Orthodontic Extrusion and Implant Restoration to Manage Localized Advanced Bone Loss: A Clinical Case Review
Restorative dentists must consider and respect the preferences of their patients when developing treatment plans. They must also communicate openly with both the patient and their interdisciplinary team regarding treatment objectives, particularly in challenging cases such as the one presented herein, in which the patient had severe recession above her upper laterals and cuspids, was congenitally missing molars, and had a history of full-mouth scaling and root planing as well as periodontal surgery in the maxillary arch. This case incorporated four phases of treatment—endodontics, orthodontics, surgical, and restorative—to achieve the desired results.
In an era when patients' esthetic and functional expectations are high, their demands often extend to the active phases of treatment. Patients can refuse treatment protocols that may be in their best interest due to the temporary inconvenience that they may cause. Patients have been known to refuse traditional orthodontics, provisional removable prosthetics, or temporarily edentulous spaces during the active phase of treatment. Therefore, patient preferences during the treatment phase must be considered and respected when developing treatment plans.
This case demonstrates that success can be achieved in challenging cases when the restorative dentist utilizes a carefully selected interdisciplinary team approach to treatment. It underscores the critically important responsibility of the restorative dentist in overseeing all treatment decisions, while working closely and in open communication with the patient and an interdisciplinary team skilled and in complete alignment about treatment objectives.
Clinical Case Overview
Patient History and Chief Complaint: A 32-year-old woman presented with the chief concern about the severe amount of recession above her upper laterals and cuspids. She had been treated recently at the periodontist for periodontal disease and was concerned about the length of her laterals and cuspids. The patient was congenitally missing all second and third molars. In addition, she had a history of full-mouth scaling and root planing and periodontal surgery in the maxillary arch.
Periodontal: The examination revealed light to moderate bleeding upon probing and no probing depths greater than 4 mm. However, advanced bone loss was present in the lower anterior and the upper cuspid and lateral areas (Figure 1). The periodontal diagnosis was moderate periodontitis with localized advanced periodontal disease (Figure 2, Figure 3, Figure 4). One to two degree mobility was present on the upper and lower anterior teeth.
Biomechanical: Upon clinical examination, several acceptable direct restorations in the pit and fissure areas of the posterior molars were charted. There was no history of interproximal carious lesions or any clinical or radiographic indication of active caries.
Functional: A diagnosis of occlusal dysfunction was based on the patient’s history of occasional headaches and mobility of the anterior teeth. Due to the amount of the bone loss, it was difficult to determine if the mobility was primary from bite forces or secondary from bone loss. A deprogrammer was not used in this case, since it would have had no effect on the treatment decisions.
Dentofacial: The patient had medium lip dynamics (Figure 5), although she had very high esthetic demands that adversely affected the esthetic prognosis of this case.
Risk: Medium to high
Medical: The patient had no known medical contraindications to dental treatment and her medical history was within normal limits.
After thorough consideration of all treatment options—including a consultation with an orthodontist and periodontist—the final decision was made to attempt to move the alveolar crest and gingival tissues coronally by orthodontic extrusion.1 Treatment decisions centered on meeting the patient’s esthetic objectives and her important requirement of avoiding the use of any removable provisional restorations during any phase of the treatment. Additionally, treatment utilized interdisciplinary dentistry to address genuine concerns about the retention and longevity of her upper lateral incisors and cuspids and to restore lost osseous and soft tissue in those areas, as well as establish esthetic harmony with both soft tissue and restorative materials.
The treatment plan consisted of a consultation with the orthodontist and periodontist and development of a complete understanding among all treating dentists and the patient about treatment phases and realistic expectations. Treatment included root canal therapy and lingual composites on the upper cuspids and laterals, and orthodontic treatment to slowly erupt the upper cuspids and laterals using careful attention and extreme caution to prevent movement of the roots labially. The cuspids and laterals were reduced at every phase of extrusion to keep these teeth out of occlusion during orthodontic treatment.
Teeth Nos. 7 and 10 were prepared for provisional crowns, with distal cantilevers over the cuspid sites. Teeth Nos. 6 and 11 were extracted, followed by immediate implant placement by the periodontist. Teeth Nos. 6 and 11 were restored with Atlantis® abutments (Astra Tech, www.astratech.us) and porcelain-fused-to-metal (PFM) crowns, and teeth Nos. 7 and 10 were restored with feldspathic crowns.
Phase I: Endodontics
Due to the amount of orthodontic extrusion required, root canal treatment was performed on the upper laterals and cuspids to prevent the sensitivity that would result when the required tooth reduction was performed to prevent occlusal contact. Pulpotomies without gutta percha were performed on the cuspids, since they were ultimately treatment planned for extraction. Endodontic treatment was performed to completion on the laterals, since they would be retained after extrusion. All four teeth received composite restorations over the endodontic access openings.
