CASE REPORT

Orthodontic treatment in a periodontal patient with pathologic migration of anterior teeth Yijia Xie,a Qing Zhao,b Zhen Tan,c and Shuliang Yangd Chengdu, China

A 22-year-old man with severe periodontitis and pathologic tooth migration sought orthodontic treatment. He was treated successfully with effective control of the strength and the direction of the orthodontic forces, and a combination of periodontic and orthodontic treatment. After 22 months of orthodontic treatment, his occlusal trauma resulting from pathologic tooth migration was relieved, a stable occlusion was achieved, and mutual aggravation of occlusal trauma and periodontitis was prevented. Furthermore, the patient's facial esthetics and selfconfidence were improved. Newly formed trabecular bone could be seen in the periapical x-rays in some regions where resorption had been severe. This case report shows that resorption of alveolar bone can be prevented and that multidisciplinary orthodontic treatment of a periodontal patient with pathologic tooth migration is effective and helpful. (Am J Orthod Dentofacial Orthop 2014;145:685-93)

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s more adults seek orthodontic treatment, orthodontists are seeing more patients with periodontal problems.1,2 Pathologic tooth migration is a common complication of moderate to severe periodontitis and is often the motivation for patients to seek orthodontic therapy.2,3 As a result of pathologic tooth migration, occlusal trauma and periodontitis are mutually aggravated, resulting in greater loss of attachment, extrusion, and mobility of the displaced teeth.4,5 Pathologic tooth migration in the anterior region affects facial esthetics.3,6 Orthodontic correction of pathologic malpositioned teeth can relieve occlusal trauma, stabilize the dentition, and improve the periodontal status.7-10 Intrusion of periodontally extruded teeth is controversial, however.4,9,11 Recent studies have suggested that light intrusive forces can be used to

From Sichuan University, Chengdu, China. a Postgraduate student, Orthodontic Centre, West China Hospital of Stomatology, and State Key Laboratory of Oral Diseases. b Associate professor, Orthodontic Centre, West China Hospital of Stomatology, and State Key Laboratory of Oral Diseases. c Associate professor, State Key Laboratory of Oral Diseases and Oral Implant Centre, West China Hospital of Stomatology. d Postgraduate student, State Key Laboratory of Oral Diseases and Oral Implant Centre, West China Hospital of Stomatology. All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest, and none were reported. Address correspondence to: Qing Zhao, Department of Orthodontics, No. 14, Section 3, Renmin Nan Rd, Chengdu, Sichuan, 610041, China; e-mail, [email protected]. Submitted, May 2013; revised and accepted, August 2013. 0889-5406/$36.00 Copyright Ó 2014 by the American Association of Orthodontists. http://dx.doi.org/10.1016/j.ajodo.2013.08.018

correct pathologic extrusion and migration.12-14 But many other issues might complicate the orthodontic treatment of a periodontal patient with pathologic tooth migration: eg, periodic periodontal maintenance, strength and direction of orthodontic force, and surveillance of periodontal status.1,6-8,11 DIAGNOSIS AND ETIOLOGY

A man (age, 22 years 6 months) came to the orthodontic office of our hospital in Chendu, China. His chief complaints were displaced maxillary and mandibular anterior teeth and large gaps between the incisors. He was eager to improve both his appearance and selfconfidence by orthodontic treatment. He was selfconscious about the appearance of his teeth. He had no history of smoking. He had a symmetrical face with a straight profile. Angle Class I canine and molar relationships on both sides were observed, with an acceptable occlusion in the posterior segment. The main problem was in the anterior region. He had a severe deep overbite, and a deep gap was visible when he smiled. His mandibular right central incisor just impinged on the mesial cervix of the maxillary right central incisor, with rotation of the maxillary right central incisor and extrusion of both maxillary and mandibular right central incisors. Severe gingival recession was observed in the incisors. A 3-mm-deep periodontal pocket could be explored in the mesial aspect of the maxillary right central incisor, with a 4-mm-deep pocket in the mesial aspect of the mandibular right central incisor. Penpyema (pyorrhea of periodontium observable on periodontal probing) could be seen in the pocket of 685

