Periodontology 2000, Vol.
4, 1994, 148-159
Priiited in Denmark . All rights reserved
Orthodontics as an adjunct
to rehabilitation
BIRTEMELSEN& NINAAGERB~EK
The possibility of saving and rehabilitating a deterio-
rated dentition not only depends on the number of
remaining teeth and their periodontal status and de-
gree of destruction but also largely on the mor-
phology of the alveolar process and the position of
the teeth within the alveolar process.
Orthodontics plays an important role as an ad-
junctive discipline in generating the optimal base for
the re-establishment of a healthy, well functioning
dentition - hopefully with a lifelong prognosis.
The need for orthodontics as an integrated part of
therapy is often related to migration of teeth. Once
the balance between forces acting on the teeth and
the constraints of the periodontal tissues have been
disturbed by either extraction of teeth and/or reduc-
tion of the periodontium, an unstable situation
arises. The migration may then lead to a change in
function, which further aggravates the situation. At
the same time, the migration as well as the loss of
teeth per se leads to a change in the alveolar process
with respect to morphology and height. Such
changes may compromise the possibility of a later
satisfactory reconstruction (25, 27, 30).
Indication for orthodontic
treatment
The indication for orthodontic treatment may vary
considerably in the eyes of different clinicians (36,
38). It is essential, however, to differentiate between
orthodontics as an alternative and orthodontics as a
treatment component without which the treatment
result will be seriously compromised.
With the introduction of implants, the necessity of
a specific distribution of teeth in partially edentu-
lous patients as bridge pillars has greatly been re-
duced (1). Even in edentulous arches, the use of im-
plants has made it possible to produce implant-
borne dentures with satisfactory stability. Earlier re-
quirements for the width and height of the alveolar
148
Copyright Q Munksgaard 1994
PERIODONTOLOGY 2000
ISSN 0906-6713
process for an acceptable prognosis for osseointegr-
ation of implants have also to some degree vanished.
The use of a combination between osseointegration
of implants and guided tissue regeneration has re-
duced the requirements for the height and width of
the alveolar process. Ample evidence has been pre-
sented on bone regeneration around implants (4-6,
12, 15, 18, 29, 41, 42). Nevertheless, the aug-
mentation of bone to the alveolar process is limited
to addition to the original morphology. The ortho-
dontic tooth movement can, on the other hand, gen-
erate bone along with the displacement, thereby re-
modeling and rebuilding the alveolar process in all
directions (2, 10, 11, 31).
It is, however, well known that orthodontic tooth
movement may also lead to displacement of the
tooth outside the existing alveolar process, with a
dehiscence as a result (9, 19, 37, 39).
Tissue reaction to orthodontic
tooth movement
In summary, the orthodontic tooth movement can
occur as tooth movement with bone or tooth
movement through bone.
If tooth movement is occurring with bone, the
tooth movement is characterized by a direct resorp-
tion of bone on the pressure side of the periodontal
ligament. A corresponding bone apposition takes
place on the opposite side, where the ligament is
being stretched and on the external surface of the
alveolar process corresponding to the pressure site.
This process simulates a remodelling with a coupling
of the resorption and apposition. The tooth is mov-
ing with its surrounding periodontium, including
bone, and continuously rebuilding its alveolar pro-
cess.
In the other situation - tooth movement through
bone - the periodontal ligament is compressed to a
degree that local ischemia occurs, and a hyaliniz-

ation zone has been described (3, 31-33). The initial
resorption takes place at a distance from the peri-
odontal ligament starting in the bone marrow of the
compression side gradually approaching the peri-
odontal ligament. Once the resorption has reached
the periodontal ligament, the tooth is moving in a
step, and a widening of the periodontal ligament is
occurring, since no apposition has taken place dur-
ing the undermining resorption period. A de-coup-
ling between resorption and apposition is occurring
when the tooth is moving through bone and is thus
moved outside the alveolar process (9, 16, 35, 37).
Both biological reactions may be of importance
when patients with a deteriorated dentition are
treated.
Tooth movement through bone
The indications for tooth movement through bone
are limited to the vertical dimension. A situation in
which it could be of interest to extrude a tooth out
of its socket is in case of a root fracture, the purpose
being to displace the fracture line above the alveolus.
