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Orthodontic extrusion for implant site

development revisited: A new classication


determined by anatomy and clinical outcomes
Mark N. Hochman, DDS,1 Stephen J. Chu, DMD, MSD, CDT,2 and
Dennis P. Tarnow, DDS3
A contemporary approach to achieving optimal implant esthetic-restorative
outcomes requires the knowledge to properly diagnose, coordinate, and
execute complex interdisciplinary care. Implant site development utilizing
orthodontic extrusion requires an understanding of many important concepts
and principles of both disciplines of orthodontics and periodontics. This article
reviews basic concepts of orthodontic extrusion and emphasizes a new
diagnostic periodontal classication scheme of the pre-treatment anatomy
that anticipates osseous and soft tissue responses to orthodontic extrusion.
Type 1 classication, the attached gingiva is connected to both bone and root
surface, and during orthodontic extrusion an increase in the width of attached
gingiva will occur. Type 2 classication, the attached gingiva and MGJ is
connected to the root surface, and during orthodontic extrusion the gingival
tissue moves coronally with the tooth, but an increase in the width of attached
gingiva does not occur. Type 3 classication; a periodontal pocket is present
and during orthodontic extrusion the free gingival margin does not move
coronally until there is a complete elimination of the periodontal pocket. In
addition, the article provides a greater understanding of the orthodontic
biomechanical principles and techniques that should be selected based on
anatomical considerations for each patient. Mastering the diagnostic and
technical aspects of orthodontic extrusion is an invaluable addition to the
interdisciplinary practice as it can provide an effective means to treat soft
tissue and osseous vertical deciencies of the periodontium. Orthodontic
extrusion may therefore represent a unique treatment alternative to some
of the most challenging esthetic situations. (Semin Orthod 2014; 20:208227.)
& 2014 Elsevier Inc. All rights reserved.

Introduction
here is, arguably, nothing more rewarding
for today's dentists than to gain condence
in their ability to achieve predictable outcomes in

1
Former Associate Clinical Professor, NYU College of Dentistry;
Private Practice of Periodontics and Orthodontics, New York, New
York, USA; 2Clinical Associate Professor, Department of Periodontology and Implant Dentistry, Department of Prosthodontics, NYU
College of Dentistry, New York, New York, USA; 3Clinical Professor,
Director of Implant Education, Columbia University College of Dental
Medicine, New York, New York, USA.
Address correspondence to Mark Hochman, DDS, 150 East
58th Street, Suite 3200, New York, NY 10155, USA. E-mail:
PerioOrtho@aol.com

& 2014 Elsevier Inc. All rights reserved.


1073-8746/12/1801-$30.00/0
http://dx.doi.org/10.1053/j.sodo.2014.06.007

208

the esthetic zone. One testament is the myriad of


treatment alternatives that have been developed
to address a wide scope of dental concerns. When
developmental or pathologic processes afict
patients causing them to seek esthetic-restorative
solutions in the anterior region of the oral cavity,
orthodontic extrusion has emerged as an innovative and unique alternative for achieving
optimal results.15
Orthodontic extrusion, also known as forced
eruption, was rst identied as a treatment
option to change the relative position of teeth
within the alveolar housing through active vertical eruption of teeth in an occlusal direction.6
The application of a controlled orthodontic
force to teeth resulted in a mechanically
mediated eruption to occur, hence the term

Seminars in Orthodontics, Vol 20, No 3 (September), 2014: pp 208227

Orthodontic extrusion for implant site development revisited

209

Figure 1. Pre-treatment view on left and orthodontic extrusion post-treatment view on right displaying
reformation of the interdental papilla. Improved gingival contour and esthetics.

forced eruption.7 This type of tooth movement


was initially used to change the bony topography
around teeth by taking advantage of bone
responses to orthodontic forces. In 1972,
Brown8 described such a technique as a
corrective procedure toward elimination of
infrabony defects resulting from periodontal
disease. He suggested that altering the osseous
conguration
through
controlled
tooth
movement could improve and even eliminate
intra-osseous vertical defects. The novel idea of
using a discipline outside of periodontics to treat
bone loss, i.e., orthodontics, can be considered
the catalyst that led to interdisciplinary dental
treatment used widely today to address many
challenging dental problems.
In 1974, Ingber9,10 described orthodontic
extrusion as an effective means of treating teeth
deemed non-restorable because of clinical crown
fracture and/or subgingival dental caries. He
further described the use of orthodontic

extrusion to resolve the restorative challenge of


insufcient clinical crown length for proper
restorative ferrule, which otherwise required
either periodontal surgical crown lengthening or
exodontia as the denitive form of treatment.
Ingber pointed out the resultant unfavorable
crown-to-root ratio from surgical removal of
supporting bone when utilizing periodontal
crown-lengthening procedures. In contrast, he
highlighted the benecial effect orthodontic
extrusion has on the crown-to-root ratio and the
overlying soft tissues (i.e., increase of the width of
attached gingiva). Therefore, Ingber is credited
with advancing the concept of interdisciplinary
treatment through clinical case reports and the
detailed descriptions of using this type of
orthodontics in the treatment of various restorative challenges.
More recently, Salama and coworkers were the
rst to publish a series of articles using orthodontic extrusion to augment bone and soft tissue

Figure 2. Pre-treatment view on left and orthodontic extrusion post-treatment view on right displaying the
increase in the zone of attached gingival tissue.

