Forced orthodontic eruption for augmentation of soft and hard tissue prior to implant placement

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1 [Downloded free from on Tuesdy, July 16, 2013, IP: ] Click here to downlod free Android ppliction for this jour Forced orthodontic eruption for ugmenttion of soft nd hrd tissue prior to implnt plcement Rfel Scf de Molon, Éric Dorigtti de Avil 1, João Antonio Chves de Souz, Andress Vils Bos Nogueir, Crolin Chn Cirelli 2, Rogerio Mrgonr 3, Joni Augusto Cirelli Astrct Forced orthodontic eruption (FOE) is non surgicl tretment option tht llows modifying the osseous nd gingivl topogrphy. The im of this rticle is to present clinicl cse of FOE, which resulted in n improvement of the mount of ville one nd soft tissues for implnt site development. Ptient ws referred for tretment of moility nd unesthetic ppernce of their mxillry incisors. Clinicl nd rdiogrphic exmintion reveled inflmed gingivl tissue, horizontl nd verticl tooth moility nd interproximl ngulr one defects. It ws chosen multidisciplinry tretment pproch using FOE, tooth extrction, nd immedite implnt plcement to chieve etter esthetic results. The use of FOE, in periodontlly compromised teeth, promoted the formtion of new one nd soft tissue in coronl direction, without dditionl surgicl procedures, enling n esthetic, nd functionl implnt supported restortion. Keywords: Bone remodeling, forced eruption, multidisciplinry tretment, orthodontic extrusion Introduction The presence of n unstisfctory recipient site cused y lveolr ridge resorption in result of periodontl disese mkes unfesile the idel 3 dimensionl implnt position in the nterior mxill. In ddition, the gingivl contour follows the osseous crest resulting in severe esthetic prolems tht compromise susequent prosthetic restortion. Thus, the replcement of compromised nterior tooth y dentl implnt remins one of the most difficult chllenges for the dentists. [1] In these situtions, different surgicl techniques such s guided tissue regenertion, [2] one nd connective Deprtments of Dignosis nd Surgery, 1 Dentl Mterils nd Prosthodontics, nd 2 Orthodontics, School of Dentistry t Arrqur, Univ Estdul Pulist - UNESP, 3 Deprtment of Helth Sciences, Discipline of Periodontology nd Integrted Clinic, University Center of Arrqur - UNIARA, Arrqur, São Pulo, Brzil Correspondence: Dr. Rfel Scf de Molon, Deprtment of Dignosis nd Surgery, Univ Estdul Pulist UNESP, Ru Humitá, 1680, Arrqur, São Pulo, Brzil. E mil: molon.for@yhoo.com.r 243 Quick Response Code: Access this rticle online Wesite: DOI: / X grft procedures, [3,4] distrction osteogenesis, [5] nd ridge splitting [6] hve een widely used in clinicl prctice to increse the mount of ville one nd/or gingivl tissue t the potentil implnt site nd improve implnt esthetic nd/or nchorge. Insted of surgicl trditionl techniques, nother pproch to improve the 3 dimensionl topogrphy of the implnt recipient site is the forced orthodontic eruption (FOE). This is non surgicl tretment tht ims to otin hrd nd soft tissue formtion t potentil implnt sites, extruding orthodonticlly hopeless teeth nd their periodontl pprtus. [7] Among the dvntges of this technique re: Leveling of isolted infrone defects, lengthening the clinicl crown, repositioning of the gingivl mrgin, improvement of primry nchorge of dentl implnt nd incresed mount of ttched gingiv nd one. [7] This one nd gingivl ugmenttion improves the recipient implnt site for more estheticl restortion. During the orthodontic extrusion, mechnicl stresses exerted onto the lveolr one led to ctivtion of ngiogenic growth fctors, which would contriute to the formtion of new support tissue: Gingivl nd periodontl fiers, nd deposition of new one vi osteolstic ctivity t the lveolr crest. [8] As