CLINICIAN’S CORNER

A novel approach for implant site developmentthrough root tipping

Flavio Uribe,a Thomas Taylor,b David Shafer,c and Ravindra Nandad

Farmington, Conn

Implant site development through orthodontic extrusion can regenerate hard and soft tissue volumes lost toperiodontal disease. This extrusive procedure is indicated especially when a maxillary incisor is severelycompromised and the esthetic demands are high. This article describes a novel approach to alveolar bonedevelopment that enhanced the volume of the implant site. The technique involves tipping themaxillary incisorin the direction of the angular defect to increase alveolar bone volume in the implant site; simultaneousimprovement of the interproximal papillary height can also be expected. With this procedure, immediate load-ing of the endosseous implant is possible due to the quality of the bone developed. (Am J Orthod DentofacialOrthop 2010;138:649-55)

Alveolar bone development before the placementof an endosseous implant can be accomplishedthrough the slow orthodontic eruption or

‘‘extraction’’ of a severely periodontally compromisedtooth.1-3 This procedure is particularly useful whena maxillary incisor is compromised. Because themaxillary incisor is in an important esthetic zone, thismethod generates tissues that are sufficient to mimic thecontralateral incisor and maximizes the development ofhard and soft tissue contours. With a light, continuousorthodontic force applied, the tooth is slowly broughtincisally along with its gingival attachment and alveolarbone, improving the surrounding bony architecture.4-8

The success of an endosseous implant depends onadequate soft and hard tissue volumes in the recipientsite.2 As the compromised tooth is erupted, the cross-sectional area of the root is reduced because of its con-ical shape. As a result, bone fill is deficient, since theroot’s capacity of regenerating bone is limited in themesiodistal and buccolingual directions. To circumvent

From the School of Dental Medicine, University of Connecticut, Farmington.aAssociate professor, Division of Orthodontics, Department of Craniofacial

Sciences.bProfessor and head, Department of Oral Rehabilitation, Skeletal Development

and Biomaterials.cAssociate professor and chair, Division of Oral and Maxillofacial Surgery,

Department of Craniofacial Sciences.dProfessor and head, Department of Craniofacial Sciences, alumni endowed

chair.

The authors report no commercial, proprietary, or financial interest in the

products or companies described in this article.

Reprint requests to: Flavio Uribe, Division of Orthodontics, University of

Connecticut Health Center, 263 Farmington Ave, Farmington CT 06030;

e-mail, Furibe@uchc.edu.

Submitted, December 2008; revised and accepted, January 2009.

0889-5406/$36.00

Copyright � 2010 by the American Association of Orthodontists.

doi:10.1016/j.ajodo.2009.01.027

this problem, Zuccati and Bocchieri3 described a proce-dure to increase the buccolingual width of the ridgedevelopment by purposely torquing the root labially asthe orthodontic eruption is advanced. An alternative tothis method is tipping the incisor to maintain adequatebuccolingual and mesiodistal widths of the remnantroot. In addition, the tipped root fragment might havethe potential of developing the papilla lost to periodon-tal disease. This case report describes the forcederuption concurrent with tipping of the remaining rootfragment of a maxillary left central incisor with a severealveolar bone defect in the mesial aspect. The fulltreatment plan included replacement of this tooth withan endosseous implant.

CASE REPORT

A 30-year-old woman was referred by a periodontistfor an orthodontic consultation, and a significant angu-lar defect was found on the maxillary left central incisor.A significant deepbite was noted during the intraoral ex-amination, as well as a Class II end-on molar occlusionon the right and a Class I occlusion on the left. From thefrontal view, the patient displayed uneven gingivalheights in the anterior region with mild recession onthe maxillary left central incisor and open gingivalembrasures in the anterior maxillary region (Fig 1).

The periodontal examination with the periapicalfull-mouth series (Fig 2) showed generalized moderateperiodontal disease. Angular bone defects were limitedto the mandibular first molars and the maxillary centralincisors. The magnitude of the bony defects of the man-dibular molars was mild; however, the angular defect inthe mesial aspect of the maxillary left central incisorwas severe, extending to the apex. The severity of the

649

Fig 1. Pretreatment intraoral photos.

Fig 2. Full-mouth periapical radiographs depicting the areas of localized angular bone loss.