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Hochman et al

Figure 3. Type 1 classication. In this anatomical situation, the attached gingiva is rmly connected to both bone
and root surface, and the mucogingival junction is located on the bone. During orthodontic extrusion, an increase
in the width of attached gingiva will occur.

of the recipient dental implant site.1113 A classication scheme related to ndings and treatment was developed by these authors presenting
diagnostic guidelines and the therapeutic benets of using orthodontic extrusion to enhance
sites receiving implants. These authors stated the
notion that a hopeless tooth is not a useless
tooth, in which they advocated using periodontally compromised teeth to dramatically
improve the esthetic-restorative implant outcome. Salama and coworkers added to the work
of Ingber and Brown by using orthodontic
extrusion in another clinical situation, as a presurgical periodontal augmentation technique
prior to implant placement.

This article focuses on a contemporary


understanding of orthodontic extrusion with an
emphasis on discussing how the adaptive capacity
of the periodontal attachment leads to improved
conditions both esthetically and biologically.
Differences in biomechanical principles that
separate orthodontic extrusion from other
orthodontic movements are also discussed.

Principles of orthodontic extrusion


When compared to periodontal regeneration
techniques, orthodontic extrusion has the
potential to be an effective alternative for hard
and/or soft tissue augmentation.1417 The dental

Figure 4. Type 1 classication. In this anatomical situation, the attached gingiva is rmly connected to both bone
and root surface, and the mucogingival junction is located on the bone. During orthodontic extrusion, an increase
in the width of attached gingiva will occur.

Orthodontic extrusion for implant site development revisited

211

Figure 5. Type 2 classication. In this anatomical situation, the attached gingiva and associated MGJ is rmly
connected to the root surface and not found on bone. During orthodontic extrusion, the gingival tissue moves
coronally with the tooth, but an increase in the width of attached gingiva does not occur.

anatomy of the intact periodontium consists of


the tooth cementum, bone, gingiva, and the
periodontal ligament bers. Orthodontic tooth
movement affects these anatomical structures by
translating forces to produce a predictable biologic response. The mechanical eruption of the
tooth involves applying a direct force to the tooth
in a specic direction. This force creates a tension on the periodontal ligament bers, making
them stretch and elongate. This stretching of the
periodontal bers on the surface of the bone can
mediate cellular changes that lead to the desired
formation of new bone.18 When orthodontic
eruption is implemented, new bone formation is
produced at the crestal aspect of the alveolar
bone and along the surface of the bone

approximate to the root.1921 Therefore, the


periodontium can be predictably manipulated by
using controlled tooth movement to provide the
desired and only non-surgical technique of
producing new bone.
Orthodontic extrusion also has an additional
benet that affects the overlying gingival soft tissues.10,11,14 There can be an increase in the spatial
volume, particularly the height, of the gingival soft
tissue as a result of this type of movement.4 This has
important clinical implications as orthodontic
extrusion compared to surgical techniques is
reported as the most predictable means of correcting the loss of the interdental papilla4,5,16,17,22,23
(Fig. 1). Orthodontic extrusion, therefore, provides
a predictable solution in situations where there has

Figure 6. Type 2 classication. In this anatomical situation, the attached gingiva and associated MGJ is rmly
connected to the root surface and not found on bone. During orthodontic extrusion, the gingival tissue moves
coronally with the tooth, but an increase in the width of attached gingiva does not occur.

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Hochman et al

Figure 7. Type 1 and Type 2 classications. The image on the left is Type 1 and the image on the right is Type 2.
The relative position of the MGJ is identied in blue and the position of the crest of the bone is marked in green.
To anticipate the outcome from orthodontic extrusion, these landmarks need to be identied.

been a loss of the height of the gingival soft tissues,


which can be particularly problematic in the
esthetic zone24,25 (Fig. 2).

supracrestal bers. As the tooth is moved to its


new location, these bers become the
supporting structure for the reformation of

Periodontal gingival response to


orthodontic extrusion
The response of the periodontium to orthodontic forces is evident both on a macro- and
micro-level. This discussion is in context with the
understanding that the periodontal attachment
and the supracrestal bers of the gingival complex both play a role in the soft tissue anatomy.
As these structures collectively form the attachment coronal to the crest of the bone, they play a
critical role in changing the hard and soft tissue
topography during tooth movement.18,19 The
periodontal ligament and the supracrestal gingival bers connect the tooth to the bone. As the
orthodontic force moves the tooth coronally,
these bers stretch; this in turn produces tension
in the bone on a cellular level, which causes
bone deposition.26 The supracrestal bers play
a central role in the soft tissue morphology
before and after tooth movement. The papilla
and surrounding gingival tissue is mainly
composed of connective tissue with highly
organized ber groups. These are the circumferential, transseptal, dento-gingival, and
dentoperiosteal, collectively known as the

Figure 8. Type 3 classication. In this anatomical


situation, a periodontal pocket is present and is
conrmed with a loss of attachment. During orthodontic extrusion, the free gingival margin may not
move coronally until there is a complete elimination of
the periodontal pocket and the eversion of the apical
attachment of the periodontal pocket produced
during extrusive tooth movement.