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the maxillary central incisor. Both the maxillary and mandibular right incisors were extruded. The exposed root length of the mandibular right incisor was almost half of the whole. There were mild arch-length discrepancies in both arches: the maxillary available space was 6.0 mm, and the mandibular space was 2.0 mm. The anterior Bolton index was 74.39%, and the overall Bolton index was 88.6%. The curve of Spee was about 3.5 mm (Figs 1-4). The panoramic radiograph showed that all teeth were present except the 4 third molars. Pathologic migration of the maxillary and mandibular right central incisors was also observed on the panoramic radiograph (Fig 3). Extensive resorption of alveolar bone could be seen on the film, mainly in the premolar and anterior regions. In some sites of the anterior teeth, the resorption area was as large as half to two thirds of the root surface; eg, the maxillary and mandibular right central incisors. An infracrestal pocket was faintly visible in the mesial aspect of the maxillary right central incisor (subsequent follow-up periapical films during treatment also confirmed this). Cephalometric analysis showed a Class I skeletal pattern (with a slight Class III tendency) with the pathologically displaced maxillary right central incisor protruded (Fig 4, Table I) and the mandibular plane angle within the normal range (28.7 6 5.3 ). Based on these findings, the patient was diagnosed with a skeletal Class I malocclusion with severe periodontitis and pathologic tooth migration. TREATMENT OBJECTIVES

The orthodontic treatment objectives for this patient were to achieve a stable occlusion; restore esthetics, function, and periodontal health in the anterior region; and maintain the existing occlusion in the posterior region. These objectives were aimed at preventing mutual aggravation of occlusal trauma and periodontitis, leading to better facial esthetics and enhancing selfconfidence. The orthodontic treatment objectives were built on a complete treatment plan for this periodontal patient. The complete treatment plan for this patient consisted of 4 main phases: systemic, hygienic, corrective, and maintenance (supportive periodontal therapy). In the hygienic phase, the periodontists gave the patient oral hygiene instructions and motivated him to maintain his oral hygiene. Scaling and root planing of all teeth were carried out at the same time. Before the corrective phase, the following criteria had to be satisfied: proper infection control, full-mouth plaque index within 25%, the full-mouth percentage of positive bleeding on probing sites less than 30%, and no residual pockets deeper than 5 mm. Once orthodontic treatment was finished,

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the maintenance phase began. The patient was required to be reviewed every 3 to 6 months to prevent reinfection and recurrence. A multidisciplinary approach was chosen for this patient because the final result must be guaranteed by a qualified dental team: orthodontists, periodontists, and prosthodontists. It was necessary for the orthodontists to cooperate with the periodontists throughout the treatment and also cooperate with the prosthodontists when the orthodontic treatment was finished. Appropriate intrusion and uprighting of anterior teeth were involved in the progress of the treatment; these were combined with thorough scaling and planing of the root surfaces of particular anterior teeth. For the poor periodontal status, light forces to move teeth and minimize occlusal trauma were used. At the beginning of the alignment, Australian archwires shaped to the original alignment of the dentition were chosen to extenuate the aligning force exerted on each tooth. An occlusal splint was used to prevent occlusal trauma to the anterior teeth during the early stage of alignment. Slightly grinding the crown of the extruded mandibular right central incisor to reduce the ratio of crown to root length could also contribute to reducing the occlusal trauma. According to our model analysis, the Bolton index was slightly deviated from normal, so restorative treatment might be required for the maxillary lateral incisors after orthodontic treatment. Since there was discoloration of the maxillary right central incisor, necrosis of the pulp was suspected. We requested an endodontic consultation for this tooth, and restorative treatment might be necessary after orthodontic treatment. TREATMENT ALTERNATIVES

Treatment modalities for such a patient include orthodontic treatment and after extraction of severely displaced teeth. In view of the patient's age and because the occlusal trauma and periodontitis aggravated each other, prosthodontic treatment was not thought to be a good alternative. Prosthodontic treatment cannot resolve a deep overbite, an esthetic problem of the anterior region caused by a periodontal defect. Also, prosthodontic treatment might result in health hazards of other teeth. With orthodontic treatment, we could reestablish a stable occlusion, restore esthetics and function, and prevent mutual aggravation of occlusal trauma and periodontitis. Orthodontic treatment assisted by regular periodontal treatment was considered the best choice for this young patient. The decision was made to use relatively simple orthodontic treatment mechanics: the direction and strength of the orthodontic forces were well controlled step by step, with whole monitoring of the periodontal status.

