ODONTOLOGÍA VITAL P. 69

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Management and Follow-up of Orthodontic Forced

Extrusion: A Case Report.

Manejo y seguimiento de la extrusión forzada de

ortodoncia: Un informe de caso.

English version

Abstract

The case of an adult patient with a complicated crown

fracture of the right upper canine due to trauma is

reported, diagnosing a class VII Ellis coronal fracture.

There are several treatment alternatives that range

from the extraction, placement of a bone graft and

placement of an implant, to a forced root extrusion

with bone removal to allow the biological space and

subsequently be restored.

In the present case, a multidisciplinary orthodontic

forced extrusion treatment is performed, which

allows to increase the amount of clinical remnant,

preserving the periodontal support and maintaining

the biologic thickness, thus achieving to maintain

the root remnant with good length so that prosthetic

rehabilitation is facilitated.

The clinical and radiographic follow-up was 12 months.

The multidisciplinary treatment

involved: Root canal treatment, forced extrusion with

orthodontics, ﬁbrotomy with root planing and ﬁxed

prosthesis.

Key words:

Trauma, Coronary fracture, Endodontics, Forced

extrusion, Prosthetic Restoration.

Introduction

Some of the main reasons why patients go to the

dentist are: Aesthetic and chewing problems, so

patients prioritize this type of treatment (Uribe et al.,

2010). Dental trauma represents a real therapeutic

Ojeda-Gutiérrez, F, Martínez-Zumarán, A, Manzur-Sandoval, N, González-Correa, R, Ojeda- Juárez, JF, Garrocho-

Rangel, JA, Zavala Alonso, NV., Ojeda-Gutiérrez, F. Manejo de extrusión forzada ortodóntica: Reporte de un caso.

Odontología Vital No. 38, Vol 1, 58-67. 2023, ISSN:2215-5740 Versión traducida al inglés. Originalenespañol.

Revista Odontología Vital

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odontologiavital

ISSN: 2215-5740

Ojeda-Gutiérrez F, Martínez-Zumarán

A, Manzur-Sandoval N, González-Correa

R, Ojeda- Juárez JF, Garrocho-Rangel

JA, Zavala Alonso NV.

Ojeda-Gutiérrez F. Facultad de

Estomatología. Universidad Autónoma

de San Luis Potosí. E-mail: fojeda@

uaslp.mx. Orcid: 0000-0002-4034-4583

Martínez-Zumarán A. Facultad de

Estomatología. Universidad Autónoma

de San Luis Potosí. E-mail:alanzuma@

uaslp.mx. Orcid: 0000-0001-5494-1816

Manzur-Sandoval N. Facultad

de Estomatología. Universidad

Autónoma de San Luis Potosí. E-mail:

manzur_nahim@hotmail.com. Orcid:

0000-0003-4770-8156

González-Correa R. Facultad de

Estomatología. Universidad Autónoma

de San Luis Potosí. E-mail: rogelio.

gonzalez@uaslp.mx. Orcid: 0000-0002-

8163-4093

Ojeda- Juárez JF. Facultad de

Estomatología. Universidad Autónoma

de San Luis Potosí. E-mail: francisco.

ojeda@uaslp.mx. Orcid: 0000-0003-

0912-0466

Garrocho-Rangel JA. Facultad

de Estomatología. Universidad

Autónoma de San Luis Potosí.

E-mail: arturo.garrocho@uaslp.mx.

Orcid:0000-0001-9123-0300

Zavala-Alonso NV. Facultad de

Estomatología. Universidad Autónoma

de San Luis Potosí. E-mail:nveroza@

fest.uaslp.mx. Orcid: 0000-0001-6014-

0994

Facultad de Estomatología.

Universidad Autónoma de San Luis

Potosí.

Autor de correspondencia: Dr.

Francisco Ojeda Gutiérrez. Manuel

Nava # 2. Zona Universitaria. C.P. 78290.

San Luis Potosí, S.L.P., México. E-mail:

fojeda@uaslp.mx

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dilemma for the professional of

stomatology (Koyuturk & Malkoc, 2005).

Most dental injuries occur within the

ﬁrst two decades of life, although

they can occur at any age, the most

susceptible teeth being the central and

lateral incisors (AAPD, 2008-Forsberg

& Tedestam, 1993). Fractures of the

permanent teeth constitute the most

frequent type of dental trauma, with a

percentage of 26 to 76%.

These injuries involve the loss of

dental tissues hard (Andreasen &

Ravn, 1972-Andreasen, 1993), although

they can involve enamel, or enamel

and dentin, without affecting the

pulp (Arapostathis et al., 2006), good

prognosis (De Blanco, 1996); however,

when it affects the pulp (Cavalleri

& Zerman, 1995-Ojeda et al., 2011),

especially in cases of complex injuries

of root and complicated crown the

prognosis is generally less favourable

long-term (Keinan et al., 2013).

