orthodontic forced eruption · 2017-10-26 · orthodontic treatment in the presence of severe...

Continuing Education

Orthodontic ForcedEruption:

A Team Approach in Aesthetic Treatment

Authored by Ahmad Soolari, DMD, MS; Duane Erickson, DDS; and

Amin Soolari, CDRT

Course Number: 175

Upon successful completion of this CE activity 2 CE credit hours may be awarded

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Opinions expressed by CE authors are their own and may not reflect those of Dentistry Today. Mention of

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contact their state dental boards for continuing education requirements.

Dentistry Today, Inc, is an ADA CERP Recognized Provider. ADA CERP isa service of the American Dental Association to assist dental professionalsin indentifying quality providers of continuing dental education. ADA CERPdoes not approve or endorse individual courses or instructors, nor does itimply acceptance of credit hours by boards of dentistry. Concerns orcomplaints about a CE provider may be directed to the provider or to ADA CERP at ada.org/goto/cerp.

Approved PACE Program ProviderFAGD/MAGD Credit Approval doesnot imply acceptance by a state orprovincial board of dentistry orAGD endorsement. June 1, 2012 toMay 31, 2015 AGD PACE approvalnumber: 309062

LEARNING OBJECTIVESAfter participating in this CE activity, the individual will learn: • The literature-supported scientific basis for the clinicaluse of forced orthodontic eruption.

• A team approach to treating a difficult periodontal-restorative challenge in the anterior maxilla for a patientwith extreme aesthetic concerns.

ABOUT THE AUTHORSDr. Ahmad Soolari is a Diplomate ofAmerican Board of Periodontology. He hasa certificate in periodontics from theEastman Dental Center and an MS degreefrom the University of Rochester (NewYork). He earned his DMD degree from the

University of Mississippi Medical Center. A former clinicalassociate professor at the University of Maryland, DentalSchool in Baltimore, he operates a specialty practice in theSilver Spring and Gaithersburg areas of Montgomery County,Md. He can be reached via e-mail at [email protected].

Disclosure: Dr. Ahmad Soolari reports no disclosures.

Dr. Erickson has been in private practicein orthodontics for 25 years and has officesin Silver Spring and Olney, Md. He earnedhis dental degree at the University ofMaryland, Baltimore, and practiced generaland restorative dentistry for 9 years before

receiving his certification in orthodontics in 1988 from FairleighDickinson University in New Jersey. He is past president of theMaryland State Orthodontic Society and has served aschairman of the education committee of the Mid dle AtlanticAssociation of Orthodontists. He can be reached [email protected].

Disclosure: Dr. Erickson reports no disclosures.

Mr. Amin Soolari is a student in the pre-dental program at the University ofMaryland. He has been a dental assistantfor 6 years and has experience inorthodontics, periodontics, and assistingin general treatment and oral surgery,

and he is currently taking courses to prepare for dentalschool. He started his career in a periodontal office, wherehe be came a Certified Dental Radiation Tech nologist. Hecan be reached via e-mail at [email protected].

Disclosure: Mr. Amin Soolari reports no disclosures.

INTRODUCTIONExtraction of maxillary anterior teeth with severe attachmentloss leaves an obvious defect that is difficult to reconstruct.The lost soft and hard tissues must be regenerated prior toimplant therapy or fixed partial denture placement to replacethe missing tooth for the most aesthetically consciouspatients. Orthodontic forced eruption (OFE) has beenpracticed as one method of restoring the soft and hardtissues lost due to periodontal disease.1-3

This article illustrates a team approach to treating adifficult periodontal-restorative challenge in the anteriormaxilla for a patient with extreme aesthetic concerns. Hergummy smile, midline diastema, and severe periodontaldisease were successfully treated with periodontal therapy,forced extrusion, and crown lengthening surgery prior to therestorative phase. This method can be used in similarpatients as a more conservative, predictable alternative toachieve aesthetic harmony versus more invasive and time-consuming techniques such as ridge augmentation.

Periodontal disease causes loss of both hard and softtissues. The loss may be uniform throughout the dentition,but more often it is asymmetric.4,5 Especially in the aestheticzone (ie, the anterior jaws), asymmetry coupled withperiodontal disease presents a challenge for dentists. Inaddition, in patients with severe periodontal disease, a toothor teeth may be deemed unrestorable if attachment loss issignificant.

