PIO08_46-57_Paolone 3-11-2008 16:26 Pagina 46

1 Lingual Orthodontics and Forced Eruption

Lingual Orthodontics and Forced Eruption:

A Means for Osseous and Tissue Regeneration.
Case Report

Maria Giacinta Paolone*, Roberto Kaitsas**, Gaetano Paolone***, Vassilios Kaitsas****

*Specialist in Orthodontics, Private Practice, Rome, Italy.

**Oral Surgeon, Private Practice, Rome, Italy.
***Private Practice, Rome, Italy.
****Professor Dental Materials, Faculty of Chemistry, Univeristy of Siena, Italy.

Correspondence to:
Maria Giacinta Paolone
Viale dei Quattro Venti, 233 - 00152 Roma Italia
Tel/Fax: +39-06-583.58.57
e-mail: paolone.mg@gmail.com

An hopeless upper central incisor was subjected to forced eruption in

Introduction
Orthodontic tooth movement can
modify and improve the perio-
dontal anatomy of the hard and
soft tissues morphology even con-
cerning periodontally damaged or
fractured teeth1-7. Orthodontic ex-
trusion or forced eruption is a non-
surgical technique undertaken to
increase the amount of available
alveolar bone for implant site de-
velopment and fixture place-
ment8,9. The periodontal ligament
can be used for distraction-osteo-
genesis. The fibers of periodontal
ligament are inserted in the perio-
steum of the alveolar bone. If a
tension is applied new bone is de-
posited. If the force of tension is
order to improve and develop the implant site by distraction of the pe-
riodontal ligament-alveolar bone complex. The orthodontic extrusion
was carried out with two aesthetic approaches: lingual orthodontics
and a composite resin 2-2 veneer pontic. The first part of the extrusion
was realized with lingual orthodontics alone, then, when the crown
had been remodelled in its greatest part and the aesthetics was no mo-
re acceptable to the patient a composite resin 2-2 veneer pontic was
bonded to the vestibular side of the other three incisors to mimetise the
extruded tooth and to be anchorage to the lingual mechanics. The or-
thodontic preparation of the implant site allowed the correction of the
periodontal defect due to the fracture, the enhancement of the alveo-
lar bone and the soft tissue remodelling.
M Gi Paolone, R Kaitsas, G Paolone, V Kaitsas. Lingual Orthodontics and
Forced Eruption: A Means for Osseus and Tissue Regeneration. Case Report.
Prog Orthod 2008;9(2):46-57.

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Lingual Orthodontics and Forced Eruption 2

