Alveolar bone loss represents a critical challenge in orthodontic treatment, as it affects the structural integrity of the periodontium and influences the feasibility and outcomes of tooth movement. This narrative review synthesizes evidence from peer-reviewed studies published between 2020 and 2025 to examine the interplay between alveolar bone morphology, defects, force application, and treatment planning in orthodontics. The alveolar bone's morphology, including thick and thin morphotypes, plays a pivotal role in determining susceptibility to defects such as dehiscences and fenestrations during orthodontic forces, which induce remodeling through mechanobiological pathways involving cytokines, matrix metalloproteinases, and the RANK/RANKL/OPG axis. Defects can slow tooth movement rates and increase risks like root resorption, particularly in compromised periodontal conditions. Force application must be optimized—using light, controlled magnitudes—to minimize bone loss, with finite element analyses highlighting the importance of moment-to-force ratios in edentulous areas. Treatment planning requires multidisciplinary approaches, sequencing periodontal regeneration before or during orthodontics, and incorporating AI for predictive modeling of bone changes. Key findings indicate higher incidence of defects with clear aligners in certain malocclusions, the benefits of occlusal intervention prior to orthodontics for balancing osteoblast-osteoclast activity, and innovations in regeneration using growth factors and stem cells. Objectives include providing clinicians with evidence-based strategies to mitigate risks, enhance bone preservation, and improve long-term stability. This review underscores the need for personalized, technology-aided planning to address alveolar bone loss effectively.