When planning restoration of a tooth, dentists canchoose from many different techniques to regain the lost


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Orthodontic Forced Eruption: A Team Approach in Aesthetic TreatmentEffective Date: 7/1/2014 Expiration Date: 7/1/2017

hard and soft tissues. Guided tissue regeneration, bonegrafting with either blocks or particulated material, ridgeaugmentation, gingival grafting, distraction osteogenesis,and sinus elevation are some of the most frequently usedand documented methods of restoring tissue architecture.However, these methods are invasive, time-consuming, andexpensive. They are also associated with morbidity (forexample, at graft donor sites)6 and, occasionally, unpre-dictable resorption.7 Thus, noninvasive and morepredictable techniques have been sought.

In the mid-1970s, Ingber1,8 advocated forced eruption ofdiseased teeth to treat one- and 2-wall defects. Salama andSalama9 introduced forced eruption as a method ofdeveloping/restoring tissues prior to im plant treatment.Subsequent studies reported success with this techniqueprior to both conventional and implant therapies.2,10-13 Themethod is predictable and can be done more quickly thanmany other techniques, saving time and expense.

The current report details the treatment of a patient withexcessive gingival display, a midline diastema, asymmetry atthe maxillary central incisors, and significant attachment losscaused by periodontal disease. Her disease activity wascontrolled, attachment levels were improved and stabilized,and a poor aesthetic appearance was corrected throughperiodontal therapy, OFE, and crown lengthening surgery.

CASE REPORTA 55-year-old female smoker was not happy with her smileand rejected a proposed treatment plan from another officethat involved extraction of “2 upper front teeth” and placementof 2 adjacent implants. Clinical and radiographic evaluationdisclosed excessive gingival display, incomplete passiveeruption, asymmetry of the maxillary central incisors, amidline diastema, and significant attachment loss in theanterior maxilla (Figures 1 to 4). The only tooth in her anteriormaxilla that showed aesthetic proportions was the left centralincisor (No. 9); the other teeth had rather short crowns.

A treatment plan was recommended to harmonize theremaining teeth in the aesthetic zone with the maxillary leftcentral incisor. The proposal included OFE followingnonsurgical periodontal therapy (scaling and root planing)and surgical treatment, which included flap surgery to treatteeth No. 8 (maxillary right central incisor) and No. 9, and

crown lengthening surgery for the remaining maxillaryanterior teeth. The patient agreed to periodontic-


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Orthodontic Forced Eruption: A Team Approach in Aesthetic Treatment

Figure 1. Initialappearance of thepatient (June 7,2010). Excessivegingival display, amidline diastema,gingival anddental asymmetry,

rotated maxillary left canine (No. 11), and short clinical crowns on mostteeth are apparent.

Figure 2. Initialperiapical view ofthe maxillary central incisors(June 7, 2010).

Figure 3. Palatalview showingsignificant attachment loss,dehiscence, andheavy subgingivalcalculus (October9, 2010).

Figure 4. Facialview of teeth Nos.8 and 9 showingthe buccal plate,which was missingon the palatalaspect (October 9,2010).

orthodontic-restorative therapy. The OFE was needed tominimize the ridge deformity; these are hard to hide anddifficult to manage following the removal of maxillaryanterior teeth. The key to the success of this treatment planwas careful implementation of OFE to support therestorative effort.

The periodontal surgery disclosed severe bone loss onthe palatal aspect of teeth Nos. 8 and 9 with heavy calculusdeposits. The bone loss was more severe on No. 9 than onNo. 8 (Figure 2). Following removal of infected tissue andcalculus, periodontal regenerative therapy (PRT) wasperformed; this included bone grafting, application ofdemineralized freeze-dried bone allograft (LifeNet Health),and placement of a resorbable bilayer collagen membrane(Geist lich Bio-Gide [Geist lich Pharma North America]).