Hereby a prosthetic replacement can be produced
Fig. 1. a. A young woman presented with an endodont-
ically treated incisor. X-ray revealed a root fracture situ-
ated approximately2 mm below the gingiva and mesially
2 mm below the bone level. b. The tooth had to be crown-
ed due to its dark color as well as due to the fracture. The
fracture line had to be involved in the preparation - and
Orthodontics as an adjunct to rehabilitation
without altering the contour of the marginal gingiva.
Alternatives would be a gingivectomy often with
bone contouring, extraction and the insertion of an
implant or a more conventional replacement of the
tooth with a bridge. These approaches are all less
biological than the orthodontic solution. The disad-
vantage of the extrusion is the shorter root, that is,
the increased crown root ratio. The orthodontic solu-
tion is also most cost-beneficial. An example is seen
in Fig. 1.
Another situation in which tooth movement
through bone is desirable is where teeth have not
erupted normally for one or another reason. When
the decision has to be made as to whether to move
an impacted tooth into the dental arch orthodon-
tically or to replace it prosthetically, the costs and
benefits have to be evaluated in the widest sense.
Are the adjacent teeth going to suffer? How long is
the patient going to wear the appliance? What are
the chances of getting the tooth into the correct po-
sition in all three planes of space?
The most frequently impacted teeth in the perma-
nent dentition are the upper canines and the lower
third molars (34). Problems around the canines be-
long to the adolescent period and are most fre-
without extrusion of the tooth, gingivectomy and some
bone contouring would be necessary. c. The bracket was
placed on the incisor and a plate with an active spring
was inserted. d. After 3 months the tooth was extruded
about 2 mm. e. The crown was produced. f. The X-ray
shows the changed crown root ratio.
149
Melsen & Agerbaek
quently solved at that age. In the older, partially
edentulous patient, however, the impacted molars
may generate a potential for longer dental arches
that should not be overlooked (Fig. 2).
The forced eruption of an impacted molar can
produce a posterior bridge pillar with a normal
attachment level and the maintenance of the al-
veolar process quantitatively. A secondary gain of the
forced eruption is a bone modelling, adding to the
width and the height of the alveolar process. If, as
an alternative, removal is performed, the surgery
cannot avoid to generate a certain bone destruction.
A consequence of a surgical removal of the tooth is
inevitably an undesirable atrophy of the alveolar
process.
A complicating factor related to the forced erup-
tion of the third molars is lack of attached gingiva.
This can and should be handled by grafting surgery
(Fig. 2c).
When second molars are present but teeth more
anteriorly in the dental arch are lost, a forced erup-
tion of third molars can serve two purposes: to
elongate the dental arch and to serve as anchorage
for a forward movement of other teeth, thereby facil-
itating space closure. An example of this type of
treatment is seen in Fig. 3.
The forced eruption shown in Fig. 3 has brought
the teeth through bone, out of the bone, and second-
Fig. 2. a. A 45-year-old patient had experienced extraction
of both lower molars and the second premolar in one side
of the lower jaw. He had been wearing a partial denture
for some time and attended the orthodontist to get an in-
creasing diastema in the lower front closed. Radiographic
examination revealed an impacted third molar. The third
molar was brought forward orthodontically with a simple
fixed appliance pulling in an occlusal and mesial direc-
150
arily produced modelling of the alveolar process
around and adjacent to the tooth.
Tooth movement with bone
Tooth movement through bone is primarily per-
formed in an occlusal direction, whereas movement
with bone, with the capacity of reshaping the al-
veolar process, may be needed in all directions.
The eruption of teeth can thus be produced both
through and with bone, whereby the alveolar process
can be build up (40). The need for such treatment
may be related to deeply impacted teeth. Such an
impaction may be the consequence of early extrac-
tion of deciduous teeth because of caries. Another
example is shown in Fig. 4. Removal of the impacted
premolar surgically would further damage the al-
veolar process, and after removal, the alveolar canal
would be right underneath the cortex. No implant
could be inserted, and a conventional bridge would
be very unsatisfactory due to the lack of an alveolar
process. Instead the tooth was moved orthodon-
tically (Fig. 4b-d), first with a forced eruption
through bone and secondarily with eruption with
bone building up the alveolar process.
