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3]3 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 Henry Sa/ama, DMD* Maurice Sa/ama, DMDt Abstract the planning of the periodontal, oc- clusal, and restorative aspects of the A classification scheme that systematizes the wide range of regenerative potential of common extraction site topographies is presented. Within this system, the parameters for immediate implant placement and preliminary ridge augmentation are discussed. In addition, a new adjunctive role for orthodontic extrusion is introduced. This approach is intended to manipulate "hopeless" teeth to modify their local defect environments, thereby enhancing the predictability of subsequent implant placement at those sites. (Int J Periodont Rest Dent fixture-assisted One dental restoration. aim of these new criteria must be the preparation ly adequate of a dimensional- and potentially esthetic recipient site for the implant. important treatment planning Other consid- erations include (7) whether any teeth can be predictably maintained a periodontal-prosthetic (2) whether tracted; any teeth should (3) techniques the subsequent sequence receptor site and (4) the optimal of implant mucogingival be ex- to augment potential when necessary; from perspective; placement and surgical modalities. 1993; 13:313-333.) One of the more difficult problems Osseointegrated have enjoyed dental long-term the rehabilitation implants success in with the ex- protocols contin- and updated the benefits of evident as dentistry to integrate this ap- into the more varied environedentulous Along with the many predictability pa- benefits and options, the ever-evolving seointegrated implants ment of the partially and Periodontics periodontally hopeless fully at those factor success- sites. A complicating is the need to maintain tional and esthetic harmony also created This becomes jacent natural teeth. Simple extraction followed by a healing period in the treat- edentulous new jaw challenges. of the periodontally promised patient are incorporated the treatment comin plan. These challenges height of the extraction may negate esthetically a clear need for new criteria to guide of a sigA severe the implant compromising strategic areas. opin Because the ability to preseNe8 or regenerate ridges postextraction the original have created socket, how- part of the ridge. too of or at the crestal ever, may result in collapse nificant as proto- bone resorption plates tion or prove and prosthetic demands col.5-7 Subsequent defect apparent of up to 12 months was recommended thin labial role of os- especially when the periodontal of enhanced func- with ad- part of the initial Bronemark added has of teeth and to place implants into clinical practice. ment of the partially University of Pennsylvania School of Dental Medicine 4001 Spruce Street Philadelphia, Pennsylvania 19104 Central to such cases is the question traction planning tient. in Orthodontics tooth. treatment proach Student compromised the residual has endeavored tology t Postgraduate existing defects often associated This is particularly Implan- of an of how best to manage osseointegration and at the site an implant patients.l-4 Every aspect of traditional to better incorporate tics, Periodontal-Prosthesis or prefer- able to place of totally edentulous ues to be reevaluated * Assistant Clinical Professar of Periodon- arises when it is essential approach has increased,9 seems inade- quate or, at best, unnecessarily time consuming. Volume 13, Number 4, 1993 314 Extraction implant followed placement by immediate has been advo- cated as a more expedient to replacing hopeless approach teeth with im- plants.10-12 This approach rates the principles regeneration incorpo- of guided tissue (GTR), a method utilizes a barrier membrane clude epithelium that to ex- and connective tis- Techniques that preserve eliminate future and should placement problems when a treatment developed for a compromised mands de- that there be a certain- mini- mal amount the apical yond, also of engageable. bone at end of the socket or be- to stabilize the implant. While immediate es- tablished over time, the principles of GTR, as they relate to Nyman place- however, of the buccolingual dimensions ridge deformities, of in .the buccolingual a case re- augmented, crease gin migrates cogingival of position ronally an emphasis and main- vention. odontal breakdown hopeless teeth is particularly severe. ing. The augmentative pres- troduce of sig- ently available treat the ridge defect utilizes ously compromise the final result. In addition, the potential implant seri- esthetic for instability from a lack of en- of extraction vantage gageable bone in the severely com- modify promised ridge may preclude ment an implant. Where use of the potential im- on creating or at a later date. be such an endeavor need must gical intervention. been movement be employed. grafts used to augment implant have