Phase II: Orthodontics
Orthodontic treatment was initiated in May 2006, with careful and strict precautions taken to ensure that tooth movement occurred gradually1 and orthodontic forces were applied to prevent any movement that would cause the roots to move labially. Additionally, the patient required regular visits to the restorative dentist so diligent monitoring of tooth movement and any necessary adjustments to the laterals and cuspids could be accomplished to ensure there was no occlusal contact. The cuspids and laterals were positioned to allow the cuspids to emerge in the ideal location for future implant placement. The orthodontist was instructed to keep the laterals and cuspids in close proximity for maintaining a maximum width of alveolar ridge (Figure 6 and Figure 7). Orthodontic treatment continued until July 2007, at which time the determination was jointly made by the treating dentists that the treatment objective of leveling the gingival margins was achieved (Figure 8).
Phase III: Surgical
On the day of surgery, the restorative dentist prepared the lateral incisors for crown preparations at the surgeon’s office. Minimally invasive extractions were performed on teeth Nos. 6 and 11.2 These extractions were accomplished using periotome and extraction forceps. A periapical cyst was noted on the root tip of tooth No. 11. An absence of the majority of the buccal plate was noted at both extraction sockets.
After curetting and irrigating, the sockets were prepared with drills for immediate implant placement.3 Caution was used to ensure the osteotomy was from the palatal aspect of the socket and extended far beyond the apex of the shortened root tip. The residual defect of the periapical cyst on tooth No. 11 was obliterated by the final drill.
In both osteotomies, a 3.5-mm x 11-mm implant (OsseoSpeed™, Astra Tech) was placed with a 1-mm cover screw. The implants were placed 3 mm apical to the buccal free gingival margin and 2 mm palatal4 from the missing buccal plate.5 The implant/soft tissue gap on the buccal and the implant/socket gap on the mesial and distal were filled with a composite graft of mineralized freeze-dried bone allograft (BIOMET 3i, www.biomet3i.com) and growth-factor enhanced matrix (GEM 21S®, Osteohealth, www.osteohealth.com). No membrane was used.
The restorative dentist then relined two acrylic shell provisional cantilever bridges with temporary resin (Caulk C&B Resin, shade 62, DENTSPLY Caulk, www.caulk.com) to restore the missing teeth. The provisionals were cemented with temporary cement (TempBond®, Kerr Corporation, www.kerrdental.com).
Healing was unremarkable (Figure 9), and 5 months postoperatively the implants were uncovered. While the implant in the No. 6 position had integrated, the implant in the No. 11 position failed to integrate and was removed. The buccal plate that was missing at initial implant placement was now present. Mineralized freeze-dried bone was placed in the lost implant site, and after a 6-month healing period, a new 3.5-mm x 11-mm implant was placed. The implant was uncovered after a 3-month healing period, at which time it was found to have integrated.
Phase IV: Restorative
Although not intentional, the restorative phase of the treatment plan occurred in two different stages. Due to the lack of implant integration in the No. 11 position, the decision was made to restore the right and left side at two separate times. During the appointment when the right implant was uncovered and integration confirmed, a polyvinylsiloxane (PVS) impression was made of the upper arch using an open tray pick-up impression coping6 (Astra Tech) to register the position of the implant, as well as the prepared tooth No. 10.
The laboratory instructions were to fabricate a titanium abutment (Altantis) and a PFM crown on the implant abutment. An all-porcelain feldspathic crown was prescribed for the lateral incisor. Although there was minimal enamel on the lateral incisor in which to bond, after considering the medium to high dentofacial risk and the low biomechanical and functional risks (ie, there was no centric contact on this tooth), the decision was made to place a full porcelain crown.
The instructions for the design of the abutment included flaring the emergence profile on the distal in order to be positioned 2 mm from the mesial root of tooth No. 5, with a similar flare on the mesial and the facial margin to approximate the root emergence of tooth No. 5. The gingival margins were to be located 0.5 mm subgingival on the distal and lingual surfaces, and 1.5 mm subgingival on the mesial and facial.7 Due to the shortened gingival papilla from the absence of bone between the implant and lateral incisor, the laboratory was instructed to extend the proximal contact to within 1 mm of the gingival margin.8 Shallow cuspid guidance on the cuspid was requested.
At the insertion appointment, proper seating of the abutment was verified radiographically before tightening the implant abutment screw to 25 Ncm. Both crowns were tried in to verify the margins and proximal contacts, esthetics, and occlusal function. After confirming that all of the dentist’s objectives were met, the patient’s approval was sought and obtained before final cementation of the crowns.
