Orthodontic Extrusion

Orthodontic extrusion in dentistry, an overall look.

This brief presentation will explain the main points regarding: 1- Indications &
Contraindications
2- Extrusion Types,
3- Biological Response,
4-Optimum Force,
5-ExtrusionProtocols,
6- Case,
7-Knowledge Gap.

This presentation is well cited based on previous published researches, and different books like Profitt contemporary orthodontics.

It was supervised and presented to a group of orthodontics who are highly respected in their field.In addition to dental interns, orthodontic attachments and seniors of the Saudi Board of Orthodontics.

1. Orthodontic extrusion as
an adjunctive treatment
Abdulsamad Habeeb
BDS, Taibah University, Saudi Arabia

2. Table of contents
Indications &
Contraindications
Introduction
5
Optimum Force
1 3
4
Biological Response
Extrusion Types
2
6
Extrusion
Protocols
7
Case
8
Knowledge Gap

3. Introduction
1
3

4. Extrusion:
A translational form of tooth displacement with
movement occlusally directed and parallel to
the long axis of the tooth.
(1)
Orthodontic extrusion (Forced eruption):
Tooth movement in a coronal direction to
modify the tooth position or to induce changes
on the surrounding bone and soft tissue with a
therapeutic purpose.
(2)
Definitions
1:Daskalogiannakis, John, “Glossary of Orthodontic Terms” . American Association of Orthodontists, 2012.
2:González-Martín, Oscar et al. “Orthodontic Extrusion: Guidelines for Contemporary Clinical Practice.”The International journal of periodontics &
restorative dentistry(2020).

5. In 1973, Heithersay proposed for the first time the use of
orthodontic extrusion with a therapeutic purpose other than
orthodontic tooth alignment.
The purpose of his study was to manage endodontically treated
teeth with subgingival and transversal root fractures by moving
the roots to a more coronal level to allow possible treatment.
Ziskind, D et al. “Forced eruption technique: rationale and clinical report.”The Journal of prosthetic dentistry (1998).
Lemon, R R. “Simplified estheticroot extrusion techniques.”Oral surgery, oral medicine, and oral pathology (1982).
History

6. 1- Endodontic treatment.
2- Tooth extrusion by banding adjacent teeth.
Keeping the fractured
tooth fragment.
Removing the fractured
tooth fragment.
Heithersay, G S. “Combined endodontic-orthodontic treatment of transverse root fractures in the region of the alveolar crest.”Oral surgery,
oral medicine, and oral pathology (1973).
History

7. By applying bands over the adjacent teeth and a
spring attached to the post, thus allowing proper
access to the remaining tooth structure for
restoration.
"This approach is a new technique for the retention
and restoration of teeth and roots that were
previously extracted "
(1)
History
Simon, J H et al. “Extrusion of endodontically treated teeth.”Journal of the American Dental Association (1978).

8. Review and modification of the
Heithersay approach has been
presented by Simon and associates.
Elastic bandsLabial arch wire
History
Simon, J H et al. “Extrusion of endodontically treated teeth.”Journal of the American Dental Association (1978).

9. Indications & Contraindications
2

10. 2. Exposing submarginal dental structure.
Indications
1-Quirynen , et al. “Periodontal health of orthodontically extruded impacted teeth. A split-mouth, long-term clinical evaluation. J Periodontol” ( 2000).
2-Zyskind, et al. “Orthodontic forced eruption: Case report of an alternative treatment for subgingivally fractured young permanent incisors (1992).
1. Infraoccludedteeth.