severely arches in the vertical dimensions and atrophic horizontal prior to or at the time of placement.13,14 A review the literature,15-17 however, that this technique source demanding useful in the fully of indicates is extremely re- and may be more edentulous than in areas exhibiting tulous spans. for further The Autogenous arch small eden- able hard well to efficacy reduce sur- of extrusive architecture Ingber29-31 highlighted tooth the soft and documented.23-27 has been Brown28 and molar upright- ing and forced eruption, respectively, as methods and gingival of modifying the osseous topography. Since the gingival fiber apparatus lacks elastic- ity , stretching tooth it during move- ment imparts tension to the alveolar bone. It is widely the alveolar journal of Periodontics & Restorative Dentistry vertical margin may accepted that this at crest.32-34 Extrusive tooth and co- extraction. By deformities in placement, effectively and create a greater volume of bone and soft tissue in the plane without surgical inter- of this paper is to in- a new perspective, orthodontic "hopeless" and tooth be shifted prior to tooth one that extrusion of teeth to enhance the soft hard tissue dimensions of po- tential implant recipient clear parameters sites. To set for its application, this technique will be presented within the framework of a systematic proach to managing defect environment. will be shown tension stimulates bone deposition The International in the augmentative to improve tissue environ- Success may Alad- positively defect extraction. mised, approaches be a great the potential before plant receptor sites are thus comproalternative either at the time it would to crest may The purpose techniques and its ramifications ternatively, of the gingival this approach taining a space for GTR during heal- can extrusive for implant with the as a means by which the isolated be ineffective in areas where the peri- existing recession, examined preparation situations with excellent results, it may nificant have controlled the bone available because we movement spans Soft tissue defects, while the mu- addressing Buser et al22 also this mar- In view of these well-established tion of short edentulous the coronally utilizing GTR, prior to im- on the osseous during the gingival junction remains stable.36 processes, uniquely around because type of movement augmenta- ment can be used effectively in many occurs the gingiva.35 This in- was placement. reported site deficient dimension of attached role localized may be utilized.18-2° et al21 presented port wherein an implant plant implant site. defects become osseous portion of be plan is Once extraction the ingrowth This strategy implant considered lectively bone around the exposed the volume zone can the augmentation the implant. olso enhances tion site, thereby seof movement of the soft tissue by increasing sue from the wound promoting or aug- ment the ridge at the time of extrac- and technique. ap- the extraction Several to illustrate cases rationale 315 Classification and treatment guidelines Extraction sites involving compro- mised teeth exhibit a socket environment at "the apical form of extraction at the coronal fore, where quirements end aspect it anticipated planning re- necessary to in the area of an ex- isting compromised varying some (Fig 1 ). There- treatment make place implants and defect environment tooth, that local complexity it can be deformities tered. The criteria for treatment proaches of will be encounap- to sites that are compro- mised will be discussed based on the severity of the residual defect envi- The first step to successful treat- ronment (Fig 2). ment planning classification is the recognition of the problem(s). have formulated a classification and Fig 1 Extraction sites of compromised ent defect-socket ratios. teeth are usually complex and may exhibit differ- We sys- tem that focuses on the residual defect morphology tive potential and the regenera- at the extraction These guidelines site. are comparable to those used to classify periodontal in- frabony Fig 2 A diagnosis prior to extraction is dependent on ascertaining the extent and dimensions of the defect environment along the root surface. Probing and bone sounding are indispensable. defects.37 The regenerative potential of an similarly extraction be expected to the number maining. vironment to be related of osseous Accordingly, is defined site can walls re- a socket en- as being con- tained within four osseous walls and having the best regenerative poten- tial. A on the defect other hand, environment, has three osseous walls or fewer and is associated respondingly less seous regeneration with cor- predictable around MODERATE os-' exposed surfaces of an implant. Volume 13, Number 4, 1993 316 Fig 30 (top left) Fig 36 (bottom Fig 3c (center) Fig 3d (right) left) Figs 3a to 3d Type 7 extraction sites, such as the ones associated with root fractures, retain a dominant