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osseous angular defect in the maxillary left incisor wasof concern but not directly related to the microbial pla-que observed, suggesting that a genetic predispositionmight have contributed to the progression of the disease.

The distal aspect of the maxillary left central incisorand the mesial and distal aspects of the maxillary rightincisor had lost approximately 60% of the angularbone. The clinical examination also showed mild tomoderate crowding in both arches and increased mobil-ity in the maxillary left incisor.

Cephalometric analysis confirmed a straight softand hard tissue profile with short lower facial height

and a reduced mandibular plane angle. Maxillaryincisor display at smile was 100%, and the maxillaryincisors were slightly retroclined.

The primary treatment objective for this patient wasthe regeneration of adequate height and width of thealveolar bone and gingival tissue lost to periodontaldisease in the maxillary anterior region. The site wouldbe used for an ideal 3-dimensional placement of anendosseous implant to support a prosthetic restorationfor the maxillary left central incisor.

The specific orthodontic objectives were to maintainthe maxillary incisal edges and relieve the crowding by

Fig 3. Initial segmental approach extruding the maxillary left central incisor and the mandibularanterior segment.

Fig 4. Elective endodontic treatment of the maxillary in-cisor was necessary as the forced eruption progressed.

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distalizing the maxillary right canine, thereby finishingin a full-cusp Class II molar occlusion on the right anda Class I on the left. The mandibular arch was to bealigned through approximately 2 mm of incisor flaring.In the vertical dimension, the objective was to abso-lutely intrude the anterior teeth from canine to canineto correct the overbite. The incisal edges of the maxil-lary incisors were to be maintained as well as thepatient’s skeletofacial and soft-tissue drape.

The treatment alternatives for the localized peri-odontal problem were the following.

1. A thorough debridement with gingival tissue regen-eration procedures. This would address the diseaseand result in possible bone deposition and attach-ment gain. Although some alveolar bone gainwould be expected, the extent of regenerationwould be limited and most likely result in approxi-mately 50% of root coverage. Additionally, the gainin gingival tissue height, with the obvious estheticbenefits, would probably be negligible.

2. Extraction of the maxillary left central incisor andextensive debridement and grafting to gain alveolarbone height and width. The advantage of this proce-dure would be that the site could be ready for im-plant placement in a shorter time, compared withan orthodontic forced-eruption approach. However,the occlusal relationship in the form of a deepbitewas not favorable to receive an implant, and itsplacement would need to be delayed until intrusionof the mandibular incisors was accomplished. Twoother disadvantages of this tripartite approach werethe unpredictability of soft-tissue gain and the needfor additional surgical procedures before theendosseous implant placement.

3. Eruption of the maxillary left central incisor afterdebridement of the anterior region in conjunctionwith periodontal maintenance visits every 3months. The advantages of this option were bothesthetic and functional. Functionally, a greateramount of bone could be obtained in both heightand width for an ideal implant site. Esthetically,

the gingival tissue would follow coronally, therebymatching the contralateral tooth and achieving op-timal soft-tissue contours. Furthermore, tippingthe root apex of the maxillary left central incisorin a mesial direction toward the right central incisorwould have the added benefit of potentially restor-ing the papilla lost to periodontal disease in the me-sial aspect. A larger surface area of the periodontalligament would remain with this method, and, asa result, increases in bone width and height wouldbe achieved. In contrast, the direct vertical eruptionof the incisor limited the beneficial influence of theperiodontal ligament because of the reduced sur-face area.

The periodontist who referred the patient had per-formed a thorough scaling and root planing procedureby quadrants before the orthodontic consultation. Thepatient had also been placed on a 3-month recall sched-ule. The treatment was divided into 2 phases: the firstphase involved eruption of the maxillary left central in-cisor and intrusion of the mandibular anterior segment.The second phase involved extraction of the maxillaryright first premolar and space closure. An endosseousdental implant was to be immediately placed afterorthodontic treatment.

Fig 5. A, The maxillary central incisor was tipped mesially, and composite buildup was placed in themesial aspect for cosmetic reasons. Note the interproximal papilla compression. B, The maxillaryincisor tipped without the aesthetic composite buildup before extraction. Note the gingival heightgain. C, The panoramic radiograph shows the amount of incisor tipping achieved.