Orthodontic extrusion for implant site development revisited

213

Figure 9. Type 3 classication. In this anatomical situation, a periodontal pocket is present and is conrmed with a
loss of attachment. During orthodontic extrusion, the free gingival margin may not move coronally until there is a
complete elimination of the periodontal pocket and the eversion of the apical attachment of the periodontal
pocket produced during extrusive tooth movement.

the interdental papilla and mid-facial gingiva in


its new location. The concept of orthodontic
extrusion leading to papilla regeneration is
therefore a misnomer; it is more accurately
described as the reformation of the papilla in a
new location.
Gingival health and the absence of gingival
inammation and/or disease are critical to
ensuring successful biologic and esthetic outcomes.11 Tooth movement in the presence of
gingival inammation has long been understood
as a contraindication to treatment for multiple
reasons. The undesirable outcomes of
accelerated bone loss, increased mobility, and
unpredictable soft tissue responses have been
reported when teeth are moved in the presence
of inammation.2628 Gingival inammation
produces a cascade of cellular responses that
disrupts the highly organized arrangement of
the periodontium. These pathologic changes
impact the supracrestal bers as well and can
result in changes to the osseous and soft tissue
response producing unpredictable outcomes
that can be undesirable during orthodontic
tooth movement.29,30 Therefore, every effort
must be made to create a healthy tissue environment prior to initiating orthodontic movement of teeth.31,32

Classication of soft tissue response to


orthodontic extrusion
The authors have identied three distinct outcomes of the soft tissue in response to orthodontic extrusion. Anticipating the gingival

response is based upon an understanding of the


following three parameters: (1) measuring the
sulcus or pocket depth prior to tooth movement,
(2) determining the position of the mucogingival
junction (MGJ) relative to the crest of the bone,
and (3) transgingival probing under local anesthesia or bone sounding to determine
the location of the crest of the bone and whether
there is attached gingiva connected to the
root surface and/or the periosteum of the
bone.4,16,33,34

Figure 10. Bodily tooth movement in which undermining bone resorption occurs all along the entire surface
on the pressure side of the tooth. This is contrasted by
bone apposition along the entire tension surface of the
tooth when moved in a horizontal direction.

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Hochman et al

Type 1: Increase of width of attached gingiva and


overall soft tissue width.
This outcome results when MGJ is attached to the
underlying surface of the bone and the attached
gingiva is connected to both bone and root
surface (Fig. 3). As the tooth is orthodontically
moved in a coronal direction, one can expect an
increase in the width of attached gingiva. In this
anatomical situation, the attached gingiva is
rmly connected to the bone thus preventing
MGJ from migrating coronally with the tooth.
Therefore, the only available biologic response of
the attached gingiva is to expand vertically
resulting in an increased width of this zone
(Fig. 4).
Figure 11. An extrusive force applied in a coronal
direction upon the facial surface of a maxillary
anterior tooth. It will produce a clockwise moment
that will cause the apex of the tooth to move in a facial
direction.

Type 2: Increase of overall soft tissue width with


no effect on the width of attached gingiva.

Proper evaluation of these parameters


prior to tooth movement increases the predictability of the resulting soft tissue architecture after orthodontic extrusion and helps
informing the patient regarding outcomes and/
or the need for additional procedures after tooth
movement.
This classication describes three types of soft
tissue responses to orthodontic extrusion, which
are as follows:

This outcome results when MGJ and the attached


gingiva is connected to the root surface and not
the surface of the bone (Fig. 5). Clinical
scenarios where MGJ is located on the root
surface include developmental factors such as a
bony dehiscence defect or a Type 2 altered
passive eruption or pathological situations such
as a history of bone loss. As a result, when the
tooth moves coronally, it carries along with it the
point of attachment of MGJ and the attached
gingiva (Fig. 6).

Figure 12. The series illustrates an anterior maxillary tooth with a normal incisal inclination. When a coronal force
is applied to the facial surface of the tooth during orthodontic extrusion, it will cause the apex of the tooth to move
in a facial direction if a counter-torqueing moment is not provided. This will lead to an undesirable outcome of
either a fenestration or dehiscence of facial plate of bone as a consequence of this type of tooth movement.

Orthodontic extrusion for implant site development revisited

215

Figure 13. A clinical example of orthodontic extrusion using a provisional restoration to apply a force through the
long axis of a tooth. This technique minimizes a forward clockwise movement from being produced during vertical
extrusion of these teeth thus preserving the facial plate of bone during this type of tooth movement. Pre-treatment
view of teeth number 8 & 9 requiring orthodontic extrusion of non-restorable fractured teeth.

Figure 14. A clinical example of orthodontic extrusion using a provisional restoration to apply a force through the
long axis of a tooth. This technique minimizes a forward clockwise movement from being produced during vertical
extrusion of these teeth thus preserving the facial plate of bone during this type of tooth movement. Use of intracoronal elastic thread applied through a provisional restoration. View of provisional restoration showing the access
holes in which elastic threads will pace to engage teeth number 8 & 9.