The patient was referred to an orthodontist, andexamination and treatment were as follows: The orthodonticexam revealed a good Class I occlusion with generalizedperiodontitis; in particular, severe horizontal and verticalbone loss around teeth Nos. 8 and 9. Teeth Nos. 8 and 9 hada hopeless prognosis due to severe perio dontal defects,mobility, poor crown-to-root ratios, and unaesthetic crowns.The treatment plan was to remove Nos. 8 and 9 and replacethem with implant restorations. However, the periodontaldefects and the likelihood of further alveolar resorptionfollowing the extraction of teeth Nos. 8 and 9 meant that theprognosis for placement of implants was poor. Therefore,OFE would be accomplish ed in order to create new alveolarbone so that implants could be placed.

Orthodontic treatment in the presence of severeperiodontal disease is not recommended. Therefore, perio -dontal treatment was performed to control disease activity. Dueto the significant attachment loss and heavy subgingivalcalculus on the palatal aspect of teeth Nos. 8 and 9 (Figure 2),periodontal surgery was performed to gain access to the rootsof the teeth and the bony defects to resolve the inflammation,stop bleeding on probing, reduce the pocket depth, andremove the calculus. After a flap was raised and the necrotictissue and calculus were removed, PRT was performed toprepare teeth Nos. 8 and 9 for OFE. The proposed orthodontictherapy would slowly erupt teeth Nos. 8 and 9 to improvealveolar height and minimize bony defects in the alveolus thatwould result from the extraction of these teeth.

On November 24, 2010, partial fixed orthodonticappliances (0.018-inch Innovation-R [GAC Interna tional] self-ligating brackets) were placed on the anterior teeth (Nos. 6 to11), and anchor tubes were placed on teeth Nos. 3 and 14(0.022-inch) (Fig ures 5 to 7). A 0.016-inch Ni-Ti wire wasplaced to align teeth Nos. 6 to 11; No. 11 in particularrequired derotation. Derota tion of No. 11 took somewhatlonger than expected but was accomplished by May 4, 2011(Figure 5). At this time a 0.016- x 0.022-inch braided wire(Quad Cat) was placed with 1.5-mm step-down bends to


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Figure 5. Intraoralview (April 25,2011) after 8weeks oforthodontictreatment to rotatethe maxillary leftcanine (No. 11).

Figure 6.Periapicalradiograph takenduring orthodonticforced eruption(OFE) (July 6,2011).

Figure 7. Clinicalappearance onJuly 6, 2011,during orthodontictherapy, after 8weeks of forcederuption of theincisors and

canines and reduction of the central incisor crowns from fremitus.

slowly super-erupt teeth Nos. 8 and 9. During the next several months, the patient was seen

about every 3 to 4 weeks; at each appointment, the wire wasactivated 0.5 to 1.0 mm to erupt teeth Nos. 8 and 9. In addition,at each appointment, the teeth were evaluated to eliminate anyfremitus (traumatic occlusion) and the clinical crowns of teethNos. 8 and 9 were adjusted accordingly (Figures 6 and 7). Theobjective during this time was to slowly erupt the teeth so thatthe tension on the periodontal ligament would stimulateosteoblastic activity and the erupting tooth would bring bonewith it. Close monitoring and elimination of fremitus wereimportant so that untoward occlusal forces would not result inthe destruction of bone. During this time, teeth Nos. 8 and 9each erupted 4 to 5 mm, and the interproximal spaces weredistributed for ideal restoration. On September 29, 2011, thefixed appliances were removed. The patient was instructed towear a clear (Essix-type) retainer for 12 hours per day and toreturn to the periodontist and general dentist to plan for thereplacement of teeth Nos. 8 and 9.

However, tooth No. 8 had responded positively toperiodontal-regenerative therapy; therefore the decisionwas made to retain it and utilize it as an abutment for thedefinitive prosthesis. Tooth No. 9 re mained hopeless. Theoriginal treatment plan included placement of an implantfollowing the extraction of tooth No. 9, but the patient nowrefused the implant, since the remaining teeth in theaesthetic zone would still require prosthetic restoration toachieve an acceptable appearance. The OFE improvedalveolar height for both Nos. 8 and 9. This approachresulted in the creation of new alveolar bone. Themultidisciplinary treatment in this case significantlyimproved the aesthetic appearance of a patient who wasnot happy with her diastema, excessive gingival display,midline asymmetry, tooth mobility, and significant bone loss.