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Fig 1. Pretreatment facial and intraoral photographs.

Fig 2. Pretreatment dental casts.

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Table I. Cephalometric measurements Measurements SNA ( ) SNB ( ) ANB ( ) MP-SN ( ) Y-axis ( ) S-Go/N-Me (mm) U1-SN ( ) FMIA ( )

Fig 3. Pretreatment panoramic radiograph.

Fig 4. Pretreatment lateral cephalogram.

TREATMENT PROGRESS

First, we consulted with physicians, determining whether further examination was required to exclude other systemic diseases. Second, the patient was required to see a periodontist periodically. The periodontist gave him oral hygiene instructions and motivated him to maintain oral hygiene, and scaling and root planing of all teeth were carried out at the same time. Three months later, the orthodontists and periodontists held a consultation. We made sure that the periodontal status satisfied the criteria: proper infection control, full-mouth plaque index within 25%, the full-mouth percentage of positive bleeding on probing sites less than 30%, and no residual pockets deeper than 5 mm; this meant that the periodontitis had moved to a chronic phase. Then the patient was referred to our orthodontic office again. Before the appliance was bonded, the

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Mean 81.69 6 2.54 78.94 6 2.19 2.75 6 1.16 32.85 6 4.21 63.54 6 3.23 65.85 6 3.83 74.94 6 6.22 57.0 6 6.79

Pretreatment 82.07 80.62 1.45 28.43 60.85 69.64 63.79 67.77

Posttreatment 81.60 80.09 1.51 28.14 60.96 71.46 75.01 71.86

extruded mandibular right central incisor was ground to reduce the ratio of crown to root length. A 0.022-in preadjusted edgewise appliance was placed in the mandibular arch (from first premolar to first premolar), and a prepared occlusal splint was placed on the maxilla to relieve the occlusal interference and trauma between the maxillary and mandibular incisors (Fig 5, A). A 0.014-in Australian archwire with a step between the 2 mandibular central incisors (shaped to the original step between the teeth) was used to align the mandibular arch segmentally and gradually. Four months later, the extruded and rotated mandibular right central incisor had been corrected slightly, and a 0.022-in preadjusted edgewise appliance was placed in the maxillary arch (from second premolar to second premolar). A 0.014in Australian archwire shaped to the original alignment of the maxillary arch was installed (Fig 5, A). After 9 months, the occlusal trauma between the maxillary and mandibular incisors had been relieved, with the displaced anterior teeth uprighted and intruded little by little (Fig 5, B). The occlusal splint was removed. A 0.016-in Australian archwire was installed, and the remaining 4 first molars and 2 second premolars were bonded, aiming to further level the occlusal curve and open the deepbite. Two months later, leveling and alignment of the bimaxillary arch had been completed. Two 0.018-in Australian archwires were installed, with an elastic chain centralizing and closing the scattered space in the dentition step by step (Fig 5, C). Six months later, most of the space had been closed, and the deepbite had been opened (Fig 5, D). After 17 months of treatment, the preliminary goal of treatment had been achieved. Then 2 stainless steel archwires (0.018 3 0.025 in) were installed, and the fine-adjustment phase of treatment could begin. Continuous ligation of the brackets was used to prevent the dentition gaps emerging again, with an elastic chain used at the same time. Overjet and torque were also guaranteed during this period. We monitored the periodontal status of this patient throughout the whole process with periapical x-ray films (Fig 6).

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Fig 5. Treatment progress: A, 4 months after the start of orthodontic treatment; B, 9 months after the start of orthodontic treatment; C, 11 months after the start of orthodontic treatment; D, 17 months after the start of orthodontic treatment.

Fig 6. Periapical x-ray films during treatment.

After 22 months of treatment, a stable occlusion had been achieved and maintained for a period of time. Overjet and overbite were proper, except for minor gaps between the incisors for preparing for the restorations (Figs 7 and 8). After removing the appliance, fixed lingual retainers were bonded for retention in both the maxilla and the mandible. We requested him to complete the root canal treatment for the maxillary right central incisor and have the incisors restored as soon as possible. Because he was rushing to get to a

job far from our hospital, he sent us 3 intraoral photos that he took himself after resin restorations were completed elsewhere (Fig 9). Although the orthodontic treatment was finished, maintenance of the periodontitis continued. The periodontist required the patient to be reviewed every 3 to 6 months. It was essential to prevent reinfection and recurrence after the successful treatment; continuous diagnosis and regular supportive therapy were also necessary.

