INTRODUCTION
It has been said that replacing the maxillary central incisor remains the most challenging procedure in implant dentistry.1 Factors impacting success include the amount of available bone, the type of soft tissue, correct positioning of the implant, the provisional restoration, the design and material of the implant abutment, and the final restoration.2
Achieving the ideal tissue drape is often considered the most difficult aspect of this restorative process. Since the gingival contours follow the underlying osseous crest, the presence of adequate alveolar bone at the implant site is paramount.3,4 Patients with teeth requiring replacement due to periodontal disease typically have osseous defects that, if left untreated, can yield catastrophic aesthetic failures. There are a bevy of studies supporting the use of orthodontic extrusion as a viable treatment approach, which can result in significant gains in both alveolar bone and soft tissue prior to implant placement.5
This article chronicles the sequence of one such case from site development to final restoration. It demonstrates that failing to execute all of the surgical protocols can result in an aesthetic compromise. In this case, the lack of orthodontic retention following active therapy compromised the newly formed labial plate, which adversely impacted the gingival margin on the final restoration.
ORTHODONTIC EXTRUSION: A REVIEW
The employment of this treatment approach to augment hard and soft tissue is based upon the principle that the periodontal fibers are secured to the bone. When placed under tension, the result is deposition of new bone. The result is an increase in vertical height of the existing defect. Additionally, a coronal migration of the overlaying periodontal tissue and marginal gingiva occurs.6
Orthodontic extrusion is not new. In 1993, Salama and Salama7 reported that teeth with a hopeless prognosis could be extruded for 6 weeks, and retained an additional 6 weeks prior to extraction and implant placement.4 Simon, et al8 further explained the retention time. At 2 weeks, they reported radiolucent areas filled with immature bone, osteoid, and a normal periodontal ligament. By week 7, normal bone formation was confirmed histologically.8 A 2008 article reviewed by Korayme, et al5 established the following guidelines with orthodontic extrusion:
• Light, constant extrusion forces are recommendable; 15 g for anterior teeth/50 g for posterior teeth.
• The rate should be steady and slow, no more than 2.0 mm per month.
• A retention and stabilization of no less than one month for every month of active extrusion.
• Overlay wires were recommended to avoid tipping of the adjacent teeth.
| Phased Treatment Planning | |||||||||||||||||||||||||||||||||||||
| Tom M. Limoli, Jr Dr. Rasner presents a very detailed, as well as classic, case report on many facets of a very comprehensive phased treatment plan. In that this case presented so many opportunities for reimbursement commentary, it was necessary in the space allotted to simply start and limit any observations to the initial diagnostic and presurgical phases. D0150 represents your diagnostic baseline prior to the initiation of a sequential treatment plan. The codes definition clearly reads, “It is a thorough evaluation and recording of the extraoral and intraoral hard and soft tissues.” This procedure includes the construction of a detailed periodontal chart, so do not waste your time and efforts looking for a separate code and associated fee. The comprehensive oral evaluation is incomplete and not billable without an evaluation of the patients’ periodontal health and occlusal (including TMJ) relationships. D0210 identifies the singular diagnostic entity of securing and interpreting the multiple periapical and bite-wing films so as to establish a singular yet complete radiographic survey. Rarely will the patients’ benefit plan consider for reimbursement both an intraoral—complete series and panoramic film for the same patient during the same exclusionary period. With your diagnostic baseline now documented we are ready to begin the treatment sequence. Continuing care must always be based upon that which the patient is responding to. In other words: start with your documented diagnosis, render treatment based upon that diagnosis, document the patient’s response to that treatment, and then continue treatment based upon patient response. The actual treatment sequence most often begins with scaling and root planing. On a per quadrant basis (4 or more teeth) the code is D4341. When addressing less than a quadrant (one to 3 teeth) the code is D4342. When a patient presents with Case Type II or greater, definitive therapy is the order of the day. In most clinical situations, periodontal scaling and root planing is indicated. The procedural definition as provided in current dental terminology has changed over the years but is still quite clear as it remains therapeutic and not prophylactic in nature. Following the conclusion of initial therapy, sufficient time must be allowed for proper healing and resolution. Both periodontists and generalists will agree that (usually) a 90-day interval should elapse after the conclusion of initial therapy. However, the astute clinician may on occasion find it more prudent (because of the patients’ inability to properly sustain home care) to shorten that interval to 6 weeks or 2 months. D4910 frequency can only be determined in conjunction with the patient’s dedication to home care as well as their individual response to therapy. |
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CASE REPORT
Diagnosis and Treatment Planning
A 42-year-old male patient presented with a chief complaint of unaesthetic maxillary anterior teeth. Specifically, the patient was unhappy with a diastema between his maxillary central incisors as well as the appearance and mobility of his upper right central incisor (Figures 1 and 2).
