CASE REPORT

Six-year follow-up of maxillary anteriorrehabilitation with forced orthodonticextrusion: Achieving esthetic excellencewith a multidisciplinary approach

Luiz Antonio Borelli de Barros,a Maur�ıcio de Almeida Cardoso,b �Erica Dorigatti de Avila,c Rafael Scaf de Molon,d

Danilo Furquim Siqueira,b Francisco de Assis Mollo-Junior,e and Leopoldino Capelloza Filhob

Araraquara and Bauru, S~ao Paulo, Brazil

aAssisUniv.bAssisBaurucPhDDentadPhDUniv.eAssisAraraAll auPotenReprintol�ogiHumayahooSubm0889-Copyrhttp:/

Orthodontic extrusion with multidisciplinary treatment can provide predictable outcomes in selected situations,reducing the costs and the adaptation times of gingival tissues after implant integration. Forced orthodonticextrusion is strongly related to interactions of teeth with their supportive periodontal tissues. This article reportsa case of orthodontic extrusion of the maxillary incisors for later implant rehabilitation in a patient with periodontaldisease. Slow forces were applied for 14 months. After this time, the teeth were extracted, and the implants wereplaced on the same day. Also in the same session, the provisional crown was fabricated for restoration of theanterior maxillary interdental papillae loss and for gingival contouring. Clinical and radiographic examinationsat the 6-year follow-up showed successful tooth replacement and an improved esthetic appearance achievedby this multidisciplinary treatment. The decision to perform orthodontic extrusion for implant placement in adultpatients should be multidisciplinary. (Am J Orthod Dentofacial Orthop 2013;144:607-15)

Periodontal disease is characterized by inflamma-tion of the supporting tissues of the teeth, result-ing in gingival recession and apical migration of

the junctional epithelium with pocket formation andalveolar bone loss.1 In the maxillary anterior teeth, theseconditions cause functional discomfort and compromisethe esthetics.2

Since the immune and inflammatory responses arecritical factors in the pathogenesis of periodontitis and

tant professor, Department of Social Dentistry, Araraquara Dental School,Estadual Paulista, Araraquara, S~ao Paulo, Brazil.tant professor, Discipline of Orthodontics. University of Sagrado Corac~ao,, S~ao Paulo, Brazil.student, Department of Dental Materials and Prosthodontics, Araraquaral School, Univ. Estadual Paulista, Araraquara, S~ao Paulo, Brazil.student, Department of Diagnosis and Surgery, Araraquara Dental School,Estadual Paulista, Araraquara, S~ao Paulo, Brazil.tant professor, Department of Dental Materials and Prosthodontics,quara Dental School, Univ. Estadual Paulista, Araraquara, S~ao Paulo, Brazil.thors have completed and submitted the ICMJE Form for Disclosure oftial Conflicts of Interest, and none were reported.t requests to: �Erica Dorigatti de Avila, Departamento de Materiais Odon-cos e Pr�otese, Faculdade de Odontologia de Araraquara, UNESP, Ruait�a, 1680, Araraquara, S~ao Paulo, 14801-903 Brasil; e-mail, erica.fobusp@.com.br.itted, September 2012; revised and accepted, October 2012.5406/$36.00ight � 2013 by the American Association of Orthodontists./dx.doi.org/10.1016/j.ajodo.2012.10.027

are related to countless aerobic and anaerobic bacteria,the rehabilitation of these patients becomes a challengeto the professional because of the need to restore func-tion and especially esthetics.3 Unfortunately, peri-odontal regeneration procedures, onlay bone grafts,and mucogingival therapy do not have entirely predict-able outcomes, especially when systemic disease such asdiabetes mellitus is present because this condition im-pairs the bone healing around dental implants,4 mainlyin relation to bone and tissue height gain in the anteriormaxilla.1