Figure 15. A clinical example of orthodontic extrusion using a provisional restoration to apply a force through the
long axis of a tooth. This technique minimizes a forward clockwise movement from being produced during vertical
extrusion of these teeth thus preserving the facial plate of bone during this type of tooth movement. Use of intracoronal elastic thread applied through a provisional restoration.

216

Hochman et al

Figure 16. A clinical example of orthodontic extrusion using a provisional restoration to apply a force through the
long axis of a tooth. This technique minimizes a forward clockwise movement from being produced during vertical
extrusion of these teeth thus preserving the facial plate of bone during this type of tooth movement. Pre-treatment
view on the left and the post-treatment orthodontic extrusion on the right. Note an increase in the zone of attached
gingiva as this patient exhibits a Type 1 classication.

It is important to diagnose which anatomical


situation is present, Type 1 or Type 2, prior to
tooth movement so that one may anticipate the
resulting tissue architecture (Fig. 7). Additional
soft tissue procedures, such as soft tissue grafting,
may be needed in Type 2 situations to increase
the zone of keratinized tissue after tooth
movement is completed.

Type 3: Width of attached gingiva and overall


width of soft tissue are unchanged.
After orthodontic extrusion is completed, the
position of the free gingival margin has not
moved. This outcome is found in cases where
there has been an advanced loss of periodontal
attachment on the surface of the root and there is
a periodontal pocket present (Fig. 8). In this
situation, neither the MGJ nor the attached
gingiva is connected to the root surface.
Therefore, before there is any gain in gingival
width, the periodontal pocket must rst be fully
eliminated through tooth movement. This
extrusive movement results in a complete
eversion of the base of the periodontal pocket
prior to observing any changes in the gingival
width. If the depth of the pocket is greater than
the distance the tooth is extruded, there will be
no increase of soft tissue width (Fig. 9).
With the aforementioned understanding of
how the pre-existing anatomy inuences the soft
tissue response to orthodontic extrusion, it
should be mentioned that surgical and/or
inammatory insults would change the outcomes

described above. A series of studies were conducted in which supracrestal berotomies were
performed simultaneously with forced eruption
to determine if the osseous and soft tissue
responses could be altered.20,35 The primary
objective of these studies was to eliminate the
need for a subsequent surgical crown lengthening in patients with insufcient clinical crown
length of fractured teeth. The studies demonstrated that intra-sulcular incisions made to the
bone crest, i.e., berotomies, performed simultaneously with orthodontic extrusion eliminated
the need for a subsequent surgical crownlengthening procedure on these teeth. These
ndings conrmed that the surgical dissection of
the supracrestal bers prevented coronal movement of bone during orthodontic extrusion.
Additionally, it was demonstrated that there was a
reduction in the increase of the gingival width
when compared to teeth in which berotomies
were not performed. These studies concluded
that berotomies alter the coronal migration of
both the osseous and gingival soft tissues through
the disruption of the supracrestal bers.20,35 It is
therefore critical to identify the soft tissue classication type and the intended use of orthodontic extrusion when considering berotomies.
If crown lengthening is the goal of the orthodontic extrusion, berotomies may be indicated
as an adjunctive procedure as long as an increase
of soft tissue width is not required. However, if
implant site development with tooth removal is
the treatment endpoint, one should rst determine the soft tissue classication and consider

Orthodontic extrusion for implant site development revisited

217

Figure 17. A clinical example of orthodontic extrusion using a provisional restoration to apply a force through the
long axis of a tooth. This technique minimizes a forward clockwise movement from being produced during vertical
extrusion of these teeth thus preserving the facial plate of bone during this type of tooth movement. Flapless
extraction of teeth numbers 8 and 9 with immediate implant placement.

whether berotomies will interfere with the


desired soft tissue outcome. Note, in almost all
situations of implant, site development combined
with tooth removal berotomies is contraindicated, as they will impede the maximum
amount of bone that can be formed.

Principles of orthodontic extrusion


Biomechanics
Orthodontic tooth movement is traditionally
understood as a discipline that is concerned with
space management in the three planes of space:
sagittal, coronal, and transverse. The primary
movements of teeth are related to tooth movements that facilitate the correction of bodily
movement, rotations, tipping, torque, and space

management in the faciallingual, inciso-gingival, and mesialdistal directions.


A review of literature on the subject of
orthodontic extrusion reveals that it has been
referred to as a simple or uncomplicated
movement.8,9,11 The authors have come to
understand that, although applying such a force
may be simple, the effects of such a force are
found to be far more complicated than one
might expect. A more thorough analysis of the
application of force, center-of-resistance, and
resultant movement demonstrated that orthodontic extrusion is complex requiring an
understanding of multiple variables in order to
achieve predictable results.
A simple movement, in orthodontic terms,
refers to a movement that results from the
application of a vector of force in a single

Figure 18. A clinical example of orthodontic extrusion using a provisional restoration to apply a force through the
long axis of a tooth. This technique minimizes a forward clockwise movement from being produced during vertical
extrusion of these teeth thus preserving the facial plate of bone during this type of tooth movement. Flapless
extraction of teeth numbers 8 and 9 with immediate implant placement.

