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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
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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.
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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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.
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.
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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.
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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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.
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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.
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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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.
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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.
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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.
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
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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.
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.
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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.
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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.
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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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.
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.
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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.
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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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.
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.
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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.
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.
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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;
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.
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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
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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.
References
1. Spear FM, Mathews DM, Kokich VG. Interdisciplinary
management of single-tooth implants. Semin Orthod. 1997;
3:4572.
2. Kan J, Rungcharassaeng K, Fillman M, et al. Tissue
architecture modication for anterior implant esthetics:
an interdisciplinary approach. Eur J Esthet Dent. 2009;4:
104117.
3. Buser D, Martin W, Belser UC. Optimizing esthetics for
Implant restorations in the anterior maxilla: anatomic
and surgical considerations. Int J Oral Maxillofac Implants.
2004;19(suppl 9):4361.
4. Amato F, Mirabella AD, Macca U, et al. Implant site
development by orthodontic forced extraction: a preliminary study. Int J Oral Maxillofac Implants. 2012;27:411420.
5. Chou YH, Du JK, Chou ST, et al. An interdisciplinary
treatment approach combining orthodontic forced eruption with immediate implant placement to achieve a
satisfactory treatment outcome: a case report. Clin Implant
Dent Relat Res. 2013;15:113120.
6. Reitan K. Some factors determining the evaluation of
forces in orthodontics. Am J Orthod. 1957;43:3245.
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