Surgical Extrusion of Three Premolars to Re-establish the Biological Width: Case Series.

AIM: This case series was to describe the use of surgical extrusion for three different cases as a technique to re-establish the biological width in patients with insufficient crown height. BACKGROUND: Surgical extrusion serves as an important means to reestablishing a proper biological width. Such method provides an excellent alternative for the restoration of teeth with insufficient ferrule and ensuring a suitable dental restoration. CASES DESCRIPTIONS: This case series describes the management of three different cases with compromised teeth #25, #35, and #44, respectively. The approach involved the surgical extrusion of the compromised sites from subgingival to supragingival and the splinting of the teeth using a semi-rigid splint. A successful prognosis was observed on follow-up visits. CONCLUSION: This technique is a good alternative for general practitioners because of its easy implementation and time efficiency. In addition, the method requires less equipment and provides for adequate space for the re-establishment of biological width. CLINICAL SIGNIFICANCE: Such technique can re-establish a healthy biological width, the existing occlusion can be maintained without alterations, and it demonstrated the suitability of surgical extrusion technique in such clinical situations. Case selection is equally important. Cases with single-rooted teeth with fractures or caries in proximity to the marginal bone level without vertical root fractures generally provide positive outcomes on providing this treatment. How to cite this article: Boreak N, Al Moaleem MM, Zain AA, et al. Surgical Extrusion of Three Premolars to Re-establish the Biological Width: Case Series. J Contemp Dent Pract 2024;25(6):593-598.

Survival evaluation of surgical extrusion for the management of complicated crown-root fractured maxillary incisors: A clinical study.

This study aimed to clinically evaluate the survivability of surgically extruded teeth, to assess the success rate and predictable factors pertaining to alterations in both hard and soft tissues adjacent to extruded teeth. A total of 46 complicated crown-root fractured maxillary central and lateral incisors with >75% tooth structure loss relatively due to trauma were included. Preoperative clinical and radiographic variables were recorded. Single operator performed endodontic treatment before surgical extrusion. Patients were recalled for review at 6, 12, 18, 24 and 36 months. Survivability was assessed using Kaplan-Meier survival analysis. With a mean follow-up of 2.8 years, survival rate was 95.7%. Mobility observed in only two cases. The crown-root ratio was favourable (1:2) in all the cases except for five teeth. Only two teeth displayed non-progressive root resorption. Survival of surgically extruded teeth relies on significant predictors like favourability of CRR and implementation of atraumatic extrusion.

Management of luxation injuries in line with International Association of Dental Traumatology guidelines - Two case reports.

Luxation injuries represent significant traumatic events for permanent teeth. This article presents the management of intrusive and extrusive luxation injuries, following the International Association of Dental Traumatology (IADT) guidelines, through two case reports. The first case involves a 30-year-old female with an intruded maxillary left central incisor, managed through surgical extrusion, stabilization, and endodontic treatment. The second case features a 15-year-old female with an extruded maxillary left central incisor, repositioned and splinted. Follow-up examinations revealed the resolution of symptoms in both cases. These cases highlight the efficacy of IADT guidelines in diagnosing and treating luxation injuries, resulting in favorable outcomes.

Tooth autotransplantation gives teeth a second chance at life: A case series.

Traditional transplantation, surgical extrusion and intentional replantation procedures are important treatment options that clinicians may consider performing in their daily clinical practice. There should be a well-constructed treatment plan for teeth with problems. In this paper, we present a series of case reports on three treatment methods used in autologous tooth transplantation and a literature review on the prevention of postoperative complications and the advantages of autologous tooth transplantation compared to dental implantation. The purpose of this study was to improve the understanding of autologous tooth transplantation.

Forced surgical extrusion using an axial tooth extraction system as a practicable technique for preserving severely destroyed teeth? - Clinical outcomes up to 4.8 years.