Fig 6. A, Flapless approach to implant placement. Notethe papillary preservation and the bone volume achievedbuccolingually and mesiodistally. B, The extracted toothand root.

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The first phase started with two 0.022-in preadjusteddouble tubes bonded to the maxillary first molars anda bracket bonded to the maxillary left central incisor.An 0.018-in stainless steel archwire with an extrusiveactivation force of approximately 20 g was extendedto the central incisor from the molar tubes. A 0.022-inslot preadjusted appliance was bonded to the mandibu-lar first molars and premolars. A 0.020-in stainless steelwire segment was bonded directly, without brackets,from the right lateral incisor to the mandibular leftcanine (Fig 3). Brackets were not placed in this regionto prevent potential occlusal interference with the max-illary incisors, particularly in this patient, whose maxil-lary left incisor was being extruded as the mandibularincisors were being intruded.

Two 0.0173 0.025-in stainless steel segments wereplaced in the mandibular buccal segments from the firstmolar to the first premolar. An intrusion arch madeof .020-in titanium-molybdenum alloy was extendedfrom the auxiliary tubes of the first molars to the man-dibular anterior segment and tied mesially to the lateralincisors.

As extrusion in the maxillary left incisor was ac-complished, the incisal edge was adjusted for estheticreasons. After significant tooth eruption, elective end-odontic treatment with calcium hydroxide was per-formed on this tooth to continue the eruptive process(Fig 4). Incisal and lingual tooth structure reductionwas needed as the tooth erupted.

After the root was extruded approximately 4 mm,the maxillary right premolar was extracted. The maxil-lary teeth from the left second premolar to the right sec-ond premolar were bonded, and the teeth were alignedand leveled. En-masse space closure was started, by-passing the left central incisor. The mandibular anteriorsegment of a wirewas removed after the intrusion of thissegment reached the level of the buccal segments; thenbrackets were bonded to these teeth and a continuousarchwire placed.

As space closure continued, the bracket on the max-illary incisor was bonded more gingivally, and this toothwas tipped mesially to develop extra bone and achievea papilla in the mesial aspect. The forced eruptioncontinued, and, as the tooth started to tip significantly,composite was added to the mesial aspect of the crownfor esthetics (Fig 5).

Space closure was completed, and the patient wasfinished and debonded. On the same day as appliance re-moval, the root fragment was extracted (Fig 6), and animmediate bone-level SLActive endosseous dental im-plant (Straumann, Basel, Switzerland; height, 10 mm;width, 4.1 mm) was placed and torqued to greaterthan 35 N per centimeter, with good primary stabilityobtained. At the time of surgery, the alveolar bone com-pletely filled the defect. This surgery was performedthrough a flapless procedure. Notably, the crestal bonein the extraction site needed to be reduced for placementof the implant 3 mm below the gingival level. A tooth-colored provisional abutment was hand tightened andprepared to receive a temporary acrylic crown. As a pro-tective measure, the occlusion was relieved from con-tact with the mandibular incisors. Also, at this samevisit, a plastic vacuum-formed retainer was delivered

Fig 7. A, The implant was loaded immediately after placement, and a temporary acrylic crown wasplaced. B, Posttreatment panoramic radiograph. C, Posttreatment intraoral photographs after theendosseous implant was permanently restored.

Fig 8. Occlusal view showing the difference in cross-sections of the root when tipped vs vertically extruded.

American Journal of Orthodontics and Dentofacial Orthopedics Uribe et al 653Volume 138, Number 5

to ensure no contact with the endosseous implant. Eightweeks later, the final restoration was complete (Fig 7).

The specific objectives of treatment were met, interms of both implant site development and correctionof the malocclusion. The bony architecture was fully de-veloped, as demonstrated by the fact that it was evennecessary to remove alveolar bone from the crest tomatch the gingival level of the contralateral tooth.Both alveolar height and width were obtained; this al-lowed for a flapless approach in the implant placementprocedure. In addition, the interproximal papilla in themesial aspect was significantly enhanced and the opengingival embrasure considerably reduced. The qualityof the bone generated was adequate, allowing for imme-diate loading of the implant. The occlusal result waspositive, since the excessive overbite improved mark-edly and a Class I canine occlusion was obtained.Furthermore, on the right side, a Class II molar relation-ship was achieved after extraction of the maxillary firstpremolar. The mandibular incisors were significantlyintruded.

