Regenerative periodontal surgery and orthodontic therapy in the treatment of patients with stage IV periodontitis and pathologic tooth migration

BACKGROUND: Patients suffering from stage IV periodontitis are often characterized by pathologic tooth migration, drifting, flaring, posterior bite collapse, and secondary occlusal trauma (case type 2). Many times, these patients seek treatment because of functional and esthetic demands. The majority of these patients could benefit from an integrated, interdisciplinary approach combining periodontal therapy and orthodontics. MATERIALS AND METHODS: This narrative review aimed to update the scientific evidence on current treatment approaches for patients with stage IV case type 2, presenting with intrabony defects and pathological tooth migration. The strategic sequencing and timing of periodontal-regenerative surgery and orthodontic tooth movement are emphasized. RESULTS: Managing these patients is complex and requires careful coordination between periodontal and orthodontic specialists. Until recently, the timing of periodontal regeneration and orthodontic tooth movement has been unclear. However, new treatment guidelines and results from ongoing clinical research have provided new information. Based on the currently available evidence, it can be recommended that following a successful completion of steps 1 and 2 of periodontal therapy and regenerative periodontal surgery of intrabony defects using biomaterials according to current guideline recommendations at the migrated teeth, orthodontic tooth movement can be initiated as early as 4 weeks postoperatively. Provided patients maintain excellent oral hygiene and strictly adhere to an individualized supportive care program, favorable periodontal outcomes with significant improvements of their periodontal status can be expected with long-term stability up to 10 years. Moreover, this approach also leads to favorable orthodontic outcomes and does not increase the risk of external root resorption. These results were consistent regardless of the type of movement (translation, intrusion/extrusion, or buccal/lingual) or the type of biomaterial used. CONCLUSIONS AND CLINICAL RELEVANCE: Patients suffering from stage IV periodontitis with pathologic tooth migration requiring periodontal-regenerative therapy and orthodontic treatment can be successfully managed in the long term. The synergistic effects of a combined periodontal-regenerative and early orthodontic therapy have been demonstrated to result in a significantly improved oral health-related quality of life for patients, with restoration of function and esthetics.