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Guidelines for aesthetic restorative options and implant site enhancement: The utilization of orthodontic extrusion

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... More recently, Salama and coworkers were the first to publish a series of articles using orthodontic extrusion to augment bone and soft tissue Orthodontic extrusion for implant site development revisited of the recipient dental implant site. [11][12][13] A classification scheme related to findings and treatment was developed by these authors presenting diagnostic guidelines and the therapeutic benefits of using orthodontic extrusion to enhance sites receiving implants. These authors stated the notion that a "hopeless tooth is not a useless tooth," in which they advocated using periodontally compromised teeth to dramatically improve the esthetic-restorative implant outcome. ...
... 4,5,16,17,22,23 More recently, the use of orthodontic extrusion as an effective tool in implant site development has become an area of great interest, as this technique provides patients and clinicians with many advantages when compared to surgical techniques. 4,11,[12][13][14][15][16][17][18][19][20][21][22][23][24][25] There are several disadvantages of using orthodontic extrusion as a therapeutic form of treatment. During vertical tooth movement, occlusal interferences and contact to the opposing arch must be eliminated. ...
... Se não o puder ser, então deve-se proceder á sua substituição por um implante. Porém um dente perdido pode ser útil para preparar o periodonto de um futuro implante (por exemplo através de extrusão ortodôntica para ganhar tecido duro ou mole) 35 . ...
... Se sim -existe vantagem na colocação de um implante. A extrusão ortodôntica diminui a relação coroa/raiz podendo predispor o dente a fractura 49 , provoca também uma assimetria a nível cervical ficando o colo do dente mais estreito devido á configuração anatómica das raízes cónicas dos dentes anteriores esteticamente desfavorável 35 . ...
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The main goal in dentistry is to preserve teeth and adjacent structures. When a tooth is lost, its rehabilitation evolves fixed, removal or a combination of both prosthodontic modalities.With the phenomenon of osseointegration the endosseous implants came to add another tool to prosthodontic solutions. Not only it came to rehabilitate edentulous ridges but also it arouses the discussion about when to keep compromised teeth. The discussion between Implants Vs Endodontic treatments has traditionally been reduced to the debate around success and survival rates of each modality. Nowadays we know that despite of both being use as abutments for a future restoration they also share important differences.The goal of this literature review is to enhance the differences, advantages and disadvantages of each one in the aesthetic area.The second part of this work will present a classification system to help in the correct decision.
... ( fig. 1a) A perda dos 4 incisivos superiores é uma situação de reabilitação oral que pode estar presente na nossa prática clínica onde, apesar de adjacentes, os caninos não estão (na maioria das situaç ões) incluídos na perda 14 Esta situação deve-se em parte à localização dos caninos na arcada (longe da zona tradicional de traumatismo e fratura e na zona de melhor escovagem) 14 . ...
... ( fig. 1a) A perda dos 4 incisivos superiores é uma situação de reabilitação oral que pode estar presente na nossa prática clínica onde, apesar de adjacentes, os caninos não estão (na maioria das situaç ões) incluídos na perda 14 Esta situação deve-se em parte à localização dos caninos na arcada (longe da zona tradicional de traumatismo e fratura e na zona de melhor escovagem) 14 . ...
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Implant supported rehabilitation is a high survival and success therapy, however compared to tooth supported rehabilitation it has some aesthetic limitations.In the upper incisor area we need to enhance all properties of dental implants to get maximum aesthetic.It is also important the appropriate integration between crown and gingival tissues, interproximal papillae and gingival prosthodontic materials, tooth proportion, occlusion and function.The symmetry of the IPP, the bone contours and the recreation of a full periodontal is a challenge and an integration of the correct selection of the number and type of implants to be used, materials and techniques of Prosthodontics and tissue regeneration.Implant rehabilitation of the four upper central incisors despite some advantages, has surgical and prosthodontic factors that have to be taken into account.The objective of this literature review is to determine what are the decision factors as well the advantages and disadvantages in the elaboration of an implant treatment plan of the four upper incisors.
... 18 Orthodontic extrusion may also be helpful for implant site development, eliminating or reducing periodontal infrabony defects and esthetic gingival margins. 30 Among the orthodontic appliances used for forced orthodontic extrusion, fixed appliances are the standard treatment option 24 ; however, both treatment and stabilization are long. This simplified approach with intracoronal elastic and metal ligatures shortens the procedure, minimizes forward clockwise movements during vertical extrusion, and preserves the buccal bone plate. ...
Article
When restoring severely compromised teeth, respecting the supracrestal tissue attachment and retaining the most coronal and radicular tooth structure is essential to achieving a sufficient ferrule. Forced orthodontic extrusion is a minimally invasive method that allows hard- and soft-tissue conservation. This article describes the treatment of a severely damaged maxillary central incisor that was managed by using a simplified orthodontic extrusion method with intracoronal elastic and metal ligatures applied through a palatal bar and followed by the biologically oriented preparation technique (BOPT). This orthodontic procedure reduces a forward clockwise advance during vertical extrusion, thus maintaining the buccal bone plate.