socket environment. The high regenerative potential at these sites makes them ideal for immediate implant placement. Potential extraction sites can be Myriad proportions of very different. the socket-to-defect may be environments exhibited. to 5-mm offset is best, because site allows The Type 1 site is an incipient defect environment with a good tive potential and an acceptable is manifested thetic prognosis: and dominates cal topography to 7 extraction which one or the other environment determining The degree Type the lo- serves as one of the factors for choosing optimal treatment ditional factor that influences treat- ment decisions is the quantity of the remaining labial is especially approach. the An od- plate of bone. important This in the anterior segment because of the more de- manding esthetic requirements. We suggest the following classifying guidelines for and treating extraction site deformities. 1 .The ent of Periodontics & Restorative by The osseous third of the beyond initial stabilization 3. Osseous to be extracted is manageable, crestal line or in posterior Type 1 extraction (ie, 4 the apex for of an implant. topography permitting discrepancy an ones exhibited placement quadrants). about fractured GTR. The critical requirement ac- ble at these is most readily of of initial achievaal- though the volume of the socket can be large, the potential traction (Figs 3a to 3d). a 3- implant sites. In addition, tion in that environment socket, and the necks of roots, utilizing the principles stabilization is between teeth. Usually or sites, such as the the head of the fixture, in the ex- Dentistry is ade- where esthetics is not paramount are best suited for immediate bone is available to 6 mm) plate of bone (ie, in a patient with a low smile- root to be extracted. harmonious, Journal 4. The labial deshiscence-type crests lie in the coronal the adjacent International is dominated direction). 2. Adequate from the fixture. es- (5 mm or less in the api- cocoronai ceptable The regenera- it emergence profile of the restoration socket or the incipi- three-wall defect optimal quate, and recession on the tooth environment the four-wall an for regenerais also great 317 The obvious mediate advantages of im- as the ones characteristic placement are its 2 implant expediency and relative predictabili- ty. Compared ditional to the duration cedures, the length of treatment implant restorations creased time vanced performing regenerative in the healing gration. techniques phase It is, therefore, ment with immediate regeneration in- Therefore, to achieve apy and potential that increases to treatplace- added fication become necessary , es- increased length of the fixture is re- Type A 2 Type extraction 2 site site promised is a moderately com- and esthetic 1 .A defect environment predominant, through the and it middle root; this includes is extends third of the dehiscences of 2. The discrepancy seous crests between of the the os- remaining socket and the necks of adjacent teeth is substantial. 3. Recession is significant and loss of the labial plate of bone is moderate. This is especially critical in the anterior region of the mouth in a patient with a high smileline. examples been teeth Specifical- these through tooth movement, tissues in the more compromised environment, potential for positively potential implant therefore, for optimizing offers the altering recipient usual as hopeless, treatment planning spective for the fixture-assisted toration currently suggests The first the treatment environment poses several functional and esthetic limitations. regenerative The reduced potential of the significant vironment defect en- may force a more apical and possibly less than ideal restrictions may place- (Fig 4). Anatomic require the shorter fixtures. In addition, use of compro- per- prove res- view of these challenges, extract as part of control and, when fea- The second immediately. hopeless teeth a temporarily provisional while implant esthetically extrusive sented tooth as an approach unacceptable. movement is adjunctive for the Type 2 environ- ment. to help restoration environment tained orthodontically across the entire length of its attachment. fixtures are osseointe- Therefore, it is recom- grated. These hopeless teeth, however, af- essary , the ford tion to achieve maximal unique advantages that can results of cosmetic procedures. most alluring the and regenerative Because are not necessarily prior enhance hopeless that these teeth offer resides in their remaining attachment tal ligament, apparatus, benefits. The for this process, all the augmentative to the orthodontic because benefits inherent extrusive process. used alone, best for teeth with moderate hard tissue defects, usually works soft and because teeth of three-wall de- regenerating amount of attachment tissues, to extrac- its purpose is to extract the tooth with is ironic that so much effort is put into these valuable hopeless