DISCUSSION

Generalized chronic periodontal disease can mani-fest clinically with sites of localized severe attachment

loss. The classification of advanced severity is deter-mined by attachment loss of more than 5 mm.9 Insome instances, the attachment loss can extend to theapex, creating a significant angular defect. The treat-ment of these localized areas with significant periodon-tal tissue loss depends on the type of defect and usuallyinvolves resective surgical procedures such as root am-putation (in the posterior teeth) or, more recently, regen-erative procedures such as bone grafting and guidedtissue regeneration membranes.2,10

Treatment of an extensive angular osseous defect inthe maxillary anterior zone is challenging. In these pa-tients, function and esthetics are critical. The gingivalheight of a compromised incisor generally is more api-cal than the contralateral unaffected incisor, and bone

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loss of the affected tooth, not surprisingly, increases mo-bility. Surgical treatment, with the objective of regain-ing attachment, can reduce the mobility and somewhatimprove the gingival height contours, but the resultsmight be less than optimal.

Compromised hard and soft tissue architecture in thedental arch is often best addressed with extraction of theaffected tooth and a prosthetic replacement, includinga bridge or an implant-supported restoration. The estheticand long-term success of an implant-supported restora-tion depends on the bone characteristics (3-dimensionaltopography) of the implant site.1 Bone grafting proce-dures can provide height and width for the alveolarbone lost to disease; however, the soft-tissue characteris-tics of the contralateral incisor might be difficult tomimic.2 Additionally, at least 1 surgical procedure mightbe needed to reproduce the natural contours before the en-dosseous implant placement.11 Therefore, an alternativeapproach such as orthodontic forced eruption might bea better choice, since bone is regenerated from the host’scompromised attachment apparatus.

The forced eruption of teeth for implant site devel-opment has been previously reported and is based onseminal work by Ingber5 and Brown,4 who described al-tering bone and soft-tissue morphology through ortho-dontic movement. The success of this proceduredepends on good plaque control, careful monitoring ofthe disease, and at least a third to a fourth of the apicalattachment remaining intact.2,3 In this patient, minimalremnant bone and attachment were available in thedistal portion, but not in the mesial aspect of thecentral incisor. As mentioned, this patient had anosseous angular defect in the mesial aspect thatextended as far as the apex.

Zucatti and Bocchieri3 were the first to suggesttorquing the root labially while encouraging eruptionas an alternative to the traditional forced vertical erup-tion of the tooth to the apex. This labial root displace-ment was attempted to achieve better alveolar widthin a patient with absent labial cortical bone and gingivaltissue. Similarly, this case report describes a novelmethod of forced eruption that could enhance bonewidth and encourage the formation of interproximalpapillary height. The traditional method of verticaleruption of an incisor is less effective, since the incisorroot’s conical shape results in incapacity to generatebone as the tooth is erupted (Fig 8). In contrast, thismethod affords greater bone, since the width is main-tained at the middle third as the root tip continues toerupt. In addition, tipping the root in the direction ofthe maxillary right central incisor potentially enhancespapillary height attainment through bone formation inthis area and compression of the soft tissue.12

Immediate loading is becoming a more commonprotocol in the placement of single endosseous im-plants. The bone quality after bone developed throughtooth eruption and tipping has not been studied. How-ever, an animal study in dogs found improved bonequality of the developed bone compared with healedbone analyzed after tooth extraction.13 This patientwas successfully treated with an immediately placedand loaded implant of the central incisor; this suggeststhat good bone quality was obtained by alveolar devel-opment with tooth movement. Additionally, this findingconcurs with another case report in which immediateloading was performed after implant site developmentwith orthodontic extrusion.11

CONCLUSIONS

Implant site development can recreate ideal gingivalarchitecture through tissue engineering obtained bymeans of slow incisal displacement of the attachmentapparatus. Although the minimum amount of attach-ment needed for bone regeneration has not been deter-mined, it appears that lateral tipping of a tooth mightprovide a means of achieving adequate bone widthand interproximal papilla development. Furthermore,because the quality and quantity of bone seemed to bemore than adequate, an additional benefit of this methodwas that immediate implant loading could be imple-mented after alveolar bone development.

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