11. 4. Implant site development for replacement of non-restorable teeth.
3-Alsahhaf, et al “Orthodontic extrusion for pre-implant site enhancement: Principles and clinical guidelines.”Journal of prosthodontic research (2016).
4-Mesquita, et al. “Therapeutic alternatives for addressing pink esthetic complications in single-tooth implants: A proposal for a clinical decision
tree.”Journal of esthetic and restorative dentistry (2019).
3. Treatment of periodontal vertical/angular bone defects.
Indications

12. 5. Modification of the soft tissue deficiencies.
Kovich, V. “Estheticsand anterior tooth position: an orthodontic perspective. Part I: Crown length.”Journal of estheticdentistry(1993).
Indications

13. Kwon EY, et al. Effect of slow forced eruption on the vertical levels of the interproximal bone and papilla and the width of the alveolar ridge.
Korean J Orthod. 2016
Indications
5. Modification of the soft tissue deficiencies.

14. Jung, S. et al. “Orthodontic Extrusion of Mandibular Third Molar With a Miniscrew and Cross-Arch Elastic.”Journal of oral and maxillofacial
surgery (2021).
6. Extraction related.
Indications

15. Jung, S. et al. “Orthodontic Extrusion of Mandibular Third Molar With a Miniscrew and Cross-Arch Elastic.”Journal of oral and maxillofacial
surgery (2021).
Indications
6. Extraction related.

16. Issues:
1-Loss of interdental papillae.
2-Black triangle.
3-Bone loss.
Lin, et al. “Management of interdental papillae loss with forced eruption, immediate implantation, and root-form pontic.”Journal of periodontology(2006).
6. A Combination
Indications

17. 1: Vertical root fractures.
2: Tooth ankylosis.
3: Root proximity.
4: Prosthetic purposes:
A-Less than 1:1 crown-root ratio.
B-Insufficient prosthetic space.
C-Furcation exposure.
Contraindications
-Huang G, et al. “Clinical Considerations in Orthodontically Forced Eruption for Restorative Purposes” J Clin Med 2021.
-Bach, Normand et al. “Orthodontic extrusion: periodontal considerations and applications.”Journal of the Canadian Dental Association (2004).

18. Contraindications
Exception:Implant site development for
bone or soft tissue augmentation.
Ré, et al “Rapid orthodontic extrusion of a subgingivally fractured incisor.”The Journal of prosthetic dentistry(2016) .
1: Vertical root fractures.
2: Tooth ankylosis.
3: Root proximity.
4: Prosthetic purposes:
A-Less than 1:1 crown-root ratio.
B-Insufficient prosthetic space.
C-Furcation exposure.

19. 4. Severe root resorption.
Kim S, et al. Effect of orthodontic treatment on the periapical radiolucency of endodontically treated teeth: a CBCT analysis. BMC Oral Health (2023).
Contraindications
5. periapical pathology.

20. Extrusion Types
3

21. A-Stainlesssteel wire + Elastic.
B-Flexible wire.
C-Inter-arch elastics.
D-One-couple system (Lever).
E-Miniscrew
1-Orthodontic Extrusion
Proffit, William R., et al. Contemporary Orthodontics. 6th ed., Elsevier, (2018).

22. 1-Orthodontic Extrusion
A-Stainlesssteel wire + Elastic.
B-Flexible wire.
C-Inter-arch elastics.
D-One-couple system (Lever).
E-Miniscrew
Proffit, William R., et al. Contemporary Orthodontics. 6th ed., Elsevier, (2018).

23. A-Stainlesssteel wire + Elastic.
B-Flexible wire.
C-Inter-arch elastics.
D-One-couple system (Lever).
E-Miniscrew
1-Orthodontic Extrusion
Proffit, William R., et al. Contemporary Orthodontics. 6th ed., Elsevier, (2018).

24. 1-Orthodontic Extrusion
A-Stainlesssteel wire + Elastic.
B-Flexible wire.
C-Inter-arch elastics.
D-One-couple system (Lever).
E-Miniscrew
Proffit, William R., et al. Contemporary Orthodontics. 6th ed., Elsevier, (2018).