218

Hochman et al

direction, producing a movement in a single


direction. An example is horizontal bodily
movement of a tooth (Fig. 10). More complex
movements are produced when a force is applied
at a specied distance from the center-ofresistance resulting in a rotational movement
known as a moment (Fig. 11). This specic
movement has even more complexity particularly
when it occurs in a constrained body, such as a
tooth held in the alveolar bone.
One must also keep in mind that the current
generation of orthodontic bracket designs used

in xed appliances were never intended for pure


vertical extrusive movements. These brackets
were designed to optimize movement of teeth
into an idealized position within the alveolar
bone. In contrast, orthodontic extrusion often
has the intended objective to move teeth to
extreme positions, often to the point of extraction. In essence, effective tooth movement for
implant site development involves moving teeth
to the limits of the alveolar bone. This outcome is
hampered by current bracket design technology,
as will be addressed later.

Figure 19. A clinical example of orthodontic extrusion using a provisional restoration to apply a force through the
long axis of a tooth. This technique minimizes a forward clockwise movement from being produced during vertical
extrusion of these teeth thus preserving the facial plate of bone during this type of tooth movement. (A)
Immediate post-operative view on the day of removal of teeth numbers 8 and 9 on the left, and 9-month postsurgical view with nal restorations of the maxillary anterior teeth on the right. Note the general health of the
gingival tissues, retention of the interdental papilla, and an improved clinical crown length (tooth proportion) of
teeth numbers 8 and 9 resulting in a favorable esthetic-restorative implant outcome. (B) This series illustrates an
anterior maxillary tooth during orthodontic extrusion into a provisional restoration. When a vector of force is
applied directly through the center-of-resistance into the provisional restoration in a coronal direction, the apex of
the tooth will move in that same direction. This will eliminate the undesirable forward clockwise movement of the
apex of the tooth during extrusion.

Orthodontic extrusion for implant site development revisited

219

Figure 20. Clinical exam shows a patient with 34 mm of gingival recession and 5 mm of probing depths on teeth
numbers 8 and 9. The patient's chief complaint included loss of interdental papilla, food entrapment in space and
excessive mobility of these teeth.

Anatomic considerations in the esthetic


zone
The biomechanical principles of orthodontic
extrusion are also affected by the anatomy of the
pre-maxilla. Therefore, implant site development and papilla reformation in the anterior
maxillary region present challenges not found in
the posterior region since these teeth have an
upright and vertical axial inclination. Maxillary
anterior teeth have an inherent proclined axial
inclination. This angulation can be measured
using standard cephalometric analysis such as the
Steiner analysis. The analysis uses the interincisal
angle and maxillary central incisor to NA angle to
determine if the inclination of the maxillary
incisor is normal, retroclined, or proclined relative to the skeletal base.36,37 The anterior tooth
with a proclined axial inclination will produce a
forward clockwise (leftright) moment upon the

apex of a tooth when moved in a coronal


direction. The forward clockwise moment will
cause the apex of the tooth to be driven in a facial
direction with possible perforation through the
apical portion of the facial alveolar bone plate. It
is interesting to note that the dental literature has
recently documented that the facial plate of bone
thickness on anterior teeth is 0.51.0 mm on
average (0.3 mm) even when 10 mm apical
from the CEJ.3840 Therefore the more proclined
an anterior tooth is, the greater the risk of perforation and the greater the need to counteract
the forward clockwise moment at the apex
(Fig. 12). These authors contend that the axial
inclination of anterior teeth requires a more
careful evaluation of this facialpalatal perspective prior to orthodontic extrusion movement. In
addition, careful consideration with respect to
appliance design is warranted to prevent apical
bone perforation or facial dehiscence.

Figure 21. Radiographic evaluation reveals 4050% horizontal bone loss on teeth numbers 8 and 9 in periapical
radiographs. In addition, CBCT suggests a lack of labial cortical plate of bone on teeth numbers 8 and 9.

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Hochman et al

Figure 22. Orthodontic extrusion of teeth numbers 8 and 9 with a base archwire and a secondary archwire (0.016
NiTi) to produce vertical extrusion. Active tooth movement is performed over a 12-month period. Extensive
occlusal equilibration was required during orthodontic extrusion. Note the new position of the gingival margin
and improved position of the interdental papilla.

Previous publications have documented a high


incidence of fenestrations as a result of orthodontic extrusion. This undesirable outcome was
most likely the result of a lack of control of the
forward clockwise moment that was produced
during orthodontic extrusion.9,10,16,41
Torque control can be managed in three
different ways: (1) negative torque brackets in
combination with rectangular archwires, (2)
vertical loops with rectangular archwires, and (3)
bracket-less technique by using a tooth-borne
xed provisional restoration to anchor the
extrusive force. Each of these techniques will be
subsequently discussed.