... • Ridge width • Soft tissue volume • Smile line In cases with insufficient width of the alveolar crest, guided bone regeneration procedures are required to create conditions for optimal esthetic outcome. In anterior areas with optimal bone and soft tissues thickness, it is recommended the sculpting of the tissue with ovate pontics to produce an illusion of interproximal papilla S10 [44]. The root submergence technique was suggested to maintain the natural attachment apparatus of the tooth in the pontic site, to allows for complete preservation of the alveolar bone frame and to create satisfactory esthetic result in adjacent multiple tooth-replacement cases [45]. ...
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The esthetic component is critical for the successful outcome and patients' satisfaction regarding the implant-prosthetic therapy. The esthetic outcome success depends mostly on the optimization of the algorithms specific to the pro-implant and implant stage as well as to the designing and technological execution of the future prosthetic restoration. A proper planning of optimal facial esthetics must involve a multidisciplinary approach with inclusion of periodontists, orthodontists, oral surgeons and implantology specialists. The dental practitioner must consider various factors that influence the esthetic outcome (tooth position, root position of the adjacent teeth, biotype of the periodontium, tooth shape, smile line, implant site anatomy, implant positioning). Also, some factors (anatomical limits of the implant site, periodontal status, occlusal parameters), which can alter the final esthetic result, must be assessed prior to planning the esthetic parameters of the future prosthetic restoration. The esthetic outcome can be improved by using new digital technologies based on software applications for assessment of clinical and biological indices of the prosthetic field, virtual planning of implants positioning and design projection of future prosthetic restoration.
... By grinding roots and making soft tissue proliferate over it, sufficient keratinized tissue is made available simulating natural dentition, since the presence of root holds the bone and the soft tissue component in place and removes the complications related with the bone resorption. Salama et al 17 suggested that from a prosthetic viewpoint, mixed environment of natural teeth and implants is difficult to control, and establishment of exact occlusion which remains stable becomes challenging. In such cases, sometimes the remaining tooth is replaced by a pontic. ...
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ROOT SUBMERGENCE TECHNIQUE TO MAINTAIN THE ALVEOLUS
... As the papilla height facing the missing tooth area is dependent on the supracrestal fiber of the adjacent natural tooth, 14-16 a study by Kan et al. 17 also supported this concept. The presumed level of the interproximal bone helps determine the feasible position of the post-prosthetic papilla, 18 as the interproximal bone level determines the presence and vertical level of the papilla. 19 Salama et al. 20 reported that the enhancement of the alveolar bone height through forced eruption is effective for increasing the papilla height. ...
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Objective Forced eruption has been proposed for the reconstruction of deficient bone and soft tissue. The aim of this study was to examine the changes in the alveolar ridge width and the vertical levels of the interproximal bone and papilla following forced eruption. Methods Patients whose hopeless maxillary anterior teeth were expected to undergo severe bone resorption and soft tissue recession upon extraction were recruited. In addition, patients whose maxillary anterior teeth required forced eruption for restoration due to tooth fracture or dental caries were included. Before and after forced eruption, the interproximal bone height was measured by radiographic analysis, and changes in the alveolar ridge width and the interproximal papilla height were measured with an acrylic stent. Results This prospective study demonstrated that the levels of the interproximal alveolar bone and papilla were significantly increased by 1.36 mm and 1.09 mm, respectively, in the vertical direction. However, the alveolar ridge width was significantly reduced by an average of 0.67 mm in the buccolingual direction. The changes in the level of the interproximal alveolar bone and papilla were positively correlated. Conclusions Although the levels of the interproximal bone and papilla were significantly increased, the alveolar ridge width was significantly decreased following forced eruption. There was a modest positive and significant correlation between the changes in the height of the interproximal alveolar bone and the papilla. Based on our findings, modification of vertical forced eruption should be considered when augmentation of the alveolar ridge width is required.
... Or tho dontic extrusion for ap proximately 8 to 12 weeks followed by 4 to 6 weeks of stabilization can align disharmonious gingival margins and improve the osseous topography of a compromised site (Figures 4a to 4d). 6 How ever, as a tooth is extruded, coro n o p l a s t y (every 2 weeks) may be needed to accommodate the lengthened tooth. After orthodontic movement, the bone should be allowed to mature for 3 to 6 months before it is used for implants because it is not fully calcified, and the apical area needs to fill in with bone. ...