Orthodontic extrusion to correct periodontal in-frabony defects can be successful when there is noinflammation and with adequate control of dentalplaque.5 According to Taba et al,6 the success of peri-odontal regeneration depends on 4 elements: cells,appropriate signals, scaffold, and blood supply. Theestablishment of a new vascular supply is essentialfor periodontal regeneration because this providesnutrients for cell growth. During orthodontic extru-sion, mechanical stresses exerted on the alveolarbone lead to activation of angiogenic growth factors,which would contribute to the formation of new sup-porting tissues.7 The regeneration of periodontal tissuesupport allows implant placement and predictabletreatment results. However, it is recommended that

607

Fig 1. Facial pretreatment photographs.

Fig 2. Intraoral photographs showing that most teeth were periodontally compromised.

608 de Barros et al

in patients with periodontal disease, orthodontic treat-ment should start 2 to 6 months after periodontal ther-apy to allow for periodontal healing and stabilization.8

At the same time, light continuous forces should beimplemented for efficient tooth movement in acompromised periodontium: ie, the ideal constant or-thodontic forces during extrusion should allow move-ment of $2 mm per month.9

According to Gkantidis et al,10 the harmonious coop-eration of a general dentist, a periodontist, and anorthodontist offers great possibilities for successfultreatment. Although there are many studies in the scien-tific dental literature about orthodontic extrusion, only afew cases of placing dental implants after orthodonticextrusion have been reported.11 Therefore, we reporton a case of orthodontic extrusion of the maxillary

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anterior incisors to facilitate implant placement in apatient with periodontal disease.

DIAGNOSIS AND ETIOLOGY

A 56-year-old woman was seen in the prosthodonticclinic in the Department of Dental Materials and Pros-thodontics at Araraquara School of Dentistry, S~ao Paulo,Brazil, for extraction of her maxillary central incisors andreplacement with endosseous implants. The patienthad no systemic problems and did not smoke. However,she had periodontal disease characterized by loss ofsupporting alveolar bone and tissue, mainly aroundthe maxillary anterior teeth. This condition preventedthe rehabilitation before a new treatment plan wasconsidered.

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Fig 3. A, Class I cephalometric characteristics; B, panoramic radiographs showing generalized peri-odontal bone loss.

Fig 4. Pretreatment dental casts.

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The initial facial photographs showed a Class Ipattern with good facial relationships and a normalprofile (Fig 1). In the clinical examination, the probingpocket depth was 8 mm around the maxillary centralincisors. In the other areas, probing depths rangedfrom 3 to 5 mm. The periodontal examination showedgingival recession of the maxillary right central andlateral incisors, canine, and first premolar, and themaxillary left central and lateral incisors, canine, andfirst molar (Fig 2). The first appointment was scheduledfor orthodontic documentation for multidisciplinaryplanning.

The cephalometric characteristics were normalwithout clinically significant skeletal deviations (Fig3, A). The panoramic radiograph showed generalizedhorizontal bone loss and vertical bony defects on

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the distal aspect of the maxillary right first premolar,the distal aspect of the mandibular right first molar,and the mesial aspect of the mandibular left thirdmolar (Fig 3, B). However, the dental casts showed acomplete Class II molar relationship on the left side(Fig 4).

TREATMENT OBJECTIVES

The treatment plan consisted of 4 stages. In the firststage, periodontal therapy was provided, and plaquecontrol was encouraged. In the second stage, orthodon-tic extrusion was to gain bone in the vertical direction.Therefore, it was possible to reduce the vertical bone de-fects around themaxillary central incisors before implantplacement. The third stage consisted of extraction of the

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Fig 5. A, Onset of orthodontic extrusion treatment; B, intraoral progress photograph after 7 months;C, eruptive phase followed by stabilization; D, provisional titanium cylinders connected to the implantcentral incisors after the orthodontic treatment was finalized.

Fig 6. A, Initial periapical radiographic examination; B and C, periapical radiographic examinationshowing the complete orthodontic treatment after 14 months. Note that the bone migrated in the apicaldirection when an orthodontic force was applied.

