THE JOURNAL OF PROSTHETIC DENTISTRY ZISKIND, SCHMIDT, AND HIRSCHFELD

246 VOLUME 79 NUMBER 3THE JOURNAL OF PROSTHETIC DENTISTRY

Forced orthodontic eruption was first described in1973 by Heithersay.1 The clinical benefits of this proce-dure have been repeatedly demonstrated by restoringsubmerged roots,2-13 root perforations at the coronalthird,14 and treating infrabony pockets.15 Extrusion el-evates the root, expands periodontal fibers, and resultsin coronal shift of marginal gingiva and bone.2 Periodon-tal surgery is performed when necessary, before proceed-ing with restorative procedures to compensate for thisprocess.16-21

Orthodontic brackets that use edgewise, and Johnsontwin-wire, or Universal bracket techniques were bondedto three or four adjacent teeth, at a specific height fromthe tips of their cusps. A straight piece of wire was thenlaid passively in the horizontal channel of the brackets.This orthodontic device has certain disadvantages bothfor patient and dentist, such as an increased risk of den-tal caries, trauma to adjacent soft tissue, compromisedesthetics, and technically difficult construction of a thera-peutic device.

This clinical report describes an alternative for forcederuption that minimizes the need for special orthodon-tic devices.

CLINICAL REPORT

A 42-year-old man with the main complaint of a cari-ous maxillary left second premolar was evaluated for treat-ment. The patient’s dental profile revealed inconsistentoral hygiene with calculus and slight gingival inflamma-tion. The patient’s medical history family background andextraoral examination were noncontributory.

The intraoral examination revealed a carious root withremaining thin facial enamel. The first premolar was re-stored with an amalgam restoration that possessed faultymargins. The second molar had a mesiocclusal cariouslesion. The mesial and the palatal surfaces of the rootranged from 1 to 2 mm below the free gingival height(Fig. 1).

A periapical radiograph of the second premolar con-firmed that the root was endodontically obturated with-out pathosis (Fig. 2). The dental history revealed termi-nation of dental treatment 7 years ago, which presum-ably caused the present dental condition.

aLecturer, Department of Restorative Dentistry.bLecturer, Department of Oral Rehabilitation.cAssociate Professor and Head, Department of Restorative Dentistry.J Prosthet Dent 1998;79:246-8.

Forced eruption technique: Rationale and clinical report

Daniel Ziskind, DMD,a Ami Schmidt, DMD,b and Zvia Hirschfeld, DMDc

Hebrew University, Faculty of Dental Medicine, Jerusalem, Israel

After dental prophylaxis and oral hygiene education,conservative treatment was completed. The carious le-sions on the second premolar and the first molar wereidentified with a dental caries detector solution (cariesindicator, Seek, Ultradent, South Jordan, Utah), and ex-cavated. After periodontal surgery of the second pre-molar, forced eruption was performed. The goals of treat-ment were accomplished; namely, preserving biologicwidth, the ferrule effect, and esthetics. The surfaces ofadjacent teeth made this patient suitable for simplifiedforced eruption technique.

The surfaces were prepared for accommodation ofhorizontal wire by tooth preparation of a channel in the

Fig. 1. Intraoral examination reveals subgingivally located cari-ous maxillary left second premolar. First premolar restoredwith faulty amalgam restoration and second molar with me-sial carious lesion.

Fig. 2. Periapical radiograph of second premolar.

CLINICAL SCIENCES Malcolm D. Jendresen ▲ William F. P. Malone ▲ Thomas D. Taylor

ZISKIND, SCHMIDT, AND HIRSCHFELD THE JOURNAL OF PROSTHETIC DENTISTRY

MARCH 1998 247

amalgam restoration of the first premolar and a smallmesial occlusal-type cavity in the first molar. Acrylic resin(Pattern-resin, G.C. Corp., Tokyo, Japan) was used toadapt a hook to canal walls that was then cemented witha temporary cement. A segment of a titanium rod (Para-post, Whaledent, New York, N.Y.) was adjusted in thespace of the missing coronal surfaces of the second pre-molar. The surfaces of the amalgam and enamel wereacid etched for 30 seconds, and the surface of dentin for10 seconds, then rinsed and dried. The titanium postwas fixed directly over the cemented hook by using aflowable composite (Revolution, E & D Dental prod-ucts, Orange, Calif.). An elastic thread was tied betweenthe hook and post to exert the extrusive force (Fig. 3).

Special instructions with regard to the use of a prox-a-brush and daily fluoride rinses were given to thepatient. The elastic thread was replaced weekly, andafter 3 weeks, the extrusive movement was completed.The coronal shift of the root with adjacent structuresmade continuous shortening of facial enamel neces-

sary. Periodontal surgery was completed to correctthe coronal shift of bone and gingival architecture.After 8 weeks of programmed retention and soft tis-sue healing, no relapse of the anticipated movementwas evident and restorative treatment was accom-plished. After making a monophase impression(Aquasil LV, Dentsply De Trey GmbH, Konstanz,Germany), the first premolar and molar were restoredwith ceramic Inlays (Celay system Mikroma AG,Spreitenbach, Switzerland). The ceramic inlays werecemented with a composite resin cement (Enforce,Dentsply Int., Milford, Del.). A cast post and coreand a metal/ceramic crown were fabricated for theroot of the second premolar (Figs. 4 through 6). Itwas decided to cement the crown provisionally. Themetal frame of the crown was designed with a lingualprojection to facilitate removal. This approach resultedin compromised lingual esthetics during the provi-sionally cementation period (Fig. 5). The duration oftreatment was 4 months.