The alveolar process may also be atrophic second-
arily to extraction of first molars and/or agenesis of
tion. b. Gingival problems related to the new position of
the third molars, since no attached gingiva at all was pres-
ent. c. Free mucogingival grafts were prepared surround-
ing the tooth in all sides. d. Following a healing period of
6 months, the tooth was prepared for a crown. e. The final
bridge. f. Radiographs taken 20 years after treatment
(courtesy of Laura Guerra and Franco Milano).

Fig. 3. a. A 30-year-old woman presented to the orthodon-
tics department. Several years earlier a periodontal treat-
ment had been performed including the removal of her
first molars. The progression of the disease had stopped,
but she now had a traumatic occlusion on both second
molars which had tipped severely mesially. b. A biomech-
teeth. In the case shown in Fig. 5a, a marked lateral
open bite had developed, and the patient had only
occlusal contact on the last molars and central inci-
sors. The molars were uprighted and erupted with
bone, and the third molars were erupted through
bone. The treatment can be followed through Fig. 5.
If a deep bite is a consequence of the collapse of
the dentition, it may be desirable to erupt the teeth
Orthodontics as an adjunct to rehabilitation
anical force system was generated that at the same time
would intrude and upright the second molar and extrude
the third molar. This was done over a period of 9 months.
c. Here is seen the result just prior to the final removal of
the appliances. d. The X-ray situation after 15 years. e.
The clinical aspect after 15 years.
of the side segments, thus building up the alveolar
process and adding to the vertical height (Fig. 6).
Indication for intrusion
If, on the other hand, the deep bite is the result of
an overeruption of the anterior teeth, an eruption of
151
Melsen & Agerbsek
Fig. 4. a. Impacted premolar. b. Orthodontic treatment in
progress. The premolar is now visible and being pulled
forward against the fixed appliance and the anterior part
of the lower jaw. c. At the end of the treatment the patient
also wished to have uprighting of the molars on the left
side. The right premolar is now brought into place. d. A
pontic is placed on the lingual arch serving as retainer.
the side segments would lead to an increased overjet
and a major augmentation of the facial height. The
patient will not usually tolerate this. In such cases
intrusion is desirable.
It is, however, important to establish whether the
orthodontic intrusion should be along the axis of the
tooth or whether a change in inclination, proclin-
ation or retroclination, is desirable and to monitor
the force system accordingly (Fig. 7).
In many patients with a degenerating dentition, the
bite is often deepened as a result of tooth loss and mi-
gration. The migration of the periodontally involved
incisors will lead to spacing and eruption. The degree
of migration will differ from tooth to tooth, according
to the periodontal destruction and the forces acting
on the single tooth. A classic example of this type of
tooth movement can be seen in Fig. 8.
Besides their periodontal problems, these patients
also often have a serious cosmetic problem, which
may well be aggravated following adequate peri-
odontal therapy.
Thus, in the usual treatment plan for the severely
periodontally damaged dentition, orthodontic treat-
ment may well be a sine qua non; both with the pur-
pose of improving the cosmetic quality and to re-
place or change position of teeth to be used in a
reconstruction (24, 26).
A very common problem in periodontal patients
is spacing in the front and extrusion of one or more
152
e. Periapical radiograph of the premolar showing a some-
what shorter root. The root is probably underdeveloped
due to the close contact with the mandibular canal during
the impaction. No pocket can be measured mesial to the
molar. A scar in the bone of the previous position of the
tooth can be seen at the arrow.
teeth. Space closure will reduce the overjet but will
most likely even increase the overbite if the spaces
are closed through a lingual tipping of the incisors.
It is therefore important that the space closure can
be combined with intrusion. An example of space
closure and intrusion can be followed in Fig. 9. In
this case a conventional bridge solution as well as a
treatment plan including insertion of implants
would have represented a serious morphological
problem (Fig. 9a).
Tissue reaction to intrusion
The tissue reaction seen in relation to intrusion
varies according to the periodontal status at the start
of the treatment.
Intrusion of teeth with a normal periodontium
causes a modelling of the alveolar process, which
does not influence the amount of periodontal sup-
port. This also applies to a reduced, but healthy peri-
odontium.