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maxillary central incisors and immediate implant place-ment. In the fourth stage, the definitive restoration ofthe maxillary central incisor implants was completed.

TREATMENT ALTERNATIVES

An alternative to orthodontic extrusion would beextraction of the anterior teeth, then implant placementfollowed by compensation of the defect with soft tissueand/or increasing the prosthetic crown length. Thishypothesis, although immediate and without orthodon-tic treatment, was rejected because of the risk of markedbone loss and the possibility of unfavorable estheticresults related to papillae leveling.

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The second option would be block bone graft surgeryto increase the alveolar bone thickness. This procedurewould favor the implant surgery and esthetics. In thiscase, the patient would have 2 surgeries, with the addi-tional risk of worsening the bone loss.

Another option of more conservative treatmentwould be to keep the maxillary central incisors and torehabilitate with facets. However, the esthetics in thispatient would have been compromised.

TREATMENT PROGRESS

The initial treatment stage comprised plaque controland gingival inflammation reduction. For this patient,

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Fig 7. A and B, Atraumatic extractions of the maxillary right and left lateral incisors; C, placement ofimplants.

Fig 8. Panoramic and periapical radiographic examinations showed the correct angulations of adja-cent teeth as well as the correct positions of the implants in the maxillary arch.

Fig 9. Removal of the orthodontic appliances after 22 months of initial treatment.

de Barros et al 611

periodontal treatment and oral hygiene instructionswere performed according to the study of Gkanditiset al.8 After 4 months, a careful clinical examinationwas performed before the orthodontic treatment.

The orthodontic treatment began by placement offixed appliances in the maxillary arch with brackets andarchwires. The maxillary right and left second molarsreceived bonded tubes, providing comfort and the possi-bility of complete individualization of bonding. Themaxillary right and left central incisor brackets wereplaced more apically to facilitate the extrusive movement.

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The incisal and distal surfaces of themaxillary right centralincisor and the distal surface of the maxillary left centralincisor were equilibrated. On the same day, a 0.014-inNitinol wire (3M Unitek, Monrovia, Calif) was placed.One month later, treatment began in the mandibulararch with direct bonding of brackets, including themandibular right first molar and left third molar. Themandibular central and lateral incisors did not receivebrackets to prevent protrusion (Fig 5, A).

After 7 months, the mandibular left third molarbecamemobile andwas extracted; 2 implantswere placed

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Fig 10. Follow-up facial photographs at 6 years.

Fig 11. Definitive restorations with feldspathic porcelain crowns.

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in the region of the mandibular left first and second mo-lars. In the nextmonth, the brackets on themaxillary rightand left central incisors were repositioned cervically, anda 0.014-in Nitinol wire was placed to potentiate theextrusion mechanics. To prevent intrusion of theanchorage teeth, an 0.018-in stainless steel auxiliaryarch was used to stabilize the segmented wire (Fig 5, B).

In the tenth month, implant surgery was performedin the region of the maxillary right second premolar.The periapical radiographs showed bone gain achievedby the vertical mechanical extrusion. At this time, thepatient was referred for implant evaluation.

The patient was seen 2 weeks later for reduction ofthe incisal surfaces of the extruded teeth and apical re-positioning of the lateral incisor bracket along the root

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surface. After 10 weeks, the segmented arch had stabi-lized. This eruptive stage was followed by 4 weeks ofstabilization (Fig 5, C). Orthodontic treatment wascompleted after 14 months. Radiographic examinationsshowed the preorthodontic and postorthodontic extru-sion treatment (Fig 6).

