Pathologic tooth migration (PTM) refers to tooth displacement resulting from a disturbance in factors that maintain normal tooth position. PTM is common in periodontal patients, with prevalence studies finding rates of 30-55%. The primary factor in PTM is periodontal bone loss resulting from periodontal disease. Other factors include occlusal changes from tooth loss, soft tissue pressures, oral habits, and periapical or gingival inflammation. Treatment involves periodontal therapy, sometimes with adjunctive orthodontics or prosthodontics, while prevention focuses on periodontal disease control and management of predisposing occlusal and habit factors.

1. PATHOLOGIC TOOTH
MIGRATION
DR. SRUTHI K NAIR
PG STUDENT

2. CONTENTS
 DEFINITION
 PREVALENCE
 FACTORS INFLUENCING TOOTH POSITION
 TREATMENT
 PREVENTION
 CONCLUSION
 REFERENCES

3. DEFINITION
 Pathologic tooth migration (PTM) refers to tooth displacement
that results when the balance among the factors that maintain
physiologic tooth position is disturbed by periodontal disease.
 most frequently occurs in the anterior region, but posterior
teeth may also be affected
 in the occlusal or incisal direction is termed extrusion.

4. PREVALENCE
Prevalence studies of PTM indicate that it is common in periodontal
patients.
Martinez-canut et al. 1997
 Examined 852 patients who reported with developing diastema
 A PTM prevalence of 55.8% was found.
Towfighi et al. 1997
 343 patients with moderate to severe periodontitis were studied
before treatment.
 A diagnosis of PTM was made by asking the patients if they were
aware of anterior tooth migration in the last 5 years
 PTM prevalence was 30.03%

5. Demetriou et al. 1991
 gave questionnaires to 330 periodontal patients asking them
about symptoms that motivated them to seek treatment. Tooth
migration was listed by 36.96% of the patients.

6. DRIFTING
 Drifting of teeth into the spaces created by unreplaced missing
teeth often occurs.
 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.

7.  Drifting generally occurs in a mesial direction,
combined with tilting or extrusion beyond the
occlusal plane. The premolars frequently drift
distally.
 Although drifting is a common sequela when missing
teeth are not replaced, it does not always occur

8. Two major factors play a role in maintaining the
normal position of the teeth:
 the health and normal height of the periodontium
 the forces exerted on the teeth.

9. FACTORS INFLUENCING TOOTH POSITION

10. 1. DESTRUCTION OF PERIODONTAL SUPPORTING
TISSUES
 destruction of periodontal tissues plays a significant role in the
etiology of PTM.
Selwyn 1973
 studied bone loss in 30 patients with periodontal disease
complicated by migrated incisors 30 control patients with
periodontal disease whose incisors had not migrated. Statistically,
more bone loss was found in the migrated group compared to the
non-migrated group

11. Martinez-Canut et al.
 studied 852 private practice periodontal patients and found
that PTM was statistically associated with bone loss ,tooth
loss and gingival inflammation.
 As bone loss increased, the probability of PTM increased
from 2.95 to 7.97 times. The authors concluded that no single
factor is clearly associated with PTM, but the primary factor is
periodontal bone loss.

12. Towfighi etal.
 measured attachment loss on 75 pairs of migrated and non-
migrated contralateral teeth in 44 periodontal patients.
 The mean attachment loss of migrated teeth (4.79 ± 0.28 mm)
was significantly greater (P <0.001) than control non-migrated
teeth (3.21 ± 0.18 mm).
 The results confirm that periodontal disease destruction of the
attachment tissue plays a major role in the etiology of PTM.

13.  Primate studies indicate that a specific part of the
periodontium, the transseptal fibers, may play an especially
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. (Moss
J etal 1982)

14. FIG 3

15.  Gingival overgrowth caused by severe inflammation or drugs
such as phenytoin.
 Fu etal. 1997
showed that gingival overgrowth in rats, induced by gastric
feeding of cyclosporin, consistently caused tooth migration.

16. 2. OCCLUSAL FACTORS
Posterior bite collapse (PBC)
 Most common cause of PTM.
 Unfavourable occlusal changes that occur most frequently
after first molar teeth are lost and not replaced.
 Results in flaring of anterior teeth.

17. FAILURE TO REPLACE FIRST MOLAR
 The second and third molars tilt, resulting in a decrease in
vertical dimension.
 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.
 Anterior overbite is increased. The mandibular incisors strike
the maxillary incisors near the gingiva or traumatize the
gingiva.

18.  The maxillary incisors are pushed labially and laterally.
 The anterior teeth extrude because the incisal apposition has
largely disappeared.
 Diastema are created by the separation of the anterior teeth.

19. Arch integrity
 Loss of arch integrity Etiologic factor for PTM.
 Occlusal forces are distributed to teeth in the arch through
interproximal contacts. If these contacts are destroyed, tooth
migration can occur. (Stern etal 1975)
 Besides tooth loss other factors that can destroy interproximal
contacts include dental caries, faulty restorations, and severe
attrition.