25. Horliana, et al “Dental extrusion with orthodontic miniscrew anchorage a case report describing a modified method.”Case reports in dentistry (2015).
1-Orthodontic Extrusion
A-Stainlesssteel wire + Elastic.
B-Flexible wire.
C-Inter-arch elastics.
D-One-couple system (Lever).
E-Miniscrew

26. Disadvantages:
1- Intrusion of anchor tooth.
2- Rotation.
3- Tipping.
Bilinska M, et al. Cantilevers: Multi-Tool in Orthodontic Treatment. Dent J (Basel). 2022
1-Orthodontic Extrusion

27. 2-Surgical Extrusion
Bauer, Bryan. "Surgical Extrusion Technique." Bauer Smiles, 2014,

28. Orthodontic magnetic extrusion: A case report.
3-Other Modalities
Casaponsa, et al. “Magnetic extrusion technique for restoring severely compromised teeth: A case report.”The Journal of prosthetic dentistry(2022).

29. Crownlengtheningprovidesanalternative
approach,butitdoesattheexpenseofthe
adjacentteeth,thebonemustberemoved
fromtheadjacentteethaswell.
(1)
Asaconsequence,softtissuerecession
mayarise,andthepatientmaycomplain
ofsensitivity.
(2)
1: IngberJ.S. Forced eruption. I. A method of treating isolated one and two wall infrabonyosseous defects-rationale and case report.J. Periodontol(1974).
2 :Brown I.S. The effect of orthodontic therapy on certain types of periodontal defects. I. Clinical findings.J. Periodontol(1973).
A common alternative

30. Orthodontic extrusion VS crown lengthening
Rosentstiel, et al (2018) contemporary of fixed prosthodontics (fifth edition). Elsevier.

31. -Huang G, et al. Clinical Considerations in Orthodontically Forced Eruption for Restorative Purposes. J Clin Med (2021).
-Oesterle L, et al. “Raising the root. A look at orthodontic extrusion.”Journal of the American Dental Association (1991).
Advantages: Disadvantages/Complications

Non-invasive.
Limited involvement of adjacent
teeth.
Preserves periodontium
(Recession/Bone loss).
Improved esthetics.
Maintains crown-root ratio.
Orthodontic extrusion

32. Advantages: Disadvantages/Complications

Non-invasive. Occlusal reduction.
Limited involvement of adjacent
teeth.
Possible endodontic
treatment.
Preserves periodontium
(Recession/Bone loss).
Prolonged treatment.
Improved esthetics. Minor surgery might be
required.
Maintains crown-root ratio. Possible ankylosis.
-Huang G, et al. Clinical Considerations in Orthodontically Forced Eruption for Restorative Purposes. J Clin Med (2021).
-Oesterle L, et al. “Raising the root. A look at orthodontic extrusion.”Journal of the American Dental Association (1991).
Orthodontic extrusion

33. Biological Response
4

34. Movement of a tooth by extrusion involves applying
traction forces in all regions of the PDL tostimulate
apposition of crestal bone.
As gingival tissues are attached to the root by
connective tissue, the gingiva follows the vertical
movement of the rootduring the extrusion process.
Similarly, the alveolus isattached to the root by the
periodontal ligament and is inturn pulled along by
the movement of the root.
Bach, Normand et al. “Orthodontic extrusion: periodontal considerations and applications.”Journal of the Canadian Dental Association (2004).
How do tissues respond to extrusion?

35. Mechanicalstressesexertedwillleadto
activationofangiogenicgrowthfactors,
whichwouldcontributetotheformationof:
1-Gingival fibers.
2-Periodontal fibers.
3-Bone.
Shiu YT, et al. The role of mechanical stresses in angiogenesis.Critical Reviews in Biomedical Engineering (2005).
How do tissues respond to extrusion?

36. Inthenormalcourseofevents,boneandgingivalresponseare
producedunderlow-intensityextrusiveforces.
Whenstrongertractionforcesareexerted,asinrapidextrusion,
coronalmigrationofthetissuessupportingthetoothisless
pronouncedbecausetherapidmovementexceedstheircapacity
forphysiologicadaptation.
However,thesearticlesdidnotspecifytheextrusionforceneeded
forthesecascadesofactions.
Bach, Normand et al. “Orthodontic extrusion: periodontal considerations and applications.”Journal of the Canadian Dental Association (2004).
How does tissue react to extrusion?