applied in a vertical extrusive di- improve the osseous and tissue and the consequent surgical thera-
rection the alveolar bone height anatomy to provide a better and pies. The preservation of alveolar
can be improved if the force, the more predictable implant surgery dimension appears important in or-
speed and the inflammation is con- and to obtain a better aesthetical der to reduce further surgical pro-
trolled. The biologic potential of prosthetic result11-13. The loss for cedures14. The “orthodontic extru-
the periodontal ligament stimula- fracture or periodontal reasons of sive remodelling”11 increases and
ted by extrusive forces can enhan- an anterior tooth and the subse- modifies not only the hard-tissue
ce the regenerative potential of fu- quent implant substitution is a chal- profile but also the soft-tissue level
ture periodontal surgery including lenging procedure for both the sur- of the potential implant sites15-20.
guided tissue regeneration, elimi- geon and prosthodontist due to As the anterior and aesthetic
nating an intra-bony defect and high esthetic demands during and aspect of the mouth is often invol-
augmenting a vertically reduced after treatment. The vestibular cor- ved in this condition, the literature
alveolar ridge deformity10. For the- tical plate covering the roots of the suggests lingual devices as ae-
se reasons a tooth of poor pro- maxillary teeth is very thin and its sthetic anchoragage21-24.
gnosis should not be extracted as porosity makes it susceptible to The aim of this work is the propo-
first choice but can offer with ad- easy resorption following perio- sal of a “total” aesthetic approach
junctive procedures an an aid to dontal and periapical infections for orthodontic extrusion: the com-
bination of a classical lingual ap-
pliance and a composite resin 12-
11-x-22 veneer pontic to minimise
Un incisivo centrale superiore condannato all’estrazione è stato sot- the aesthetic impact of the extru-
toposto ad estrusione forzata ed estrazione ortodontica al fine di svi- sion: this double aesthetic solution
luppare un corretto sito implantare attraverso la distrazione del com- allowed us as clinicians to propo-
plesso legamento parodontale-osso alveolare. L’estrusione ortodonti- se the complete treatment including
ca è stata realizzata attraverso due approcci estetici: l’ortodonzia lin- implant site development and re-
guale ed una mascherina in composito cementata sulla superificie ve- duce compromises.
stibolare dei rimanenti tre incisivi. La prima parte dell’estrusione è sta-
ta eseguita con la sola ortodonzia linguale, appena la corona non era
più accettabile esteticamente per il paziente, è stata cementata la ma- Case report
scherina in composito per mimetizzare il residuo radicolare estruso
e per ancoraggio. La preparazione ortodontica del sito impiantare ha The patient was a Caucasian 57
permesso la correzione del difetto parodontale dovuto alla frattura, years old male. His dental history in-
l’aumento dell’osso alveolare ed il rimodellamento dei tessuti molli. cluded a previous episode of den-
tal trauma 5 years previously treated
by another practitioner with root ca-
nal treatment and a fixed crown
and metal post core. The recent hi-
story of concerns related to a sub-
sequent traumatic episode three
months previously restored with a
consequent root fracture below the
bone level on the mesio-vestibular si-
Key words: Orthodontic eruption, orthodontic extrusion, forced de with the loss of the mesio-vesti-
eruption, implant, implant site development, lingual orthodontics, bular alveolar wall. The patient was
osseous regeneration, tissue regeneration. very cooperative and presented no

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3 Lingual Orthodontics and Forced Eruption

contraindication to orthodontic treat-
ment. The probing evaluation re-
vealed a mesio-vestibular defect of
9mm on the mesial and 5 not on
the vestibular aspect (Tab. 1). The
radiographic examination confir-
med the presence of the fracture
with a displaced root fragment be-
low the bone level, the osseous de-
fect, and the definite loss of the
Tab. 1 Periodontal probing of the tion: crown lengthening was not
upper two central incisors. appropriate due to a possible poor
11 21
aesthetic result. Forced eruption fol-
V 212 953 lowed by prosthetic restoration co-
P 212 642 uld not be completed due to a
poor crown-root ratio.
tooth (Fig. 1a-g). The patient presented a class II pro-
The treatment alternative was file with a retrognathic mandible,
crown lengthening and forced erup- the profile confirmed a class II ske-
tion followed by prosthetic restora- letal pattern with a small mandi-

a b

c d

e f g

Fig. 1a-g Pre-treatment records.

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Lingual Orthodontics and Forced Eruption 4

