Modality and risk management for orthodontic extrusion procedures in interdisciplinary treatment for generating proper bone and tissue contours for the planned implant: a case report
© Maeda and Sasaki. 2015
Received: 8 September 2015
Accepted: 29 September 2015
Published: 23 October 2015
In adult interdisciplinary treatments with using dental implants, limited orthodontic treatment, especially orthodontic extrusion (OE), offers many benefits by both correcting teeth alignment and by contributing to the regeneration of periodontal tissues. However, orthodontic procedures carry some risks and unpredictabilities that might compromise tooth and/or periodontal tissue health. Especially in complex cases, it is difficult to decide which orthodontic treatment modalities should be combined, in what sequences they should be applied, and what their force systems and treatment times are.
To achieve optimum results, some cases require two or more OEs to the same site being carried out at different times while taking the treatment effects into consideration. Such staged OE offers minimum intervention and maximum efficiency. In this case report, OE was first applied for orthodontic extraction. After bone regeneration followed by an implant placement and another surgical operation, a second OE was applied to align the inclination of an adjacent tooth. As a result, a predictable prognosis of implants as well as greatly improved esthetics and periodontal tissue health were achieved.
KeywordsInterdisciplinary treatment Implant Orthodontic extrusion (OE) Combination of orthodontic modalities Risk management Orthodontic extraction Esthetics Periodontal tissue health Minimum intervention
Adjunctive orthodontic treatment for adults is tooth movement that is carried out to facilitate other dental procedures necessary to control disease, restore function, and/or enhance appearance . Orthodontic extrusion is an adjunctive orthodontic treatment with the potential to improve bone anatomy in consideration of implant placement .
Because OE is regarded as being simpler and easier than comprehensive orthodontic treatment, this treatment can be mistakenly considered simple and completed without careful planning, which can lead to an unsatisfactory clinical outcome. Orthodontic treatments involve some risks for tooth and/or periodontal tissue that may lead to unpredictable and unsatisfactory results regardless of the complexity of treatments [7–9].
To achieve optimum results, it is important to decide which orthodontic treatment modalities should be combined. In addition, the sequence in which they are applied, the force system, and their treatment time must be considered .
In this case report, two LOTs were applied to the same site at different times, along with tooth extraction and guided bone regeneration followed by implant placement. For this patient, limited orthodontic treatment provided twice during the sequence of overall treatment resulting in improved esthetics and soft tissue health.
A 28-year-old male visited our clinic with a chief complaint of poor esthetics in the maxillary anterior region. The patient was in good general health, and his medical and dental history indicated no contraindications to dental treatment.
Initial preparation with scaling and root planing
Orthodontic extrusion and extraction of the right maxillary central incisor
Implant placement with a bone grafting procedure
A second implant operation for an abutment connection
Orthodontic treatment for the right lateral incisor
Final restoration and retention
An esthetic implant-supported crown with symmetric soft tissue contours was achieved with the combined orthodontic extrusion, orthodontic alignment, and grafting procedures. The maintenance phase has been uneventful.
Orthodontic treatment plays a major role in adult interdisciplinary dentistry. In this case, orthodontic treatments were applied in two stages. In the first stage, OE of the right maxillary central incisor was carried out. In the second stage, the flaring adjacent lateral incisor on the same side was corrected. The first orthodontic treatment made optimal implant placement possible because of regenerated hard and soft tissue after the extraction. In addition, the first stage facilitated esthetic restoration with regenerated alveolar bone and soft tissue [11–13].
The second orthodontic treatment was employed to correct the position and angulation of the lateral incisor using an osseointegrated implant as the orthodontic anchor.
It was important that these orthodontic treatments were not applied simultaneously or with the same force system (orthodontic term: combination of all the forces and moments acting on these teeth).
There were two reasons for selecting a staged approach instead of a simultaneous one. First, if these tooth movements were attempted simultaneously, not only would the extrusion of the central incisor not be effectively achieved, but also the mesio-palatal movement of the right lateral incisor could not be sufficiently controlled. Since a lateral incisor will move to an unhealthy bone-defected area close to a central incisor, there could be the risk of an attachment loss of the lateral incisor [14–16]. In contrast, a staged approach would not incur the risk of attachment loss of the lateral incisor because regenerative therapy was applied first [17–19].
Orthodontic treatments in adults carry higher risks, such as gingival recession, alveolar bone resorption, and root resorption, compared with those in children [22, 23]. When a continuous arch wire is placed on many teeth to provide anchorage, balancing forces can result in unintended outcomes. In this case, the movement of the lateral incisor was achieved in a short period of time by using only one adjacent tooth as anchor because the anchorage for the implant was already in place. Adverse effects of orthodontic force could be minimized because the orthodontic treatment was performed in the shortest period of time possible and in a limited treatment area. The staged approach of orthodontic treatment in this study was carried out with minimum intervention and maximum efficiency.
To prepare optimum implant placement site with improved esthetics and healthy periimplant tissue, orthodontic extrusion is one of the most effective and minimum invasive modalities, however, some cases require staged process with different type of orthodontic approach at different times.
Written informed consent was obtained from the patient for the publication of this report and any accompanying images.
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