almost It still have these a significant remaining. The 5 mm or less considering in the implant carded as part of "strategic extraction. " By contrast, our approach to this remaining treatment osseous tissues in a vertical direction. literature,38,39 no guidance is given for treating more extensive defects, such how quickly they are dis- or nec- authors suggest the term orthodontic This approach, ie, periodon- bone, and cementum. designated be extruded extraction teeth useless teeth, the advantage tooth its is con- that, when feasible other pre- treatment mended to extraction In controlled The ability of a tooth to affect possibility is to retain the stabilize restora- tions or uneven gingival margins may only two is to the site and, and final result. os- measuring reported of of successful seous regeneration hiscences resources. manipulation ment of the implant the Type 2 hopeless teeth strategically greater than 5 mm. have For teeth designated sible, to place implants moderate While hopeless ly, mises in the form of longer inflammatory environment: modi- site. possibilities. regenerative more expe- is orthodontic of the defect; an and is time can be used to modify the quired. serve this it requires A relatively sites, however, pecially where esthetic detailing or an would these valuable The Type 2 extraction Preliminary surgical procedure dient approach adjunctive vital. However, consuming. ther- the regenerative becomes purpose. that im- greater suc- cess in the Type 2 environment, ad- ment. In more severely compromised techniques of the plant surface. fortunate alternative by the potential with ridge augmentation implant successful is limited reduced regenerative of osseointe- many cases are amenable of the Type cases, site and the increase in exposed of the additional in In these pro- is significantly because involved bone of tra- periodontal-prosthetic site. planning capitalizes on aim of this technique tically is to manipulate attachment to augment orthodon- the gingival and Volume 13 Number 4 1993 318 Fig 4 Present options for treatment of the Type 2 extradion site. All of them involve GTR utilizing a baITier membrane. (A) A Type 2 extraction site, the defect environment extends into the middle third of the root and possibly involves a dehiscence of greater than S mm. (B) The implant is placed so that the head of the fixture is positioned ideally in relation to the neck of the adiacent tooth (3 to S mm). Thispositioning, however, leaves a large segment of the fixture supraosseous and makes success less predictable. (C) More apical placement of the fixture into the more regenerative environment may create soft tissue compromises or an unesthetically long clinical crown. (D) To address the treatment concerns, preliminary ridge augmentation may become necessary. In essence, by relocating regenerative socket environment ronally we are eliminating generative defect the more co- the less re- environment and The osseous thodontic offers several mediate leveling effect of or- extraction at the Type 2 site benefits implant over the im- placement turning a Type 2 site inta a Type 1 dure. The most important site (Fig 5). Also, where the campro- the creation mised teeth have flared available traction can labially, be performed re- simulta- neausly during the extrusive pracess. This will favorably environment realign the socket palatally plant can be placed will nat compromise restaration The International (Fig 6). sa that the imat an angle that the prosthetic of a greater bone procebenefit volume to engage cent studies placement areas that of into extraction involve have revealed exhibit immediate a Journal of Periodonncs & Restoranve Dentis"" Re- sockets or seam implant augmented may eventually be attrib- utable to the short observation quisition of a natural deshiscence befween the initially exposed nary and od. implant fibrous the newly is that some specimens an interposing and bone.4°.41 These results are prelimi- of the im- plant at the time of placement. surface However, entially more we believe ac- and circumfer- intimate tween the implant that peri- contact be- and the adjacent bone at the leveled site may result in greater initial stabilization and possibly of the fixture earlier osseointegration over a larger surface area (Fig 7). 319 Fig 5 (A) A hopeless tooth with a Type 2 classification. (B) A pulpectomy is performed, periodontal inflammatory control is instituted, and extrusi,:,emechanics is employed. (C) !he result transforms a Type 2 site into a Type 1 site: (.D) Greater predictable success.with immediate Implant placement may be achieved because more surface area of the fixture IS In IntImate contact WIth the suIToundlng bone than would have been the case in the original situation (A) Further, the increase in the gingival dimension that is achieved embodies reduces the possibilily bule will be shallow. that the vestiIn many in- significant esthetic and technical ben- stances, these soft tissue benefits will efits. Beside providing reduce or eliminate the need for mu- able esthetic gingival margins, of leveled this approach lows the regeneration papilla the consider- advantage cogingival procedures later. al-, of the gingival (Fig 8). The lip of bone that follows the erupting tooth can create and maintain restoration. the attached a papilla at the final The increased gingiva, width of in addition, minimizes the need to lift the tissue to cover the extraction site, and thereby Volume 13 Number 4. 