Orthodontic edgewise brackets are designed


with an angulation of tip and torque incorporated into every bracket specic for each individual tooth of the maxillary and mandibular
jaws. Andrews popularized this treatment
approach.42 This is accomplished by the bracket's
slot design and angulation to the bracket base.
Negative high-torque brackets used in the premaxillary region will provide increased lingual
root torque to position the apex of the tooth root
toward the palate. It is noteworthy that a rectangular archwire needs to be engaged in the
bracket slot when an edgewise bracket is used to
control torque as this can maximize the force

Figure 23. Orthodontic extrusion of teeth numbers 8 and 9 with a base archwire and a secondary archwire (0.016
NiTi) to produce vertical extrusion. Active tooth movement is performed over a 12-month period. An additional 6
months of stabilization was provided after active tooth movement to allow bone maturation prior to tooth removal
and the placement of dental implants. Left image shows the repositioning of brackets on the root surface of teeth 8
& 9 during treatment which was necessary. Right image is of the nal position of teeth after orthodontic extrusion.
Note the reformation of the interdental papilla on teeth 8 & 9 and an increase in the width of attached gingiva at
completion of tooth movement.

Orthodontic extrusion for implant site development revisited

221

Figure 24. Orthodontic extrusion of teeth numbers 8 and 9. Pre-treatment radiograph (far left) displays 40% to 50%
horizontal bone loss prior to movement. Sequential radiographs taken at six, nine and twelve months demonstrates
the reformation and improved vertical height of the alveolar crest of bone that was achieved during treatment.

exerted to the apex of the tooth. Utilizing round


archwires in an edgewise bracket cannot effectively produce proper counterbalancing movements. Therefore, it is equally important to use
the proper size and shape of rectangular archwires when relying upon orthodontic coupling
forces to control the clockwise moment during
orthodontic extrusion. The authors have used
this approach with success.
A second effective means of controlling root
torque during orthodontic extrusion is using

individually constructed archwires that possess


wire-specic congurations. For instance, the use
of vertical T loops can be made using a rectangular Beta-Titanium wire to produce a vertical
extrusive force. This type of wire construction
allows greater control in the vertical direction
while simultaneously enabling effective root
torque control that is produced by a rectangular
archwire. The negative implications of using
vertical T loops and the like can be the additional time it takes to construct these appliances.

Figure 25. Cross-sectional CBCT radiograhic views of teeth numbers 8 (left image) and 9 (right image) at the
completion of tooth movement. Controlled facial extrusion in combination with vertical extrusion produced
increased bone dimensions in both the vertical as well as the buccallingual dimensions of the alveolar ridge. This
non-surgical bone augmentation using orthodontic tooth movement was sufcient to allow the placement of
dental implants at site numbers 8 and 9.

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Hochman et al

Figure 26. A apless extraction of teeth numbers 8 and 9 was performed concurrently with immediate implant
placement at site numbers 8 and 9. Note soft tissue preservation of the interdental papilla and the surrounding
normal gingival architecture.

The comfort of the patient is also a factor when


using archwires with loops and elaborate designs;
however, when properly designed, they can be
well tolerated.
A third means for providing effective root
torque control during extrusion is by applying a
force from an alternative point on the tooth.
A biomechanical appliance design in which the
force vector moves through the center-ofresistance of the tooth minimizes and can
often eliminate the undesirable forward clockwise moment that is seen when a facial bracket is
placed on the tooth. The key factor in the design
of such an appliance is to align the vector of force

along the long axis of the tooth. A tooth-borne


provisional restoration offers this unique
requirement. Full-coverage acrylic provisional
restorations used to house the erupting tooth
not only provide long-axis vectoring forces but
also a more esthetic option during movement
when compared to bracket placement on the
labial surface of an anterior tooth since there are
no buccal brackets on these teeth (Figs. 1319).
There are many creative options using a
provisional restoration as an orthodontic appliance. The following features need to be present
to accomplish these goals. The provisional
restoration needs to be supported by the

Figure 27. Occlusal clinical view of implant position at site number 8 and 9 immediate post implant placement.
Radiograpic view of implants immediate post implant placement.

Orthodontic extrusion for implant site development revisited

223

Figure 28. The images from left to right show a series of steps required in the fabrication of a properly contoured
immediate implant provisional crowns at the time of implant placement. The development of a proper emergence
prole in the subgingival area tissues is emphasized with the bold arrows on the labial surface of these restorations.

adjacent teeth and/or implants. The tooth to be


extruded requires sufcient reduction of the
remaining clinical crown (tooth preparation) so
that it can be accommodated into the provisional. Modications to the internal surface of
the provisional restoration need to be made so
that the prepared tooth has sufcient internal
clearance during tooth movement. Lastly, a
means of generating adequate force from the
provisional to the tooth to be moved, typically an
elastic thread (0.025 in.), can be used with a light
force of less than 80 g. This will provide movements of 12 mm per month. Frequently, prophylactic endodontic therapy is performed to
eliminate the potential for pulp exposure during
tooth reduction and to allow preparation
through the clinical crown for elastic ligation as
previously described.

