Orthodontic extrusion: Its use in restorative dentistry

David W. Ivey, D.M.D.,* Richard L. Calhoun, D.M.D.,** William B. Kemp, D.D.S.,***

Howard S. Dorfman, D.M.D.,**** and John E. Wheless, D.D.S.*
Medical College of Virginia, School of Dentistry, Richmond, Va.

T he use of orthodontic
as forced eruption,
extrusion, also referred to
has met with limited use in
restorative dentistry. Heithersay’ in 1973 and more
recently Ingber’ have written articles on the use of
forced eruption in the management of isolated
nonrestorable teeth. This application of orthodontic
movement results in tooth eruption that aids in
lengthening of the clinical crown.
Exposure of additional clinical tooth structure by
periodontal surgery in the anterior portion of the
dental arch is often discouraged due to the resultant
compromise in esthetics and the possible adverse
periodontal change to adjacent teeth. This is partic-
ularly true when extrusion of a single-tooth crown is Fig. 1. A. Maxillary left lateral incisor with subgingival
required in an otherwise intact arch. caries.
The patients reported in this study demonstrate
the concepts involved in establishing an esthetic
result while maintaining a healthy periodontium. A
brief discussion of this possible alternative to extrac-
tion is presented.

CASE REPORTS
Patient 1
A 29-year-old man needed root canal treatment of
the maxillary left lateral incisor (Fig. 1, A). Exami-
nations revealed extensive caries and a history of
long-term pulpal exposure (Fig. 1, B). The carious
process on the tooth approached the crestal bone
interproximally, creating a questionable prognosis.
Because the patient expressed a strong desire to
retain this tooth in spite of the guarded prognosis,
alternatives to extraction were considered. It was
decided that orthodontic extrusion (forced eruption)

The views expressed herein are those of the authors and do not
necessarily reflect the views of the United States Air Force or
the Department of Defense.
*Former Resident in Periodontics; now in private practice.
**Former Resident in Endodontics; now in private practice.
***Associate Professor, Department of Endodontics. Fig. 1. B. Radiograph of the maxillary left lateral incisor
****Associate Professor, Department of Periodontics. prior to therapy.

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Fig. 1, C to E. C, Polycarbonate crown in place following completion of root canal therapy

and fabrication of a cast post and core. D, Orthodontic wire engaged to initiate eruption of
the tooth. E, Five weeks later at completion of eruption. Note the bracket alignment.

should be attempted. A rubber dam was placed, the

caries excavated, and root canal treatment initiated.
The endodontic treatment was completed at a subse-
quent appointment. A direct self-polymerizing post
and core pattern was constructed, cast in gold, and
cemented into place. A polycarbonate crown was
temporarily placed (Fig. 1, C). Following pumicing
and acid etching, mesh-backed orthodontic brackets
were placed on both central incisors and the adjacent
canine with direct bonding adhesive. A plastic
bracket was bonded to the polycarbonate crown
approximately 3 mm apical to the other brackets,
and a multistrand orthodontic wire was positioned
to engage all five brackets (Fig. 1, D).
The patient returned in 2 weeks; the erupting
incisor exhibited mobility and some degree of extru-
sion. By the fifth week the forced eruption. was
complete (Figs. 1, E and F) and the crown was
adjusted to prevent occlusal interference. After 6
additional weeks of stabilization, an evaluation was
made regarding the need for a surgical crown exten-
sion procedure. This procedure was carried out
under local anesthetic, utilizing inverse-bevel scal-
Fig. I, F. Radiograph upon completion of the forced loped incisions and full-thickness facial and palatal
eruption. Note the change in radiodensity at the apex flaps. Minimal osteoplasty was necessary to expose
associated with root movement. approximately 3 mm of sound tooth structure inter-

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Fig. 1, G to I. G, The crown extension on the mesial aspect of the lateral incisor. H, Three
weeks after surgery, the clinical crown exposure and poor marginal adaptation of the original
temporary crown. I, Porcelain-fused-to-metal restoration in place.

proximally on the lateral incisor and allow an the canine in a manner similar to that described for
adequate dimension for periodontal connective Patient 1. The bracket on the left lateral incisor, the
tissue attachment (Fig. 1, G). The flaps were then tooth requiring eruption, was placed approximately
placed at the crest of the alveolar margin and 4 to 5 mm apical to the level of the other brackets.
stabilized with 4-O silk suture. A periodontal dressing The twist wire was engaged and secured in posi-
was placed and maintained for 7 days, and the tion.
postoperative course was without incident (Fig. Within 2 weeks the lateral incisor showed some
1, fo eruption, and by the fourth week the orthodontic
The final crown preparation and fabrication was extrusion of approximately 4 to 5 mm was
completed 4 weeks after surgery (Fig. 1, I). completed. The twist wire was left in place for
retention for 6 additional weeks (Fig. 2, B).
Patient 2 Due to unfavorable soft tissue contours that devel-
An 18-year-old woman presented with extensive oped during the orthodontic movement, a periodon-
caries of the maxillary left lateral incisor (Fig. 2, A). tal flap procedure was deemed necessary. The proce-
Examination revealed previous root canal therapy in dure carried out was similar to that described in
these teeth and carious lesions on the lateral incisor patient I, except that osteoplasty was not necessary
approaching the crestal alveolar bone. Full-thickness (Fig. 2, C). Four weeks later the patient was evalu-
facial and palatal flaps were elevated to expose ated (Fig. 2, U) and referred for placement of the
sufficient tooth structure for evaluation and caries final restoration.
excavation. A decision was made to extrude the left
lateral incisor. Post and core direct patterns were
Patient 3
fabricated, cast in gold, cemented, and followed by A 20-year-old man was examined with a crown-
placement of temporary crowns. root fracture of the maxillary right central incisor
Direct bond wire-mesh brackets were placed on from a job-related incident (Fig. 3, A). Examination
the two central incisors, the left lateral incisor, and revealed an angular nature to the fracture that