1993 320 Fig 6a A 58-year-old patient with hypermobile and flared anterior teeth presented for treatment. Fig 6b A panoramic radiograph reveals wide circumferential defects around the maxillary canines. The roots of the canines extend to the floor of the nasal cavity, and the amount of bone is not adequate to engage and stabilize an implant. The International Journal of Periodontics & Restorative Dentistrv Fig 6c A provisional restoration was placed from the right canine to the left first molar. The crowns of the canines were removed and pulpectomies were performed. The roots were debrided to the base of the pocket with a diomond used at high speed. Extrusiveand retraction mechanics were employed within the provisional restoration. 321 Fig 6d Figure 6{ Tissue at completion of the orthodontic phase. Figure 6g Figs 6e to 6h Periapical radiographs of the right and left sides before and after extrusion. Figure 6h Volume 13, Number 4, 1993 322 Figs 6i to 6n Reformatted computerized tomographic scans taken before and after orthodontic extrusion. Note the verlical increase in engageable bone and the qualify of the transformed recipient sites after extrusion. In Figs 6m and 6n, the effect on the ridge of simultaneous palatal extraction of the left canine is evident. (Courtesy of Biometrix Tech.) Figure 6i Figure 6k Figure 6i The International journal of Periodontics & Restorative Dentistry 324 Fig 60 Stage 1 surgery. Note the complete elimination of the defect environment. Fig 6p The left lateral incisor and canine have been extracted and implants have been placed. A membrane will be placed for GTR on the two exposed threads on the labial aspect of the canine area and to augment the thin labial plate of bone. Fig 6q Two 13-mm fixtures and three 10-mm fixtures have been placed in the left and right sides, respectively. Periapical radiographs at 3 months. The International Journal of Periodontics & Restorofive Dentistry 325 Fig 7a Maxillary right canine with 9-mm probing depth interproximally and 6-mm probing depths facially and palatally. Including the 5 mm of recession and the biologic width, the labial crest can be assumed to be approximately 13 mm apical to the cementoenamel iunction; therefore, this is a Type 2 site. Fig 7b Use of an implant was planned to assist stabilization of a maxillary restoration. The canine was extruded and retraded to modify the recipient site. Fig 7c Postextrusion radiographs of the defect environment during stabilization, (left to right) at 0, 2, and 6 weeks. Fig 7d New coronal position (arrow) labial crest of bone. of the Fig 7e Implant placed completely in a socket environment. Volume 13, Number 4, 1993 326 Fig 7f Tissue during osseointegrotion phase. Note harmony of mucogingival margin. Fig 80 A 61-year-old patient presented for treatment with a failing maxillary restoration associated with recession. There is inadequate bone to place implants in the maxillary right quadrant. The Internationol Journal of Periodontics & Restorotive Dentistry Fig 7g Radiograph at 3 months. Figs Bb to Be Moxillary right canine prior to extrusion. 327 Figure Bc Figure Bd Figure Be Fig Sf The vertical dimension of the bone at the recipient site is increased postextrusion. Fig Bg The postextrusion soft tissue changes are dramatic, as revealed by the formation of (arrow) new papilla. Fig Bh Compare shown in Fig Be. soft tissue to that Volume 13, Number 4, 1993 328 The eruptive phase in this tech- mediate implants or sufficient remain- Treatment of the Type 3 environ- nique usually requires 4 to 6 weeks. ing attachment It is followed by 6 weeks of stabili- the principles of GTR should be used bridement of the extraction site. In our zation the tooth to achieve preliminary protocol, this placement of a mixture of decalcified before and the implant approach While this ridge augmen- tation. adds to.the length of treat- ment, it is significantly than is removed is placed. for effective extrusion, GTR tech- technique to address defect environment dictable the moderate allows more pre- placement plants because Use of this of longer the coronal tion of the osseous im- reloca- crest. The tech- Type 3 extraction site implant the adjacent One natural teeth. contraindication erupting teeth uncontrollable lesions, including presence diate endo- lesions and frac- It is suspected fiber apparatus that the of such teeth is ex- compromised. control inflammation fection may healing of to acute in- and also and Inability adversely overall affect response to treatment. Even if the roots can be main- implant placement 1. Vertical and buccolingual placement mediate and stabilization their adjacent The abil- teeth to influence tissues is limited by the quantity of the remaining attachment the labial plate of bone is severe. 