OBJECTIVE: Several extrusion techniques have been described to restore teeth with insufficient coronal tooth structure and to avoid their extraction. Still, there is little evidence for a treatment concept combining surgical extrusion using an atraumatic axial extraction system. MATERIALS AND METHODS: A total of nine patients, each with an iso- or subgingival fractured tooth, were retrospectively examined. Treatment of the damaged tooth comprised an atraumatic forced surgical extrusion performed with an axial tooth extraction system and a more coronal positioning within the socket. The teeth were initially splinted and subsequently restored. The follow-up period was up to 57.1 months and averaged 36.5 (SD: ±13.5) months. RESULTS: All nine teeth were still in situ, without signs of inflammation. During the period of the provisional restoration, six prosthetic complications occurred, which were resolved with little effort, whereas, success rate for the definitive restoration was 100%. No biological complications were observed concerning the root apex or soft tissue. The radiographically measured mean extrusion distance was 3.4 (SD: ±1.0) mm, so that a sufficient prosthetic ferrule could be reestablished. CONCLUSIONS: Surgical extrusions using an axial tooth extraction system demonstrate low biological and prosthetic complications rates over observation time. CLINICAL SIGNIFICANCE: The presented extrusion approach preserves soft and hard tissue and is an efficient treatment option for severely destroyed teeth. Saving hopeless teeth by this relatively predictable and feasible procedure has hardly any disadvantages for patients, and in case of failure, an implant or fixed partial denture are still an option.

Morpho-functional restoration of an element in esthetic area through modified intentional replantation: A case report with 16 months follow-up.

This study aims to evaluate the success of the morpho-functional restoration of a tooth with subgingival carious lesion using the modified replantation technique, which entails the rotation of the element of 180° on its axis. This study has a follow-up of 16 months. A 68-year-old man comes to rehabilitate the esthetic and the functionality of element 1.2, affected by destructive carious process extended below the gingival margin. At the clinical and radiological examination, the possibility of a conservative approach is excluded due to the total lack of healthy dental tissue to construct the ferula. It is executed the technique of modified intentional replantation, followed by a rehabilitative phase. After 16 months of follow-up, it can be appreciated the stability of the hard and soft tissue, the lack of pathological probing or symptomatology, and radiographically there is no evidence of bone or root resorption. The modified intentional replantation can be a valid alternative to the surgical lengthening of the clinical crown, to the orthodontic extrusion or to the surgical extrusion. This variation allows obtaining an apical stop during the replanting phase, which contributes to the stabilization of the element. Due to the short follow-up examination from us, further studies are necessary.

Prosthetic restoration after atraumatic surgical extrusion: a report of two cases.

Preservation and restoration of teeth with little coronal tooth structure due to crown-root fractures or caries lesions, ensuring restoration margins do not encroach on the biologic width, constitute a challenge. Available treatment options include surgical crown lengthening and orthodontic or surgical extrusion. This report presents two patients in which teeth were restored by surgical extrusion with an atraumatic extraction system and prosthetic therapy.

Present status and future directions: Surgical extrusion, intentional replantation and tooth autotransplantation.

Surgical extrusion, intentional replantation and tooth autotransplantation procedures are important treatment options that clinicians may consider performing in their day-to-day clinical practice. Despite compromised teeth are generally considered for extraction, clinicians must be aware that these cases could be suitable for management by these alternative predictable treatment options. Surgical extrusion, intentional replantation or tooth autotransplantation have similar treatment protocols which includes atraumatic tooth extraction, visualisation of the root portion and replantation. Surgical extrusion is defined as the 'procedure in which the remaining tooth structure is repositioned at a more coronal/supragingival position in the same socket in which the tooth was located originally'. Intentional replantation is defined as the 'deliberate extraction of a tooth and after evaluation of root surfaces, endodontic manipulation and repair, placement of the tooth back into its original position'. Tooth autotransplantation is defined as the 'transplantation of an unerupted or erupted tooth in the same individual, from one site to another extraction site or a new surgically prepared socket'. The same team previously published a narrative review (International Endodontic Journal. 2020, 53, 1636) and European Society of Endodontology position statement (International Endodontic Journal. 2020, 54, 655) on this topic in International Endodontic Journal. The aim of the current updated review was to provide the reader a complete overview and background on these procedures, to established clear clinical protocols and step-by-step for technically perform these therapies in their clinical practice and to establish future directions on the topics. The clinicians must periodically update their knowledge about these three procedures to achieve success.