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Fig. 2. A, Maxillary left lateral incisor during the initial examination. B, Following eruption,
the orthodontic wire was utilized for the 6 week retention period. C, The lateral incisor after
eruption and immediately following soft tissue recontouring. D, Four weeks following soft
tissue surgery and prior to placement of the final restorations.

involved the palatal root surface (Fig. 3, B). The Patient 4

following treatment options were considered: (1) A 34-year-old man was seen 2 weeks following a
extraction and placement of a three-unit fixed pulpectomy and placement of a temporary post-core
partial denture, (2) periodontal crown extension crown in a maxillary right lateral incisor. The
surgery, endodontic therapy, and fabrication of a patient, an endodontist, reported that trauma
single post-core crown, and (3) endodontic therapy, a during a sporting event 13 years ago had resulted in
post-core restoration, and forced eruption prior to a horizontal subossesous root fracture. His family
the crown restoration. Because of the existing diaste- dentist felt the tooth was nonrestorable, but advised
ma, possible esthetic compromise, and the subcrestal against extraction at that time. The tooth remained
involvement of the palatal root fracture, the forced comfortable and moderately mobile for 11 years.
eruption treatment plan was chosen. Within the previous 2 years mobility had increased.
Following endodontic therapy and the cast post- Two weeks prior to examination, the crown
core cementation, the eruption procedure was completely separated from the gingiva. Fig. 4, A is a
initiated, as described previously (Fig. 3, C). Three copy of a radiograph made 1 year prior to crown
weeks later, after alignment with the multistrand loss.
wire, it was decided that further eruption was Extraction followed by a fixed partial denture or
necessary, and a 0.02-inch arch wire with compensat- crown extension had been previously considered
ing bends was placed (Fig. 3, 0). undesirable because of diastemas between the maxil-
After extrusion and a retention period, an apically lary anterior teeth and because of the subcrestal level
positioned flap was utilized to correct the discrepan- of root fracture, respectively. Still faced with these
cy in gingival height. After a total treatment time of unesthetic features, forced eruption was chosen as a
10 weeks, the final crown restoration was constructed possible alternative.
without esthetic compromise (Fig. 3, E). Following endodontic therapy, a post-core restora-

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Fig. 3. A, The crown-root fracture of the maxillary right lateral incisor. B, The incisal and
palatal dimensions of the crown-root fracture following minimal gingival resection to
accommodate endodontic therapy and post preparation. C, Beginning of orthodontic extrusion
with the multistrand wire engaging th.e apically positioned bracket of the right central incisor.
D, Maxillary right central incisor in the final stage of eruption. Note that the gingival tissue has
followed the erupting tooth (relative to adjacent incisors) creating a discrepancy in the coronal
gingival height. E, Following extrusion and an apically repositioned flap, the right central
incisor is ready for the planned crown restoration.

tion, and placement of a temporary crown, forced gingivoplasty was performed to facilitate refinement
eruption was initiated with the bracket on the of the crown preparation. Subsequently the patient
involved tooth approximately 4 to 5 mm apical to was referred for final restoration of the tooth (Fig.
the alignment of the adjacent teeth (Fig. 4, B). 4, c).
For 6 weeks no perceptible mobility or eruption
DISCUSSION
was noted. However, within the next 3 weeks the
desired movement occurred and the tooth was stabi- The orthodontic procedure described is a segmen-
lized for 8 weeks. tal approach that uses acid-etched orthodontic
Prior to preparation for the crown restoration, a brackets and a very flexible multistrand wire. The

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 IVEY ET AL.

Fig. 4. A,
A,Radiograph
Radiograph of the maxillary right lateral incisor made I year prior to crown loss. B,
B,’
At the onset of eruption, the orthodontic wire was placed approximately 4 to 5 mm out of line.
C, Following completion of extrusion and retention, the patient was referred for the
porcelain-fused-to-metal restoration.

periodontal crown lengthening procedure that vitally important and have been described by
followed the extrusion in Patients 1 and 2 provided Ingber.?
sufficient tooth structure for the restorative needs Another restorative consideration that has
that followed. Several authors”-’ have described received attention more recently is an anatomic area
eruptive tooth movement resulting in a coronal shift referred to as the biologic width.“, ” Palomo and
of the supporting connective tissue attachment and Kopczyk” state that “at least 1% mm between the
alveolar bone. As demonstrated in Patients 2 and 4 base of the sulcus and the crest of alveolar bone”
this may not be a predictable occurrence, since should exist to maintain periodontal health. This
ostectomy was not found necessary. However, when area is said to allow for epithelial and connective
the attachment structures do follow the tooth coro- tissue attachment to the tooth. Similarly, Ingber’
nally, the ostectomy necessary should include remov- and Ingber and associate? state that at least 2 mm is
al of only that alveolus which moved cosonally. Also, needed for the connective tissue and epithelial
the gingival fibers that are stressed, posing a possible attachment to maintain the biologic width.
relapse problem, have to be severed during flap These authors discuss maintaining the biologic
reflection. This closely parallels the rationale width and its importance in restorative dentistry. At
described by Edwards’. 7 in his transseptal fiber present, the only histometric study available from
resections used to prevent postorthodontic rotational which this concept is drawn was done by Gargiulo
relapses of teeth. and associates”’ in 1961. Their findings are based on
Restorative considerations that result from the 30 human cadaver jaws containing 287 teeth of
narrow mesiodistal width of the extruded roots are uncertain gingival health. Measurements were made

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