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Fig 7. Posttreatment facial and intraoral photographs.

TREATMENT RESULTS

The posttreatment facial photographs showed marked improvement of facial esthetics. Selfconfidence was seen in his eyes. Normal overjet and overbite were established, and a stable occlusion was achieved, with improved torque and occlusion in the posterior region. The pathologically migrated maxillary and mandibular right central incisors were corrected by properly intruding and uprighting them, and also by grinding the crown of the mandibular right central incisor little by little at every visit (Figs 1, 7, and 9). Normal incisal and canine guidance in the anterior region had been established without occlusal interference according to our evaluation of jaw movement after treatment. The occlusal trauma had been relieved, and the severe periodontitis had been controlled well during the whole orthodontic treatment. The posttreatment panoramic radiograph showed acceptable root parallelism and no marked root resorption; most importantly, the level of alveolar bone had been maintained (Fig 10). Newly formed trabecular bone could even be seen in some regions where resorption had been severe (Figs 6 and 10). This

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suggested that further resorption of alveolar bone had been prevented by our treatment. This was an exciting finding. The posttreatment cephalometric evaluation and superimposed cephalometric tracing showed no marked skeletal changes, except a little clockwise rotation of the mandible (Figs 11 and 12, Table I). DISCUSSION

As previously mentioned, various kinds of prosthodontic treatment (removable partial denture, fixed bridge, and dental implant) could have been used for this patient. However, prosthodontic treatment can only be used after extraction of severely displaced teeth. It includes implant prostheses, fixed bridges, and removable partial dentures.15 No prosthodontic method can resolve a deepbite and improve the esthetics of the anterior region. The esthetic problems resulting from periodontal tissue defects are challenges for prosthodontists. Although guided bone regeneration and bone grafting can be used to improve alveolar bone levels in implant restorations, the results are still unpredictable, and the costs are too high.16 In other words, prosthodontic treatment can bring few

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Fig 8. Posttreatment dental casts.

improvements for such a patient. On the other hand, proper orthodontic treatment assisted by periodontal treatment can achieve a better occlusion, with the occlusal force along the axis of the tooth, thus preventing mutual aggravation of occlusal trauma and periodontitis.17 Because of the patient's age, orthodontic treatment was undoubtedly the best choice for him. Treatment for such a patient with pathologic tooth migration is systemic, comprehensive, and multidisciplinary. It includes 4 phases: systemic, hygienic, corrective, and maintenance (supportive periodontal therapy).18-20 In the systemic phase, the periodontists should consult with physicians to determine whether further examination is required. In the hygienic phase, patients are motivated to achieve and maintain good oral hygiene by themselves, while scaling and root planing of all teeth under local anesthesia are carried out at the same time. Oral hygiene instructions should be provided by periodontists, such as recommending the Bass brushing technique and interdental brushes. The periodontal status of patients should be reevaluated by periodontists after 6 to 8 weeks. Before the beginning of our orthodontic treatment, the following criteria had to be satisfied: proper infection control, full-mouth plaque index within 25%, the fullmouth percentage of positive bleeding on probing sites less than 30%, and no residual pockets deeper than 5 mm. The animal experiments of Garlet et al21 showed that proper orthodontic force and tooth movement do

not cause further damage to the periodontal tissues, but with plaque, the same force can cause bone defects and attachment loss. Thus, controlling plaque and eliminating inflammation are extremely important during the orthodontic treatment of patients with periodontal disease. In the corrective phase, we orthodontists supervise the patient to obtain periodontal treatment periodically and when oral hygiene worsens. We also monitored the periodontal status of this patient throughout the whole process with periapical x-ray films (Fig 6). Once orthodontic treatment is finished, the maintenance phase begins. The patient was required to be reviewed every 3 to 6 months to prevent reinfection and recurrence. Controlling the orthodontic force is crucial for a patient with periodontitis.20,22 The remodeling of periodontal tissues under orthodontic force has been studied by many.23-26 Periodontal tissue remodeling is a complex mechanical-biological reaction process under orthodontic force, which is important in conducting the orthodontic force, making teeth move in the bone tissue and stabilizing teeth in their new positions.23 Alveolar bone tissue is highly plastic under orthodontic force, manifested as bone deposition in the stretched side and bone resorption in the compressed side.25 We controlled the intensity and direction of forces throughout the treatment of this patient. Australian archwires shaped to the original alignment of the dentition were used during the aligning stage in this patient