In the third stage and after 14 months, atraumatic ex-tractions were performed on the maxillary right and leftcentral incisors without flap elevation (Fig 7, A and B),and 2 implants were placed: Alvin Cone Morse, 3.53 13mm, on the right side, and Titamax Cone Morse, 3.5 313mm, on the left side (Neodent, Curitiba, Paran�a, Brazil)(Fig 7, C). Adequate insertion torque (\40 Ncm) allowedfor immediate placement of 2 screw-retained provisionalrestorations. After 8 months, the implants had attained

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Fig 12. Follow-up cephalometric, periapical, and pano-ramic radiographs at 6 years.

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adequate stability, and 2 provisional titanium cylinderswere connected to the central incisor implants to createsufficient space and allow rehabilitation with definitiveprostheses (Fig 5,D). Radiographs showed the correct an-gulations of the adjacent teeth as well as the correct posi-tions of the implants in the maxillary arch (Fig 8).

After 22 months of initial treatment, the orthodonticappliances were removed, plaque control was per-formed, and a Hawley plate was placed to maintainthe teeth in the correct positions (Fig 9).

Four months after the removal of the devices, themandibular first right molar had a furcation defect,and the multidisciplinary team decided that extractionof the tooth and placement of an osseointregratedimplant were indicated.

In the fourth stage, 8 months after implant sur-gery, the prosthetic procedures were started by trans-fer impression for fabrication of the coping. Theuniversal Neodent screwed abutment of 4.5 3 2.53 6.0 mm was customized to create an estheticgingival contour within the limitations of the biologicdistances. Then feldspathic porcelain crowns (IPSEmpress II lithium-disilicate glass-ceramic restora-tions; Ivoclar Vivadent, Amherst, NY) were prepared

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and placed over the implants to obtain excellentesthetic results.

TREATMENT RESULTS

Six years postoperatively, the facial (Fig 10), clinical(Fig 11), panoramic, cephalometric, and periapicalradiographic (Fig 12), and cephalometric superimposi-tions (Fig 13) showed excellent esthetic results, andthe patient was highly satisfied. Posttreatment dentalcasts taken after 6 years (Fig 14) showed the stable rela-tionship between the dental arches.

DISCUSSION

One of the most difficult challenges in dentistry isrehabilitation of the anterior maxilla with implantswhen there are periodontally compromised teeth.12 Themain discussion is how to manage the residual defectsassociated with extraction of periodontally compromisedteeth and then to place implants successfully in thosesites. A complicating factor is the need to maintain func-tional and esthetic harmony with the adjacent naturalteeth.13 Extraction followed by immediate implantplacement has been advocated as a faster approach toreplace hopeless teeth with implants. This procedurecan be effectively used in many situations with excellentresults, but it might be ineffective when the periodontalbreakdown around the hopeless teeth is particularlysevere in areas with bone defects, as in our patient.14,15

Other treatment possibilities would be a bone graftbefore implant placement. However, a literature reviewindicated that the bone graft technique is extremelydemanding andmight be more useful in fully edentulousarches than in areas with small edentulous spaces.16,17

In this patient, the treatment option was forced or-thodontic extrusion. This method associated with othermultidisciplinary treatment can provide predictable out-comes in some situations, minimizing the need for costlyand time-consuming alterations of gingival tissues afterimplant integration.11

This treatment alternative depends on several factors,including the absence of ankylosed teeth, inadequateperiodontal support, and patient cooperation, and in sit-uations where hard-tissue augmentation is mandatory.The possibilities of correction of isolated infrabony de-fects and repositioning of the gingival margin withoutsurgery and before implant placement define this as aconservative treatment.

A therapeutic goal for adults should be individualizedtreatment. The aim of orthodontic treatment is to createthe necessary conditions for rehabilitation and replace-ment of missing teeth. Orthodontic extrusion reduces

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Fig 13. A, Superimposed cephalometric tracings show the changes from pretreatment (red line) toposttreatment (black line); B, partial superimpositions: maxilla and mandible.

Fig 14. Posttreatment dental casts after 6 years.