Periodontal and Periapical Outcomes of Surgical Extrusion: A Prospective Clinical Volumetric Study.

INTRODUCTION: Outcome predictors for the restoration of endodontically treated teeth mainly include cavity wall integrity and the presence of a 1.5-2 mm ferrule. However, in some clinical situations, the aforementioned predictors cannot be achieved. Three different techniques have been proposed to obtain an adequate ferrule respecting the supracrestal tissue attachment: surgical crown lengthening, orthodontic forced eruption, and surgical extrusion. There are little published prospective data evaluating periodontal changes after surgical extrusion. Therefore, the aims of this study were to report the outcome of surgical extrusion in single-rooted teeth, to digitally evaluate soft tissue volumetric changes after surgical extrusion, and to observe patient satisfaction regarding the treatment after a minimum of 1 year. METHODS: This prospective clinical study was performed between 2017 and 2020. Thirteen patients referred for surgical extrusion met the following inclusion criteria: nonsmokers; systemically healthy with at least 1 straight, single-rooted tooth with an insufficient ferrule; a favorable tooth crown-to-root ratio, and no periodontal pathology. Preoperative clinical variables included patient age, sex and phenotype, tooth number, tooth mobility, crown-to-root ratio, gingival index (GI), probing pocket depths at 6 sites, bleeding on probing (BOP), and mesial and distal interproximal papillae volume. Surgical extrusion was performed by a single operator who completed the root canal treatment/retreatment and restored the teeth with a crown. One year later, all patients were controlled, and the following variables were recorded: tooth mobility, crown-to-root ratio, GI, pocket depth, BOP, interproximal papillae aspect, soft tissue rebound, periapical healing, marginal bone loss, and patient-reported outcome measures of the treatment. All variables were analyzed using a descriptive method (mean, %). The Wilcoxon test was used to evaluate pre- and postoperative clinical parameters at a significance level of .05. RESULTS: At a mean follow-up period of 18.8 months, no teeth were extracted. Compared with preoperative GI and BOP, a significant reduction was observed at 1 year after surgery. Likewise, no significant differences in probing depths were shown, and only 1 tooth presented a type 2 mobility. The mean soft tissue rebound was -0.46 ± 0.69 mm. Overall, no significant interproximal papillae height loss was observed.Apical lesions were completely healed after surgery. The tooth crown-to-root ratio was favorable in all cases before extrusion, whereas in 3 cases it was appropriate (1 = 1), and only 1 case presented >25% of marginal bone loss during the follow-up period. The reported success rate was 92.3%, and patients were generally satisfied with the outcome. CONCLUSIONS: Surgical extrusion of single-rooted teeth was successful with minimal or no soft tissue loss, and patients were satisfied with the surgical procedure and the esthetic result.

Orthodontic Extrusion vs. Surgical Extrusion to Rehabilitate Severely Damaged Teeth: A Literature Review.

The need to rehabilitate severely compromised teeth is frequent in daily clinical practice. Tooth extraction and replacement with dental implant represents a common treatment choice. However, the survival rate for implants is inferior to teeth, even if severely damaged but properly treated. In order to reestablish a physiological supracrestal tissue attachment of damaged teeth and to arrange an efficient ferrule effect, three options can be considered: crown lengthening, orthodontic extrusion and surgical extrusion. Crown lengthening is considered an invasive technique that causes the removal of part of the bony support, while both orthodontic and surgical extrusion can avoid this inconvenience and can be used successfully in the treatment of severely damaged teeth. The aim of the present narrative review is to compare advantages, disadvantages, time of therapy required, contraindications and complications of both techniques.

Surgical extrusion: A reliable alternative for saving fractured anterior teeth.

