PATHOLOGIC TOOTH MIGRATION .pptx

PATHOLOGIC TOOTH MIGRATION

1. PATHOLOGIC TOOTH MIGRATION Presented by Dr . Swapna.E

2. CONTENTS Introduction Definition Etiopathogenesis Treatment Prevention Conclusion Reference

3. INTRODUCTION Chronic periodontitis is one of the myriad challenges faced by a professional in dental practice. Among the most notable clinical signs of advanced periodontitis is pathological tooth migration. The destruction of tooth supporting structures is the most relevant factor associated with pathologic migration

4. The position of teeth in the dental arch depends on the health and height of the periodontium and on the forces exerted upon the tooth, mainly occlusion and pressure of lips, cheeks and tongue. The alteration of any of these factors provokes a sequence of interrelated changes in the environment of a single tooth or of a group of teeth that results in pathological migration. Prevalence studies of PTM indicate that it is common in periodontal patients with a prevalence of 55.8%

5. 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. Pathologic migration refers to tooth displacement that result when the balance among the factors that maintain physiologic tooth position is disturbed by periodontal disease.( carranza ) DEFINITIONS AND TERMS

6. EXTRUSION. Pathologic migration in the occlusal or incisal direction is termed extrusion . DRIFTING Moving of teeth into the spaces created by un replaced missing teeth that often occurs is known as drifting. Drifting differs from pathologic migration in that it does not result from destruction of the periodontal tissues. However, it usually creates conditions that lead to periodontal disease, and thus the initial tooth movement is aggravated by loss of periodontal support. Drifting generally occurs in a mesial direction, combined with tilting or extrusion beyond the occlusal plane , but the premolars frequently drift distally

7. ETIOPATHOGENESIS Many factors influence tooth position and, therefore,there are many possible etiologic factors for PTM.

8. DESTRUCTION OF PERIODONTAL SUPPORTING TISSUES Selwyn -concluded that more bone loss was found in PTM compared to control group Martinez- canut et al concluded that PTM was statistically associated with bone loss, tooth loss, and gingival inflammation and has bone loss increased probability of PTM increased from 2.95 to 7.97 times Towfighi et al -concluded that mean attachment loss of PTM was greater than normal tooth

9. Primate studies indicate that a specific part of the periodontium, the transseptal fibers , may play an important role in PTM They form a chain from tooth to tooth and are thought to help maintain contacts between teeth throughout the arch. It has been suggested that if the continuity of this chain is broken or weakened by periodontal disease, the balance of forces is upset and displacement of the teeth can occur.

10. Fu et al. findings supported that PTM was seen in humans who take cyclosporin or other drugs causing gingival overgrowth. Gingival overgrowth Gingival overgrowth caused by severe inflammation or drugs such as phenytoin is known to cause PTM.

11. Posterior bite collapse Posterior bite collapse (PBC). This condition is a common cause of PTM. It is a pattern of unfavorable occlusal changes that occur most frequently after first molar teeth are lost and not replaced. Shifman et al. -although bite collapse is often found with anterior flaring, there are many other etiologic factors that can cause tooth migration in the absence of PBC. No prevalence studies of PBC in the general population were found.

12. Arch integrity Occlusal forces are distributed to teeth in the arch through interproximal contacts. If these contacts are destroyed, tooth migration can occur. Besides tooth loss, other factors that can destroy interproximal contacts include dental caries, faulty restorations, and severe attrition. Recently, tooth loss has been significantly correlated with PTM, supporting earlier observations that loss of arch integrity is an important factor in PTM.

13. Class II malocclusion. Selwyn’s study of 10 of 30 patients with PTM found that 17 of the 30 had an Angle Class II occlusion, while only 8 of 30 control patients had Angle Class II occlusions. This difference was statistically significant ( P <0.05). But more research is needed to substantiate this finding.

14. Occlusal interferences Disruptions, such as supraerupted teeth, have been described as one of the etiologic factors for PTM. Thielman reported consistent findings of elongation of anterior teeth diagonally opposite in the dental arch to occlusal interferences. He observed this clinical situation so often that he called this combination of signs Thielman’s Law Watkinson and Hathorn described interferences that deflect the mandible anteriorly into the maxillary incisors as important etiologic factors in PTM. Their observations revealed that these interferences may arise from restorative procedures, but also may be present in the unrestored natural dentition

15. Anterior component of force During occlusal function, it is believed that a portion of occlusal forces is projected anteriorly and has been termed the anterior component of force (ACF). ACF is thought to cause axial inclination of the posterior teeth during occlusal loading

16. Protrusive pattern of mastication Yaffe et al, using sagital tracings of mastication, studied a group of 27 patients with a protrusive pattern of function. The investigators suggest that this protrusive pattern of mastication should be considered an etiologic factor for anterior PTM

17. Bruxism Bruxism forces are known to damage the dental attachment apparatus. It also result in abnormal occlusal forces that are frequent and of long duration . Parafunctional habits have been reported as a prognostic factor associated with tooth loss, and so, in this way, may indirectly be a factor in PTM. In a review of the literature on the effects of bruxism, no mention was made of a connection between bruxism and tooth migration. Martinez et al . did not find any correlation of PTM and bruxism.

18. Shortened dental arches Witter et al. studied PTM in patients with shortened dental arches. A shortened dental arch (SDA) was defined as a dentition where most posterior teeth are missing, resulting in loss of molar support and function. Significantly more interdental spacing was found in the SDA group than the controls, especially in patients less than 40 years of age and in mandibular teeth.

