A systematic and comprehensive protocol for rapid orthodontic extrusion.

OBJECTIVE: The aim of the present paper is to describe a systematic and detailed protocol for rapid orthodontic extrusion, and to summarize the main results of this protocol in terms of migration of dental, hard and soft tissues, for 10 cases. CLINICAL CONSIDERATIONS: The working design was to apply a protocol lasting 4 weeks of active phase with intense forces (greater than 300 g), perform weekly the circumferential supra-crestal fiberotomy procedure associated with root-planning, follow up with a passive stabilization phase of another 4 weeks and evaluate the results. CONCLUSIONS: We believe that despite the partial migration of periodontal tissue, the defined protocol we used is, for simplicity of application, brevity of treatment and results, a viable alternative to the surgical technique of clinical crown lengthening in those cases where it is necessary to have more dental tissue exposed for restorative and prosthetic purposes.

Orthodontic tooth extrusion to regenerate missing papilla adjacent to maxillary anterior single implants: A 2- to 7-year retrospective study.

INTRODUCTION: Regeneration of the missing papilla adjacent to single implants in the esthetic zone has always been challenging, despite advances in vertical hard and soft tissue regeneration. Orthodontic tooth extrusion has been shown to effectively gain alveolar bone and gingival tissue. This retrospective study evaluated the effectiveness of orthodontic tooth extrusion on regenerating missing papilla between existing maxillary anterior single implant and its adjacent tooth. METHODS: Patients who underwent orthodontic tooth extrusion to regenerate missing papilla adjacent to a single implant in the esthetic zone were included in this study. The gingival phenotype, orthodontic extrusion movement, proximal bone level, dento-implant papilla level, facial gingival level, mucogingival junction level, and keratinized tissue width, of the extruded tooth were recorded at pre-orthodontic extrusion (T0 ), post-orthodontic extrusion and retention (T1 ), and latest follow-up (T2 ). RESULTS: A total of 17 maxillary single tooth had orthodontic tooth extrusion to regenerate missing papilla adjacent to 14 maxillary anterior single implants in 14 patients. After a mean follow-up time of 48.4 months, implant success rate was 100% (14/14), with none of the orthodontically extruded teeth being extracted. After a mean extrusion and retention period of 14.3 months, a mean orthodontic extrusion movement of 4.62 ± 0.78 mm was noted with a mean proximal bone level gain of 3.54 ± 0.61 mm (77.0% efficacy), dento-implant papilla level gain of 3.98 ± 0.81 mm (86.8% efficacy), and facial gingival tissue gain of 4.27 mm ± 0.55 mm (93.4% efficacy). A mean keratinized tissue width gain of 4.17 ± 0.49 mm with minimal mean mucogingival junction level change of 0.10 ± 0.30 mm were observed. The efficacy of orthodontic eruption movement on dento-implant papilla gain was less in the thin (80.5%) phenotype group when compared with that in the thick (91.5%) phenotype group. CONCLUSIONS: Within the confines of this study, orthodontic extrusion is an effective, noninvasive method in regenerating mid-term stable proximal bone and papilla adjacent to maxillary anterior single implants. CLINICAL SIGNIFICANCE: This retrospective study presents a mid-term result on orthodontic extrusion as a mean to regenerate dento-implant papilla defect. The extended retention period following orthodontic extrusion showed stable and efficacious proximal bone and papilla gain.

Health economic evaluation of forced orthodontic extrusion of extensively damaged teeth: up to 6-year results from a clinical study.