Crown-lengthening procedures are necessary to rehabilitate supracrestal insertion tissue and to guarantee a suitable dental restoration. The objective of this article was to report a surgical extrusion procedure as a treatment option for a fractured anterior tooth. A 24-year-old male patient presented to our department to rehabilitate his maxillary right lateral incisor. The tooth was fractured due to a trauma and presented a healthy periodontium. Endodontic treatment was performed before the surgical extrusion. A fixed crown was cemented after complete reduction of tooth mobility after 6 months. No complication was observed at 6 months post-operatively. A minimally traumatic surgical extrusion technique provided highly successful results in both functional and esthetic aspects, especially in the anterior region, where the latter is of great interest.

European Society of Endodontology position statement: Surgical extrusion, intentional replantation and tooth autotransplantation: European Society of Endodontology developed by.

This European Society of Endodontology (ESE) position statement on surgical extrusion, intentional replantation and tooth autotransplantation represents the consensus of an expert committee, convened by the ESE. A narrative review in the International Endodontic Journal (Plotino et al. 2020, international Endodontic Journal, 53, 1636-52) formed the basis for the position statement. The review provided detailed information on the background, clinical procedures and the outcome of surgical extrusion, intentional replantation and tooth autotransplantation techniques. The aim of the current statement is to summarize the best available evidence on these clinical techniques to provide appropriate clinical guidance to undergraduate and postgraduate students, dental practitioners, clinical teachers and researchers. The current position statement will be updated by the ESE periodically to reflect new evidence as it becomes available to provide the most current treatment guidance for clinical practice.

Effects of different splinting times on surgically extruded teeth with a crown-root fracture: A randomized controlled trial.

BACKGROUND/AIM: Clinical studies evaluating the splinting time for surgically extruded teeth with crown-root fractures are lacking. The aim of this study was to compare 2-week splinting versus functional splinting times after surgical extrusion. MATERIAL AND METHODS: Children aged 8-13 years who presented with crown-root fractures were included. Surgical extrusion was performed, and teeth were splinted either for 2 weeks or until normal Periotest values were achieved (functional splinting time). The outcome measures were tooth mobility, tooth loss, root resorption, marginal bone resorption and ankylosis. Measurements were taken at baseline, weekly after splint removal, and after 1, 3, 6 and 12 months. RESULTS: Nineteen patients were included in the analysis. Surgically extruded teeth splinted for 2 weeks showed significantly higher mobility directly after splint removal and at 1 month after splinting compared with the functional splinting time group. The mean differences for horizontal Periotest values were 14.96 (95% confidence interval: 8.52, 21.39) and 6.63 (95% confidence interval: 0.25, 13), respectively. The vertical Periotest values were 10.47 (95% confidence interval: 1.95, 18.99) and 4.81 (95% confidence interval: -1.57, 11.18), respectively. At the 3-, 6- and 12-month follow-up intervals, there were no statistically significant differences between the groups. One tooth in the 2-week splinting group was lost. None of the teeth had ankylosis, marginal bone resorption or root resorption. CONCLUSIONS: Although both groups showed neither statistical nor clinically significant differences after 12 months, there was a significant difference immediately after splint removal, with greater tooth mobility in the 2-week splinting group. Thus, a functional splinting time (4-6 weeks) can be suggested for better healing and optimal stability to allow placement of the final restoration directly after splint removal.

Clinical procedures and outcome of surgical extrusion, intentional replantation and tooth autotransplantation - a narrative review.

Surgical extrusion is defined as the procedure in which the remaining tooth structure is repositioned at a more coronal/supragingival position in the same socket in which the tooth was located originally. Intentional replantation is defined as the deliberate extraction of a tooth and after evaluation of root surfaces, endodontic manipulation and repair, placement of the tooth back into its original position. Tooth autotransplantation is defined as the transplantation of an unerupted or erupted tooth in the same individual, from one site to another extraction site or a new surgically prepared socket. The advent of titanium implant rehabilitation has reduced the use of these treatments in day-by-day clinical practice; however, the re-emerging trend to conserve and preserve natural sound tissues has led to a rediscovery of these treatments. All three distinct surgical methods are closely related, as they act to treat teeth that cannot be predictably treated using other more conventional procedures in endodontics, periodontics and restorative dentistry. Furthermore, these procedures share the same treatment approach and include the atraumatic extraction of a tooth, visual inspection of the tooth/root and its subsequent replantation. The clinical procedures for surgical extrusion, intentional replantation and tooth autotransplantation treatment have undergone several changes in recent years, and currently, there are no clear clinical treatment protocols/guidelines available. The clinician should be aware of the outcome of these treatments. Hence, the aim of this narrative review is to provide the background, clinical procedures and outcomes of surgical extrusion, intentional replantation and tooth autotransplantation.