The crown over the implant abutment was cemented with a universal self-adhesive resin cement (RelyX™ Unicem, 3M ESPE, www.3MESPE.com). The feldspathic crown for tooth No. 7 was silanated (Bis-Silane™, Bisco, www.bisco.com). Tooth No. 7 first was cleaned with a particle abrasion of 27 μm aluminous oxide (PrepStart™, Danville Materials, www.danvillematerials.com) at 40 psi, with a 0.015 tip at a 2 mm distance. It then was etched with 35% phosphoric acid (Bisco), rinsed, and blotted dry and treated with two coats of a one-step adhesive (One-Step®, Bisco), which was thinned out and cured for 10 seconds. The feldspathic crown for tooth No. 7 then was cemented into place using a translucent shade of an adhesive resin cement (RelyX™ ARC, 3M ESPE) and light-cured.9 The final radiograph (Figure 10) confirmed fit and removal of excess cement.
The second stage of restorative treatment occurred after integration of the implant in the No. 11 position. The instructions for the restoration of teeth Nos. 10 and 11 were identical to those followed for the right side.
The patient was “thrilled” with her treatment outcome, stating that it “exceeded her expectations” (Figure 11, Figure 12, Figure 13 and Figure 14). This treatment illustrates the results that can be achieved when there is complete alignment and communication among all members of the interdisciplinary team, as well as the patient. It is essential that the restorative dentist oversee all treatment decisions and communication among the treating dentists and patient.10 Setbacks and unexpected circumstances can occur during any phase of treatment, but desirable outcomes can be achieved predictably if these situations are promptly recognized and addressed by the treating dentists and patient.
There were several factors that greatly contributed to the success of this case. All members of the restorative team were committed to working together cooperatively; communication was frequent and effective. Both the orthodontist and periodontal surgeon, each very reputable and highly skilled in their respective fields, were comfortable allowing the restorative dentist to provide the overall direction for the case. In addition, the patient was most cooperative and understanding. She was very patient and exhibited great confidence and trust in the recommendations and treatment plan. Ultimately, her understanding influenced the decision to maintain her lateral incisors, which essentially allowed the team to achieve a more successful, esthetic result. These teeth still have a very guarded prognosis, but it was her desire to maintain them as long as possible, with full knowledge and understanding of the risks.
The author would like to thank Scott Tyler, DDS, MS, for providing the orthodontic care in this case; Abbey Sayed, DDS, MS, for placing the implants; and Leon Hermanides for delivering the natural-looking porcelain restorations.
1. Kokich VG. Adjunctive role of orthodontic therapy. In: Newman MG, Takei HH, Klokkevold PR, eds. Carranza’s Clinical Periodontology. 10th ed. St. Louis, MO: Saunders Elsevier; 2006:856-871.
2. Chen ST, Darby IB, Reynolds EC, Clement JG. Immediate implant placement postextraction without flap elevation. J Periodontol. 2009;80(1):163-172.
3. Covani U, Barone A, Cornelini R, Crespi R. Soft tissue healing around implants placed immediately after tooth extraction without incision: a clinical report. Int J Oral Maxillofac Implants. 2004;19(4): 549-553.
4. Kois JC. Predictable single-tooth peri-implant esthetics: five diagnostic keys. Compend Contin Educ Dent. 2004;25(11):895-900.
5. Elian N, Cho SC, Froum S, et al. A simplified socket classification and repair technique. Pract Proced Aesthet Dent. 2007;19(2):99-104.
6. Daoudi MF, Setchell DJ, Searson LJ. A laboratory investigation of the accuracy of two impression techniques for single-tooth implants. Int J Prosthodont. 2001;14(2):152-158.
7. Kois JC, Kan JY. Predictable peri-implant gingival aesthetics: surgical and prosthodontic rationales. Pract Proced Aesthet Dent. 2001;13(9):691-698.
8. Choquet V, Hermans M, Adriaenssens P, et al. Clinical and radiographic evaluation of the papilla level adjacent to single-tooth dental implants. A retrospective study in the maxillary anterior region. J Periodontol. 2001;72(10):1364-1371.
9. Kois JC. Anterior adhesively retained restorations. Kois Center Symposium Manual: Always Handout. July 23-25, 2009; Seattle WA.
10. Kokich VG, Kokich, VO. Interrelationship of orthodontics with periodontics and restorative dentistry. In: Nanda R, ed. Biomechanics and Esthetic Strategies in Clinical Orthodontics. St. Louis, MO: Elsevier Saunders; 2005:348.
About the Author
Edward A. Borio, DDS
Bloomfield Hills, Michigan