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the probing depth, increases the attachment, and conse-quently changes the periodontal structure: ie, it promotesthe growth of periodontal tissues, thus correcting infrab-ony defects and craters caused by periodontal dis-ease.18,19 According to the scientific literature, thecoronal formation of gingival tissues is stimulatedunder extrusive force; in most clinical situations, thegingival margin follows tooth movement.1,20,21

During forced eruption, the bone and gingiva sur-rounding the extruded tooth migrate coronally when alight force is used.19,22 Salama and Salama13 showedthat the attachment could be used to increase bone andgingiva in an occlusal direction to improve a potential

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implant site. They also suggested that forced eruption ofhopeless teeth was an effectivemethod for bone augmen-tation in sites where alveolar ridge defects complicate thecorrect implant placement and increase the keratinizedgingiva with the augmented alveolar bone.13

Forced eruption has also been used to restore imper-fect papillae in teeth with periodontal disease andfor implant site development before implant place-ment.11,23-25 Gingival and periodontal ligament fibersare stretched during forced eruption, promoting coronalgingival repositioning and new bone apposition in thedirection of movement.26,27 The provisional crown, afterimplant placement, can be fabricated for restoration of

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de Barros et al 615

anterior maxillary interdental papillae loss and gingivalconditioning.28

For our patient, slow forced orthodontic eruption al-lowed occlusal movement of the periodontal tissues andthereby increased the bone height. The forced orthodon-tic extrusion associated with other procedures providedeasier and more predictable results. Furthermore, thetherapeutic goals for the treatment of adults should beindividualized, and the treatment planning must bedone in detail, considering the necessity of acting pro-fessionally from related areas in an integrated way topredict the best results.

CONCLUSIONS

The decision to perform orthodontic extrusion forimplant site development in older patients should bemultidisciplinary because the ultimate treatment successdepends on the sequential clinical stages described.Combination treatment, including forced eruption,tooth extraction, and immediate implant placementwith fabrication of a provisional crown, was used tomake an esthetic and functional restoration of hopelessteeth compromised by periodontitis.

REFERENCES

1. de Molon RS, de Avila ED, Nogueira AV, de Souza JA, Avila-Campos MJ, de Andrade CR, Cirelli JA. Evaluation of the hostresponse in various models of induced periodontal disease inmice. J Periodontol 2013 Jun 27; http://dx.doi.org/10.1902/jop.2013.130225 [Epub ahead of print].

2. de Molon RS, de Avila ED, Cirelli JA. Host responses induced bydifferent animal models of periodontal disease: a literature review.J Investig Clin Dent 2012 Nov 27; http://dx.doi.org/10.1111/jicd.12018 [Epub ahead of print].

3. Taubman MA, Kawai T, Han X. The new concept of periodontaldisease pathogenesis requires new and novel therapeutic strate-gies. J Clin Periodontol 2007;34:367-9.

4. de Molon RS, Morais-Camilo JA, Verzola MH, Faeda RS,Pepato MT, Marcantonio E Jr. Impact of diabetes mellitus andmetabolic control on bone healing around osseointegrated im-plants: removal torque and histomorphometric analysis in rats.Clin Oral Implants Res 2013;24:831-7.

5. Corrente G, Abundo R, Re S, Cardaropoli D, Cardaropoli G. Ortho-dontic movement into infrabony defects in patients with advancedperiodontal disease: a clinical and radiological study. J Periodontol2003;74:1104-9.

6. TabaM Jr, Jin Q, Sugai JV, GiannobileWV. Current concepts in peri-odontal bioengineering. Orthod Craniofac Res 2005;8:292-302.

7. Chiu PP, McNamara JA Jr, Franchi L. A comparison of two intraoralmolar distalization appliances: distal jet versus pendulum. Am JOrthod Dentofacial Orthop 2005;128:353-65.

8. Gkantidis N, Christou P, Topouzelis N. The orthodontic-periodontic interrelationship in integrated treatment challenges:a systematic review. J Oral Rehabil 2010;37:377-90.