ble. The cephalometric evaluation nation showed the absence of the was performed with a lingual ap-
confirmed the facial analysis with right second premolar and confir- pliance in order to preserve ae-
an antero-posterior discrepancy med a dental molar class I and ca- sthetics during the mechanics. The
(ANB 6°) a mandibular deficiency nine class II with an increased OVJ patient refused a completed ortho-
(SNB 71°) an almost normal ma- and OVB. dontic treatment which should have
xilla (SNA 77°) and reduced man- At the very beginning the patient included maxillo-facial surgery. For
dibular plane angles (FMA 19°, was treated with a periodontal ap- this reason the lingual appliance
SNpM 32°). The patient referred proach with initial therapy. After 8 was applied only on the upper an-
no history of TMJ and muscular weeks the periodontal re-evaluation terior teeth including the first pre-
pain or sound. The dental exami- was realized. Orthodontic treatment molars in order to perform the only
orthodontic extraction of the upper
incisor. The patient was bonded
Une incisive centrale supérieure avec un pronostic défavorable a with lingual brackets (Ormco 7th
étée soumise à l’éruption othodontique forcée afin d’améliorer et dé- gen) and a .016 CuNiTi for the
velopper le site implantaire par la distraction du complexe ligament- first month (Fig. 2). The crown of
alvéolaire périodontale et os. L’extrusion orthodontique a été réalisée the incisor was etched with HF (fluo-
avec deux approches esthétiques: l’orthodontie linguale et un veneer ridric acid) and pretreated with si-
2-2 de résine composite. La première partie de l’extrusion a été faite lane. The brackets on the fractured
avec une orthodontie linguale seule, puis, quand la couronne avait été incisor was placed apically in rela-
coupée dans sa plus grande partie et l’esthétique ne semblait plus ac- tion to the level of the others. The pa-
ceptable au patient on a utilisé un veneer de résine composite 2-2 col- tient was seen every two weeks to
lée sur le côté vestibulairedles trois incisives saines pour simuler la dent activate the appliance, to obtain a
soumise à l’éruption othodontique forcée et pour être un ancrage à slow and light osseous movement of
la mécanique linguale. La préparation orthodontique du site implan- 0.5mm per month and to level the
taire a permis la correction du défaut périodontique, l’amelioration de incisal edge. In the meanwhile the
l’os alvéolaire et le remodelage du tissu mou. patient was under periodontal con-
trol to reduce inflammation. During
Traduit par Maria Giacinta Paolone the second month the extrusion was
performed with a .016 TMA (Fig.
3), then with .017x.017 TMA to
Un mal pronóstico sometió la erupción forzada de un incisivo central control and prevent radicular vesti-
superior, a fin de mejorar y desarrollar la zona implantar con la dis- bular torque which could destroy
tracción del ligamento periodontal en un hueso alveolar complicado. the thin cortical plate17. The extru-
La extrusión ortodontica se realizo con métodos estéticos diferentes: sion movement was realised with
con un “eneer pontic” de 2-2 . La primera parte de la extrusión se hi- lingual orthodontic mechanics and
zo con ortodoncia lingual y cuando la mayor parte de la corona fue using the traction to the pontic in
remodelada, el paciente no acepto la situación estética. Entonces el order to have a detailed control of
“veneer pontic” de 2-2 se cemento por vestibular utilizando como an- the radicular movement in terms of
claje la parte lingala. force and direction. For this reason
La preparación de ortodontica a de la zona del implante permitio la After two months the brackets on
corrección del defecto periodontal debido a la fractura, la mejora de the incisor was re-bonded more api-
los hueso alveolar y la remodelación de tejidos blandos. cally, then, when it was no more
possible to use the crown for brac-
Traducido por Santiago Isaza Penco ket bonding because the greatest
part of the crown had been reduced

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PIO08_46-57_Paolone 3-11-2008 16:26
5 Lingual Orthodontics and Forced Eruption
Fig. 2 .016 CuNiTi alignment.
and the aesthetics were not accep-
table a multi-disciplinary device was
realised combining an endodontic
retention with a composite resin 12-
11-X-22 veneer pontic. A post (Para-
post Whaledent) was prepared
a b
c d
50
Pagina 50
with a hole for anchorage and was
luted in the root canal with an ossi-
phosphate zinc cement (De Trey
Zinc Dentspy). On the vestibular fa-
ce of the remaining three incisors a
2-2 veneer pontic was bonded in
composite resin and bonded to the
three incisors for orthodontic at-
tachment (Fig. 4a-d). During the
whole treatment each month an in-
traoral radiograph was undertaken
(Fig. 5a-c). The red patch was ob-
served for eversion of the non-kera-
tinized sulcular epithelium. When
overcorrection and over-extrusion
was obtained, the tooth was stabi-
lised before extraction and implan-
tation for 6 months with a
.017x.022 ss in order to reduce re-
lapse and obtain a maturation of the
soft tissue and alveolar bone.
Surgical Phase
After the stabilization period the
remaining root fragment was ex-
tracted with an atraumatic proce-
dure using a periotome (periotome
Fig. 3a-d .016 TMA
sequence of extrusion.
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Lingual Orthodontics and Forced Eruption 6

a b

c d

Fig. 4a-d Parapost insertion and composite veneer 2-2 for anchorage.

