|Year : 2018 | Volume
| Issue : 2 | Page : 89-93
Determinants of pathological tooth migration
Leelarani Moka1, Ramanarayana Boyapati2, Shyam S Salavadhi2, Srikanth Chintalapani2, Kotya Naik Maloth3, Kirankumar Nagubandi2
1 Department of Periodontics, G S L College of Dental Sciences, Rajahmundry, Andhra Pradesh, India
2 Department of Periodontics, Mamata Dental College, Khammam, Telangana, India
3 Department of Oral Medicine and Radiology, Mamata Dental College, Khammam, Telangana, India
|Date of Web Publication||6-Jun-2018|
Dr. Ramanarayana Boyapati
Department of Periodontics, Mamata Dental College, Khammam, Telangana
Source of Support: None, Conflict of Interest: None
Objective: Pathological tooth migration (PTM) is an esthetic and functional problem that may be associated with multiple etiological factors. The purpose of this cross-sectional epidemiological study is to determine prevalence of PTM among periodontitis patients and investigate the association of various contributing factors such as tongue thrusting, missing posteriors, trauma from occlusion, class II malocclusion, and aberrant frenum.
Materials and Methods: A cross-sectional study was conducted with a total of 445 participants (age of 25–65 years) with chronic periodontitis.
Results: Comparison of categorical values was done using Chi-square test and continuous variables were done using independent-sample t-test. Statistically significant results were seen in patients with tongue thrusting (P < 0.002), missing posteriors (P < 0.032), trauma from occlusion (P < 0.007). The results are not statistically significant with abnormal frenum, class II malocclusion.
Conclusion: We conclude that tongue thrusting, missing posteriors, and trauma from occlusion are associated with PTM in periodontitis patients. Though class II malocclussion and aberrant frenum are seen in patients with pathological migration, significant association is not present.
Keywords: Diastema, facial flaring, pathological migration, periodontitis
|How to cite this article:|
Moka L, Boyapati R, Salavadhi SS, Chintalapani S, Maloth KN, Nagubandi K. Determinants of pathological tooth migration. J NTR Univ Health Sci 2018;7:89-93
|How to cite this URL:|
Moka L, Boyapati R, Salavadhi SS, Chintalapani S, Maloth KN, Nagubandi K. Determinants of pathological tooth migration. J NTR Univ Health Sci [serial online] 2018 [cited 2018 Jun 19];7:89-93. Available from: http://www.jdrntruhs.org/text.asp?2018/7/2/89/233846
| Introduction|| |
Chronic periodontitis results in inflammation within the supporting tissues of the teeth that causes attachment loss, periodontal pocket formation, bone loss, mobility, and may be associated with pathological tooth migration (PTM). PTM is defined as a “Change in tooth position that occurs when there is disruption of forces that maintain teeth in a normal relationship.” PTM is of more concern in dentofacial aesthetics as its impact is more in adults; it needs to be addressed by creating awareness towards early diagnosis instead of a challenge to treat psychological destruction and its effects.
Teeth position relies on two factors; health, normal height of the periodontium, and the forces exerted on the teeth. Imbalance among the factors that maintain physiological tooth position result in PTM. The prevalence of PTM among periodontitis patients is 30.03–55.8%. Equilibrium in tooth position may become disrupted by several factors such as periodontal attachment loss, pressure from inflamed tissue, occlusal factors, unreplaced missing posteriors, abnormal frenal attachment, and oral habits such as tongue thrusting, digit sucking, playing of wind instruments.
PTM is a sign caused by complex and multiple factors, and its treatment in advanced stage is complex, expensive, time consuming, and requires interdisciplinary approach. Importance of complete periodontal examination along with dental examination should be emphasized upon for timely detection and intervention. PTM associated with parafunctional habits, occlusal factors, and aberrant frenum requires correction of respective anomalies apart from periodontal treatment alone. Hence, a clinician should focus on thorough examination of oral cavity pertaining to correct diagnosis and eliminate the etiologic factors. The aim of this study is to determine the various factors contributing to PTM in patients with chronic periodontitis.
| Materials and Methods|| |
A cross-sectional study is conducted on chronic periodontitis patients during 2015–2016, with age group of 25–65 years. A total of 445 participants (249 females and 196 males) were selected among patients attending the department of periodontics. An informed consent form was obtained from the patient after thorough explanation of the study. The study was conducted after obtaining an institutional ethical committee clearance.