9. KorayemM, Flores-Mir C, Nassar U, Olfert K. Implant site develop-ment by orthodontic extrusion. A systematic review. Angle Orthod2008;78:752-60.

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10. Gkantidis N, Halazonetis DJ, Alexandropoulos E, Haralabakis NB.Treatment strategies for patients with hyperdivergent Class II Divi-sion 1 malocclusion: is vertical dimension affected? Am J OrthodDentofacial Orthop 2011;140:346-55.

11. de Molon RS, de Avila ED, de Souza JA, Nogueira AV, Cirelli CC,Margonar R, et al. Forced orthodontic eruption for augmentationof soft and hard tissue prior to implant placement. Contemp ClinDentistry 2013;4:243-7.

12. Avila ED, Molon RS, Assio Mollo F Jr, Barros LA, Capelozza Filho L,Almeida Cardoso M, et al. Multidisciplinary approach for theaesthetic treatment of maxillary lateral incisors agenesis: thinkingabout implants? Oral Surg Oral Med Oral Pathol Oral Radiol 2012;114:e22-8.

13. Salama H, Salama M. The role of orthodontic extrusive remodelingin the enhancement of soft and hard tissue profiles prior to implantplacement: a systematic approach to the management of extrac-tion site defects. Int J Periodontics Restorative Dent 1993;13:312-33.

14. Barzilay I, Graser GN, Caton J, Shenkle G. Immediate implantationof pure titanium threaded implants into extraction sockets[abstract]. J Dent Res 1988;67:234.

15. BeckerW, Becker B. Guided tissue regeneration for implants placedinto extraction sockets and for implant dehiscence: surgical tech-niques and case reports. Int J Periodontics Restorative Dent 1990;10:377-91.

16. Listrom RD, Symington JM. Osseointegrated dental implants inconjunction with bone grafts. Int J Oral Maxillofac Surg 1988;17:116-8.

17. Keiler EE, Von Roekei NB, Desjordins RP, Tolman DE. Prosthetic-surgical reconstruction of the severely resorbed maxilla with iliacbone grafting and tissue-integrated prosthesis. Int J Oral Maxillo-fac Implants 1987;2:155-65.

18. Heithersay GS. Combined endodontic-orthodontic treatment oftransverse root fractures in the region of the alveolar crest. OralSurg Oral Med Oral Pathol 1973;36:404-15.

19. Brown IS. The effect of orthodontic therapy on certain types ofperiodontal defects. J Periodontol 1973;44:742-56.

20. Batenhorst KF, Bowers GM, Williams JE Jr. Tissue changes result-ing from facial tipping and extrusion of incisors in monkeys.J Periodontol 1974;45:660-8.

21. Stern N, Becker A. Forced eruption: biological and clinical consid-erations. J Oral Rehabil 1980;7:395-402.

22. Ingber JS. Forced eruption: part II. A method of treating nonres-torable teeth—periodontal and restorative considerations. J Perio-dontol 1976;47:203-16.

23. Mantzikos T, Shamus I. Forced eruption and implant site develop-ment: soft tissue response. Am J Orthod Dentofacial Orthop 1997;112:596-606.

24. Mantzikos T, Shamus I. Forced eruption and implant site develop-ment: an osteophysiologic response. Am J Orthod DentofacialOrthop 1999;115:583-91.

25. Covani U, Cornelini R, Barone A. Bucco-lingual bone remodelingaround implants placed into immediate extraction sockets: acase series. J Periodontol 2003;74:268-73.

26. Reitan K. Clinical and histologic observations on tooth movementduring and after orthodontic treatment. Am J Orthod 1967;53:721-45.

27. Lin CD, Chang SS, Liou CS, Dong DR. Management of interdentalpapillae loss with forced eruption, immediate implantation, androot-form pontic. J Periodontol 2006;77:135-41.

28. Chee WW. Provisional restorations in soft tissue managementaround dental implants. Periodontol 2000 2001;27:139-47.

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