The definitive prosthesis was placed a year later. Excellentaesthetics and strong function were established for this patient,who originally suffered from generalized moderate andlocalized severe periodontitis. The patient was pleased with thefinal appearance of her smile (Figures 8 to 11) and stoppedsmoking. The aesthetics of the definitive restoration may havebeen improved by moving the gingival margin of crown No. 8apically to make it symmetrical with pontic No. 9. This highlightsthe need for meticulous detailed communication between

the treating professionals and the patient during all phasesof this type of treatment.


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Figure 8. Clinicalappearance onSeptember 29,2011, followingremoval oforthodonticappliances.

Figure 9. Finalappearance(March 24, 2012)after one year ofperiodontic-orthodontic-restorativetherapy.

Figure 10. Finalappearance in theaesthetic zone.The prosthesis issupported byhealthy, pink, andfirm keratinizedgingiva.

Figure 11.Radiographicappearance afterOFE, extraction,crown length-ening, andprosthesisplacement.

DISCUSSIONDentists have been exploring the possibility of forced eruptionof diseased teeth as a means of augmenting soft and hardtissue and eliminating infra bony defects since the 1970s.1,8

Since then, many reports of successful forcederuption/extrusion followed by retention and conservativerestoration of what would have been hopeless teeth have beenpublished.2,10-12 In ad di tion to its predictability, forced eruptioncan usually be completed fairly quickly; Biggerstaff et al2

completed treatment in 3 patients within about 4 weeks.Van Venrooy and Yukna3 provided proof of principle for

OFE in an animal study. The attachment apparatus wasdamaged and periodontal disease was induced in beagledogs. Teeth extruded with orthodontic elastics were lessmobile and displayed shallower pockets, less bleeding, andradiographic bone gain, whereas control (untreated) teethshowed no improvement after 21 days.

In clinical studies, many authors have investigated theuse of extrusion for teeth that would otherwise beconsidered nonrestorable. Biggerstaff et al2 “reclaimed”nonrestorable teeth with OFE in 3 patients with teeth withcompromised gingival margins caused by tooth fractures orperforation of the gingiva. The authors2 found that thetechnique was relatively simple and quick, and bone supportwas regained because the process re sembled normal tootheruption. Ca mar go et al10 declared OFE the “technique ofchoice” prior to crown lengthening in the aesthetic zone.Fakhry11 also advocated OFE as a more conservativemethod of restoring teeth, even in sites with minimal coronaltooth structure in the aesthetic zone, but cautioned againstoveraggressive use of the technique to prevent periodontaldamage and harm to coronal tooth structure.

Many authors have reported on the use of OFE torestore fractured teeth or roots as a means of avoidingmore aggressive treatment, including extraction. Goenka etal14 discussed the use of OFE for teeth that had fracturedat or coronal to the gingival level. They14 reported on thesuccessful treatment of such a case with OFE followed byprosthetic treatment. Addy et al15 reviewed the literature ontreatment of root fractures, noting that sufficient root lengthwas needed to ensure success and avoid extraction of theinjured tooth. Valerio et al16 stated that, in addition, theferrule should be adequate and the biologic width of the

injured tooth/root must be intact to perform OFE and avoidsurgical treatment.

As the use of implants has in creased, clinicians haveused OFE more frequently prior to implant placement toprepare sites to receive implants. Makhmalbaf and Chee17

cited forced eruption as a viable alternative topreimplantation bone augmentation in their treatment of awoman with bone and gingiva loss. Mankoo and Frost12 usedOFE in 2 patients with advanced periodontal loss. Theprocedure provided sufficient vertical augmentation for im -plant placement. Mirmarashi et al18 showed that OFE couldassist in the transition to definitive implant prosthetictreatment. While the teeth to be extracted remained in situ,they were used not only to assist in developing anappropriate soft- and hard-tissue profile, but they alsosupported a fixed provisional restoration so that a removableprovisional was not needed. Amato et al19 found that OFEprior to implant treatment was successful for boneregeneration about 70% of the time and for gingivalaugmentation in about 60% of cases. The implant survivalrate in their series19 of 11 patients (27 implants) was 96%.Kan et al20 used an interdisciplinary ap proach (periodontics,orthodontics, and prosthodontics) to modify the tissuearchitecture in the aesthetic zone for multiple adjacent teeth.