Surgical extrusion of a maxillary premolar after orthodontic extrusion: a retrospective study.

OBJECTIVES: Crown-root fracture and cervical caries in maxillary premolars constitute a challenge in cases of subgingival placement of restoration margins. Surgical extrusion has been practiced successfully in permanent anterior teeth. The aim of the present retrospective study was to assess the clinical outcome of surgical extrusion after orthodontic extrusion in maxillary premolars. MATERIALS AND METHODS: Twenty-one single, tapered root maxillary premolars with subgingival crown-root fracture or caries were included. Presurgical orthodontic extrusion was performed on all teeth to prevent root resorption. Extent of extrusion and rotation was determined based on crown/root ratio. The postoperative splinting period was 7 to 14 days. Clinical and radiographic examination was performed at an interval of 1, 2, and 3 months. RESULTS: After the mean follow-up of 41.9±15.2 months, failure was observed as increased mobility in 3 of 21 cases. No significant difference was observed in the outcome of surgical extrusion based on tooth type, age, sex, 180° rotation, or time for extraction. Furthermore, marginal bone loss was not observed. CONCLUSION: Surgical extrusion of maxillary premolars can be a possible therapeutic option in cases of subgingival crown-root fracture.

Intra- Socket Transplantation of Bicuspid to Re-establish Biologic Width.

Transplantation and reposition of a tooth in its socket is relatively simple and predictable and can be considered as an alternative treatment option particularly in patients with financial limitation. This report describes a case of intra- alveolar transplantation of tooth #43 in a 35- year-old man. Clinical and radiographic examinations revealed tooth #43 with complicated crown-root fracture that had undergone endodontic treatment five months earlier. Reposition of mandibular bicuspid in its socket to re-establish biologic width and crown ferrule is an alternative treatment in cases with complicated crown-root fracture. Immediate replantation preserve viability of periodontal ligament cells and fibers attachment and good chance of healing is predicted.

Periodontal status of anterior teeth following clinical crown lengthening by minimally traumatic controlled surgical extrusion.

BACKGROUND/AIMS: The number of fractured anterior teeth following trauma has been increasing while not every patient is able to afford a dental implant instead of maintaining the injured tooth. Thus, a tooth conservation solution is required to place an aesthetic and functional restoration without biologic width violation. The aim of this study was to evaluate the effectiveness of minimally traumatic controlled surgical extrusion in fractured anterior teeth crown lengthening by assessing the periodontal status through clinical examination and radiographs. METHODS: This longitudinal observational study investigated a group of 18 patients (six males and 12 females) at the Department of Periodontology, National Hospital of Odonto-stomatology, Ho Chi Minh City, Vietnam. Following pre-surgery procedures and examination, minimally traumatic controlled surgical extrusion was carried out using a periotome. Patients were examined at four follow-up appointments after 1 week, 1, 3 and 6 months to record the following experimental variables: periodontal parameters including the gingival index (GI), pocket depth (PD), bleeding on probing (BOP), mobility, marginal gingiva position, alveolar ridge resorption, periapical osteogenesis, tooth resorption and ankylosis. RESULTS: All periodontal parameters were significantly decreased at 3 and 6 months post-procedure (P < 0.001). Tooth mobility decreased gradually following surgery, and at 6 months, all teeth became normal at level 0. Periapical osteogenesis changes were significantly increased at 1, 3 and 6 months in comparison with pre-surgery (P < 0.001). Marginal gingiva position and alveolar ridge resorption were not significantly different between pre-surgery and 1, 3 and 6 months post-surgery. No cases of root resorption or ankylosis were observed at 6 months post-surgery. CONCLUSION: A minimally traumatic controlled surgical extrusion technique for clinical crown lengthening yielded highly successful results in both aesthetic and functional aspects, and no cases had unfavourable outcomes during the 6-month follow-up period.