OBJECTIVES: Clinical data on retaining extensively damaged teeth using forced orthodontic extrusion followed by restorative rehabilitation are scarce, and economic evaluations are basically absent. A health economic evaluation of this method was performed based on a clinical study. MATERIALS AND METHODS: In a convenience sample of individuals recruited from routine care, extensively damaged teeth were orthodontically extruded prior to restoration. Patients were followed up for up to 6 years. The health outcome was tooth retention time. Direct medical, non-medical, and indirect initial and follow-up costs were estimated using the private payer's perspective in German healthcare. Association of initial direct medical treatment costs and cofounding variables was analyzed using generalized linear models. Success and survival were secondary outcomes. RESULTS: A total of 35 teeth in 30 patients were followed over a mean ± SD of 49 ± 19 months. Five patients (14%) dropped out during that period. Median initial costs were 1941€ (range: 1284-4392€), median costs for follow-up appointments were 215€ (range: 0-5812€), and median total costs were 2284€ (range: 1453 to 7109€). Endodontic re-treatment and placement of a post had a significant impact on total costs. Three teeth had to be extracted and in three patients orthodontic relapse was observed. The survival and success rates were 91% and 83%, respectively. CONCLUSIONS: Within the limitations of this clinical study, total treatment costs for orthodontic extrusion and subsequent restoration of extensively damaged teeth were considerable. Costs were by large generated initially; endodontic and post-endodontic therapies were main drivers. Costs for retreatments due to complications were limited, as only few complications arose. CLINICAL RELEVANCE: The restoration of extensively damaged teeth after forced orthodontic extrusion comes with considerable initial treatment costs, but low follow-up costs. Overall and over the observational period and within German healthcare, costs are below those for tooth replacement using implant-supported crowns. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: DRK S00026697).

Forced orthodontic extrusion to restore extensively damaged anterior and premolar teeth as abutments for single-crown restorations: Up to 5-year results from a pilot clinical study.

STATEMENT OF PROBLEM: Clinical data on orthodontic extrusion to restore teeth deemed unrestorable because of their defect size are scarce. It remains unclear for which defects forced orthodontic extrusion and tooth retention is preferred to extraction. PURPOSE: The purpose of this pilot clinical study was to investigate the survival, frequency, and type of complications of extensively damaged teeth requiring single-crown restorations after forced orthodontic extrusion. MATERIAL AND METHODS: Participants were recruited from consecutive patients in need of restorative treatment of extensively damaged teeth at a university clinic. The teeth were orthodontically extruded to reestablish the biologic width and to ensure a 2-mm ferrule preparation before restoration. The primary endpoint was restoration success and survival. At recall, survival was defined as the tooth being in situ and success as a symptom-free tooth with an intact, caries-free restoration and with physiological pocket probing depths, no signs of intrusion, ankylosis, root resorption, or periapical radiolucency. Recalls were performed every 6 months; the outcome was assessed by radiographic and clinical evaluation after up to 5 years of clinical service. Quantitative parameters were described with mean values and standard deviations. RESULTS: Thirty-four participants were assessed for eligibility and enrolled (mean ±standard deviation age: 53.4 ±18.9 years). Four participants were premature dropouts. Data were analyzed for 35 teeth in 30 participants. The amount of extrusion varied between 2 and 6 mm (mean ±standard deviation 3.4 ±0.9 mm). The mean duration of extrusion was 18.9 ±12.6 days and the mean duration of retention was 126.94 ±88.1 days. The mean ±standard deviation crown-to-root ratio after treatment was 0.8 ±0.1 (range: 0.5 to 1.0). Three participants exhibited orthodontic relapse before restoration. Teeth were successfully restored after repeated extrusion. After a mean observation period of 3.3 years (range: 1 to 5.2 years), 29 of 31 teeth were still in situ. Two teeth were fractured, and 4 participants were not available for recall. Thus, the survival rate was 94%. No resorption or periapical translucencies were observed radiographically. Clinical examinations revealed physiological probing depths and absence of ankyloses. One tooth presented with marginal bone loss. The most frequent type of complication was orthodontic relapse at recall (n=3). A total of 84% of teeth were considered a success. CONCLUSIONS: Forced orthodontic extrusion allowed for the restoration of anterior and premolar teeth deemed as nonrestorable because of their defect size. Tooth retention of extensively damaged teeth and their use as abutments for single-crown restorations can be recommended.

Orthodontic management of a horizontally impacted maxillary incisor in an adolescent patient.

Horizontal maxillary incisor impaction is not common, but it affects facial esthetics, phonetics, and the patient's self-esteem. Therefore, it is necessary to manage this problem as early as possible. This case report presents a patient with an unerupted maxillary left central incisor combined with anterior and left posterior crossbite, edge-to-edge overbite on the right and left anterior open bite, low smile line, and mild skeletal Class III discrepancy. The treatment consisted of 3 stages: (1) maxillary expansion and sufficient space creation for the impacted tooth; (2) surgical exposure by closed-eruption technique; and (3) induced eruption of impaction. The treatment outcome was highly favorable. Maxillary impaction erupted in the proper position with a normal clinical crown height and consonant gingival line with the adjacent teeth. Maxillary and mandibular teeth had normal and stable occlusion. The 3-year follow-up demonstrated an esthetically functional outcome after orthodontically induced tooth eruption. This treatment required a good treatment plan by the orthodontist to obtain satisfactory results.