The biomechanical advantage to employing a


provisional restoration is shown in the accompanying diagram (Fig. 19B). Note that when the
force application can be applied from the center
of the crown in a coronal direction, the force
vector can be applied through the center-ofresistance of the tooth. This biomechanical
model demonstrates bodily movement through
pure translation in an occlusal direction.
Therefore, the use of a provisional restoration
provides a means to avoid creating the forward
clockwise moment typically found when xed
facial brackets are used.
Awareness of the aforementioned principles
enables clinicians to understand the subtle but
critical differences between conventional tooth
movement and orthodontic extrusion. This
knowledge and the proper application of a

Figure 29. The images from left to right show a series of steps required in the fabrication of a properly contoured
immediate implant provisional crowns at the time of implant placement. The development of a proper emergence
prole in the subgingival area tissues is emphasized.

224

Hochman et al

variety of innovative techniques will yield great


predictability of functional and esthetic results.

Case presentation
A 48-year-old male patient with an unremarkable
medical history presented for comprehensive
dental treatment. A periodontal diagnosis of
localized moderate to severe periodontitis with
localized horizontal bone loss and moderate to
severe (localized) gingival recession was noted
on the maxillary central incisors (Fig. 20). The
patient's chief complaint was I have a large space
between my front teeth and these teeth feel
loose. Radiographic evaluation revealed 40
50% bone loss of teeth numbers 8 and 9
(Fig. 21). Clinical exam revealed localized
probing depths of 5 mm with 34 mm of
gingival recession on the facial aspect of these
teeth. This patient was diagnosed as a Type I
attachment in which MGJ is attached to the
periosteum and the attached gingiva is
connected to the root surface. Mobility was
scored as Class II according to the Miller scale.
These teeth had previous endodontic therapy as
a result of severe root sensitivity. Cone beam
computer tomography (CBCT) suggested a lack
of the facial cortical plate of bone on these teeth
(Fig. 21). Pertinent cephalometric information
included Steiner analysis, an incisal angle of 1251,
and an interincisal angle of 971. Multiple
treatment options were proposed. One
treatment option was closure of the diastema
with conventional xed orthodontic appliances;

however, this did not address the patient's chief


complaint that included the loss of the
interdental papilla. In addition to the esthetic
concern, the black triangle led to difculty in
speaking and food entrapment. After careful
interdisciplinary analysis, a treatment alternative
designed to correct this deciency was proposed
to the patient. Orthodontic extrusion leading to
extraction of numbers 8 and 9 would be used for
repositioning the interdental papilla and vertical
bone growth with the anticipation of placement
of dental implants at these sites (Figs. 2224).
CBCT revealed the faciallingual thickness of
bone would be insufcient to accommodate the
appropriate size of implants. To meet this challenge, and with the knowledge of the biomechanical principles already discussed, an
innovative approach was proposed to augment
the recipient implant site. Owing to the axial
inclination of these teeth and the local anatomy
of the pre-maxilla of this patient, the authors
proposed that applying an excessive forward
clockwise moment to the apex of teeth numbers
8 and 9 would cause the roots to be labial to the
facial plate of bone. The authors term this
technique controlled facial extrusion dened
as a variant of orthodontic extrusion in which a
controlled facial (forward clockwise) moment is
employed to allow bone apposition along the
palatal aspect of the root thereby regaining the
lost facialpalatal dimension of the alveolar ridge
(Fig. 25). This deliberate controlled movement
would result in orthodontically facilitated bone
deposition along the root surface resulting from

Figure 30. Clinical view of the nal implant supported restorations at the 1-year follow-up visit on the left. CBCT
demonstrates the presence of a facial cortical plate of bone on the surface of implant numbers 8 and 9 on the right.
Controlled facial orthodontic extrusion in combination with vertical extrusion provided effective implant site
development to the gingival tissues and the underlying supporting bone simultaneously and non-surgically.
Orthodontic extrusion represents a reliable option for the multidisciplinary patient.

Orthodontic extrusion for implant site development revisited

the tension along the entire surface of the palatal


aspect of these teeth during movement. As described previously, the surface tension promotes
bone apposition along the entire front of these
teeth as they are moved away from the bone in a
facialocclusal direction. The reformation of an
adequate thickness of the alveolar ridge using
orthodontic facial and vertical extrusion is a
unique method of movement. Additionally, the
controlled facial and vertical orthodontic
extrusion technique would result in an increase in the width of attached gingiva and the
reformation of the interdental papilla between
teeth numbers 8 and 9 fullling the second
treatment objective of using this technique. It
bears repeating that this technique is performed
with the nal goal of removing the teeth and
placing immediate post-extraction socket
implants after the completion and stabilization of
orthodontic movement.
The patient had active tooth movement over a
period of 12 months. Once the adequate
dimension of alveolar bone was conrmed via a
subsequent CBCT, the teeth were held in this
position for an additional 46 months to allow
time for bone maturation. Soft tissue repositioning and the reformation of the lost interdental papilla is noted in Fig. 23. Immediate postextraction socket implant placement was performed at the time of the removal of teeth
numbers 8 and 9 (Fig. 26). The extractions were
performed with a minimally invasive approach
dened as a apless technique using
periotomes and forceps. The biologic rationale
for a apless technique relates to preserving the
supracrestal bers and soft tissues that have been
established during tooth movement; additionally,
the apless approach preserves a critical blood
supply for the newly reformed bone.
Delayed implant placement after the extraction of these teeth is contraindicated. The
authors have observed two undesirable outcomes
when delayed implant placement is utilized after
tooth removal: (1) the newly formed orthodontically facilitated bone will resorb if direct physical bone stimulation is not maintained and (2)
the gingival tissues will undergo remodeling after
tooth removal, with a loss of height and thickness.
The immediate placement of dental implants
into the matured alveolar ridge after 46 months
of stabilization provides a favorable environment
for long-term preservation of the reformed bone

225

and soft tissues. In addition to immediate implant


placement into the regenerated sites, fabrication
of properly contoured immediate implant provisional crowns is a critical component to the
preservation of the soft tissue gingival contour
(Figs. 2729). The proper restorative contours
created by the provisional restorations were
transitioned to the denitive ceramo-metal
restorations (Fig. 30).