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| Figure 1. Preoperative view. | Figure 2. Preoperative retracted view. |
Following complete radiograph and clinical evaluation, it was determined that the patient had moderate periodontitis with localized areas of advanced periodontitis. Attachment loss was the most severe around teeth Nos. 2, 3, 8, 13, 14, 18 to 20, and 29. Subgingival plaque and calculus were present throughout the dentition. Radiographs revealed advanced osseous loss of the aforementioned teeth. The patient was missing Nos. 30 and 31, along with all third molars.
His medical history was unremarkable. He was a nonsmoker and had a history of infrequent dental care.
Initial treatment involved quadrant therapy of scaling and root planing in concert with the administration of Arestin (OraPharma). All hopeless teeth were removed, including tooth Nos. 8, 18 to 20, and 29.
A 6-week re-evaluation revealed a reduction of pocket depth, bleeding upon probing, reduced mobility and oral hygiene. The prognosis for tooth No. 8 remained hopeless. It is noteworthy that one clear contraindication for improved orthodontic extrusion is the presence of inflammatory disease.6 Ongoing periodontal maintenance is essential during active therapy.
ORTHODONTIC EXTRUSION
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| Figure 3. Orthodontic therapy. | Figure 4. Orthodontic therapy. |
GAC micro arch .018 x .022 Roth RX brackets were bonded for 8 teeth: Nos. 5 to 12. It is noteworthy that adjacent teeth with significant periodontal compromise could not be considered for anchorage.6 The bracket on tooth No. 8 was placed more apically (Figures 3 and 4). A .014-inch Australian (reg) stainless steel wire was placed in all slots and secured with o-rings. The patient was seen on 3-week intervals to activate the wire and reduce the clinical crown as needed during the forced eruption procedure. At 14 weeks, endodontic therapy was required due to the increased sensitivity in the extruded incisor.
Extraction
It is generally agreed that the extruded tooth requires retention following active therapy. One month for every month of extrusion: that meant 3 months for this case report. The author proceeded with the extraction and implant placement at 6 weeks. The result was an “undoing” of the augmentation just achieved requiring a second augmentation procedure.
At the extraction visit, a full thickness papilla-sparing incision was made and the tooth removed. The socket was carefully debrided and a 4.6 by 12 mm BioHorizons immediate implant was placed. As noted, the extraction resulted in a 5.0 x 4.0 mm defect on the midfacial of the implant. Rigid fixation was obtained. A hard-tissue augmentation utilizing a membrane (Resolute [W.L. Gore]) with a combination of 50% autogenous and 50% Min-Oss was tacked (The Auto Tac System [BioHorizons Implant Systems]). Primary closure was obtained with Vicryl 4.0 suture (Ethicon) (Figures 5 to 7). The patient was scheduled for uncovery at 4 months postoperatively.
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| Figure 5. Loss of facial plate. | Figure 6. Bone graft. |
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| Figure 7. Membrane and tacs. |
Provisional
In addition to the implant crown on tooth No. 8, the initial treatment plan included single all-ceramic restorations on teeth Nos. 7, 9, and 10. A 4-unit acrylic (Lang Dental Manufacturing) bridge from teeth Nos. 7 to 9 simplified the provisional process. At 4 months, it was apparent that the gingival drape over the cervical portion of tooth No. 8 was under-contoured, resulting in an apically positioned gingival margin. The provisional was removed and a subepithelial connective tissue graft was provided. A 4-week post-op showed significant gain in the area grafted (Figures 8 to 11).