Tarnow et al21 noted that there is about a one- or 2-mmdifference be tween the thickness of the peri-implant softtissue and that of the soft tissue around the naturaldentition, with implants being associated with thinnertissue. The crest of bone at the implant neck should be 2mm coronal to the bone around the adjacent natural toothto ensure optimal control of soft-tissue aesthetics and avoidthe “black triangle” caused by inadequate papillae.21

Rokn et al13 noted that most attempts at verticalaugmentation were unpredictable, whether done via sinuselevation, guided bone regeneration, or distractionosteogenesis; resorption might be minimal or very dramaticand uneven. In addition, these techniques are very invasive,time consuming, and expensive. Periodontal treatment andOFE followed by implant therapy in a woman withgeneralized aggressive periodontitis was successful,resulting in shallower probing pocket depths, improvedhard- and soft-tissue margins, and restoration with animplant-supported prosthesis.


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CONCLUSIONOFE may allow for retention and restoration of otherwisehopeless teeth, and it may also provide an alternative toridge augmentation surgery to regenerate lost hard and softtissues prior to implant placement or delivery of a fixedpartial denture. Extru sion will decrease perio dontal pocketdepths, and in the case presented, it saved tooth No. 8. Inconjunction with conventional perio dontal treatment ofmaxillary anterior teeth, OFE is a viable and noninvasivesolution to a patient’s aesthetic concerns when dealing withmanagement of a nontreatable tooth in the aesthetic zone.Most patients, if given a choice, will prefer quicker, lessaggressive, and more cost-effective treatment, and OFEshould be considered in appropriate cases.

ACKNOWLEDGMENTThe assistance of Jennifer Ballinger, ELS, in drafting thismanuscript is gratefully acknowledged.

REFERENCES1. Ingber JS. Forced eruption: part II. A method of treating

nonrestorable teeth—Periodontal and restorativeconsiderations. J Periodontol. 1976;47:203-216.

2. Biggerstaff RH, Sinks JH, Carazola JL. Ortho donticextrusion and biologic width realignment procedures:methods for reclaiming nonrestorable teeth. J AmDent Assoc. 1986;112:345-348.

3. van Venrooy JR, Yukna RA. Orthodontic extrusion ofsingle-rooted teeth affected with ad vanced periodontaldisease. Am J Orthod. 1985;87:67-74.

4. Papapanou PN, Wennström JL. The angular bonydefect as indicator of further alveolar bone loss. J ClinPeriodontol. 1991;18:317-322.

5. Greenstein B, Frantz B, Desai R, et al. Stability oftreated angular and horizontal bony defects: aretrospective radiographic evaluation in a privateperiodontal practice. J Periodontol. 2008;80:228-233.

6. Pandit N, Pandit IK, Malik R, et al. Autogenous boneblock in the treatment of teeth with hopelessprognosis. Contemp Clin Dent. 2012;3:437-442.

7. Schallhorn RG. Postoperative problems associatedwith iliac transplants. J Periodontol. 1972;43:3-9.

8. Ingber JS. Forced eruption. I. A method of treating isolatedone and two wall infrabony osseous defects—rationaleand case report. J Perio dontol. 1974;45:199-206.

9. Salama H, Salama M. The role of orthodontic

extrusive remodeling in the enhancement of soft andhard tissue profiles prior to implant placement: asystematic approach to the management of extractionsite defects. Int J Periodontics Restorative Dent.1993;13:312-333.

10. Camargo PM, Melnick PR, Camargo LM. Clinicalcrown lengthening in the esthetic zone. J Calif DentAssoc. 2007;35:487-498.

11. Fakhry A. Enhancing restorative, periodontal, andesthetic outcomes through orthodontic extrusion. EurJ Esthet Dent. 2007;2:312-320.

