a cosmopolitan city [13]. If the patient is reasonably motivated and responds well to the initial periodontal therapy, adult orthodontic treatment has a role in providing complete rehabilitation in terms of both function and appearance, with a satisfactory long-term prognosis. Dental health education, enhanced oral hygiene instructions and regular periodontal care are essential during orthodontic treatment [14]. Diagnosis of the periodontal disease can be made by tactile sense using a Williams probe, radiographically interpreting the structure of alveolar bone, periodontal ligament space, level of bone loss etc, patients with systemic diseases also show signs of pathological migration. Previously our team has a rich experience in working on various research projects across multiple disciplines The [4, 15-28].

Thus the aim of the study is to evaluate the percentage of patients with pathological migration of anterior teeth choosing orthodontic treatment.

Materials And Methods

A single centre retrospective study was done in an institutional setting. The ethical approval was received from the institutional ethical committee. The study involved 86000 patients in which selected patients data who had periodontitis were taken. The necessary approvals in gaining the datas were obtained from the institutional ethical committee (SDC/SIHEC/2020/DIASDATA/ 0619-0320). The number of people involved in the study were a guide, a reviewer and a researcher.

Selection of Subjects

All patients who had periodontitis from the time period of june 2019 to april 2020 were selected for the study (N=7386). All available data were taken into consideration and there was no sorting process.

Data collection

The patients’ details were retrieved from the institution’s patient record management software. Data regarding patients age, gender, periodontal condition and Orthodontic treatment were taken into consideration for this study. Cross verification was done with the help of photographs and radiographs. The data was manually verified, tabulated and sorted.

Inclusion criteria

All patients with pathological migration in the anterior maxillary and mandibular region were taken into account.

Exclusion criteria

Patients' records that were incomplete were removed from the study. Repetitive entries were also removed. Patients who had systemic illness, Multiple loss of teeth were also excluded from the study.

Statistical analysis

The tabulation of data was analysed using SPSS software (IBM SPSS Statistics version 23.0) The method of statistical analysis that was used in this study was Chi square test to compare two proportions. The analysis was done for age, gender, periodontal condition and Orthodontic treatment in this study.

Results And Discussion

A study by Khorshidi et al on pathological tooth migration says that the mean age of subjects with tooth migration due to periodontal pathology was 37.7 years. It was observed from the study that among the 7386 patients who had maxillary and mandibular anterior spacing, only 84 patients had periodontitis with pathological migration. 13 patients(0.19%) belonged to the age group of 18-30 years, 55 patients(0.82%) belonged to 31-50 years age group and 16 patients(0.24%) belonged to the age group of 50-75 years. Statistical analysis showed that the results were significant (p<0.05) proving association between age and pathological migration (Figure 1).

Even though this study showed a male predominance with 51 male patients (0.76%) and 33 (0.49%) female patients, the results obtained were statistically insignificant(p>0.05) proving that there is no association between gender and pathological migration (Figure 2) and the same study by khorshidi said that males were more prevalent to pathological migration than females, still the results were not significant [29].

Among the 84 patients who had pathological migration of anterior teeth, 6 patients who belonged to age group 18-30 years, 13 patients in age group 30-50 years and 4 patients in age group 50- 75 years underwent orthodontic treatment. While the remaining 61 patients (72.62%) did not undergo orthodontic treatment. The association between the age groups that underwent Orthodontic treatment was statistically not significant(p>0.05) (Figure 3). A study by Cirelli et al, a case report of a 36 year old female with a chief complaint of spacing in anterior tooth region, with a diagnosis of generalised chronic periodontitis. Patient was advised for a multidisciplinary approach with a combination of periodontal therapy, orthodontic and restorative treatment which reduced the effects of periodontal destruction and restored the tooth to the normal position [30].

Another study done by panwar et al showed comparison of GI, PDI and DAI before and after completion of Orthodontic treatment showed statistically significant differences, indicating the relevance of combined Orthodontic–Periodontic treatment in periodontally compromised dentition (P < 0.01)[31]. It was also observed from the study that among the 84 patients who had pathological migration in anterior teeth region, 10 male patients (11.9%) and 13 female patients (15.48%) have undergone orthodontic treatment but the results are found to be statistically not significant(p>0.05) (Figure 4).