tooth movement occurs in the coronlly direction, the gingiv nd the one ttched y the periodontl ligments migrte in the sme direction of the movement, resulting in coronl shift of the one t the se of the defect. FOE cn lso promote ugmenttion of soft tissue volume through the incresing of the ttched gingivl. The only requirement for the stisfctory ppliction of this procedure is tht the picl third of the root must mintin n intct fier pprtus nd the ptient should not present systemic prolems such dietes mellitus tht impirs the Contemporry Clinicl Dentistry Apr-Jun 2013 Vol 4 Issue 2

2 [Downloded free from on Tuesdy, July 16, 2013, IP: ] Click here to downlod free Android ppliction for this jour de Molon, et l.: Forced orthodontic eruption to implnt plcement one heling. [7,9] The regenertion of periodontl tissue support llows the instlltion of implnts nd ecomes foreseele the results of the tretment. According to Gkntidis et l. [10] hrmonious coopertion of the generl dentist, the periodontist nd the orthodontist re necessry to increse the possiilities for the successfully tretment. [11] Although it is possile to find mny rticles in scientific dentl literture out orthodontic extrusion tretment for periodontl regenertion, some uthors reinforce the need to descrie cse on the instlltion of implnts fter orthodontic extrusion. Therefore, the im of this study ws to report clinicl cse of orthodontic extrusion of mxillry nterior incisors in ptient with periodontl disese for posterior implnts rehilittion. Cse Report A 22 yer old womn ws referred to the School of Dentistry t Arrqur, with the complint of tooth moility in the right mxillry lterl incisor. She ws lso disppointed with her prosthesis. Her medicl history ws non contriutory nd her dentl history reveled root cnl therpy nd provisionl restortion on the right mxillry lterl incisor. Clinicl exmintion reveled tht the tooth presented degree II of moility, 5 mm proing depth in the interproximl surfce nd the gingivl tissue surrounding the tooth ws inflmed. The temporry crylic resin crown presented some mrginl infiltrtion, nd fter removing it, cvity ws found under the gingivl tissue [Figure 1]. Peripicl rdiogrph reveled one resorption round the root, interproximl ngulr one defects, nd stisfctory cnl tretment. Becuse it ws impossile to otin n dequte crown root rtio fter tooth tretment, it ws decided with ptient to extrct the root orthodonticlly nd to replce it y dentl implnt. It is importnt to note tht this cse report ws plnned with multidisciplinry tem, i.e., orthodontist, periodontist, nd prosthodontist. The initil phse of tretment occurred with the reduction of control plque ccumultion nd gingivl inflmmtion. For this ptient, the periodontl tretment nd orl hygiene instruction were performed during 4 months, ccording to Gknditis et l. [10] After 4 months, creful clinicl exmintion ws mde, the cvity ws treted, the excess of gingivl tissue ws removed, nd the temporry crown ws replced. The orthodontic tretment ws initited using the rckets with Roth prescription nd the right lterl incisor rcket ws positioned more cerviclly thn those on the other tissues, in order to llow the tooth extrusion with Ni Ti wire. To help prevent intrusion of the nchorge teeth, stinless steel uxiliry rch ws used [Figure 2 nd f]. Ptient ws seen every 2 weeks for reduction of the incisl surfce of the extruded tooth to prevent occlusl interferences during extrusive movement. Furthermore, the lterl incisor rcket ws repositioned s close s possile to the gingivl mrgin to llow long extruding rnge. Peripicl rdiogrphs were tken monthly to monitor progress in the one profile. After 12 weeks of orthodontic extrusion, the tooth ws stilized for 4 months in order to get proper reorgniztion of the