Fig. 5a-c Radiological control of se-

quence of extrusion.

a b c

FRIADENT®) to avoid the fracture
of the vestibular cortical plate. A
trapezoidal full-thickness flap was
elevated with two oblique relea-
sing incisions from the mesial and
distal extremities of the horizontal
incision and was controlled by the
mesio-vestibular neoregenerated
bone. A FRIALIT-2 4.5/15mm
(Dentsply FRIADENT®) root-form fix-
ture was placed in the fresh ex-
traction socket (Fig. 6a-d). The im-
plant was submerged to allow an
implant stability and an atraumatic
healing phase. A gore-tex 5/0
and VICRYL 5/0 sutures was used.
A new temporary 12-11-x-22 com-
posite resin veneer was luted to
maintain aesthetics. Systemic anti-
biotics (amoxicillin + clavulanic ac.
1 gr. every 8 hours for 4 days)
were prescribed and 0,12% chlor-
hexidine mouth rinse was prescri-
bed 3 times a day until the remo-
val of the sutures. After 10 days the
sutures were removed resuming
normal plaque control.

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7 Lingual Orthodontics and Forced Eruption

a b

Fig. 6a-d Surgical phases of the

fixture insertion.

c d

a b

c d

Fig. 7a-d Second surgical phases with the vestibular connective tissue graft.

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Lingual Orthodontics and Forced Eruption 8

a b

c d

Fig. 8a-d Prosthetic phases with the titanium customized abutment and the temporary crown.

After 6 months the second surgical
phase was attempted. The implant
was activated with a healing abut-
ment of 5mm of height. At the same
time a vestibular connective tissue
graft was completed to increase the
width of the vestibular tissue in order
to be used during the prosthetic pha-
se25,26. An intrasulcular full-thickness
flap was elevated (a crestal incision
was made in the implant zone) dra-
wing the morphology of the future pa-
pillae near the edentolous area. The
crestal part of the keratinized gingi-
va was displaced vestibularly by the
connective graft. The incision was
extended horizontally to dissect the
buccal aspect of the adjacent pa-
pillae, both mesially and distally. Do-
nor connective tissue was harvested
reducing the palatal flap from the
same surgical site and secured in po-
sition suturing the graft within the ve-
stibular flap, using it like an envelope,
with interrupted bioabsorbable sutures
(VICRYL 5/0). A ramp mattress sutu-
re27 was used to maintain coronally
positioning of the vestibular flap and
apically positioned the palatal flap
(Fig. 7a-d). A mesio-distal and apical
dissection was performed to release
residual muscle tension and facilitate
the displacement of the flap for sutu-
ring. A gore-tex 5/0 was used to su-
ture the flap. After 15 days only the
gore-tex suture was removed. A
0,12% chlorhexidine mouth rinse was
prescribed 3 times a day until the su-
ture removal. The same temporary
veneer was luted again to maintain
aesthetics and to reduce the healing
abutment visibility.
Prosthetic Phase
After a healing period of 4 months
a temporary crown was cemented
using a customized titanium abut-
ment to guide the tissue matura-
tion28,29. During the following 8
months the temporary crown was
modified, changing the contact
point, the mesial and distal aspect of
the tooth and the emergence profile
in order to obtain the definitive mor-
phology of the soft tissues (Fig. 8a-d).
When the papillae maturation was
completed the provisional crown
was removed and, using a transfer
coping, an impression with polyether
(Permadyne polyether-impression ma-
terial, ESPE®) was carried out. A
maxillary and a mandibular cast we-
re prepared and, after being moun-