Orthodontic management of a patient with short root anomaly and impacted teeth.

Short root anomaly (SRA) is a rare familial dental condition that is often misdiagnosed. Orthodontic treatment of patients with SRA is challenging because it is difficult to diagnose, it may be accompanied by other dental anomalies, and it has been reported to contribute to additional susceptibility to root resorption during orthodontic treatment. In this article, we describe a methodical and evidence-based means of diagnosing and orthodontically managing a patient with SRA. The patient had additional challenges, including impacted and ectopic teeth. An individualized treatment plan that incorporated efficient and effective mechanics led to a well seated occlusion and an esthetic smile.

Can forces be applied directly to the root for correction of a palatally displaced central incisor with a dilacerated root?

This case report describes the interdisciplinary treatment of an ectopic horizontally placed maxillary right central incisor with severe root dilaceration. The root was distally angulated and entrapped by the root of the maxillary right lateral incisor. The initial force system was aimed at an occlusal displacement and applied to the crown. During the second phase, a button was cemented onto the apex of the impacted tooth. A force from the apex to a temporary anchorage device in the palate moved the root toward the midline. Finally, a root canal and an apectomy were performed and the central incisor could be moved to its ideal position. The treatment generated a normal height of the alveolar bone and an ideal occlusion with a healthy periodontium.

Surgical extrusion with an atraumatic extraction system: A clinical study.

STATEMENT OF PROBLEM: Clinical studies evaluating the feasibility of a novel technique for the surgical extrusion of nonrestorable teeth with subgingival caries are lacking. PURPOSE: The purpose of this clinical study was to investigate the success rate and incidence of biological and technical complications after tooth extrusion with an atraumatic extraction system (AES). MATERIAL AND METHODS: Participants were recruited from 61 consecutive patients initially referred to a specialist oral surgery practice. Fifty-one participants who underwent surgical extrusion with an AES followed by endodontic treatment and coronal restoration could be re-evaluated clinically and radiographically. RESULTS: The mean observation period was 3.1 years (range: 0.8 to 6.5 years). The participants varied in age between 24.8 and 86.3 years. The amount of extrusion was between 2.5 and 5.0 mm (mean 3.2 mm). At recall, 92.2% (47 of 51) of the extruded teeth were considered successful. All extruded teeth were asymptomatic, without clinical signs of inflammation. Percussion appeared normal and did not differ from that of the adjacent teeth, indicating absence of ankylosis. Transient resorption with a slightly altered root contour was detected in 5 of the 51 teeth. Minor reduction of the bone level (less than 10%) was detected in 8 of the 51. In a further 2 teeth, bone loss amounted to 25% and 30%. Periapical periodontitis at recall was seen in 4 of the 51 teeth, and a preexisting periapical lesion healed in 10 of 13. Root perforation was identified in 3 of the 51, and a further 3 of 11 were not available for recall. Thus, the technical complication rate was 9.7% (6 of 62). CONCLUSIONS: The AES may be successfully used for surgical extrusion to save apparently nonrestorable teeth, irrespective of patient age.

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.

Retrospective evaluation of treatment time and efficiency of a predictable cantilever system for orthodontic extrusion of impacted maxillary canines.

INTRODUCTION: Orthodontic extrusion of impacted maxillary canines requires careful biomechanical planning and the use of physiologic force. The aim of this study was to evaluate the time needed for orthodontic extrusion of impactions of different severities, using a device that can predictably apply forces under 0.6 N. METHODS: Twenty-two patients who were consecutively treated were selected retrospectively, and a total of 30 impacted canines were studied. Indexes of impaction were used to measure severity on pretreatment panoramic radiographs. Statistical analysis was used to detect interactions between treatment time, complexity of impaction, age, and sex. RESULTS: Treatment time was highly dependent on the patient's age; the shortest treatment time was observed in 11- to 12-year old patients. On the other hand, the severity of impaction had no effect on treatment time. CONCLUSIONS: Applying physiologic force with the proposed device resulted in a short treatment time, which depended on the patient's age more than the impaction complexity. Few complications were associated with use of this device. Future prospective studies are needed to replicate these findings and confirm the recommended use of this device.