In this study 46 patients who had pathological migration could not be referred for Orthodontic treatment as the periodontal disease was moderate to severe. While 38 patients were advised Orthodontic treatment, 15 patients did not take it up. The reasons for this decision could be any of the following such as, low socio -economic status, anxiety about the effects of the treatment, long duration of the treatment or lack of interest. Some of the limitations of this study are that the study sample was predominantly south indian population and it is unicentered with an inadequate sample size.

Adjunctive orthodontic treatment of pathologic tooth migration has greater effects in subjects with periodontitis. Orthodontic treatment is no longer a contraindication in the therapy of severe adult periodontal disease or in the maintenance of a healthy periodontium after orthodontic treatment. Prevention of tooth migration can be made by eliminating the causative factors which are crucial for a successful orthodontic treatment and pathologically migrated teeth return to their normal position after the etiological factor is eliminated [32]. A patient judges the outcome of an orthodontic treatment by assessing the final improvement in facial esthetics [33]. Neglect of oral hygiene can lead to pathologic tooth migration which in severe cases may lead to loss of tooth which brings esthetic concerns to the patient and lowers their self esteem. Gaumet et al reported the outcomes of patients with anterior diastema due to periodontitis who underwent nonsurgical and surgical periodontal interventions and reported a complete closure of diastema in 51.5% of patients, while the remaining subjects exhibited various degrees of repositioning [34].

The results of the study can be used as a baseline data for future studies in improving the quality of patients life. The idea for this study stemmed from the current interest in our community. Clinicians should be able to diagnose pathologic tooth migration and address it to the patients. If minor pathologic tooth migration appears to be the result of periodontitis, thorough scaling and root planning should be done as a prophylactic treatment which may reverse it completely. If the migration fails to resolve, periodontal surgery as well as orthodontic and prosthetic measures should be advised to prevent the loss of tooth. Clinicians should stress the importance of regular maintenance of oral hygiene and regular dental checkup every 3 months, especially in patients with a history of periodontitis.Our institution is passionate about high quality evidence based research and has excelled in various fields [35-45].

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Figure 1:

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Figure 1. Bar graph represents the association between patients of different age groups and their periodontal status. X-axis represents the age groups and Y-axis represents the total number of patients. Blue colour represents patients with healthy periodontium and green represents patients with periodontitis. Majority of the patients did not have pathological migration but among those who had it, a higher prevalence was seen in the age group of 30-50 years compared to other age groups. (Chi square test, p-value: 0.032 (p<0.05), statistically significant.

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Figure 2:

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Figure 2. Bar graph represents the association between gender and the periodontal status. X-axis denotes gender and y axis denotes total number of patients. Blue colour represents patients with healthy periodontium and green represents patients with periodontitis. Majority of the patients did not have pathological migration but among those who had it, a higher prevalence was seen in males when compared to females. (Chi square test, p-value: 0.607 (p>0.05), statistically NOT significant.

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Figure 3:

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Figure 3. Bar graph represents the association between age groups and orthodontic treatment in patients with pathological migration of anteriors. X-axis denotes age groups and y axis denotes total number of patients. Among the 84 patients with pathological migration, the majority did not undergo orthodontic treatment(green). Whereas, 13 patients in the age group 30-50 years, 6 in the age group 18-30 years and 4 in the group 50-75 years have undergone orthodontic treatment(blue). (Chi square test, p-value: 0.254 (p>0.05), statistically NOT significant.

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Figure 4:

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Figure 4. Bar graph represents the association between gender distribution and orthodontic treatment in patients with pathological migration of anteriors. X-axis denotes gender and y axis denotes total number of patients. Majority of the patients did not undergo orthodontic treatment(green). Whereas among the 84 patients, 13 female patients have undergone orthodontic treatment(blue) compared to males. (Chi square test, p-value: 0.629 (p>0.05), statistically NOT significant.

Conclusion

Within the limits of this study pathological migration was more prevalent among the age group of 30-50 years in which males were more commonly affected. More than 50% of the patients affected with pathological migration could not undergo Orthodontic treatment due to the severity of the periodontal disease that included increased alveolar bone loss and increased mobility of teeth. Proper patient education on oral hygiene care should be able to eliminate the trivial excuses that patients cling on to avoid conservative Orthodontic treatment. It may help if the adverse effects of pathological migration are very clearly discussed with patients with periodontitis in its early stages to prevent the loss of teeth and preserve the periodontium.

Acknowledgement

The authors would like to thank Saveetha Dental College and Hospitals for providing the platform to conduct the study.