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PIO08_46-57_Paolone 3-11-2008 16:26
9 Lingual Orthodontics and Forced Eruption
ted in an articulator, the definitive re-
storation was manufactured. Great
attention was offered while transfer-
ring the information concerning the
soft tissues and the emergency pro-
file from the patient to the laboratory
cast to realise the definitive restora-
tion30,31 (Fig. 9,10). The definitive
restoration was fabricated using a
cutsomized zirconia abutment and
an all-ceramic crown (CeraBase –
FRIADENT®) (Fig. 11-14).
Discussion
Rehabilitation of the aesthetic zone
of the denture requires a multidi-
sciplinary approach from diagno-
sis to consequent therapy. Ortho-
Fig. 9 Transfer of information to the laboratory.
a b
54
Pagina 54
dontics is part of the team invol-
ved in the treatment of this chal-
lenging patient. The contribution
given from orthodontics to the ae-
sthetics is multiple and includes the
aesthetics during the treatment and
the final aesthetic result of the treat-
ment. From this point of view lin-
gual orthodontics through the “or-
thodontic extrusion” becomes a
means for the development and im-
provement of the final implant site,
its bone ant its soft tissues. Lingual
orthodontics is an aesthetic choice
in forced eruption and allows al-
veolar bone and soft tissue remo-
delling and development. This bo-
ne obtained with the distraction of
the tooth-periodontal ligament com-
plex appears to be a solution for
Fig. 10 Soft tissues at the final luting.
implant rehabilitation even in ae-
sthetical areas. The lingual ap-
pliance can solve the aesthetic de-
mand during the first phase of the
extrusion, then a composite resin
12-11-X-22 veneer pontic can mi-
nimise the altered anatomy of the
tooth which, being extruded, is no
more than a root.
The advantages of using orthodontics
as implant site development techni-
ques instead of other regenerative
therapies are multiple. First of all the
use of hopeless teeth condemned to
extraction can offer an aid in the
whole mouth rehabilitation32,33. Then
the lingual appliance can, during the
bone distraction and development, at
the same time, solve other aesthetic
problems which are present in the pa-
Fig. 11a-b The customized zir-
conia abutment and the all-ce-
ramic crown.
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Lingual Orthodontics and Forced Eruption 10

a b c

d e

Fig. 12a-f Final records.

tient’s mouth. The lingual appliance al-

so allows the use of the vestibular
veneer to avoid the aesthetic pro-
blems of the missing teeth.
Then it is possible to eliminate or re-
duce eventually more complex re-
generative techniques (such as
GBR, ERE, osseous graft). Last but
not least, the orthodontically indu-
ced implant site development ma-
kes the subsequent surgical techni-
Fig. 13 Two years control. cal phases easier such as fixture in-

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11 Lingual Orthodontics and Forced Eruption

tics, solved with the lingual ap-

proach and the composite resin
veneer pontic, and the difficult ac-
ceptation and management of or-
thodontics by the patient.
There could have been many al-
ternatives to the orthodontics-im-
plant treatment. First of all the fixed
partial denture was not realizable
as the proximal teeth were perio-
a b
dontally and endodontically
healthy. The immediate post-ex-
traction implant was not a possible
choice due to the mesio-vestibular
remaining defect that involved a
soft tissues collapse and a difficult
guided bone regeneration.

Conclusion
c d
Forced eruption is a well docu-
Fig. 14a-d Tracings and superimpositions. mented technique to enhance the
implant site and to increase the
amount of hard and soft tissues.
The association of lingual ortho-
dontics and of a composite resin
12-11-X-22 veneer pontic allowed
the realisation of the forced extru-
sion of a lost left central incisor in
a 57 years old male. The combi-
nation of these two techniques
kept, during the whole treatment,
acceptable aesthetics allowing cor-
rect implant site development.

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