Predictable method to deliver physiologic force for extrusion of palatally impacted maxillary canines.

INTRODUCTION: Orthodontic treatment of palatally impacted maxillary canines raises many difficulties; to minimize complications, careful planning of orthodontic extrusion and the use of physiologic force are crucial. The aim of this study was to quantitatively evaluate a simple and reproducible system for orthodontic extrusion of impacted canines that can provide the correct amount of force. METHODS: Ten specimens were constructed, consisting of a cantilever made with a 0.6-mm or 0.7-mm stainless steel wire modeled around a transpalatal bar with 3, 5, or 7 loops in the shape of a helical torsion spring. A mechanical testing machine was used to measure the force produced by the cantilever at 3, 6, 9, 12, and 15 mm of activation. RESULTS: The force values ranged from 1.24 ± 0.13 N for the 0.7-mm wire with 3 loops to 0.48 ± 0.04 N for the 0.6-mm wire with 7 loops. The forces measured for the 0.6-mm wire with 3 loops and the 0.7-mm wire with 7 loops were similar at 15 mm of deflection. CONCLUSIONS: The proposed system has a simple and robust design, is easy to construct and manage, and can provide the desired amount of force by changing the wire diameter and number of loops.

Combined orthodontic, surgical, and restorative approach to treat a complicated crown-root fracture in a maxillary central incisor.

This case report shows the treatment of a severe traumatic tooth injury. For the maxillary right central incisor, the trauma was considered a complicated crown-root fracture. The level of the fracture line, the length of the remaining root segment, and the presence and condition of the tooth fragment determined the type of therapy. Traumatized teeth with fractures below the alveolar crest are often considered hopeless. As this report shows, the treatment of a complicated crown-root fracture in the esthetic region can be challenging. Orthodontic extrusion and crown-length surgery were performed to bring the fracture line above the alveolar bone crest. A multidisciplinary approach was required for complete rehabilitation of the traumatized maxillary incisor. Suggestions are made to improve treatment planning of complicated crown-root fractures.

Traction of impacted canines in a skeletal Class III malocclusion: A challenging orthodontic treatment.

This case report describes the successful traction of 2 severely impacted canines. The patient, a 7-year-old girl, had good general health, nasal breathing, crossbite of the lateral incisors and canines, and a Class I molar relationship. The panoramic radiograph showed that the permanent canines were positioned above the roots of the lateral incisors, with the right canine in an accentuated inclination. The cephalometric analysis showed a skeletal Class III malocclusion with a predominance of horizontal growth. The Haas appliance associated with maxillary protraction was used during the first stage of treatment for 14 months. The second stage included the extraction of the deciduous molars, distal movement of the permanent molars to create space, and traction of the canines, and was associated with complete orthodontic treatment. The patient showed good esthetic and functional results at the end of treatment, verified by the stability over a period of 8 years after retention.

Atraumatic surgical extrusion to improve tooth restorability: A clinical report.

This clinical report describes the use of an "atraumatic" vertical extraction system to facilitate the restorative treatment of a tooth that would otherwise be considered unrestorable because of subgingival caries. Minimally invasive surgical root extrusion was undertaken using the Benex extraction system, which can provide controlled tooth extrusion with minimal deformation of the bone socket. A carious endodontically treated mandibular premolar was extruded to provide routine restorative treatment and endodontic retreatment.

Periodontal status after surgical-orthodontic treatment of labially impacted canines with different surgical techniques: A systematic review.

INTRODUCTION: Good periodontal status is essential for a successful treatment outcome of impacted maxillary canines. Whereas the surgical technique used for tooth uncovering has been shown not to affect the final periodontal status of palatally impacted canines, its effect on labially impacted canines is still unclear. METHODS: Searches of electronic databases through January 2015 and reference lists of relevant publications were used to identify studies evaluating the periodontal status of labially impacted canines after combined surgical-orthodontic treatment. Two reviewers independently screened the articles, extracted data, and ascertained the quality of the studies. RESULTS: Ninety-one studies were identified; 3 were included in the review. No included study examined the periodontal outcome of the closed eruption technique. Excisional uncovering was reported to have a detrimental effect on the periodontium (bleeding of the gingival margin, 29% vs 7% in the control group; gingival recession, -0.5 mm [SD, 1.0] vs -1.5 mm [SD, 0.8] in the control group; and width of keratinized gingiva, 2.6 mm [SD, 1.4] vs 4.1 mm [SD, 1.5] in the control group). Impacted canines uncovered with an apically positioned flap had periodontal outcomes comparable with those of untreated teeth. CONCLUSIONS: The current literature is insufficient to determine which surgical procedure is better for periodontal health for uncovering labially impacted canines.