37. Optimum Force
5

38. Ideally,extrusivemovementsshouldproducepure
tensionofPDLwithoutcompression.
However,thisismoreatheoreticalthanapractical
possibilitybecauseifthetoothtippedatallwhilebeing
extruded,areasofcompressionwouldbecreated.
Required movement
Proffit, William R., et al. Contemporary Orthodontics. 6th ed., Elsevier, (2018).

39. Thisisthesameforrotationalmovements
andthat'swhyextrusionandrotational
movementsrequirealmostthesameforce.
Required force
Proffit, William R., et al. Contemporary Orthodontics. 6th ed., Elsevier, (2018).

40. Required force
Is light continuous force always intended during extrusion?
Is there an optimal amount of force for all cases?

41. Required force
Different goals: 1-Uncover subgingival structures
2-Implant site development.
3-Modification of soft tissue profile.
González-Martín, et al. “Orthodontic Extrusion: Guidelines for Contemporary Clinical Practice.”The International journal of periodontics &
restorative dentistry(2020).
Is light continuous force always intended during extrusion?
Is there an optimal amount of force for all cases?

42. González-Martín, et al. “Orthodontic Extrusion: Guidelines for Contemporary Clinical Practice.”The International journal of periodontics &
restorative dentistry(2020).
Required force
Different cases: 1- Amount of extrusion required.
2- Number of roots.
3- Patient’s age.
4- Surrounding bone.
5- Viability of PDL.

43. According to applied force:
-Slow orthodontic extrusion.
-Rapid orthodontic extrusion.
Required force
JessicaRico, etal"InterdisciplinaryOrthodonticTreatmenttoReestablishmentSmileFunctionandAesthetics." JournalofHealth Sciences(2021)

44. In 1987 , the term “rapid extrusion” to expose teeth
presenting structural damage for restoration was
first described.
Rapid extrusion with fiber resection to complete the
desired tooth movement in the shortest period and
by minimize bone loss.
- Pontoriero, R et al. “Rapid extrusion with fiber resection: a combined orthodontic-periodontic treatment modality.”The International journal of
periodontics & restorative dentistry (1987).
- González-Martín, et al. “Orthodontic Extrusion: Guidelines for Contemporary Clinical Practice.”The International journal of periodontics &
restorative dentistry(2020).
Rapid extrusion

45. In 1991, the use of rapid extrusion without fiberotomy was
suggested.
They recommended the performance of circumferential
supracrestal fibrotomyafter the necessary extrusion is achieved,
immediately prior to the initiation of the stabilization period, in
order to minimize relapse tooth intrusion.
Malmgren O, Malmgren B, Frykholm A. Rapid orthodontic extrusion of crown root and cervical root fractured teeth. Endod Dent Traumatol (1991).
Rapid extrusion

46. There is no consensus of the specific forces that are needed
in slow and rapid extrusion.
Different literatures from case reports, series and systematic
reviews presented with a range of forces which the majority
of researches lie within.
Required force

47. Slow extrusion optimum force
-"20-30 g of eruptive force in single rooted teeth resulted in eruption with alveolar
…..crestal new bone".
(1)
-"To allow for simultaneous bone and soft tissue displacement, light and constant
…..extrusive forces should not exceed 15 g for anterior teeth and 50 g for posterior
…..teeth".
(2)
-"May be as high as 50 to 75 g in certain cases".
(3)
-"The maximum force for slow orthodontic forced eruption should not exceed 30 g“.
(4)
1: Biggerstaff, et al “Orthodontic extrusion and biologic width realignment procedures: methods for reclaiming non restorable teeth” (1986).
2: Korayem M, et al. “Implant site development by orthodontic extrusion. A systematic review.”The Angle orthodontist (2008).
3: González-Martín, et al. “Orthodontic Extrusion: Guidelines for Contemporary Clinical Practice.”The International journal of periodontics & .
. restorative dentistry(2020).
4:Reitan,K.“Clinicalandhistologicobservationsontoothmovementduringandafterorthodontictreatment.”Americanjournalof
orthodontics(1967).

