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Orthodontic extrusion with magnets:

A case report
Christian Mehl, DMD, Dr Med Dent1/
Stefan Wolfart, DMD, Dr Med Dent Habil2/
Matthias Kern, DMD, Dr Med Dent Habil3

Subgingival crown-root fractures often present clinical problems when a restorative cover-
age of the fracture line conflicts with the biological width. Accepted treatment options
include the extrusion of the remaining root with a conventional orthodontic appliance, sur-
gical crown lengthening of the root, or root extraction with prosthetic tooth replacement.
After considering esthetics and function, orthodontic extrusion with magnets might also
be a viable alternative. In this report, a simplified method of orthodontic extrusion with
magnets is presented. (Quintessence Int 2008;39:371–379)

Key words: appliance, crown, fracture, magnet, orthodontic, therapy, tooth

Because of the prominence of anterior teeth,
crown or root fractures with exposure of the
pulp often occur.1–3 Depending on the depth
of the fracture line, the condition of the adja-
cent teeth, and the soft tissue situation, there
are various therapeutic options: medical
covering of the pulp and rebonding the frag-
ment,4 composite resin buildup,5 post-and-
core restoration6 with surgical crown length-
ening,7 or orthodontic extrusion.8 Deciding
upon the best method relies on an exact
diagnosis and indication (Table 1). If the frac-
ture line is in the lower third of the crown, it is
difficult to durably rebond the fragment
1
Assistant Professor, Department of Prosthodontics, Pro-
paedeutics, and Dental Materials, School of Dentistry, Christian-
Albrechts University, Kiel, Germany.
2
Assistant Professor, Department of Prosthodontics, Pro-
paedeutics, and Dental Materials, School of Dentistry, Christian-
Albrechts University, Kiel, Germany.
3
Professor and Chair, Department of Prosthodontics, Pro-
paedeutics, and Dental Materials, School of Dentistry, Christian-
Albrechts University, Kiel, Germany.
Correspondence: Dr Christian Mehl, Department of Prostho-
dontics, Propaedeutics, and Dental Materials, School of
Dentistry, University Hospital Schleswig-Holstein, Campus Kiel,
Arnold-Heller-Str. 16, D-24105 Kiel, Germany. Fax: +49-431-597-
2860. E-mail: cmehl@proth.uni-kiel.de
while maintaining a vital pulp.9 Oftentimes,
endodontic treatment is required.9
The fracture resistance of endodontically
and post-and-core–restored teeth depends
on the degree of tooth conservation. A ferrule
design of at least 2 mm is recommended,6
whereas an incomplete crown ferrule is asso-
ciated with restrained long-term stability.10
Tooth fractures that are close to the gingival
margin (as well as subgingival fractures) usu-
ally do not allow a ferrule design of 2 mm
without violating the biological width (the dis-
tance from the marginal bone to the margin
of the restoration of 2 to 3 mm).11
There are 2 possibilities for re-establishing
the required biological width: surgical crown
lengthening7 and orthodontic extrusion.12
Orthodontic extrusion can be performed with
conventional fixed orthodontic appliances12 or
a removable splint using magnets.13,14
Orthodontic extrusion requires up to 4 weeks
of activation and 8 to 12 weeks of retention to
stabilize the tooth in its new position.8
The coronal migration of soft and peri-
odontal tissue in dental extrusion, which is a
specialty of this method, is induced by the ten-
sion provoked by gingival fibers and the peri-
odontal ligament.15 This effect is positive if soft
tissue and bone need to be corrected in the
coronal dimension. However, this often leads

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Fig 1 Initial situation with debonded but

repositioned restoration on the left maxillary
canine.

Fig 2 (left) The debonded crown after air-abrasion cleaning of cement. A suffi-
cient ferrule design of 2 mm cannot be achieved without violating the biologi-
cal width.