20. Occlusal interferences.
 Disruptions, such as supraerupted teeth, have been described
as one of the etiologic factors for PTM.
Thielman 1971
 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.

21. Watkinson and Hathorn 1986
 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.

22. Protrusive pattern of mastication
Yaffe etal.1992
 studied a group of 27 patients with a protrusive pattern of
function. These patients had anterior attrition and 16 had
flaring of the incisors. The investigators suggest that this
protrusive pattern of mastication should be considered an
etiologic factor for anterior PTM.

23. Bruxism
 Bruxism forces are known to damage the dental attachment
apparatus. Also, it is known that bruxism can result in
abnormal occlusal forces that are frequent and of long
duration.
 bruxism in some patients can act as an unfavorable
orthodontic force to cause PTM. Bruxism as an etiologic
factor for PTM does not seem to be evidence based, however.
Parafunctional occlusal habits have been listed as a
contributing factor for PTM. (shifman etal. 1998)

24.  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.

25. 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.(Proffit
1978)
 Forces as light as 1.0 gram, produced by the facial
muscles when at rest, are sufficient to initiate
displacement of incisors.

26.  Tongue and lip pressures vary greatly, but tongue
pressures are usually several times greater than lip or
cheek pressures.
 forces of the tongue, cheek, and lips, together with
the forces of the periodontal tissues, are the most
important factors that determine tooth position.

27. Periodontal and Periapical Inflammation
 As early as 1933, Hirschfeld described pathologic drifting of
teeth resulting from pressure of inflammatory tissue in
periodontal pockets.
 Subsequent case reports and case series
mentioned this phenomenon and often described the tooth
movement in a direction opposite to the deepest part of the
pockets.

28. Sutton 1985
 proposed a theory that hydrodynamic and hydrostatic forces
within the blood vessels and inflamed tissues in the
periodontal pocket may account for abnormal tooth migration.
 animal research showing that inflamed gingiva displays an
increase in interstitial fluid pressure, due to an increase in
capillary filtration.(Del fabbro etal 2001)
 The extravasation of fluid into the interstitial tissue causes a
rise in interstitial hydraulic pressure. Vascular permeability
and blood flow of the gingiva are known to increase during
gingival inflammation.

29. 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
toward 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.

30.  From an animal study it appears that the major eruptive 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.
 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.

31. Habits
 Oral habits of patients may affect tooth position and have been
associated with pathologic tooth migration.
 Habits that have been associated with PTM include lip and
tongue habits, finger nail biting, thumb sucking, pipe smoking,
and playing wind instruments.
 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.

32. TREATMENT
 Treatment of severe PTM often involves orthodontic therapy
that is preceded by non-surgical and surgical periodontal
therapy and prosthodontic treatment. (Duncan 1997)
 When PTM is in initial stages and localized, the treatment
may be greatly simplified for the patient.

33. Correction of pathologic tooth migration
Extraction and
replacement of
migrated teeth when
migration is very
severe
Spontaneous
correction of the early
stages of PTM
following periodontal
therapy
Limited or adjunctive
orthodontic therapy
Conventional
orthodontic treatment.

34.  Many case reports describing reactive positioning or
spontaneous correction of pathologic migration following
periodontal treatment.
 These reports indicate migrated teeth sometimes move back
to their normal position following non-surgical perioontal
treatment alone or in some instances when combined with
surgical methods.

35. Gaumet et al.
 studied 16 patients with 33 diastema sites of anterior teeth that
had developed in the last 5 years. Study concluded that if a
recently formed diastema of anterior teeth associated with
periodontal disease is ≤1 mm in dimension, closure is
predictable after periodontal therapy.

36.  Spontaneous correction of PTM include patients with severe
gingival overgrowth.
 When enlarged tissue is removed surgically in some cases
migrated tooth move back into a more normal position.

37.  When PTM is in the early stages, periodontal therapy alone is
sometimes effective in producing spontaneous correction of
the migration. This correction has been reported after non-
surgical and surgical treatment.
 Light intrusive orthodontic forces are effective in treating
extrusion and flaring if inflammation is controlled during all
phases of treatment.
 Most patients with PTM have moderate to severe
periodontitis. Several studies describe successful orthodontic
treatment in these patients if inflammation is controlled.

38. PREVENTING PTM
 Control of periodontal disease- most effective method to
prevent
 Treatment of occlusal factors and habits.
 Early detection

39. CONCLUSION
 Severe PTM has significant psychological effects and
treatment is expensive and time consuming, the importance of
prevention appears great.
 Based on prevalence findings, PTM needs more attention in
dental research, especially regarding etiology, prevention, and
treatment.

40. REFERENCES
 Carranza’s Clinical Periodontology, 10th Edition.
 Clinical Periodontology and Implant Dentistry, Lindhe, 4th
Edition.
 Pathologic Tooth Migration .Michael A. Brunsvold. J
periodontol 2005

41. THANK YOU……