Fig. 3. Elastic thread was tied between hook and post to exertextrusive force.

Fig. 4. Restorative treatment (mirror view). After forced erup-tion using simplified technique and periodontal surgery, bio-logic width and “ferrule effect” were achieved.

Fig. 5. Restorative treatment (occlusal view). First premolarand first molar restored with CAD-CAM fabricated ceramicinlays.

Fig. 6. Restorative treatment (facial view). Metal-ceramic crownon second premolar.

THE JOURNAL OF PROSTHETIC DENTISTRY ZISKIND, SCHMIDT, AND HIRSCHFELD

248 VOLUME 79 NUMBER 3

DISCUSSION

The simplified forced eruption technique describedhad several advantages over other methods. Orthodon-tic bands and brackets or wire bends were unnecessary.In this procedure, the adjacent teeth are used exclusivelyas anchors for orthodontic movement. A more comfort-able oral appliance resulted. Minimal irritation to softtissue was realized for improved access with a prox-a-brush and decreased risk of dental caries. Maximal ex-trusion potential of the device was possible by placingthe horizontal wire near the height of curve of Spee with-out interference. The placement of the horizontal wirewas critical for extrusion. The distance between the hookand the wire was equal to the distance the tooth can beextruded.

In the simplified method, the post was placed in thespace of the missing coronal surface over the cementedhook for maximal distance. Traditional orthodontics arecommonly more difficult in obtaining this height be-cause: (1) orthodontic brackets are cemented at a spe-cific height from tips of their cusps, and (2) bending thewire into a space may be accompanied by apical saggingdue to an increased lever arm. The resultant approxima-tion between wire and hook diminished the potentialfor root extrusion with the device. Deep fracture linesof traumatized teeth or undetected subgingival dentalcaries in certain instances and the need for 3 mm of bio-logic width can make additional extrusion necessary. Inaddition, the post rigidity and its location directly overthe hook, enabled maximal rapid pulling force describedby Simon.4

Shiloah6 and Lemon10 described a similar techniquewith the use of a splint. Shiloah6 designed an acrylic resinto fix an orthodontic wire as an intracoronal splint. Thesuperior physical characteristics of composites comparedwith acrylic resins are well known. The porosity of acrylicresin enhances plaque accumulation. In a treatmentmodality that requires surgery in the second stage of theprocedure, use of flowable composites offered an ad-vantage. There was no irritation to the healing of softtissue, which is critical for esthetics. Lemon10 used anexisting extracoronal splint, bonded with an acid etchcomposite system to the facial surface of teeth.

An extracoronal splint cannot precisely directextrusive force in an axial direction. In this method,the direction of extrusive forces were axial, not mov-ing the tooth from its natural position in the dentalarch, without exerting tilting forces on the anchor teeth.The use of flowable composites to secure the post im-mediately over the cemented hook was an uncompli-cated procedure. The simplicity of this method waspossible because of readily available biomaterials. Thisenables a single discipline approach in a short period.An abbreviated treatment period was critical for treat-ment success of a submerged root because of the ex-posed dentin of the extruded tooth.

SUMMARY

This article describes a refined, simplified forced erup-tion technique, and compared it with previous meth-ods. This simplified method is easy to perform and en-courages the use of adjunctive orthodontics in generalpractice. This relatively uncomplicated, quick, and cost-effective treatment can benefit patients.

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root fractures in the region of the alveolar crest. Oral Surg Oral Med OralPathol 1973;36:404-15.

2. Ingber JS. Forced eruption: part II. A method of treating nonrestorable teeth—periodontal and restorative considerations. J Periodontol 1976;47:203-16.

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14. Simon JHS, Kelly WH, Gordon DG, Ericksen GW. Extrusion of endodonti-cally treated teeth. J Am Dent Assoc 1978;97:17-23.

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16. Brain WE. The effect of surgical transsection of free gingival fibers on theregression of orthodontically rotated teeth in the dog. Am J Orthod1969;55:50-70.

17. Edwards JG. A surgical procedure to eliminate rotational relapse. Am JOrthod 1970;57:35-46.

18. Kaplan RG. Clinical experiences with circumferential supracrestal fibrotomy.Am J Orthod 1976;70:146-53.

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21. Kozlovsky A, Tal H, Lieberman M. Forced eruption combined with gingivalfiberotomy. A technique for clinical crown lengthening. J Clin Periodontol1988;15:534-8.

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DEPARTMENT OF RESTORATIVE DENTISTRY

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