soft tissue, nd one remodeling [Figure 3 nd c]. Before extrction of the mxillry right lterl incisor, it ws possile to oserve, clinicl, nd rdiogrphiclly, sustntil interproximl nd verticl one formtion nd n increse in the mount of ttched gingiv. After 15 months of orthodontic tretment, the lterl incisor ws extrcted [Figure 4] nd n implnt (3.3 mm 11 mm implnt, Neodent, Curiti, Brzil) ws plced immeditely, remining unloded for 6 months until the osseointegrtion period [Figure 5]. The peripicl rdiogrphic evlution showed osseointegrtion round of the implnt 6 months fter its instlltion [Figure 6]. After this time, provisionl restortion ws confectioned for llowed Figure 1: Clinicl view showing of the temporry crylic resin crown presented some mrginl infiltrtion c e Figure 2: ( nd f) The rcket positioned more cerviclly llowed the tooth extrusion with Ni Ti wire nd the wire prevented intrusion of the teeth d f Contemporry Clinicl Dentistry Apr-Jun 2013 Vol 4 Issue 2 244

3 [Downloded free from on Tuesdy, July 16, 2013, IP: ] Click here to downlod free Android ppliction for this jour de Molon, et l.: Forced orthodontic eruption to implnt plcement Figure 4: ( nd ) Extrusion of the lterl incisor c Figure 3: ( nd c) Peripicl rdiogrphs to show one topogrphy on mxillry lterl incisor Figure 5: ( nd ) Clinicl view showing implnt plcement fter tooth extrction (3.3 mm x 11 mm implnt, Neodent, Curiti, Brzil) plced immeditely Figure 6: Peripicl rdiogrphs week fter implnt plcement Figure 7: Buccl view of the provisionl restortion fter 6 months of the implnt plcement the gingivl recontouring [Figure 7]. A definitive metl cermic crown ws instlled 1 yer fter implnt plcement [Figure 8]. After 5 yer follow up, the ptient reported no complints, nd the dentl implnt ws stle nd helthy. Ptient ws very stisfied with the esthetic result. Discussion This cse descried successful FOE procedure in hopeless teeth, for implnt site development tht did not hve enough one nd soft tissue to support it. The multidisciplinry tretment for these ptients included: Bsic periodontl therpy for dequcy of the orl environment, FOE to void 245 Figure 8: Buccl view of the definitive metl cermic crown ridge collpse fter extrction nd to improve the mount of one nd soft tissues, teeth extrction, immedite implnt nd fixed provisionl crowns plcement. This tretment protocol ws used with success to restore functionl nd esthetic in mxillry compromised nterior teeth. FOE is non invsive method to increse the mount of kertinized gingiv nd one, improving the 3 dimensionl topogrphy of the periodontl pprtus. This pproch llows optimiztion of the implnt recipient site prior to tooth extrction through etter enggement of one during implnt plcement.[12,13] The increse in one nd gingivl volume is Contemporry Clinicl Dentistry Apr-Jun 2013 Vol 4 Issue 2

4 [Downloded free from on Tuesdy, July 16, 2013, IP: ] Click here to downlod free Android ppliction for this journ de Molon, et l.: Forced orthodontic eruption to implnt plcement resulted from the stretching of gingivl nd periodontl fier undles. When tension is pplied to the periodontl ligment through orthodontic extrusion movement, periodontl fiers re elongted nd osteolstic ctivity induces one formtion t the lveolus se. Studies hve demonstrted tht when tooth is extruded y using light forces, the gingiv follows one formtion in coronl direction. [14] The regenertion of periodontl tissue support llows the instlltion of implnts nd ecomes foreseele the results of the tretment. However, it ws recommended tht in ptients with periodontl disese, orthodontic tretment should strt 2 6 months fter periodontl therpy to llow for periodontl heling nd stiliztion. [10] At the sme time, the light continues forces should e implemented for