... Contact point-alveolar bone crest 100% papillae appearance (mm) Author Inter-dental papillae 45 Tarnow et al. (1992) o4.5 Kois (2001) Implant–tooth papillae o4.5 Salama et al. (1998 Salama et al. ( , 2002 rationale for this technique is that unlike other techniques, the papilla is formed with tissue from both the facial and palatal aspects, which further enhances papillary support and appearance. A sulcular incision is made 2–3 mm to the palatal side with a loop design adjacent to the implant location. ...
Article
The aims of this paper are to review and compare existing techniques for creation of interdental/interimplant papillae, to address factors that may influence its appearance and to present an approach that authors developed that could help clinicians to manage and recreate the interproximal papillae. Papers related to interdental and interimplant papillae published over the last 30 years were selected and analyzed. Thorough treatment planning is essential for maintenance of the height of the interproximal papillae following tooth removal. The key for achieving an esthetically pleasing outcome is the clinicians' ability of properly managing/creating interdental/interimplant papillae. Bone support is the foundation for any soft tissue existence, techniques such as socket augmentation, orthodontic extrusion, guided bone regeneration, onlay graft and distraction osteogenesis are often used for this purpose. Soft tissue grafts as well as esthetic mimic restorations can also be used to enhance the esthetic outcomes. An esthetic triangle is developed to address the foundations that are essential for maintaining/creating papilla. These include adequate bone volume, proper soft tissue thickness as well as esthetic appearing restorations.
... The RST should be considered from As described, the use of pontics rather than adjacent placement of implants can work effectively. On the other hand, in their six classifications (see Table 1), Salama et al 25 suggested that the interdental papillae between an implant and a natural tooth has the second highest ranking after two adjacent natural teeth. From a prosthetic viewpoint, this mixed environment of natural teeth and implants is difficult to control, and establishment of a protective occlusal scheme is challenging. ...
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A single-tooth implant in the esthetic region has good potential for success, but it is still challenging to restore multiple-tooth defects with implant-supported prostheses that resemble the natural dentition. This article suggests a strategy to provide a more predictable protocol for esthetic implant treatment for multiple-tooth defects using the root submergence technique (RST). By maintaining the natural tooth root with the RST a much greater amount of surrounding tissue may be preserved than with the commonly used socket preservation technique, which almost always leads to crestal bone resorption and thus reduction of the height of the interdental papillae and width of the edentulous ridge. RST instead maintains the natural attachment apparatus of the tooth in the pontic site, which in turn allows for complete preservation of the alveolar bone frame and assists in the creation of an esthetic result in adjacent multiple-tooth-replacement cases. In situations with periodontal bone loss, orthodontic extrusion is required to create the underlying bone support for the papilla that is necessary to guarantee predictability.
... Orthodontic extrusion for approximately 8 to 12 weeks followed by 4 to 6 weeks for stabilization also can align disharmonious gingival margins and improve the osseous topography at a compromised site. 34 However, after forced eruption, some interproximal crown lengthening may still be needed. In this regard, the length of therapy, additional costs to retain the tooth, and the willingness of the patient to wear braces for several months need to be considered. ...
Article
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In the esthetic zone, difficult decisions must be made regarding extraction or retention of compromised teeth. Numerous factors need to be considered to arrive at a proper treatment plan, which may differ from a plan devised for the posterior region of the mouth. TYPES OF REVIEWED STUDIES: Studies were selected that provided background information for clinical decision-making concerning whether a compromised tooth should be retained or removed. In the esthetic zone, before resective surgical procedures are used to resolve periodontitis, consideration should be given to the esthetic outcome. If endodontic therapy is required, additional issues need to be reviewed before initiating treatment, including restorability of the tooth, presence of a large periapical area, use of the tooth as an abutment, etc. Furthermore, before initiating periodontal or endodontic treatment, the patient's susceptibility to additional periodontal disease progression and caries should be evaluated. In the esthetic zone, deciding whether to treat or remove a compromised tooth requires careful deliberation. The possibility that additional bone loss can compromise a future implant site needs to be considered before providing periodontal therapy. This is particularly true if recession will be induced. Endodontic therapy is effective; however if crown lengthening is required because of subgingival caries or tooth fracture, thought needs to be given to removal of the tooth before altering the gingival topography. Numerous other factors need to be considered when deciding whether to save or extract a tooth in the esthetic zone: restorability, disease susceptibility, papillary and gingival considerations, tooth esthetics, etc. In conclusion, the decision to extract or maintain teeth must include deliberation with regard to benefits vs risks of retaining compromised teeth. The judgment to remove a tooth may be based on one critical issue or it may rely on collective risks related to a few factors.