Discussion
The technique of orthodontic extrusion has been
utilized for a variety of applications in dentistry
since it was rst described over 40 years ago.6,7
The initial use of this technique demonstrated
that it could be used as a means of eliminating
periodontal infrabony defects. Shortly thereafter,
this same technique was used to orthodontically
erupt fractured teeth so that a sufcient
amount of clinical tooth structure would be
available to restore a previously non-restorable
tooth. The notion to use orthodontic extrusion
to regenerate the interdental papilla has now
become routine procedure and is currently
accepted as the most predictable technique in
the reformation of the interdental papilla.4,5,16,17,22,23 More recently, the use of orthodontic extrusion as an effective tool in implant
site development has become an area of great
interest, as this technique provides patients and
clinicians with many advantages when compared
to surgical techniques.4,11,1225
There are several disadvantages of using
orthodontic extrusion as a therapeutic form of
treatment. During vertical tooth movement,
occlusal interferences and contact to the opposing arch must be eliminated. This often requires
substantial tooth reduction, which can cause
sensitivity and/or pulp exposure, requiring prophylactic endodontic therapy (even if these teeth
will eventually be extracted). The additional cost
and time must be explained to the patient.
Patients are typically seen every 34 weeks during
the active phase of tooth movement. These
appointments are used to re-activate the force
applied to the teeth. If a provisional restoration is
to be used as the appliance for tooth movement,
time must be allotted to remove the cemented
provisional, re-activate the appliance, and recement the provisional restoration. These
repeated visits require signicant chair-time for

226

Hochman et al

each visit to accomplish. The total treatment time


require to perform these procedures may be 918
months, and the duration of treatment is determined by severity of the tissue deciency and the
complexity of the tooth movement required.
Additional time for a retention phase of treatment must be added to the active treatment time,
and this is typically not needed in other treatment
modalities. One must weigh these disadvantages
against the unique advantages that orthodontic
extrusion offers.
This article highlights several important anatomical considerations and biomechanical principles affecting orthodontic extrusion, not found
in the current literature. A novel technique,
controlled facial extrusion combined with vertical eruption, was dened and described as a
method to augment the facialpalatal width
dimension of bone. The authors have sought to
call attention to the potential of producing
unwanted outcomes from poorly controlled
forces that occur and are unique to the esthetic
zone. The anatomy of the pre-maxilla, the
angulation of anterior teeth, and the thickness of
the facial alveolar bone are paramount factors to
take into account when designing the orthodontic appliance to be used for forced eruption.
As with all orthodontic interventions, gingival
health also plays a crucial role in a successful
outcome. A discussion of biomechanical vectors
and moments that occur during forced eruption
addressed how this particular type of tooth
movement markedly differs from conventional
tooth movements. Understanding and addressing these differences will ensure the desired
outcome can be achieved. The importance of
torque control was discussed, and several solutions were offered to counteract the forward
clockwise rotational moment that is generated by
extrusive forces.
Not to be overlooked is the fact that the
sequence, timing, and technique of extraction of
teeth and implant placement after orthodontic
extrusion can greatly affect the nal outcome.
Stabilization after active tooth movement during
orthodontic extrusion has been recommended
for a minimum period of 46 months to allow
bone maturation and further ossication.
A minimally invasive non-surgical apless tooth
removal should be followed by the immediate
implant placement of dental implants after
orthodontic site development. This is concurrent

with the immediate placement of a properly


contoured non-functionally loaded implant supported temporary restoration. Bone and soft tissue preservation after tooth movement requires
careful planning, execution, and timing by the
multidisciplinary team.

Conclusion
Orthodontic extrusion is a treatment alternative
with multiple benets that are not easily duplicated with other more invasive forms of treatment. Among these are the ability to predictably
regenerate osseous and soft tissues, eliminate
infrabony defects, improve the crown-to-root ratio
of compromised teeth, convert a non-restorable
tooth into a restorable tooth, and the use of a
hopeless tooth for effective site development for
implant treatment. The use of orthodontic
extrusion will improve the nal estheticrestorative implant outcome in some of the
most esthetically challenging clinical situations.
Orthodontic extrusion is often the only modality
that will achieve the optimal esthetic and functional outcome where there is extensive loss of soft
and hard tissues in the esthetic zone. Mastering
the techniques of orthodontic extrusion is an
invaluable addition to the interdisciplinary practice because they offer predictable results for
clinicians and patients alike.

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