efficient tooth movement in compromised periodontium, i.e., constnt orthodontic forces tht produce n extrusion rte of 2 mm/month is idel. [15] The use of implnt for single tooth replcement in the nterior region is one of the gretest chllenges in esthetic dentistry. [1] The min ojectives of such procedures include successful osseointegrtion of the dentl implnt, helth of the surrounding soft nd hrd tissues, nd lnce etween the finl restortion nd the djcent teeth. An importnt fctor to chieve esthetic success in n esthetic zone is the qulity of the lveolr one (height, volume, nd density of the corticl plte) t the implnt site, once the gingivl contour follows the underlying osseous crest. The integrtion of orthodontics nd implnt dentistry provides etter option in clinicl sitution compring to invsive procedures. Tooth extrction in the nterior mxillry re usully cuse defects of the lveolr ridge. An incresed interoclusl spce cn e expected fter the extrction tht results in restortion with n unfvorle crown to implnt rtio, cusing crestl one loss round the implnt or n increse in the risk of mechnicl prolems like screw loosening. Forced eruption is n interesting lterntive to prevent ridge resorption nd lso, to increse the mount of one nd soft tissues efore implnt plcement. Furthermore, forced eruption hs een effective in periodontl correction of ngulr ony defects, in repositioning the gingivl mrgin, in reducing the proing depth nd in clinicl lengthening of the crown. [7] Dentl implnts require enough mount of verticl one. Verticl ugmenttion, especilly of the uccl one plte nd crest, llows etter implnt plcement. Autogenous lock grfts llow the reconstruction of trophic ridges. However, there re complictions relted to this utogrft: Moridity, leeding, nerve injury, pin, swelling, grft filure, dehiscence nd others. [16] Moreover, the tooth needs to e extrcted nd implnt instlltion cn t e chieved ecuse the one remodeling tkes 6 9 months efore implnts cn e plced. On the other hnd, FOE of the compromised mxillry nterior teeth llows verticl one ugmenttion nd lso, the immedite replcement of tooth with fixed implnt provisionl prosthesis, without ny dditionl surgicl procedure. [11] The key fctor for the success of FOE is the ppliction of pproprite orthodontic forces nd sufficient retention period fter extrusion llowing the stiliztion of the tissues. [17] The disdvntges of this procedure re: Longer tretment time, dditionl orthodontic tretment, nd ptient coopertion. This procedure is indicted in cses of moderte ony defects nd recession of up to the middle third of the root. However, FOE is more dvntgeous when minimlly invsive procedures re performed. [17] Teeth with endodontic peripicl lesions, gingivl recession with severe uccl one resorption, nkylosed teeth, nd severe circumferentil nd ngulr defects re contrindicted for orthodontic extrction. [18] In this cse report, fter the initil forced eruption therpy, the lveolr one crest nd the gingivl mrgin were locted in norml reltion to the tissues of the djcent teeth. Surgicl procedures, including extrction nd implnt plcement, were performed with miniml trum preserving the uccl one. This sitution llowed n dequte primry stiliztion, pproprite emergency profile, nd crown implnt rtio. Consequently, it ws possile to mke n immedite provisionl restortion, fvoring the chievement nd mintennce of the esthetic results. References 1. Solkoglu O, Cooper LF. Immedite implnt plcement nd restortion in the nterior mxill: A tissue relted pproch. Oservtions t 12 months fter loding. Int J Periodontics Restortive Dent 2006;26: Zitzmnn NU, Schärer P, Mrinello CP. Long term results of implnts treted with guided one regenertion: A 5 yer prospective study. Int J Orl Mxillofc Implnts 2001;16: Winkler