Orthodontic tooth movement (OTM) in patients with periodontal compromise presents unique challenges due to altered biomechanics and increased risk of further tissue damage. This narrative review critically synthesizes existing clinical, biological, and experimental evidence on OTM in periodontally compromised patients, highlighting consensus on interdisciplinary approaches, controversies regarding treatment timing and specific movements, and clinical implications. Literature from 1990 to November 2025, including systematic reviews, consensus statements, retrospective studies, and bibliometric analyses, was evaluated. Key findings indicate that OTM is feasible and beneficial following periodontal stabilization, with regenerative therapies enhancing outcomes. Consensus exists on the necessity of inflammation control prior to orthodontics, use of light forces (5-15 g), and multidisciplinary collaboration to improve probing depths, clinical attachment levels, function, and aesthetics. Controversies persist on the optimal timing of OTM post-regeneration (early vs. late) and the safety of movements like intrusion in severe defects, with some evidence suggesting early intervention may not compromise healing and could enhance efficiency. Biological evidence underscores shifts in the center of resistance apically, necessitating adapted mechanics to minimize root resorption and attachment loss. Experimental data from animal models reveal similar RANKL/OPG-mediated bone remodeling in compromised vs. healthy tissues. Knowledge gaps include long-term stability in stage IV periodontitis and patient-reported outcomes. This review underscores evidence-driven strategies for safe OTM, emphasizing conservative management to optimize periodontal health.