Fig 3 (right) Radiograph of the maxillary left canine with a sufficient root canal
filling. No fractures were evident. The small distance between the prospective
preparation margin under adherence of the ferrule design of 2 mm is cognizable.

to problems concerning the biological width.7 CASE REPORT

In these cases, the biological width has to be
re-established after orthodontic extrusion with
surgical crown lengthening.16 A method that
helps to avoid this problem was described by
Pontoriero et al.17 During the period of forced
eruption, intrasulcular incisions were per-
formed weekly through the junctional epitheli-
um and connective tissue to eliminate any ten-
sion produced by supracrestal fibers. Partial
migration, especially that of gingival tissue,
could not be impeded, because the supracre-
stal fibers remain embedded in the root sur-
face and will reinsert into soft tissue, thus
reconstructing the gingival fiber apparatus.18
This can be avoided by additional root plan-
ing.19 Carvalho et al8 confirmed these findings
in a randomized clinical trial. They found that
after a supracrestal fiberotomy and root plan-
ing, the roots extruded with 2 mm less coronal
tissue migration, compared to the control
group without supracrestal fiberotomy and
root planing.
The purpose of the case report is to pres-
ent a simplified, step-by-step method of
orthodontic extrusion with magnets.
A 52-year-old female presented with a
debonded post and crown on the maxillary
left canine (Figs 1 to 3). The patient had
received complete oral rehabilitation with
crowns and fixed partial dentures 7 years
prior. Five years after insertion, an initial frac-
ture of the maxillary left canine on the gingival
level with debonding of the crown occurred.
After restoring the tooth with a new post and
cast-metal core, a new metal-ceramic crown
was cemented without covering 2 mm of the
sound tooth structure (ferrule design).10
Eighteen months after restoring the fractured
tooth, the post and crown debonded again,
and both were recemented. About a year later,
once again, the patient presented with a
debonded restoration (Figs 1 to 3). To avoid a
repeated failure of the restoration, an ortho-
dontic extrusion of the root with the help of
magnets was planned. The aim of the mag-
netic orthodontic extrusion was to lengthen
the clinical height of the tooth to achieve a fer-
rule design without affecting the biological
width.11 In addition, a 2-mm ferrule design
would improve the mechanical stability of the

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Fig 4 (left) Initial situation after removal of the crown. The low height of the remaining root impedes a covering of
sound tooth structure without violating the biological width.

Fig 5 (center) After positioning the casts, a thermoformed splint with a composite resin facing of the maxillary left
canine was fabricated.

Fig 6 (right) (a) The thermoformed splint for the maxilla. A cavity for placing the second magnet remained under the
composite resin facing. (b) Magnets shown magnified with a blue spacer.

restored tooth.8 To ensure a satisfying esthetic
result, the level of the marginal periodontal
and gingival tissues should not be altered.
The root canal filling was considered suffi-
cient (Fig 3), and no signs of fractures were
evident (Fig 4). The treatment plan consisted
of an orthodontic magnetic extrusion, a new
cast core on a prefabricated post, and a
metal-ceramic crown with a ceramic shoulder.
Clinical procedure
An impression (Optosil, Heraeus Kulzer) of
the reinserted post and crown of the maxil-
lary left canine was taken, and after removal
of the crown and the post, additional impres-
sions of the maxillary and mandibular arches
were taken (Alginat Super, Pluradent). The
root canal was rinsed thoroughly with a
chlorhexidine solution (Butler Gum) and
dried, and the original post and crown were
cemented provisionally (Kerr Life, KerrHawe).
After mounting the casts in an articula-
tor, a waxup of the crown was made. A ther-
moformed splint with a labial composite
resin facing of the maxillary left canine was
fabricated (Figs 5, 6a, and 6b). During the
next treatment session, the crown was
removed, the thermoformed splint inserted
(Figs 7a and 7b), and the occlusion adjusted.
Afterward, the root canal was chemically
cleaned with a chlorhexidine rinse. After dry-
ing it with paper points, the root canal was
sealed with gutta-percha and covered with
zinc phosphate cement (Harvard Dental
International; Fig 8) to avoid contamination of
the root during treatment.
The magnets (disc magnets, samarium-
cobalt 5, 2 mm ⫻ 3 mm, Fehrenkemper; Fig
6b) were coated with opaquer, and in the
area of the maxillary left canine, the thermo-
formed splint was air-abraded (50 µm alumi-
na particles at 2 bars) and activated with a
resin primer (Glaze and Bond, DMG). One
magnet was bonded to the tooth using
Optibond FL (KerrHawe) and Tetric Flow
(Ivoclar Vivadent; Fig 9). The position of the
magnet against the cavity of the splint was
chosen carefully so that it was perpendicular
to the extrusion vector.
A spacer made from a 1-mm–thick ther-
moformed foil (Drufolen, Dreve-Dentamid)
was placed between the 2 magnets (Fig 9).
Then, the thermoformed splint was filled with
composite resin for provisionals (Luxatemp

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a b

Fig 7 (a) The thermoformed splint in the maxilla in situ with composite resin facing. (b) The com- Fig 8 Filling of the root
posite resin facing of the maxillary left canine reached the gingival margin to control coronal canal with gutta-percha
migration without disturbing the extrusion of the root. and covering the precision
drilling with Harvard
cement to avoid contami-
nation of the root canal
during treatment.