A precondition is, however, that the intrusion is
carried out with the periodontal situation under full
control (43). In a clinical study of 30 consecutively
treated adult patients, 27 demonstrated a reduced
clinical crown length varying from 0.3 to 2.3 mm. In
3 of the patients the treatment resulted in increased
crown length. When the area of the bony alveolus

Fig. 5. a. A 38-year-old patient presented with an oc-
clusion characterized by a slight mandibular overjet, and
by a lateral cross-bite. She was suffering from a muscular
tenderness, and constant pain at the temporomandibular
joint. b, c. After being placed on a fully balanced splint
for a period, the mandible slided slightly back, leaving
contacts on the central incisors only. d. The intraoral
radiographic status revealed 3 impacted third molars and
an impacted canine. There was severe atrophy of the al-
veolar process in both sides of the lower jaw and in the
upper right jaw. e. An orthodontic treatment delivering
was calculated on the basis of intraoral radiographs,
it was found that 19 had experienced an improve-
ment of the bony level, 6 were unchanged, and in 5
patients the treatment had reduced the bony peri-
odontium. A typical patient from this study is seen
in Fig. 9 and 10 (25).
The tissue reaction secondary to the intrusion was
further studied in an animal experiment in which
periodontal breakdown was produced with cotton
ligatures and elastics around the collum of the upper
incisors and the upper and lower premolars in 5
adult female monkeys. The breakdown was con-
tinued until a minimum of 4 mm probing pocket
depth was generated. Following the removal of the
elastics a flap operation was performed, during
Orthodontics as an adjunct to rehabilitation
light eruptive forces to the side segments succeeded in
eruption of molars and premolars with bone to obtain
space closure uprighting of the molars and eruption of
the impacted teeth. The alveolar process in the lower jaw
was brought back by means of a translation. This was
used as reciprocal anchorage for the forward movement
of the side segments. The upper incisors were tipped for-
ward, leaving space for the impacted canine to be brought
into the dental arch. Tooth movements in the lower jaw
can be seen on the orthopantomograph. f. Corresponding
tracings. g-i. The final result.
which the epithelium and the granulation tissue
were removed. A notch at the pocket bottom just
above the bone was placed, and the teeth were di-
vided into 4 groups according to treatment: 1) only
flap operation, no postsurgical oral hygiene pro-
gram, 2 ) flap operation plus oral hygiene 3 times a
weeks with chlorhexidine cleansing, 3) flap oper-
ation plus intrusion along the long axis of the teeth
and no hygiene program, and 4) flap operation plus
intrusion as in 3 and hygiene as in 2. After the mon-
keys were killed, parasagittal histological sections
were produced and evaluated quantitatively The
analysis revealed that new cementum and collagen
attachment was formed if hygiene was maintained.
The degree of coronal displacement was, however,
153
Melsen & Agerbaek
Fig. 6. a. A 35-year-old woman complained about increas-
ing fatigue in the temporalis muscle. She feels that the
bite height is not in harmony with her muscular position.
b. Extremely deep bite. Gingival impingement buccally to
the lower incisors and lingually to the upper incisors.
c. The bite opening was initiated by a sagittal expansion
proclining the upper and lower incisors. d. Following the
also significantly related to the intrusion. The dis-
tance between the apical part of the notch and the
junctional epithelium increased between 0.7 and 2.3
mm, and attachment coronally to the notch was a
consistent finding in group 4. Intrusion in the pres-
ence of plaque did, on the other hand, prove detri-
mental, since a pronounced resorption of the mar-
ginal bone could be observed (23) (Fig. 11).
These results were further analyzed in a cell kinetic
study carried out on 11 monkeys. In 9 monkeys peri-
odontal breakdown, as described above, was induced,
and their premolars were assigned to the same regime
as group 2 and 4 in the previous study. Two monkeys
served as control. After the animals had been killed by
perfusion, a detailed cell kinetic study was performed
to evaluate the difference in cell population in the 3
groups. The width of the periodontal ligament was re-
R CR CR
c
3 the start of intrusion, since in that case, the intrusion
Fig. 7. Depending on whether the intrusive force is ap-
plied anterior to, through or posterior to the center of re-
sistance. a combination of a Droclination and intrusion a
translation or a retroclination and intrusion is occurring.