Lesions involving enamel, dentin and

pulp represent from 4 to 16% of all

traumatic dental injuries (Cavalleri &

Zerman, 1995- Stockwell, 1988), with

the central incisors accounting for 80%

and lateral incisors for 16% being the

most frequently affected teeth due to

their protruded and vulnerable anterior

position in the mouth (Andreasen, 1970).

Different criteria have been established

to classify the different types of dental

fractures. The most recognized and

used are those of Black, OMS and Ellis.

(Spinas & Altana, 2002- Ellis & Davey,

1970).

According to these criteria, the

treatment to be followed is established,

which will depend on the degree of

condition caused by the trauma, from

control and observation appointments,

direct or indirect pulp coating, partial

pulpotomy, pulpotomy, pulpectomy, to

tooth extraction.

When the fracture involves the entire

crown, particularly in the anterior sector,

a multidisciplinary dental treatment

involving several pulpal, periodontal

and restorative procedures is indicated.

In the present case, several procedures

were carried out that involved the

treatment of ducts and orthodontic

forced extrusion with ﬁbrotomy, with

the aim of achieving a sufﬁcient dental

structure and an adequate biological

space for prosthetic rehabilitation.

In 1977, Ingber developed the concept

of extrusion force, which is deﬁned

as a vertical movement that is done

with forces orthodontic controlled and

continuous low-intensity, improving

the ratio crown-root and eliminating

defects intraosseous and bags, to allow

the rehabilitation of the crown fractured

(Ingber, 1989). Pontoriero (1987)

proposes to perform the ﬁbrotomy

(resection of the periodontal ﬁbers)

together with the forced extrusion,

which allowed to reduce the eruption

time, resulting in an elongation of

the crown without the need for bone

resection (Pontoriero et al., 1987).

The objective of this report is to describe

the management and follow-up of a

case of orthodontic forced extrusion

and the multidisciplinary treatment of

the coronal fracture of an upper canine

in an elderly adult patient.

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Case Report

Apparently healthy 78-year-old patient

comes to the clinic of the Specialty of

Orthodontics and Dentomaxillofacial

Orthopedics, referred by a specialist in

Endodontics, due to corono-radicular

fracture of right upper canine, ﬁxed

bridge abutment of three units (Figure

1). The patient reports having received

a blow to the mouth about three weeks

ago.

On physical examination, he presents

good general conditions, with no

apparent wounds or edema in the oral

region.

On intraoral examination, he presents

with a cervical fracture of the crown

of the right upper canine (Ellis class

VII). Periapical radiographs and clinical

percussion, palpation and mobility tests

are performed (Figure 2).

When evaluating the case, it is

determined to carry out dental

treatment with a multidisciplinary

approach, which involves endodontics,

orthodontics (forced extrusion),

periodontics with ﬁbrotomy and

prosthetic rehabilitation.

Figure 1. Corono-root fracture of right upper canine, ﬁxed

bridge abutment.

Figure 2. Diagnostic tests and radiographs for the choice of

multidisciplinary dental treatment.

As a ﬁrst step, endodontic treatment

was performed on the dental piece and

placement of a supporting intracaval

attachment (emptied endoposteum)

(Figure 3), in order to improve

orthodontic traction.

This attachment consisted of a cast post

with perforations (Figure 4).

After an exhaustive orthodontic

diagnosis, we proceed to place ﬁxed

appliances in the upper arch with MBT

technique (slot 0.022), from the right

molar to the left canine of indirect and

passive cementing (with the slots of the

brackets aligned).

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Immediately after, a 0.019 x 0.025

rectangular arch made of stainless steel

with an extrusion bend was placed at

the level of the right upper canine. In

the same fold, a helix-type loop was

adapted that functioned as a support to

place the passive ligature (the cebanda)

(Figure 5).

Figure 3.1 Performance of endodontic treatment and

placement of endoposte (emptied post).

Figure 4. Drilling and cementation of the endopost.

(post casting)

Figure 5. Helix doublers and placement of orthodontic

appliances.

The activations of the apparatus were

carried out every week with metal

ligation (0.010), expecting an extrusive

movement of 0.5 to 1 mm per week with

a force between 15 and 20 grams per

activation in addition to the realization

of the circumferential supracrestal

ﬁbrotomy to help the extrusion and

avoid its recurrence.

The treatment time to achieve the

planned extrusion was 4 weeks, at the

rate of one millimeter per week, in

addition to 8 weeks of stabilization, for

a total period of three months before

placing the ﬁxed prosthesis.

The circumferential supracrestal

ﬁbrotomy and root planing were

performed before, during and after each

orthodontic activation, in order to be

able to decrease the stabilization time.

During the control appointments, at

three, six, nine and twelve months,

the stability of the extruded tooth was

evaluated, through palpation of the

mucosa, in addition to percussion tests

and X-ray taking, mainly verifying the

absence of clinical and radiographic

signs and symptoms (Figure 6).

