## 4 Discussion
For such patients, the need for, and timing of, a mucogingival graft with/without phenotype modification need to be assessed by a periodontitis [40]. In our case, the planned and executed teeth movement along with her normal gingival biotype did not warrant any surgical periodontal intervention. The sixth and final step is the retention of the treatment outcome including stable occlusion and a healthy periodontim. Recent systematic reviews and randomized clinical trial have concluded that a combined orthodontic-periodic approach can improve periodontal health parameters and the prospect of saving and restoring a weakened dentition without a detrimental impact on periodontal health [29; 41]. However, the literature still lacks well-controlled studies on long-term periodontal health and maintenance [29; 41]. Therefore, guidelines need to be strictly implemented to enhance the possibility of achieving reliable, predictable and stable treatment outcomes. These guidelines include the establishment of periodontal health prior to orthodontic treatment and maintenance of proper periodontal health throughout orthodontic treatment [16; 20; 40; 41]. Orthodontic treatment should be characterized by light, targeted and controlled forces in non-inflammatory conditions [29]. Orthodontic treatment should also identify principal factors of certain malocclusion to ensure stable outcomes [5; 6]. For example, soft tissue pressure that contributes to open bite relapse should be eliminated to ensure a stable outcome [4]. The application of lingual spurs, as used in our case, is an effective approach to modifying the tongue position and improving long-term stability [42]. Others advocate for myofunctional therapy to correct resting tongue posture and avoid a relapse [9]. [PERSON] and colleagues (2013) showed the importance of etiology-based and patient-centered interdisciplinary treatment for a patient with advanced periodontal loss, notable soft tissue problems and skeletal and dental malocclusion [28]. Their therapy included periodontal-endodontic treatment followed by orthodontic and orthognathic surgical correction, and their result remained stable for 11 years [28]. A previous systematic review reported insignificant differences between extraction and non-extraction methods in the long-term stability of a treated open bite [43]. Intrusion of the posterior teeth using TADs is shown to be considerably stable [6], as opposed to the challenges reported in retaining cases that were managed with traditional non-extraction treatment approaches such as bite blocks, multiloop wires and elastics [26; 44; 45]. In addition to the life-long aging process and general tendency for teeth to return to their original position, adult periodontitis involved patients have delayed cell remodeling and mobile teeth, with a tendency for spontaneous migration of teeth [29; 31]. There is a consensus regarding the validity and importance of using fixed retainers for the long-term maintenance of orthodontic correction [29]. Bonded retainers need to be flexible to allow the teeth to retain their physiologic mobility [1; 3] and need to be positioned correctly to enable good hygiene and intact dynamic occlusion [16]. For patients with severe periodontal bone loss and mobile teeth, conventional removable retainers may not be indicated due to the lack of the force-resistance equilibrium [46]. Nonetheless, patients with light and constant forces from abnormal habits, tongue position or soft tissues have a greater incidence of post-treatment relapse [44], which necessitates the use of overlay removable retainers with a habit breaker modification [43; 47]. To conclude, it is apparent that planning for permanent retention for orthodontic stability among periodontitis involved patients requires greater consideration without compromising long-term periodontal health.