S. Implnt site development nd lveolr one resorption ptterns. J Orl Implntol 2002;28: de Molon RS, de Avil ÉD, de Souz JA, Nogueir AV, Cirelli CC, Cirelli JA. Comintion of orthodontic movement nd periodontl therpy for full root coverge in Miller clss III recession: A cse report with 12 yers of follow up. Brz Dent J. 2012;23: Apricio C, Jensen OT. Alveolr ridge widening y distrction osteogenesis: A cse report. Prct Proced Aesthet Dent 2001;13: Shimoym T, Kneko T, Shimizu S, Ksi D, Tojo T, Horie N. Ridge widening nd immedite implnt plcement: A cse report. Implnt Dent 2001;10: Slm H, Slm M. The role of orthodontic extrusive remodeling in the enhncement of soft nd hrd tissue profiles prior to implnt plcement: A systemtic pproch to the mngement of extrction site defects. Int J Periodontics Restortive Dent 1993;13: Shiu YT, Weiss JA, Hoying JB, Iwmoto MN, Joung IS, Qum CT. The role of mechnicl stresses in ngiogenesis. Crit Rev Biomed Eng 2005;33: de Molon RS, Moris Cmilo JA, Verzol MH, Fed RS, Pepto MT, Mrcntonio E Jr. Impct of dietes mellitus nd metolic control on one heling round osseointegrted implnts: Removl torque nd histomorphometric nlysis in rts. Contemporry Clinicl Dentistry Apr-Jun 2013 Vol 4 Issue 2 246

5 [Downloded free from on Tuesdy, July 16, 2013, IP: ] Click here to downlod free Android ppliction for this jou de Molon, et l.: Forced orthodontic eruption to implnt plcement Clin Orl Implnts Res 2013;24: Gkntidis N, Christou P, Topouzelis N. The orthodontic periodontic interreltionship in integrted tretment chllenges: A systemtic review. J Orl Rehil 2010;37: de Avil ED, de Molon RS, de Assis Mollo F Jr, de Brros LA, Cpelozz Filho L, de Almeid Crdoso M, et l. Multidisciplinry pproch for the esthetic tretment of mxillry lterl incisors genesis: Thinking out implnts? Orl Surg Orl Med Orl Pthol Orl Rdio 2012;114:e Mirmrshi B, Torti A, Alm A, Chee W. Orthodonticlly ssisted verticl ugmenttion in the esthetic zone. J Prosthodont 2010;19: Holst AI, Nkenke E, Bltz MB, Geiselhöringer H, Holst S. Prosthetic considertions for orthodontic implnt site development in the dult ptient. J Orl Mxillofc Surg 2009;67: Mntzikos T, Shmus I. Forced eruption nd implnt site development: An osteophysiologic response. Am J Orthod Dentofcil Orthop 1999;115: Koryem M, Flores Mir C, Nssr U, Olfert K. Implnt site development y orthodontic extrusion. A systemtic review. Angle Orthod 2008;78: Pikos MA. Atrophic posterior mndiulr reconstruction utilizing mndiulr lock utogrfts: Risk mngement. Int J Orl Mxillofc Implnts 2003;18: Owmn Moll P, Kurol J, Lundgren D. Effects of douled orthodontic force mgnitude on tooth movement nd root resorptions. An inter individul study in dolescents. Eur J Orthod 1996;18: Holst S, Hegenrth EA, Schlegel KA, Holst AI. Restortion of nonrestorle centrl incisor using forced orthodontic eruption, immedite implnt plcement, nd n ll cermic restortion: A clinicl report. J Prosthet Dent 2007;98: How to cite this rticle: de Molon RS, de Avil ÉD, de Souz JC, Nogueir AV, Cirelli CC, Mrgonr R, et l. Forced orthodontic eruption for ugmenttion of soft nd hrd tissue prior to implnt plcement. Contemp Clin Dent 2013;4: Source of Support: Nil. Conflict of Interest: None declred. Announcement iphone App A free ppliction to rowse nd serch the journl s content is now ville for iphone/ipd. The ppliction provides Tle of Contents of the ltest issues, which re stored on the device for future offline rowsing. Internet connection is required to ccess the ck issues nd serch fcility. The ppliction is Comptile with iphone, ipod touch, nd ipd nd Requires ios 3.1 or lter. The ppliction cn e downloded from id ?ls=1&mt=8. For suggestions nd comments do write ck to us. 247 Contemporry Clinicl Dentistry Apr-Jun 2013 Vol 4 Issue 2