Patients with chronic periodontitis, systemically healthy, nonsmokers, have not undergone periodontal therapy previously, probing depth >3 mm, CAL >3 mm were included in the study. All participants were examined clinically for any manifestations of PTM, i.e., flaring, diastema, rotation, extrusion, and tipping of teeth. Possible contributing factors such as occlusal factors, parafunctional habits such as digit sucking lip sucking, tongue thrusting, placing coins between teeth, anatomic anomalies such as aberrant frenum, and absence of replacement of missing posteriors other than third molars were also assessed. Parafunctional habits contributing to PTM were assessed using a thorough questionnaire in the interview.
The questionnaire includes type of parafunctional habits and the duration of association with the habit. The tongue thrust was determined through lingual interposition, examination of swallow pattern, teeth indentations on tongue, and popping out of the tip of the tongue through the anterior spacing's while swallowing. Trauma from occlusion was determined through fremitus test “a palpable or visible movement of a tooth when subjected to occlusal forces.” The location of alveolar attachment of abnormal high frenum is observed by “blanching test.” Clinical parameters were assessed considering cementoenamel junction (CEJ) as the reference point. Pocket depth (PD) was measured from gingival margin (GM) to the base of the sulcus. Clinical attachment level was calculated from PD and gingival recession. Further, bone loss was evaluated using intraoral periapical radiographs obtained through paralleling angle technique. Bone loss was calculated from the CEJ to the alveolar bone crest. Clinical examination was done by a single operator to prevent bias.
| Results|| |
All the analysis was done using SPSS version 18.0 IBM SPSS (IBM Inc. Chicago). A P value of <0.05 was considered statistically significant. Comparison of categorical variables was done using Chi-square test and continuous variable was done using independent-sample t-test. This study included 445 participants (249 females and 196 males); their distribution and prevalence is presented in [Table 1] and [Chart 1]. They fall under the age group of 25–65 years, with a mean age of 48.93 years. Age distribution is displayed in [Table 2] and [Chart 2]. In the present study, the association of factors such as tongue thrusting, missing posteriors other than third molars, trauma from occlusion, class II malocclusion, and aberrant frenum with PTM in periodontitis patients was examined. Analysis of the contributing factors is presented in [Table 3] and depicted in [Chart 3].
|Table 1: Comparison and gender distribution with and without pathological tooth migration|
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|Table 2: Comparison of mean age in patients with and without pathological tooth migration|
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|Table 3: Prevalance and risk factors in patients with and without pathological tooth migration|
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Among 445 participants, the chronic association of tongue thrusting was seen in 54 participants with PTM which contributes to 23.11%; 48 participants had nonreplaced missing teeth comprising 20.51%. Trauma from occlusion is seen in 16.6% of the studied group, 8.5% of participants with class II malocclusion and aberrant frenum is seen in 3.8% of participants with PTM. Periodontitis patients with PTM with no other contributing factor were seen in 32.47% participants. PTM set out in different forms are presented in [Table 4].
| Discussion|| |
Successful treatment of PTM depends upon accurate diagnosis and early intervention. A differential diagnosis needs to be made regarding the etiology of the condition to propose a proper treatment plan. The clinician must identify different forces causing tooth movement to reposition tooth to their proper location. Kim et al. (2012) observed that, except periodontal bone loss, no other single factor was associated with PTM. Similarly, Rohatgi et al. (2011) concluded in his study that a direct relationship exists between PTM and clinical attachment loss as well as gingival inflammation. Oh in 2011 stated that adjacent teeth are held by the transeptal fibers that may play a very important role in PTM. In fact, these fibers form a chain from one tooth to another and are considered helpful in maintaining contact between teeth throughout arch. If the continuity of this chain is broken due to periodontal infection alone or in combination with the occlusal factors, imbalance in forces arise which may displace the teeth. The present study aims at targeting the contributing factors for PTM in patients with chronic periodontitis.
In the present study, smokers were excluded as smoking aggravates the loss of alveolar bone. Sutton (1985) proposed a theory affirming within the blood vessels and inflamed tissue in the periodontal pockets the hydrodynamic and hydrostatic forces may account for abnormal teeth migration. In the present study, the chronic association of occlusal factors, such as class II malocclusion, short dental arches, i.e., missing posteriors other than third molars, trauma from occlusion, oral habits such as tongue thrusting, digit sucking, and anatomic factors such as aberrant frenum were studied. Among the 234 periodontitis patients with PTM, tongue thrusting was seen in 23.11%, which is in accordance to previous studies by Profit (1978), who reported that forces from tongue, cheek, and lips together with the forces of the periodontal tissues are important factors that maintain tooth position. Emslie (1964) reporrted that the pressure from adjacent muscular organs – tongue, cheek, and lips – determine tooth position. Seki et al. (2010) emphasized the role of oral musculature of the lips, cheek, and tongue on the movement of the migrated teeth.