12. Mankoo T, Frost L. Rehabilitation of esthetics inadvanced periodontal cases using orthodontics forvertical hard and soft tissue regeneration prior toimplants—a report of 2 challenging cases treated withan interdisciplinary approach. Eur J Esthet Dent.2011;6:376-404.

13. Rokn AR, Saffarpour A, Sadrimanesh R, et al.Implant site development by orthodontic forcederuption of nontreatable teeth: a case report. OpenDent J. 2012;6:99-104.

14. Goenka P, Marwah N, Dutta S. A multidisciplinaryapproach to the management of a subgingivallyfractured tooth: a clinical report. J Prosthodont.2011;20:218-223.

15. Addy LD, Durning P, Thomas MB, et al. Orthodonticextrusion: an interdisciplinary ap proach to patientmanagement. Dent Update. 2009;36:212-218.

16. Valerio S, Crescini A, Pizzi S. Hard and soft tissuemanagement for the restoration of traumatized anteriorteeth. Pract Periodontics Aesthet Dent. 2000;12:143-150.

17. Makhmalbaf A, Chee W. Soft- and hard-tissueaugmentation by orthodontic treatment in the estheticzone. Compend Contin Educ Dent. 2012;33:302-306.

18. Mirmarashi B, Torbati A, Aalam A, et al.Orthodontically assisted vertical augmentation in theesthetic zone. J Prosthodont. 2010;19:235-239.

19. Amato F, Mirabella AD, Macca U, et al. Implant sitedevelopment by orthodontic forced extraction: apreliminary study. Int J Oral Maxillofac Implants.2012;27:411-420.

20. Kan JY, Rungcharassaeng K, Fillman M, et al. Tissuearchitecture modification for anterior implant esthetics:an interdisciplinary approach. Eur J Esthet Dent.2009;4:104-117.

21. Tarnow D, Elian N, Fletcher P, et al. Vertical distancefrom the crest of bone to the height of theinterproximal papilla between adjacent implants. JPeriodontol. 2003;74:1785-1788.


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POST EXAMINATION QUESTIONS

1. Hard- and soft-tissue loss due to periodontal diseasemay be uniform throughout the dentition, but moreoften it is asymmetric.

a. True.

b. False.

2. The following is/are the most frequently used anddocumented methods of restoring tissuearchitecture:

a. Ridge augmentation.

b. Distraction osteogenesis.

c. Gingival grafting.

d. All of the above.

3. Orthodontic treatment in the presence of severeperiodontal disease is not recommended.

a. True.

b. False.

4. In the clinical case presented, orthodontic forcederuption (OFE) of teeth Nos. 8 and 9 resulted in_______ of eruption for each tooth.

a. 2 to 3 mm.

b. 3 to 4 mm.

c. 4 to 5 mm.

d. 5 to 6 mm.

5. Forced eruption of diseased teeth as a means ofaugmenting soft/hard tissue and eliminatinginfrabony defects has been explored by dentistssince:

a. The 1950s.

b. The 1960s.

c. The 1970s.

d. The 1980s.

6. Biggerstaff et al completed OFE treatment in 3patients within approximately ________.

a. 4 weeks.

b. 8 weeks.

c. 12 weeks.

d. 16 weeks.


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7. The following factor(s) is/are necessary to ensuresuccessful OFE treatment and tooth restoration:

a. Sufficient root length.

b. Adequate ferrule.

c. Intact biologic width.

d. All of the above.

8. Amato et al found that OFE prior to implant treatmentwas successful for bone regeneration approximately______ of the time.

a. 50%.

b. 60%.

c. 70%.

d. 80%.

9. The crest of bone at the implant neck should be_________ the bone around the adjacent naturaltooth to ensure optimal control of soft-tissueaesthetics.

a. Level with.

b. 2 mm coronal to.

c. 1 mm apical to.

d. 2 mm apical to.

10. OFE may allow for retention and restoration ofotherwise hopeless teeth. OFE may also provide analternative to ridge augmentation surgery toregenerate lost hard/soft tissues prior to implantplacement.

a. The first statement is true, the second is false.

b. The first statement is false, the second is true.

c. Both statements are true.

d. Both statements are false.


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orthodontic forced eruption · 2017-10-26 · orthodontic treatment in the presence of severe...

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