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Fig 9. Intraoral photographs after resin restoration.

Fig 10. Posttreatment panoramic radiograph.

Fig 12. Superimposed cephalometric tracings.

Fig 11. Posttreatment lateral cephalogram.

(Fig 5, A). We can get a gentle and directional force by readjusting the archwire at every visit. Full surveillance of the periodontal response to the orthodontic force is also important. At the beginning of our treatment, we just bonded appliances to the premolars without the molars (Fig 5, A). We were observing the periodontium's response under the orthodontic force. Because the response was good, we continued the treatment.

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Otherwise, the treatment would have been interrupted or readjusted. We especially monitored the periodontal status of the anterior region. From the periapical x-ray films during treatment, a stable periodontal status was observed: no more bone loss, no visible root resorption, and acceptable periodontal membrane space (Fig 6). With these signs, we feel confident about the treatment. With cautious and scientific trials, the results for this periodontal patient with pathologic tooth migration were satisfactory. According to some studies, the aggravation of occlusal trauma and periodontitis is due to nonaxial occlusal force on the teeth.17,27 In our treatment of this patient, we corrected the displaced and inclined anterior teeth with gentle forces step by step, thus

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eliminating the lateral occlusal force and reducing occlusal trauma. For the same purpose, a slight intrusive movement of the extruded teeth and reduction of the ratio of crown to root length were carried out at the same time. Correction of this patient's deepbite also played an important role in the elimination of occlusal trauma. A shallow overbite can establish better incisal and canine guidance, which is important for stability of the occlusion. During the last fine-adjustment period, we used 0.018 3 0.025-in stainless steel archwires to precisely control the torque of the teeth (Fig 5, D). Excellent control of torque facilitates the stabilization of tooth roots in the central cancellous bone of the alveolar bone, preventing a concentration of stress in the edge of the cortical bone. Settling of the roots in an ideal position of alveolar bone contributes to reconstruction of the bone. All of our efforts have been proved effective by the newly formed trabecular bone shown in the periapical x-ray films (Fig 6). CONCLUSIONS

Orthodontic treatment of a periodontal patient with pathologic tooth migration is effective with multidisciplinary cooperation. Mutual aggravation of periodontitis and occlusal trauma can be prevented by treatment. Improvement of facial esthetics contributed to the self-confidence of an adult periodontal patient with pathologic tooth migration. REFERENCES 1. Proffit W. Special considerations in comprehensive treatment for adults. In: Proffit W, Fields HW, editors. Contemporary orthodontics. 3rd ed. St Louis: Mosby; 2000. p. 644-74. 2. McKiernan EX, McKiernan F, Jones ML. Psychological profiles and motives of adults seeking orthodontic treatment. Int J Adult Orthod Orthognath Surg 1992;7:187-98. 3. Brunsvold MA. Pathologic tooth migration. J Periodontol 2005; 76:859-66. 4. Serio FG, Hawley CE. Periodontal trauma and mobility. Diagnosis and treatment planning. Dent Clin North Am 1999;43:37-44. 5. Rohatgi S, Narula SC, Sharma RK, Tewari S, Bansal P. A study on clinical attachment loss and gingival inflammation as etiologic factors in pathologic tooth migration. Niger J Clin Pract 2011; 14:449-53. 6. Feng X, Oba T, Oba Y, Moriyami K. An interdisciplinary approach for improved functional and esthetic results in a periodontally compromised adult patient. Angle Orthod 2005;75: 1061-70. 7. Gkantidis N, Christou P, Topouzelis N. The orthodonticperiodontic interrelationship in integrated treatment challenges: a systematic review. J Oral Rehabil 2010;37:377-90. 8. Derton N, Derton R, Perini A, Gracco A, Fornaciari PA. Orthodontic treatment in periodontal patients: a case report with 7 years follow-up. Int Orthod 2011;9:92-109.