Fig 9 (left) Bonding of the first magnet into the maxillary left canine with low-viscosity composite resin.The second magnet was
separated from the tooth-retained magnet with a 1-mm-thick spacer (blue).

Fig 10 (center) The second magnet positioned into the thermoformed splint with low-viscosity composite resin.

Fig 11 (right) After removal of the spacer (viewed from the palatinal).

Automix, DMG) and positioned over the mag-
nets. After the resin had been cured, the sec-
ond magnet was fixed in its correct position
(Figs 9 and 10). The spacer between the
magnets was removed (Fig 11). To ensure
that the root of the maxillary left canine could
extrude freely, a silicone indicator paste
was applied (Fit-Checker, GC; Fig 12) and
checked for adequate clearance. Measure-
ments in our dental materials laboratory
showed that magnets provide an extrusion
force of 0.13 N at a distance of 1 mm and
increase to 0.3 N at a distance of 0.5 mm and
rise to 0.65 N when the magnets connect.
A local anaesthesia was applied in the
area of the maxillary left canine (UDS,
Combustin). Subsequently, an intrasulcular
incision was performed through the junc-
tional epithelium with a scalpel (Feather dis-
posable scalpel Nr. 12, Feather Safety Razor;
Fig 13) and a deep scaling/root planing with
a curette (Gracey Kürette 5/6, Hu-Friedy)
was performed. After 7 days, the root had
already been extruded 1 mm, so that the
magnets had contact with each other. This
was controlled with silicone indicator paste.
Alternatively, the gap between the 2 magnets
could have been evaluated with composite

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Fig 12 (left) The clearance between the magnets is checked with a silicone indicator paste to
allow the extrusion of the root.

Fig 13 (center) Supracrestal fiberotomy with a scalpel following root planing.

Fig 14 (right) After 1 week, the tooth extruded 1 mm as provided by the spacer (for comparison,
see Fig 9).The second magnet was taken out of the thermoformed splint and repositioned with the
help of a new spacer (blue).

Fig 15 (left) Completed extrusion after 4 weeks of treatment. In comparison to Fig 9, an extrusion of about 4 mm is seen.

Fig 16 (center) Insertion of a prefabricated post and modeling of a composite resin core.

Fig 17 (right) Adhesive luting of the post into the root canal under rubber dam.

resin (like that used for provisionals or bite
registration). In comparison to silicone film,
with composite resin, any remaining dis-
tance could be measured precisely with a
caliper. When the 2 magnets have contact
with each other, the magnet and the com-
posite resin are removed from the splint, and
the magnet is repositioned into the splint
using a spacer between the magnets (Fig
14). The position of the tooth-retained mag-
net should not be changed. An intrasulcular
incision through the junctional epithelium
and a cleaning of the root surface with a
deep scaling/root planing was performed
again. Altogether, this procedure was con-
ducted 4 times, until the root was extruded 4
mm. As a result of these procedures, a fer-
rule design of 2 mm could be achieved with-
out violating the biological width (Fig 15).
After a retention phase of 2 weeks, the
magnets and the coronal root canal filling
(consisting of zinc phosphate cement and
gutta-percha) were removed. The root canal
was cleaned, a prefabricated post was insert-
ed (Heraplat, Brasseler), and a composite core
(Pattern Resin, GC) was modeled and pre-
pared (Fig 16). The core was cast with a noble
gold alloy (Degutan, DeguDent). After a try-in,

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a b

Fig 18 Completed preparation of the left Fig 19 (a) Labial view of the provisional restoration. (b) Occlusal rests to the
maxillary canine. The gingival level has not adjacent teeth were fabricated to prevent any relapse by the intrusion of the
been altered, and sound tooth structure of 2 root.
mm is covered (ferrule design).

Fig 20 Finalization of
the metal-ceramic crown
with a ceramic shoulder.
(a) Shown from the labial
side. (b) Shown from basal
side.

a b

Fig 21 Clinical try-in of

the crown. (a) Shown from
labial. (b) Shown from
palatinal.