Endodontic Surgery of a Deviated Premolar Root in the Surgical Orthodontic Management of an Impacted Maxillary Canine.

Maxillary canine impactions are of multifactorial etiology. The incidence of maxillary canine impaction ranges from 1% to 4%. One of the reasons for canine impaction might be a deviated premolar root. This report describes surgical-orthodontic extrusion of an upper canine that occurred only after the endodontic surgery treatment of the adjacent deviated premolar root. Orthograde endodontic treatment followed by endodontic surgery with retrograde filling of the deviated premolar root was performed to obtain a surgical-orthodontic extrusion of the upper canine. A female patient, aged 15 years, with a class I molar relationship was referred to continue the orthodontic therapy. Although a correct surgical-orthodontic extrusion with adequate anchorage was carried out, the maxillary left canine had not erupted. Radiographic examination showed a deviated palatal root of the adjacent maxillary first premolar in the canine eruption path. Root canal filling followed by endodontic surgery of the first premolar deviated root has led to rapid progression of the canine and its placement in the arch in just 3 months. A multidisciplinary management involving endodontic treatment, endodontic surgery, and surgical-orthodontic extrusion could be considered a successful approach in the maxillary impacted canine cases in which adjacent premolar root is deviated. Long-term radiographic follow-up (6 years) indicated stable periodontal health of the canine and premolar without the presence of root resorption.

Surgical extrusion of multiple teeth with crown-root fractures: a case report with 18-months follow up.

The objective of this case report is to describe the treatment procedure involved in surgical extrusion of multiple crown-root fractures and review the critical factors to be considered for successful and predictable outcome. The treatment of complicated crown-root fracture in anterior teeth is likely to compromise function and aesthetics when approached with conventional surgical crown lengthening. Orthodontic extrusion has also been suggested; however, it is time-consuming, aesthetically compromising and hardly applicable on multiple anterior crown-root fractures due to the limited source of anchorage. To overcome the shortcomings of suggested treatment modalities, we performed atraumatic surgical extrusion of four anterior fractured teeth along with their rotation within the sockets. The teeth were gently luxated and extruded to the desired position, minimizing damage to the marginal alveolar bone and root surfaces without rigid splint. The treated teeth were functioning normally 18 months after the procedure, and the mobility and probing depths were within normal limits. Radiographs revealed functional periodontal ligament space along with lamina dura formation around the extruded roots. There was neither root resorption nor significant marginal bone loss. This technique might be a promising alternative to conventional crown lengthening, especially in the anterior zone to avoid functional or aesthetic complications.

Surgical extrusion as a treatment option for crown-root fracture in permanent anterior teeth: a systematic review.

BACKGROUND: A crown-root fracture is defined as a fracture involving enamel, dentin, and cementum. The possibility of saving and reconstructing teeth with such fractures has increasingly become a viable alternative to extraction and prosthetic therapy. One such treatment option available is surgical extrusion. OBJECTIVE: The aim of this review is to evaluate surgical extrusion as a treatment modality for management of crown-root fractures in permanent anterior teeth. METHODS: Electronic search of scientific papers was carried out on Entrez Pubmed and the Cochrane Central Register of Controlled Trials databases using specific keywords. The search yielded 130 papers, out of which 16 relevant papers were identified and included based on predetermined inclusion criteria and the remaining 114 were found to be irrelevant. Hand search yielded 10 articles, which were also included. These 26 articles which included only case reports and case series formed the basis of this systematic review. CONCLUSION: From the existing literature, we can conclude that surgical extrusion can be used to treat crown-root fractures successfully. But the level of evidence is very low as the studies available are only case reports and case series.