Chapter
Achieving Soft Tissue Closure in Immediate Implant Therapy Flapless Implant Installation Preserving Biological Soft Tissue Contours References
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Centric occlusion-maximum intercuspation (CO-MI) discrepancy is one of main causes of evoking premature contact and resultant mandibular shift. These non-physiological conditions can induce temporomandibular disease, periodontitis, and non-carious cervical lesion. Therefore, if CO-MI discrepancy exists in patients who need extensive prosthetic rehabilitation, it must be corrected and then physiological occlusion must be restored. This report describes the treatment procedure of removing CO-MI discrepancy and prosthetic rehabilitation in a patient with 3.5 mm discrepancy, multiple caries and periodontitis. Proper mandibular position and modified opening & closing movement were confirmed by ARCUSdigma II and transcranial radiograph.
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Purpose: Extended grafting procedures in atrophic ridges are invasive and time-consuming and increase cost and patient morbidity. Therefore, ridge-splitting techniques have been suggested to enlarge alveolar crests. The aim of this cohort study was to report techniques and radiographic outcomes of implants placed simultaneously with a piezoelectric alveolar ridge-splitting technique (RST). Peri-implant bone-level changes (ΔIBL) of implants placed with (study group, SG) or without RST (control group, CG) were compared. Materials and methods: Two cohorts (seven patients in each) were matched regarding implant type, position, and number; superstructure type; age; and gender and received 17 implants each. Crestal implant bone level (IBL) was measured at surgery (T0), loading (T1), and 1 year (T2) and 2 years after loading (T3). For all implants, ΔIBL values were determined from radiographs. Differences in ΔIBL between SG and CG were analyzed statistically (Mann-Whitney U test). Bone width was assessed intraoperatively, and vertical bone mapping was performed at T0, T1, and T3. Results: After a mean observation period of 27.4 months after surgery, the implant survival rate was 100%. Mean ΔIBL was -1.68 ± 0.90 mm for SG and -1.04 ± 0.78 mm for CG (P = .022). Increased ΔIBL in SG versus CG occurred mainly until T2. Between T2 and T3, ΔIBL was limited (-0.11 ± 1.20 mm for SG and -0.05 ± 0.16 mm for CG; P = .546). Median bone width increased intraoperatively by 4.7 mm. Conclusions: Within the limitations of this study, it can be suggested that RST is a well-functioning one-stage alternative to extended grafting procedures if the ridge shows adequate height. ΔIBL values indicated that implants with RST may fulfill accepted implant success criteria. However, during healing and the first year of loading, increased IBL alterations must be anticipated.
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o pyr i g h t b y Q u i n t e s sen z A l l e R e c h t e v o r b e h a l t e n Implantologie 2008;16(2):131-139 131 Gehrke et al. Dreidimensionale Positionierung von Implantaten Nach einer Implantattherapie kann es vorkommen, dass die Patienten mit dem ästhetischen Ergebnis ihrer Versorgung unzufrieden sind. Neben mangelnder Aufklärung über das realistisch zu erwarten-de Endergebnis kann eine Ursache in einer unzureichenden Behandlungsplanung und demzufolge falscher Positionierung der Implantate liegen. In diesen Fällen können marginale Geweberezessionen und ein Verlust der approximalen Papillen auftreten. Diese ästhetischen Einbußen können jedoch oft durch chirurgische Maßnahmen während der Implantatinsertion vermieden werden. Die prothetisch geführte Implantatinsertion in einer anatomisch orientierten, dreidimensionalen Position ermöglicht dem Behandler, das Auftreten ästhetischer Probleme zu reduzieren. Ziel dieser Arbeit ist es, verschie-dene Protokolle aufgrund der aktuellen Literatur zu beleuchten und biologische Grundlagen zu erör-tern sowie Empfehlungen für die dreidimensionale Implantatpositionierung unter Berücksichtigung der lokalen anatomischen Gegebenheiten und der geplanten prothetischen Versorgung zu geben. Dabei werden auch Faktoren zur Vorhersagbarkeit und Reproduktion von ästhetischen Implantatversorgungen analysiert.
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Severe periodontal disease leading to tooth loss causes multiple challenges when treatment planning replacement of these teeth with implant-supported restorations. Provisionalization and transitioning the patient from natural dentition to implant-supported restorations without use of removable prostheses can be difficult to achieve. A detailed evaluation and comprehensive treatment plan should precede extraction of the affected teeth. Forced eruption as a method of modifying the osseous and gingival topography has been established. This clinical report illustrates the use of nonmaintainable teeth to simultaneously develop the site for future implant placement, as well as support a fixed interim restoration during treatment. Patient was classified as an American College of Prosthodontists Prosthodontic Diagnostic Index (ACP PDI) class IV patient.
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Failures of dental implants are detrimental to both patients and dental providers. These failures are often preceded by complications at various levels of the treatment phases. Early detection of the complications that are amenable to rescue therapies may reverse the fate of the implant. This review article discusses diagnosis, classification, and treatment aspects of the reversible complications commonly encountered during routine dental implant-related procedures.
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