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| Figure 8. Preoperative photo demonstrating need for soft-tissue augmentation. | Figure 9. The 4.0 x 10 mm harvested connective-tissue graft. |
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| Figure 10. Sutured graft. | Figure 11. Three-week postoperative photo of connective-tissue graft. |
Final Impressions
Twelve weeks following soft-tissue augmentation, final impressions (soft medium body Impregum [3M ESPE]) were taken; preparations (360° shoulders) were refined on the adjacent teeth (Nos. 7, 9, and 10). A transfer coping was placed on the implant body and the dental technician team fabricated 4 single lithium disilicate (IPS e.max [Ivoclar Vivadent]) all-ceramic crowns (Figures 12 to 14).
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| Figure 12. Full contour wax-up for all-ceramic crown fabrication. | Figure 13. Sprued lithium disilicate (IPS e.max [Ivoclar Vivadent]) all-ceramic crowns for pressing. |
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| Figure 14. All-ceramic crowns prior to cut back and layering. | Figure 15. Final restorations. |
DISCUSSION AND CLOSING COMMENTS
Most clinicians would agree that the goal of anterior tooth replacement with an implant restoration is to replicate the appearance of a natural tooth. This goal then mandates that adequate bone volume be present.
This case report involved a common clinical situation where the tooth to be extracted had alveolar defects. Orthodontic extrusion was used to promote coronal proliferation of the interproximal bone and overlying gingival tissue. The author was able to vertically augment approximately 4.0 mm. (Note: The author wishes the reader to know that one of the tenets of orthodontic extrusion was violated; that one-month retention for each month of active extrusion is to be allowed.6 This necessitated a second hard-tissue augmentation procedure and delayed the final prosthesis by 5 months.)
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| Figures 16a. Resting postion. | Figures 16b. Facial view. |
Although the final restoration was satisfactory to the patient, there remains a clear gingival margin discrepancy between teeth Nos. 8 and 9 (Figures 15a to 16b).
This case report illustrates another approach the implant dentist can use to achieve predictable results. It further explains the importance of strictly adhering to all the protocols that accompany a specific augmentation procedure. Considerable patient compliance with respect to oral hygiene is also required for a successful outcome. Finally, patient selection, education, and motivation are clearly important factors in case selection.
Acknowledgement
Dr. Rasner would like to thank Valley Dental Arts, Stillwater, Minn, for their excellent ceramics as well as Dr. Bob Stern for the orthodontic care of this patient.
References
- Single tooth replacement: surgical considerations. In: Misch CE. Contemporary Implant Dentistry. 3rd ed. St. Louis, MO: Mosby; 2008:739.
- Holst S, Blatz MB, Hegenbarth E, et al. Prosthodontic considerations for predictable single-implant esthetics in the anterior maxilla. J Oral Maxillofac Surg. 2005;63(9 suppl 2):89-96.
- Sclar AG. Strategies for management of single-tooth extraction sites in aesthetic implant therapy. J Oral Maxillofac Surg. 2004;62(9 suppl 2):90-105.
- Belser UC, Schmid B, Higginbottom F, et al. Outcome analysis of implant restorations located in the anterior maxilla: a review of the recent literature. Int J Oral Maxillofac Implants. 2004;19(suppl):30-42.
- Korayem M, Flores-Mir C, Nassar U, et al. Implant site development by orthodontic extrusion: a systematic review. Angle Orthod. 2008;78:752-760.
- Danesh-Meyer MJ, Brice DM. Implant site development using orthodontic extrusion: a case report. N Z Dent J. 2000;96:18-22.
- Salama H, Salama M. The role of orthodontic extrusive remodeling in the enhancement of soft and hard tissue profiles prior to implant placement: a systematic approach to the management of extraction site defects. Int J Periodontics Restorative Dent. 1993;13:312-333.
- Simon JH, Lythgoe JB, Torabinejad M. Clinical and histologic evaluation of extruded endodontically treated teeth in dogs. Oral Surg Oral Med Oral Pathol. 1980;50:361-371.
Dr. Rasner is a general practitioner from Bridgeton, NJ. In 1998, he founded Realizing the Dream, a collection of professional management tools, including speaker services, books, and in-office training videos. He has won numerous speaking awards nationally and abroad. He can be reached at (800) 337-8435 or at the Web site realizingthedream.com.
Disclosure: Dr. Rasner reports no disclosures.