Forced eruption of impacted maxillary central incisors with severely dilacerated roots.

Treatment of impacted dilacerated incisors is challenging for clinicians because of the prominent position of the teeth and the abnormality of their roots. We report on 2 patients who had horizontally upward impacted and severely dilacerated maxillary central incisors. The first patient's root perforated the labial plate without significant resorption, and the second patient's root was resorbed. Both patients were treated by a surgical-orthodontic approach, and the crowns of the impacted teeth were brought into the arches by closed forced eruption. Therefore, if impacted teeth have dilacerated roots, patients should be told of the possibility of root resorption.

Congenitally missing maxillary lateral incisors: Long-term periodontal and functional evaluation after orthodontic space closure with first premolar intrusion and canine extrusion.

INTRODUCTION: The aims of this investigation were to evaluate associations between orthodontic space closure (including first premolar intrusion and canine extrusion for esthetic reasons) and periodontal tissue deterioration over a 10-year period in subjects with one or both missing maxillary lateral incisors and to investigate the occurrence of signs or symptoms of temporomandibular disorder (TMD). METHODS: This was a retrospective cohort study comprising patients treated by the same orthodontist. The agenesis group included 26 consecutive adolescent and young adult patients (9 male, 17 female) treated with space closure. The control group consisted of 32 orthodontic patients (12 male, 20 female) with no missing teeth and no need for extractions. In the agenesis group, full-mouth probing pocket depths and bleeding on probing were recorded at 6 locations for each of 657 teeth (3942 periodontal sites). In the control group, comparative data were collected for the maxillary first molars, premolars, canines, and lateral incisors, a total of 264 teeth (1584 periodontal sites). Mobility and gingival recession were also evaluated. Patients in both groups completed questionnaires concerning symptoms related to TMD. RESULTS: The full-mouth assessments in the agenesis group generally demonstrated periodontally healthy conditions, with probing depths below 4 mm and few bleeding sites. Some slight recessions were found, mostly on molars and second premolars, and there was normal mobility of first premolars that substituted for canines. Comparisons between the agenesis and control groups showed no statistically significant differences for the maxillary teeth regarding increased pocket depth (≥4 mm) or increased mobility. Interproximal sites in the agenesis group showed less bleeding on probing than in the control group; this was statistically significant. Anterior teeth in the agenesis group did not show any more recession than in the controls. In addition, we observed no difference in signs or symptoms between the 2 groups; this might be due to the limited sample size or the drawbacks of the surveys of TMD through subjects' recall. Thus, the long-term periodontal tissue health and the incidence of dysfunction or TMD signs were similar in the space-closure agenesis group and in the control group of nonextraction orthodontic patients. CONCLUSIONS: Orthodontic space closure including first premolar intrusion and canine extrusion in patients with missing lateral incisors does not incur risks for periodontal tissue deterioration or TMD in the long term.

Extrusion of severely impacted mandibular first molar using partial orthodontics and temporary anchorage miniscrews.

BACKGROUND: This study reports a case in which a severely impacted lower first molar was recovered with a combined orthodontic therapy and minimally invasive oral surgery with special focus to patient's aesthetic demands. CASE REPORT: A 12-year- old female patient was complaining delayed eruption of mandibular right first molar. Radiographic exam showed a severe tooth impaction with a close relationship between tooth roots and mandibular nerve. As the patient refused full arches orthodontic treatment, a partial orthodontic approach was projected. During treatment, temporary miniscrews were placed in both upper and lower arches, in order to allow dental movement with maximum anchorage. After a 24 month-therapy the tooth was extruded, so the appliance and the miniscrews were removed. CONCLUSION: The present case shows that severe tooth impaction can be resolved with a combined partial orthodontic- minimally invasive surgical treatment.