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9. Weston P, Yaziz YA, Moles DR, Needleman I. Occlusal interventions for periodontitis in adults. Cochrane Database of Systematic Reviews, 2008, Issue 3. Art. No.: CD004968. doi: 10.1002/ 14651858.CD004968.pub2. 10. Diedrich PR. Orthodontic procedures improving periodontal prognosis. Dent Clin North Am 1996;40:875-87. 11. Boyd RL, Leggot PJ, Quinn RS, Eakle WS, Chambers DW. Periodontal implications of orthodontic treatment in adults with reduced or normal periodontal tissues versus those of adolescents. Am J Orthod Dentofacial Orthop 1989;96:191-8. 12. Garat JA, Gordillo ME, Ubios AM. Bone response to different strength orthodontic forces in animals with periodontitis. J Periodontal Res 2005;40:441-5. 13. Ogihara S, Wang HL. Periodontal regeneration with or without limited orthodontics for the treatment of 2- or 3-wall infrabony defects. J Periodontology 2010;81:1734-42. 14. Panwar M, Jayan B, Mandlik VB, Jha AK. Combined periodontal and orthodontic treatment of pathologic migration of anterior teeth. Med J Armed Forces India 2010;66:67-9. 15. Cardoso JA, Almeida PJ, Fischer A, Phaxay SL. Clinical decisions for anterior restorations: the concept of restorative volume. J Esthet Restorative Dent 2012;24:367-83. 16. McClain PK, Schallhorn RG. Long-term assessment of combined osseous composite grafting, root conditioning, and guided tissue regeneration. Int J Periodontics Restorative Dent 1993;13: 9-27. 17. Jin LJ, Cao CF. Clinical diagnosis of trauma from occlusion and its relation with severity of periodontitis. J Clin Periodontol 1992;19: 92-7. 18. Kim YI, Kim MJ, Choi JI, Park SB. A multidisciplinary approach for the management of pathologic tooth migration in a patient with moderately advanced periodontal disease. Int J Periodontics Restorative Dent 2012;32:225-30. 19. Mathews DP, Kokich VG. Managing treatment for the orthodontic patient with periodontal problems. Semin Orthod 1997;3: 21-38. 20. Ong MA, Wang HL, Smith FN. Interrelationship between periodontics and adult orthodontics. J Clin Periodontol 1998;25: 271-7. 21. Garlet TP, Coelho U, Repeke CE, Silva JS, Cunha Fde Q, Garlet GP. Differential expression of osteoblast and osteoclast chemmoatractants in compression and tension sides during orthodontic movement. Cytokine 2008;42:330-5. 22. Zhao Z, Fan Y, Bai D, Wong J, Li Y. The adaptive response of periodontal ligament to orthodontic force loading—a combined biomechanical and biological study. Clin Biomech (Bristol, Avon) 2008;23(Suppl 1):S59-66. 23. Zhu J, Zhao HY, He M, Ying J. Remodeling of inflammatory periodontal tissues during orthodontic tooth movement. J Clin Rehabil Tissue Eng Res 2010;14:6262-6. 24. Li Y, Song J, Yang P, Zou R, Fan X, Zhao Z. Establishment of a three-dimensional culture and mechanical loading system for skeletal myoblasts. Cell Biol Int 2009;33:192-8. 25. Berendsen AD, Smit T, Walboomers XF, Everts V, Jansen JA, Bronckers AL. Three-dimensional loading model for periodontal ligament regeneration in vitro. Tissue Eng Part C Methods 2009; 15:561-70. 26. Melsen B. Tissue reaction following application of extrusive and intrusive forces to teeth in adult monkeys. Am J Orthod 1986; 89:469-75. 27. Ong MMA, Wang HL. Periodontic and orthodontic treatment in adults. Am J Orthod Dentofacial Orthop 2002;122:420-8.

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Orthodontic treatment in a periodontal patient with pathologic migration of anterior teeth.

A 22-year-old man with severe periodontitis and pathologic tooth migration sought orthodontic treatment. He was treated successfully with effective co...
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