154
sagittal expansion, which solved the crowding problem, a
bite plateau was inserted from canine to canine in the
upper jaw leaving the premolars to erupt. e. Posttreat-
ment occlusion. The bite has been opened, partly through
eruption with bone in the side segments. f. The eruption
has led to posterior rotation of the mandible, leaving the
pogonion less prominent. Courtesy of Bo Bloch.
duced during intrusion due to the cone-shaped form
of the root. In the presence of the mechanical stimu-
lus, both the cell density and the nuclear volume as an
assay of cellular activity were increased (27). Previous
studies (13,17,28) have clearly demonstrated that the
only cell population capable of generating a new
attachment originates from the periodontal ligament
itself. The above-mentioned study demonstrated that
the intrusive force displaced the periodontal ligament
cells coronally in a narrower periodontal ligament
and simultaneously stimulated the cell activity. This
findings may explain the change in attachment level
earlier observed. Whether the results from the animal
experiments can be extrapolated to the human situ-
ation can be questioned, but since histology is the
only reliable method for the evaluation of attachment
level, the findings should be taken into consideration
(7).
The clinical results are in good
- accordance with
the observations in the monkey studies. It is, how-
ever, essential that no pathological deepened
pockets and no vertical bony defects be present at
itself could be a potential risk factor for further
attachment loss, as more marginally placed dental
plaque could be displaced apically into even deeper
Part of an existing pocket.
On the other hand, if the supracrestal periodontal

Fig. 8. a. Family portrait of a 20-year-old woman who was
very proud of her smile. b. 26-year-old woman. An overjet
was developing with a central diastema, and it can clearly
be seen that the lateral incisors have erupted more than
the central incisors. Periodontal therapy has been per-
Fig. 9. a. A 34-year-old man with a dramatically increasing
diastema and very long teeth following periodontal
treatment. The overbite had increased most likely also
due to a light collapse of the dentition as molars had been
extracted. b. The orthodontic treatment was started by in-
trusion of the most proclined tooth, whereby this tooth
was tipped into the midline. c. Following this the canti-
lever system was used now on three incisors. A bite open-
ing was attempted by adding acrylic to the occlusal sur-
ligament fibers are intact, as is the case in a totally
healthy periodontal situation, no loss of attachment
will occur. The problem with intrusion of teeth with
a reduced but healthy periodontium is then merely
connected with the handling of the very light forces
needed. Intrusion has generally also been related to
a high incidence of root resorption (8,221.The quan-
tity of the apical root resorption is, however, highly
related to other factors, such as time, force level and
individual resistance (20, 21).
The problems related to vertical bony defects
around teeth scheduled for orthodontic treatment
Orthodontics as an adjunct to rehabilitation
formed, but although the gingiva is now healthy, the pa-
tient is not satisfied with the appearance of her teeth.
c. Following orthodontic treatment a pleasant smile was
re-established.
faces of the anchorage unit. About 1.5 mm of bite opening
was tolerated to which the spaces were closed. d. Close-
up of the final result including reduction in the clinical
crown height of 1.1 and 1.2. The result is maintained by
a bonded retainer to the lingual surhce of the incisors.
e. Happy patient following treatment. f. Treatment analy-
sis showing that the result was a combination of extrusion
and intrusion.
have been highly reduced recently, as the principle
of guided tissue generation has been introduced.
With this approach a new attachment can be estab-
lished, and there are no contraindications to the ex-
posure of a tooth treated by this procedure to ortho-
dontic movement (14).
Modelling of the alveolar process
with orthodontics
The above-mentioned tooth movement has all fo-
cused on intrusive and extrusive movement. The
155
Melsen & Agerbaek
Fig. 10. a. An 18-year-oldwoman with a slightly increased
overjet. b. The overjet is increasing following the first
pregnancy and a slight medial diastema is opening. c. The
medial diastema is markedly increased five years later.
d. Periapical radiograph revealing marked bone loss.
e. Clinical appearance with long clinical crowns follow-
ing periodontal therapy. f. Following orthodontic therapy,
majority of orthodontic tooth movements do, how-
ever, involve mesiodistal or buccolingual movement.