48. Rapid extrusion optimum force
1: Bondemark, L et al. “Attractive magnets for orthodontic extrusion of crown-root fractured teeth.”American journal of orthodontics an dentofacial
…orthopedics(1997).
2:Kwon EY, et al “Effect of slow forced eruption on the vertical levels of the interproximal bone and papilla and the width of the alveolar ridge”
Korean J Orthod (2016).
-“Rapid extrusions should be performed with a force higher than 50 g”.
(1)
-“50 –240 gfor rapid extrusion of single rooted teeth”.
(2)

49. Criteria for optimum force
BondemarkL,etal.“Attractivemagnetsfororthodonticextrusionofcrown-rootfracturedteeth.”Americanjournaloforthodonticsanddentofacial
orthopedics(1997).
"Theforcesinthisstudywerebiologicallysoundbecausetherewasno
evidenceofsofttissuedehiscence,aberrantrootmobility,orroot
resorptions"

50. 6
Extrusion Protocols
González-Martín, et al. “Orthodontic Extrusion: Guidelines for Contemporary Clinical Practice.”The International journal of periodontics &
restorative dentistry(2020).
Circumferential Supracrestal Fiberotomy (CSF) Intermediate Tooth Stabilization (ITS) Periods

51. 1-Extrusion with CSF and without ITS
Aim: Avoidance of displacement of the supporting bone and soft tissue with teeth.
Indication:Exposure of subgingival tooth structure for restoration.
Type of force: Heavy force.

52. - Alternative to crown lengthening, especially in cases of high esthetic demands.
- CSF maybe performed before or after orthodontic treatment, or repeated during
…therapy.
1-Extrusion with CSF and without ITS

53. 2-Extrusion without CSF or ITS
Aim: Preservation and stretching of supracrestal soft tissue fibers with the primary
objective to elongate gingival tissues.
Indications: 1-Modificationsof soft tissue.
2-Implant site development when bone level is not critical.
Type of force: Heavy force.

54. Disadvantage: Red patch might be visible around the marginal mucosa, which may
give the impression of an inflammatory process , gingiva becomes weak and
sustainable to recession.
-In spite of not performing CSF, bone alterations would theoretically be minimal
because of the absence of ITSand heavy force.
2-Extrusion without CSF or ITS

55. 3-Extrusion without CSF and with ITS
Aim: Tooth extrusion with traction of both gingival tissues and alveolar bone ,
compatible with conventional orthodontic protocols.
Indications:1-Impacted teeth.
2-Papillary defects.
3-Bony defects.
4-Implant site development where bone level is critical.

56. -ITS has important practical implications, since it allows for the reorganization of the
supracrestal fibers and new bone apposition as the tooth movement progresses.
-Type of force: Light continuous force.
3-Extrusion without CSF and with ITS

57. Protocols comparison

58. Important considerations:
1-Monitoring oral hygiene.
2-Modification of the orthodontic appliance.
3-Assess and adjustment of occlusion if necessary.
4-Determinination the amount of extrusion has been attained.
Considerations for extrusion

59. Case
7

63. 1 week 3 week2 weeks

66. Knowledge gap
1-Impact of orthodontic extrusion on the width of keratinized gingiva.
2-Optimal force magnitude for rapid orthodontic extrusion.
3-Efficacy of different extrusion techniques.
4-Assessing patient satisfaction following orthodontic extrusion: A survey-
based study.
5-Comparative study of orthodontic extrusion outcomes in adults vs young
patients.
6-Long-term stability of orthodontic extrusion with different retention
protocols.

67. Thank You