Download The Role of Orthodontic Extrusive Remodeling in the

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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.
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Volume '3
Number 4. 1993