Whereas the mesiodistal tooth movement can be
performed through the alveolar process, the bucco-
lingual invariably implies modelling of the alveolar
process in the direction of the tooth movement:
tooth movement with bone.
Fig. 11. Radiograph and histological picture of the area
between molar and a premolar of a monkey where the
premolar has been intruded. The radiograph demon-
strates that the bone level is maintained during the in-
trusion. The histological picture reveals that the notched
placed before intrusion is now below bone level and that
the epithelial junction is significantly different (arrows) on
the intruded and the non-intruded tooth.
156
the clinical crown length was reduced through a com-
bined intrusion and retraction. One lower incisor had
to be extracted due to total periodontal involvement.
g. Radiographic appearance following orthodontic ther-
apy shows an improved bone level and an increased den-
sity of the bone.
In case of a lack of coordination between the
upper and lower dental arch, an adaptation may be
needed before a well functioning occlusion can be
established. Often the discrepancy between the
shape of the upper and lower alveolar process has
been aggravated through abnormal functional pat-
tern, such as a lip pressure or as a result of a collapse
of the dental arch following extraction (Fig. 12). This
woman was suffering from both a transversal prob-
lem, a non-occlusion scissor bite and a large overjet.
Both problems were aggravated through a previous
extraction of the lower first premolars in an attempt
to solve a severe crowding in the lower jaw. The col-
lapse of the lower jaw had lead to a traumatic oc-
clusion of the teeth in scissor bite, which were also
loosened of the second degree. A second conse-
quence of the collapse of the lower jaw was a deep-
ening of the bite leading to gingival impingement of
the lower incisors lingual to the upper incisors, a
situation related to a chronic inflammation of the
gingiva. The problems were solved, as can be fol-
lowed in Fig. 12.
Lack of coordination of the dental arches of a
magnitude that does not allow for a normal lip clo-
sure will aggravate with increasing age-related de-
cline of resistance. This may become obvious already
in young patients and is often noted as an opening
of a diastema. The patient described in Fig. 13 re-

Fig. 12. a. A 35-year-old woman suffering from increased
overjet leading to the gingival impingement of the lower
incisors lingually to the upper incisors. Scissor bite, elon-
gated, and loosened premolars. b. Orthodontic treatment
required widening of the lower arch and retraction and
Fig. 13. a. A 30-year-old woman who has noted that her
overjet is increasing in relation to increasing medial dias-
tema. b. The overjet in this case could not be solved by
retraction of the upper incisors, since the upper lip was
very short, and the patient already showed a lot of incisors
in relaxed position. Her problem from an aesthetic point
of view was the retrognathic posterior position of the al-
veolar process in the lower jaw (Fig. 13a). c. The lower
ported an increasing diastema in the upper jaw. The
short upper lip did not allow for a retraction of the
upper incisors, and the alveolar process of the lower
jaw was therefore modelled forward to fit with the
upper arch. As a consequence, a space correspond-
ing to a third premolar was opened in one side. This
treatment, which also included correction of a severe
asymmetry of the lower arch form, demonstrated
that it was possible to move the lower incisors a con-
siderable amount forward with their surrounding
periodontium. A precondition for the successful fa-
cial lingual movement of teeth is, however, a well
monitored force system applied to teeth surrounded
by a healthy periodontium.
Orthodontics as an adiunct to rehabilitation
intrusion of the upper incisors. c. The appearance at the
day of band removal; a slight inflammation is present of
the gingiva. d. Profile at the end of treatment. This treat-
ment has involved modelling of the alveolar process both
in a transverse and in a sagittal direction.
dental arch was asymmetrical, and it was decided to move
the alveolar process forward through a tooth movement
with bone and thereby straighten the profile. During this
treatment a space for a third premolar was opened.
d. Treatment result. A harmonious profile was produced.
e. A profile after treatment. Tracing showing how much it
was possible to move the teeth forward with bone without
a loss of periodontal support.
Conclusion
During the last decade, the possibilities of restoring
an even severely deteriorated dentition has dramati-
cally increased. The daily clinical work has thereby
undoubtedly become more challenging than ever,
but it should also be stressed that the need for team
work is a must. This article has demonstrated the
state of the art of orthodontics as an adjunct to a
dental rehabilitation.
157
Melsen & Agerbaek
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