19. Soft Tissue Pressure of the Tongue, Cheek, and Lips Orthodontic research has confirmed that soft tissue forces of the tongue, cheek, and lips can move teeth, especially after loss of periodontal support. Because of their long duration, these very light forces are thought to be more important than the relative short duration of occlusal contacts during speech, swallowing, and mastication Tongue and lip pressures vary greatly, but tongue pressures are usually several times greater than lip or cheek pressures. Proffit has stated that the forces of the tongue, cheek, and lips, together with the forces of the periodontal tissues, are the most important factors that determine tooth position

20. Extrusive Forces It is known that eruption forces are small, in the range of 2 to 10 grams and are present throughout life. As an erupting tooth emerges from the gingiva and moves towards occlusal contact, movement is rapid (in the order of 0.3 to 0.5 mm per week). In adulthood, the velocity of eruption is much slower. force is localized within the periodontal membrane. Eruption forces are thought to be generated either from contraction of collagen as it matures or traction from contractile fibroblasts. No information was found directly linking eruptive forces to PTM. However, since extrusion of incisors is a very common form of PTM, eruptive forces may play a very important role as a contributing factor in PTM. More research is indicated to clarify this role.

21. Habits Habits associated with PTM include lip and tongue habits, fingernail biting, thumb sucking, pipe smoking, bruxism, and playing wind instruments. Based on the clinical observations of this reviewer, these habits sometimes require a high level of suspicion to detect In considering oral habits as a contributing etiologic factor in PTM, it is important to remember that duration of force in tooth movement is more important than force magnitude.The greater the duration of the habit, the greater potential to move teeth. Extrinsic forces can cause tooth movement when their duration is 50% of the time, even though the magnitude may be very small. In the study by Martinez et al., several cases were identified in which PTM was clearly related to habits.

22. Unreplaced missing teeth. FAILURE TO REPLACE FIRST MOLARS. The pattern of changes that may follow failure to replace missing first molars is characteristic. In extreme cases it consists of the following: 1. The second and third molars tilt, resulting in a decrease in vertical dimension.fig 1 2. The premolars move distally, and the mandibular incisors tilt or drift lingually . While drifting distally, the mandibular premolars lose their Intercuspating relationship with the maxillary teeth and may tilt distally. 3. Anterior overbite is increased. The mandibular incisors strike the maxillary incisors near the gingiva or traumatize the gingiva. 4. The maxillary incisors are pushed labially and laterally (Fig. 2). 5. The anterior teeth extrude because the incisal apposition has largely disappeared. 6. Diastemata are created by the separation of the anterior teeth

23. Demetriou N, Tsami-Pandi A, Parashis A. Is it possible for periodontal patients to recognize periodontal disease? Stomatologia (Athens) 1991;47:284-295. TREATMENT Based on the severity of pathologic tooth migration

24. Recently Reactive positioning Re implantation Regenerative procedures which include guided tissue regeneration,bone grafts,prf have been tried in a pathologically migrated tooth with good results when it is combined along with orthodontic and restorative procedures….

25. Spontaneous correction of pathologic tooth migration: before treatment (upper panel) and after periodontal treatment (lower panel) . The case reports of spontaneous correction of PTM include patients with severe gingival overgrowth. When enlarged tissue is surgically removed, in some cases migrated teeth move back into a more normal position

26. Patients with severe periodontal disease and tooth migration, intrusion can produce very favorable clinical results as long as periodontal disease is controlled prior to orthodontic therapy. Periodontal disease control should include pocket elimination and control of inflammation. Since there is evidence that plaque can be apically displaced by orthodontic treatment. The intrusive forces used in these studies were light, ranging from 5 to 15 grams per tooth. Treatment time varied from 3 to 18 months.

27. Regeneration of bone with graft materials has also been successful in treating PTM. In addition, guided tissue regeneration therapy has been utilized in treating PTM. A case report by Saurabh Gupta et al concluded that Papilla preservation flap technique along with bone graft and PRF membrane placement was considered in PTM Dadlani , et al –showed good outcome of spontaneous repositioning of the migrated central incisors and complete closure of the diastema by only periodontal ,in cases of pathological tooth migration of a mild variety. Panchal, et al 2013- Orthodontic‑ periodontic intervention of pathological migration of maxillary anterior teeth in advanced periodontal disease Intentional reimplatation -

28. Mechanism of effect of periodontal therapy for PTM Following periodontal therapy there is a reduction in edema and inflammatory cell infiltration of the soft tissues, resulting in the reduction in erythema and shrinkage of soft tissues. With this, healthy collagen fibers replace the inflammatory cell infiltrate and may contribute in the reestablishment of a normal equilibrium of forces, leading to reactive movement of migrated tooth to its original position. During the healing process, wound contraction can also contribute to the repositioning of the tooth. It occurs during healing, as fibroblasts populate the newly formed granulation tissue. Gaumet et al. also supported the role of wound contraction in spontaneous repositioning

29. Agrawal and Siddani 2011 In the case report , after restoration of occlusion by removable partial denture, PBC as well as abnormal forces on anterior teeth were eliminated and also, after periodontal therapy, the tissue remodeling that takes place during healing might be able to regenerate normal biomechanical environment at the tooth periodontium interface. Thus, this newly re-established equilibrium of forces could be responsible for reactive movement of the tooth back into the previous alignment in the dental arch.

30. Adult male patient with advanced periodontitis and marked pathologic migration of the anterior teeth before (left column) and after (right column) periodontal and orthodontic fixed-appliance treatment for 2 years. Clinical appearance of the face and dentition are dramatically improved after the combined periodontic /orthodontic treatment. The dental result is maintained by means of bonded lingual retainer wires. A maxillary two-unit and a mandibular three-unit bridge were constructed. Some interdental recession was unavoidable in the mandibular anterior region (d), but it does not show much

31. PREVENTION Control of periodontal disease Treatment of occlusal factors and habits Early detection of PTM