Orthodontic treatment of patients with severe (stage IV) periodontitis

Stage IV periodontitis is characterized, apart from high severity / complexity (attachment loss, radiographic bone loss, and deep probing depths), from loss of multiple teeth and / or alterations of the masticatory function. Periodontitis stage IV patients are often characterized by pathologic tooth migration, drifting, flaring, including posterior bite collapse, and secondary occlusal trauma. These act as complexity factors not only for the management of periodontitis, but also for the prognosis of the whole dentition, and the majority of these patients present secondary malocclusions that require interdisciplinary treatment with orthodontics. However, the management of stage IV patients is complex and requires coordination between the periodontal and orthodontic specialist, while orthodontic treatment needs to be appropriately adjusted to the specificities of adult periodontally-stable patients with severely reduced periodontium. The aim of the paper is to discuss the orthodontic management of these patients, including conditions that need to be met for orthodontic treatment to start, treatment-related considerations pertaining to appliance choice and mechanotherapy, as well as post-treatment maintenance protocols to ensure long-term stability of the treatment results. Finally, an updated systematic review with meta-analysis is presented that summarizes clinical evidence on the effect of combined periodontal-orthodontic treatment for stage IV periodontitis patients with pathological tooth migration.