3. Severe circumferential In experiments found was that only attached odontal accompanied The teeth lack Internotionol Journol of Periodontics membrane. We have, on occasion, submerged roots of hopeless as an alternative support method to the tenting teeth of adding of the mem- brane (Fig 9). Buser et al22 presented reports of cases in which minicortical screws were applied, in certain in- stances, for the same purpose. with GTR, Gottlow Another advantage of utilizing erties of the bone-morphogenic pro- shape of the tissue generated under the membrane seemed to be is for stimulating bone for- tein inherent in the graft medium.44.45 Nyman20 recently is used to enhance study of localized presented ridge a pilot augmenta- The tetracycline, potential tion in dogs. Their findings suggested provide that some age.47 The membrane less collapse occurred was where not supported. in the areas in which the did not retain its shape, regeneration was observed. Therefore, space maintenance the membrane is a critical when under compo- large defects on the other hand, of the local the osteogenic allograft46 above-described treatment approach,9,48 similar to methods used to address long-standing tation procedure, which quires 6 to 9 months usually re- for full miner- alization to occur. The second step is procedure is not sufficient. Dentistry ridge de- fects. The first step is the augmen- placement, may itself require another sur- to cover- option may be viewed as a two-step tation of im- and antimicrobial the actual implant that & Restorotive of the determined by the configuration of the " artificial space. " Seibert and the adequate is incap- the shape prop- Hence, when bone for stabilization environment able of supporting DFDBA to the root via peri- fibers hopeless bone maintenance, where the natural anatomy mation through the osteogenic defects and alveolar tooth in its movement. rounding tooth pur- is to serve as for space especially barrier main and are t~eated. et al42 studied (DFDBA) and Nyman43 found that the volume ratus. into infrabony and angu- lar defects are present. nent, especially Poison of im- implants. and the integrity of the fiber appamovement for 2. Recession is present and loss of Additionally, not create new attachment. dimen- sions of bone are inadequate relocates ity of compromised is not an of the DFDBA of the defect the membrane It does imme- option: tained, however, forced eruption only existing attachment. in which (Gore). the by GORE- The pose inflammatory combined dontic-periodontic tured roots. for forcibly is the chronic, tremely with bone allograft covered de- by Material scaffolding by creating a leveled receptor site in harmony is followed membrane mised environment a thorough TEX Augmentation A Type 3 site is a severely compro- nique also results in a more esthetic final restoration with and tetracycline, niques, which require 6 to 9 months before implant placement. begins freeze-dried more expedient ridge-augmenting ment which augmen- if the initial attempt 329 Fig 9a Radiographs reveal hopeless teeth with severe periodontal breakdown. It is likely that no bone is available for implant placement postextraction. Fig 96 At the time of extraction, a deep, concavity is found in the right anterior region Fig 9c The maxillary right first premolar has been extracted. The crown has been removed from the canine, but the root has been retained to tent the membrane. InteImalTOWpenetration has also been perfolmed. Fig 9d The membrane became exposed at 3 months and was removed. Note the complete regeneration of the ridge. The tissue demonstrates a hard, cartilaginous consistency. Implants will be placed in the future. Volume 13, Number 4, 1993 330 Fig lOa The maxillary right first premolar and canine demonstrate probing depths of 6 to 9 mm. In addition, the premolar has a Class III furcation involvement. The original treatment plan included extraction of the teeth and replacement with implants. Fig 1Ob Initial extrusion. The palatal root of the first premolar was subsequently amputated and the buccal root was extruded. Fig lOc Postextrusion. The teeth were provisionally restored to stabilize the result. Fig IOd Two months postextrusion, the first premolar and canine exhibited minimal probing depths and were so stable that they were given permanent restoralions. No surgery was ever performed. (Courtesy of Bruce Goldmon, DMD.) The International Journal of Periodontics & Restorative Dentistry 331 Discussion Summary References There can be several successful ap- When proaches extracted, opment to a problem. The devel- of a more