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Figure 6. Prosthetic rehabilitation one year after the start of

orthodontic treatment.

Discussion

The difﬁculty of treatment in the

dental organs with transverse or

intraalveolar fracture, which involves

enamel, dentin, pulp and cement,

represents a challenge for the dentist,

who must take the necessary measures

to maintain their vitality and their

subsequent restoration in an aesthetic,

pedagogical and functional way.

The accurate diagnosis of each

individual case is carried out through

the evaluation of the mobility of the

coronary segment, the demonstration

x-ray of the fracture line, and, on

special occasions, through computed

tomography, cone beam, which allows

more accurate assessment of the extent

and direction of the fracture line (May et

al., 2013).

Different treatment modalities have

been adopted for this type of injury,

ranging from control and observation

appointments to osteotomy,

gingivectomy, orthodontic extrusion

(Bondemark et al., 1997- Sönmez et

al., 2008- Saito et al., 2009) or surgical,

extraction or intentional reimplantation

(Grossman, 1966).

An alternative treatment is forced

extrusion by orthodontic means (Kumar

et al., 2019), which is a conservative

and predictable method to achieve a

supragingival margin that allows the

survival of the restoration in a longer

term.

In the present case, along with the

forced extrusion, the supracrestal

circumferential ﬁbrotomy was

performed, described by Campbell

(Campbell et al., 1975). This procedure

consists of the resection of the

periradicular ﬁbers to the bottom of

the gingival sulcus and root planing to

minimize possible recurrence (Carvalho

et al., 2006) and improve the stability of

the affected tooth (Bach et al., 2004).

These actions allow the alveolar bone

and the gingival extension to move

together with the root (Edwards,

1988- Brain, 1969). It is recommended

that the orthodontic extrusion speed

be one millimeter of root movement

(Bach et al., 2004- Durham et al., 2004-

Jorgensen & Nowzari, 2001) per month

and subsequently a stabilization period

of eight weeks (Carvalho et al., 2006).

In 2000, Jorgensen (Jorgensen &

Nowzari, 2001) recommended ﬁbrotomy

before, during and after forced

orthodontic eruption, to decrease the

necessary stabilization time.

The advantages of the procedure are

the absence of bone loss or periodontal

support, which usually occurs when

an extraction is performed; the

recurrence of the extruded teeth is

avoided and the aesthetic appearance

left by the extrusion is improved

(Yoshinuma et al., 2009- Gonçalves

et al., 2015). Its disadvantages are

the use of orthodontic devices with

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consequent aesthetic problems and the

impediment to proper oral hygiene.

The treatment time is 2 to 3 months,

plus the stabilization period; according

to Bach (Bach et al., 2004), it is

contraindicated in ankylosed teeth, in

the presence of vertical fracture, teeth

with short roots, insufﬁcient space in

the arch and exposures of the furca.

Keinan (Keinan et al., 2013) and Simon

(Simon et al., 1978) propose in some

cases, where the exposed dental

structure allows it, the placement of a

supporting intra-ductal attachment, but

this technique is not always possible.

In the present case, a hollowed post

was cemented with perforations, which

helped to pull the tooth in a progressive

and controlled way, with an extrusion

speed of one millimeter per week

(Ingber, 1989- Carvalho et al., 2006), for 4

weeks, in addition to a retention period

of eight weeks.

This procedure differed from that

proposed by Durman, who suggests

one month of stabilization for every

millimeter of orthodontic extrusion.

In independent reports, Keinan (Keinan

et al., 2013) and Farmakis (Farmakis,

2018) concluded that the prognosis

of treatment is much more favorable

in young patients. However, in this

case, adequate extrusion was achieved

in an elderly patient, along with the

immediate placement of the prosthesis,

so it represents a comprehensive

and multidisciplinary treatment that

offers good functional and aesthetic

results. During the follow-up period,

every three months until one year

was completed, no pain was reported

in the area, no signs or symptoms of

apical or periapical pathology, nor

radiographic periodontal defects were

presented as expected in an elderly

patient. Finally, the restorations placed

were functionally and aesthetically

acceptable.

Conclusion

Through an interdisciplinary

approach (endodontics, periodontics,

orthodontics and prosthetics)

the dentist can offer quality joint

treatments, such as those described in

the case reported here.

Here all the advantages offered by

forced orthodontic extrusion were taken

advantage of, even in an elderly adult

patient, achieving a traction of four

millimeters. This objective was achieved

thanks to the use of light and controlled

extrusive forces on the affected dental

organ. With the described treatment

modality, a crown lengthening can be

achieved without the need to perform

a bone resection, which allows a correct

prosthetic rehabilitation, returning the

function and aesthetics to the injured

tooth and providing an integral beneﬁt

to the patient.

We consider as a limitation of this

report that the observation time of

the case was not long enough. The

authors declare that there is no conﬂict

of interest with respect to the case

presented.

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