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Fig 22 Completed restoration.
the post and core was air abraded, condi-
tioned with a metal primer (Alloy Primer,
Kuraray), and luted into the root canal under
rubber dam 24 hours later with a composite
resin luting agent (Panavia 21, Kuraray; Fig 17).
It was then prepared again for a crown (Fig
18). The provisional restoration was made
directly (Luxatemp, DMG; Figs 19a and 19b)
and cemented provisionally (Kerr Life, Kerr-
Hawe). The provisional restoration should pre-
vent any relapse by the intrusion of the root,
which was guaranteed by 2 (mesial and distal)
occlusal rests placed on the adjacent teeth
(Figs 19a and 19b). After a retention phase of
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Fig 23 Posttreatment smile.
Fig 24 (left) Posttreatment radiograph.
Fig 25 (above) View at the 4-month recall
visit.
2 months,8 an impression (Permadyne, 3M
ESPE) was taken. After fabrication and mount-
ing of the master cast in an articulator, the
metal-ceramic crown with a ceramic shoulder
was fabricated (Figs 20a and b) and fitted clin-
ically (Figs 21 and 23).
After cleaning the tooth with pumice and
chlorhexidine solution, a radiograph was
taken to check the cemented post and the fit
of the crown (Fig 24). The crown was
cemented with glass-ionomer cement
(Ketac-Cem, 3M ESPE). Figure 25 shows the
restoration at a recall visit 4 months after
cementation.
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Intrasulcular incisions and root planing

Fractured tooth were performed each time the magnet was
repositioned to keep the gingival level at its
original position.8 Despite the simplicity of
Ferrule design possible Ferrule design not possible this procedure, it is relatively time-consuming
Biological width not violated Biological width not violated
(approximately 20 minutes) to change and
reposition the magnet in the splint and then
perform the intrasulcular incision and root
Soft tissue level correct Soft tissue level too far apical scaling/planing.
Initially, the root was extruded with a force
of 0.13 N (= 13 g) at a distance of 1 mm. The
force increased to 0.65 N when the magnets
Orthodontic extrusion with Orthodontic extrusion with
contacted each other (according to unpub-
magnets/fixed appliance magnets/fixed appliance
lished data). During forced orthodontic extru-
sion, forces of 0.5 N (= 50 g) are suggested
in the literature.8 A possible explanation for
Fiberotomy/root planing not the extrusion of the tooth, despite low forces,
Fiberotomy/root planing until the desired gingival might be an initial pneumatic pressing of the
level is obtained tooth due to bleeding in the periodontal gap.
Furthermore, the forces increase when the
magnets approach. The low starting forces
Retention phase of 2 Retention phase of 2 seem to be adequate enough to extrude a
months months tooth when supported by supracrestal fibero-
tomy and root planing.
If the gingival fibers are not cut, magnetic
Post/core fabrication extrusion enables changes of the adjacent
structures such as bone and gingiva.8
Gingival recessions can be leveled up to 2
mm compared to the adjacent teeth if the
Finalization
gingival fibers are cut when the desired posi-
tion is achieved. 8 A decision guideline for the
Table 1 Decision scheme for restoration of deeply fractured teeth.
suggested treatment procedures is present-
ed in Table 1.
Small osseous resorptions have been
reported in patients who received intrasulcu-
lar incisions and root planing during magnet
extrusion8; they were not found to be signifi-
cant from a clinical point of view and have
DISCUSSION been considered as remodeling of the
bone.8,20 Furthermore, it is possible to use
The orthodontic extrusion with fixed appli- magnetic extrusion to extrude teeth prior to
ances is a standard treatment option.8 extraction and achieve ideal soft and hard tis-
Extrusion with magnets significantly simpli- sue structures for implant placement.21,22
fies this procedure.13 The patient received a After extrusion, a retention phase of at
minimally invasive, predictable, and esthetic least 8 weeks is needed to stabilize the tooth
alternative to restoration with a single in its new position.8 Stabilization can be
implant. As the gingival tissues of the left obtained by leaving the splint and magnets
maxillary canine were healthy and in good for several weeks or with special provisionals
vertical position, surgical crown lengthening (ie, bonding on the adjacent teeth) or certain
would not have been a reasonable alternative other elements at the provisionals that pre-
to the extrusion. vent a relapse.

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CONCLUSION
Orthodontic extrusion with magnets is a safe
and simple procedure that can predictably
extrude fractured teeth.
ACKNOWLEDGMENT
The crown was fabricated by the master dental techni-
cian J. Feddern (Kieler Mund Art, Kiel, Germany).
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