rigid membrane, for example, may offer a better op- compromised satile treatment dimensions roots, able implant nance. for space In addition, and availability tors may potential mainte- the development of bone growth fac- enhance around the regenerative more compromised sites. The categories and treatments potential extraction the complexities that presently planning abound for restorations, plication, site. They highand choices in treatment fixture-assisted dental even for a specific ap- such as the management framework, of hopeless teeth and their compro- mised environment. At the same time, degrees of success vary with every modality of treatment. The techniques presented have offered the spectrum of successes. Probably isfying experience the most sat- is when the tech- defect en- a new perspective presented that allows the their attachment optimal profiles of potential peri-implant to aug- hard tissue implant Esthetic enhancement sites. of the po- gingival orthodontic demonstrated. teeth and apparatus, ment both the soft and through was and utilization of avail- assets, ie, hopeless tential cri- were outlined. Within that able light Hence, for the manage- ment of various extraction vironments as a general the placement. teria and guidelines management to viewing is neces- at these sites for predict- that have been outlined are intended guide and ver- approach sary to maintain or achieve adequate tion than the use of screws, retained or grafts teeth are to be a well-organized margin extrusion In addition, was the os- seous profile in the vertical dimension was enhanced. procedures, Combined these techniques sult in more predictable implants with GTR in sites that can re- placement may of initially have been inadequate. nique works so well that teeth initially designated tained as hopeless (Fig la). can be reAcknowledgments We would like to thank Drs Masakazu Nishibori, Fernando Presser, and Jae Hwang, Graduate Students in Periodontal-Prosthesis at the University of Pennsylvania. Their clinical support and contributions helped to enrich this paper. We are also very grateful to Daniel Freeman and Biometrix Technologies, Inc, for their technical help in reformatting and creating graphics for the CT -scans presented. 1. Bronemark P-I, et al. Osseointegrated implants in the treatment of the edentulous jaw. Experience from a 10year period. Scand J Plast Reconstr Surg 1977;11 (suppl16).1-132. 2. Adell R, Lekholm U, Rockier B, Bronemark P-I. A 15-year study of osseo integrated implants in the treatment of the edentulous jaw. Int J Oral Surg 1981 ;6.387-416. 3. Hansson HA, Albrektsson T, Bronemark P-I. Structural aspects of the interface between tissue ond titanium implants. J Prosthet Dent 1983;50.108113. 4. Lindquist L, Carlsson G, Glantz PO. Rehabilitation of the edentulous mondible with tissue integrated fixed prosthesis: A six-year longitudinal study. Quintessence Int. 1987; 18.89-96. 5. Ohrnell LO, Hirsch JM, Ericsson I, Bronemark P-I. Single tooth rehabilitation using osseointegration. A modified surgical and prosthetic approach. Quintessence Int 1988; 19:871-876. 6. Schulman LB. Surgical considerations in implant dentistry. J Dent Educ 1988;52: 712-720. 7. Barzilay I, Graser GN, Iranpour B, Natiella JR. Immediate implantation of a pure titanium implant into an extraction socket. Int J Oral Maxillofac Implants 1991;6:277-284. 8. Bahat 0, Deeb C, Golden T, Komarnyckyj 0. Preservation of ridges utilizing hydroxyapatite. Int J Periodont Rest Dent 1987;7(6).35-41. 9. Lundgren D, Nyman S. Bone regeneration in two stages for retention of dental implants. Clin Orol Impl Res 1991 ;2:203-207. Volume 13, Number 4, 1993 332 References 10. Barzilay I, Gaser GN, Caton J, Shenkle G. Immediate implantation of pure titanium threaded implants into extraction sockets. J Dent Res 1988;67.234. Abstract. 11. Lazzara RJ. Immediate implant placement into extraction sites: Surgical and restorative advantages. Int J Periodont Rest Dent 1989;9.333-343. 12. Becker W, Becker B. Guided tissue regeneration for implants placed into extraction sockets and for implant dehiscences: Surgical techniques and case reports. Int J Periodont Rest Dent 1990; 10.377-391. 13. Adell R, Lekholm U, Grondahl K, Branemark P-I, Lindstrom J, Jacobsson M.. Reconstruction of severely resorbed edentulous maxillae using osseoir1tegrated fixtures in immediately autogenous bone grafts. Int J Oral Maxillofac Implants 1990;5-223-246. 14. Lew D, Hinkle RM, Unhold GP, Shroyer JV, Stutes RD. Reconstruction of the severely atrophic edentulous mandible by means of autogenous bone grafts and simultaneous placement of osseointegrated implants. J Oral Maxillofac Surg 1991 ;49:228-233. 15. Listrom RD, Symington JM. Osseointegrated dental implants in conjunction with bone grafts. Int J Oral Maxillofac Surg 1988;17:116-118. 16. Kahnberg K-E, Nystrom E, Bertholdsson L. Combined use of bone graft and Branemark fixtures in the treatment of the severely resorbed maxillae. Int J Oral Maxillofac Implants 1989;4:297304. 