In the present study, the association of trauma from occlusion is approximately 13.2%, which is a statistically significant result. According to the literature review, TFO may cause a shift in tooth position either by itself or in combination with inflammatory periodontal disease  as a result of trauma to the maxillary anterior teeth from the mandibular antagonists; the maxillary anterior incline forwardly, resulting in an increased circumference of upper arch. Occlusal disharmony created by the altered tooth positions may traumatize the supporting tissues of the periodontium, reducing the periodontal support, and leading to further migration of teeth. Among the 234 participants, missing molars were seen in 17.5% of the patients with PTM, showing statistically significant association between the two. This is in accordance to Sarita Paulo et al. (2010), conducted a study, the results of which affirm that the extreme shortened dental arches had significant more interdental spacing's, occlusal contacts of incisors, and vertical overlap compared to complete dental arches. The occlusion and its effect on the periodontium have been reported in the literature as early as 1970s. Posterior bite collapse and occlusal interferences have been implicated as a common cause of PTM.
In the present study, the association of PTM with class II malocclusion is seen in 8.5% of the participants. This association is supported by studies of Craddock and Youngson (2004) and Fujita et al. (2010) who reported PTM as having association with factors such as occlusion. Selwyn (1973) conducted a study, stating that a class II skeletal pattern was more common in patients with migrated incisors. Absence of lip seal associated with angles class II division I and direct trauma to the gingiva by mandibular anterior in angles class II division II have been an aggravating factor in developing periodontal diseases, which potentiates tooth migration. However, the results obtained in the present study are not statistically significant in causing PTM.
Most researchers such as Angle et al. reported that high labial frenal attachment causes midline diastema. In this study, the association of aberrant frenum with PTM is seen in approximately 3.8% of the study sample. This is not a statistically significant result. Ceremello (1933) found no correlation between frenum attachment and diastema width, between frenum width and diastema, or between frenum height and frenum width. High frenal attachment and muscle pull have been considered deleterious to periodontal health as it pulls away the gingival margin, contributing to accumulation of plaque and calculus, leading to periodontitis. Hirschfield (1939) is a pioneer who called to attention the marginal attachment of the frenum as a causative factor in periodontal disease and recommended its excision. Periodontitis alone as an etiological factor is seen in 234 participants (32.47%), showing that inflammatory granulation tissue and bone loss are major contributing factors to tooth migration. According to studies by Towfighi et al. (1997), most common form of manifestation of teeth migration is facial flaring which accounts to approximately 90.9 ± 4.4%, diastema 88.6 ± 4.8%, rotation 72.7 ± 6.8%, extrusion 68.2 ± 7.1%, tipping 13.6 ± 5.2%. Similar results are seen in the present study with facial flaring amounting to 87.1%, diastema about 81%, rotation 72%, extrusion 45.04%, and tipping 12.07%. Finally, after knowing the different contributing factors of PTM, considerations have to be made with the different concepts of repositioning the migrated teeth. Many studies by Kumar et al. (2009) support the spontaneous repositioning of teeth. Gaumet et al. (1999) also support the role of wound contraction in spontaneous repositioning. Following periodontal therapy, there is decrement of inflammatory cell infiltrate resulting in diminution in edema and soft tissue shrinkage. Healthy collagen fibers replace the inflammatory cell infiltrate and may contribute to the re-establishment of a normal equilibrium of forces, leading to reactive movement of migrated teeth to its position. In case of shortened dental arches, the missing teeth are to be replaced. Extreme forces can cause tooth movement when their duration is approximately 50% of time even though the magnitude is very low. Deleterious habits need to be corrected by habit breaking appliances and by psychological approaches. Failure to consider occlusal factors can lead to fruitless treatment; hence, occlusion correction should me made prior to specific treatment modality. With adequate orthoperio treatment approaches, a healthy and well functioning dentition with good occlusion, sufficient masticatory function, and satisfactory esthetics that will improve psychological status of the patient can be re-established.
| Conclusion|| |
In the present study, tongue thrusting, missing posteriors, and trauma from occlusion showed significant association with pathological migration in periodontitis patients. These results conclude the multifactorial etiology of pathological migration, which emphasize the importance of differential diagnosis so that the actual cause of diastema rather than the space alone can be treated.
Limitations of the study
In this study, the number of missing teeth is not quantified and the duration since the teeth are missing is not considered. Duration of the deleterious habits is recorded based on questionnaire given to subjects. Hence, patient's subjective perception may lead to exaggeration of the real prevalence of pathological migration which could be confounding. Individual factor without periodontitis is not studied. Limited data may reduce the impact of conclusions made. Further studies are required emphasizing all the associated factors causing PTM and to corroborate the study results.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4]