17. Keller EE, Van Roekel NB, Desjardins RP, Tolman DE. Prosthetic-surgical reconstruction of the severely resorbed maxilla with iliac bone grafting and tissue-integrated prosthesis. Int J Oral Maxillofac Implants 1987;2: 155-165. 18. Dahlin C, Linde A, Gottlow J, Nyman S. Healing of bone defects by guided tissue regeneration. Plast Reconstr Surg 1988;81 .672. 19. Dahlin C, Linde A, Gottlow J, Nyman S. Healing of maxillary and mandibular defects by a membrane technique: An experimental study in monkeys. Scand J Plastic Reconstr Hand Surg 1990;24.13. 20. Seibert J, Nyman S. Localized ridge augmentation in dogs. A pilot study using membranes and hydroxyapatite. J Periodontol 1990;61.157-165. 21. Nyman S, Lang N, Buser D, Bragger U. Bone regeneration adjacent to titanium dental implants using guided tissue regeneration. A report of 2 cases. Int J Oral Maxillofac Implants 1990;5.9-14. 22. Buser D, Bragger U, Lang NP, Nyman S. Regeneration and enlargement of jaw bone using guided tissue regeneration. Clin Oral Impl Res 1990; 1.2232. 23. Oppenheim A. Artificial elongation of teeth. Am J Orthod Oral Surg 1940;26.931-942. 24. Reitan K. Clinical and histologic observations on tooth movement during and after orthodontic movement. Am J Orthod 1967;53.721-745. 25. Ritchey B, Orban B. The crests of interdental alveolar septa. J Periodontal 1953;24.75--87. 26. Van Venrooy JR, Yukna RA. Orthodontic extrusion of single-rooted teeth affected with advanced periodontal disease. Am J Orthod 1985;87.1:67-74. 27. Berglundh T, Marinello CP, Lindhe J, Thilander B, Liljenberg B. Periodontal tissue reactions to orthodontic extrusion. J Clin Periodontol 1991; 18.330336. 28. Brown IS. The effect of orthodontic therapy on certain types of periodontal defects. J Periodontol 1973;44.742756. 29. Ingber JS. Forced eruption. Part 1. J Periodontol 1974;45: 199-206. 30. Ingber JS. Forced eruption. Part 2. J Periodontol 1976;47.203-216. 31. Ingber JS. Forced eruption. Alteration of soft tissue cosmetic deformities. Int J Periodont Rest Dent 1989;9.417-425. The International Journal of Periodontics & Restorative Dentistry 32. Reiton K. Effects of force magnitude and direction of tooth movement on different alveolar bone types. Angle Orthod 1964;34.244. 33. Simon JH, lythgoe JB, Torabinejad M. Clinical and histologic evaluation of extruded endodontically treated teeth in dogs. Oral Surg Oral Med Oral Pathol 1980;50:4.361-371. 34. Pontoriero R, Celenza F Jr, Ricci G, Carnevale G. Rapid extrusion with fiber resection: A combined orthodonticperiodontic treatment modality. Int J Periodont Rest Dent 1987;7(5).31-43. 35. Batenhorst KF, Bowers GM, Williams JE. Tissue changes resulting from facial tipping and extrusion of incisors in monkeys. J Periodontol 1974;45:660668. 36. Ainamo J, Talari A. The increase with age of the width of attached gingiva. J Periodont Res 1976;11.182-188. 37. Goldmon HM, Cohen DW. The infrabony pocket. Classification and treatment. J Periodontol 1958;29.272-291. 38. Dahlin C, lekholm U, linde A. Membrane-induced bone augmentation at titanium implants. A report on ten fixtures followed from 1 to 3 years after loading. Int J Periodont Rest Dent 1991;11.273-281. 39. Jovanovic SA, Spiekermann H, Richter EJ. Bone regeneration around titanium dental implants in dehisced defect sites. A clinical study. Int J Oral Moxillofac Implants 1992; 7 :233-245. 40. Coudill RF, Meffert RM. Histologic analysis of the osseointegration of endosseous implants in simulated extraction sockets with and without ePTFE barriers. Part I. Preliminary findings. Int J Periodont Rest Dent 1991;11 :207-215. 333 41. Zablotsky M, Meffert R, Caudill R, Evans G. Histological and clinical comparisons of guided tissue regeneration on dehisced hydroxylapatitecoated and titanium endosseous implant surfaces: A pilot study. Int J Oral Maxillofac Implants 1991 ;6:294-303. 42. Poison A, et al. Periodontal response after tooth movement into intrabony defects J Periodontol 1984;55: 197. 43. Gottlow J, Nyman S, Karring T, lindhe J. New attachment formation as a result of controlled tissue regeneration. J Clin Periodontol 1984; 11 :494-503. 44. Urist MR, Strates BS. Bone morphogenic protein. J Dent Res 1971 ; 50.1392. 45. Urist MR, leitze A. A non-enzymatic method of preparation of soluble bone morphogenic protein (BMP). J Dent Res 1975;59(special issue A) .415. 46. Drury GI, Yukna RA. Histologic evaluation of combining tetracycline and allogenic freeze-dried bone on bone regeneration in experimental defects in baboons. J Periodontol 1991 ;62.652658. 47. Egyedi P, Guggenheim B. The uptake and release of antibiotics by lyophilized bone. J Maxillofac Surg 1973; 1.177-182. 48. Nevins M, Mellonig JT. Enhancement of the damaged edentulous ridge to receive dental implants: A combination of allograft and Gore- Tex membrane. Int J Periodont Rest Dent 1992;12.97111. Volume '3 Number 4. 1993