Orthodontic Extrusion With or Without Circumferemtial Spracrestal Fiberotomy and Root Planing

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87
Orthodontic Extrusion With or Without

Circumferential Supracrestal
Fiberotomy and Root Planing
Cássio Volponi Carvalho, DDS, MS* Forced eruption, or orthodontic extru-

Flávio Paim Falcão Bauer, DDS, MS** sion, was proposed by Heithersay1 for
Giuseppe Alexandre Romito, DDS, MS, PhD*** the treatment of horizontal fractures
Cláudio Mendes Pannuti, DDS, MD, PhD* in the middle third of the root. Simon
Giorgio De Micheli, DDS, MS, PhD*** et al2 described techniques for dental
extrusion for endodontic purposes.
These authors mentioned that ortho-
dontic extrusion requires 1 to 3 weeks
The aim of this randomized clinical trial was to carry out a biometric comparison of activation and 8 to 12 weeks of
between the orthodontic extrusion (OE, group B) technique and OE combined retention for the stabilization of the
with fiberotomy and root planing (OEFRP, group A). Twenty single-root teeth were tooth in its new position. Ingber3,4
extruded and assigned to two different groups. In both groups, fixed orthodontic reported the need for surgical crown
appliances were activated weekly during the course of 3 weeks. After activation, lengthening after the retention phase.
the extruded teeth were maintained in retention for a period of 8 weeks. In group
The purpose of surgical crown length-
A, along with weekly activation, fiberotomy and root planing were carried out on
ening is to re-establish biologic width5
the top of the alveolar bone crest. Statistical analysis revealed that the amount of
through the removal of gingival and
dental structure exposed was greater in group A, where the gingival margin and
bone tissue remained stable (P < .05). Group B presented coronal migration of the
bone tissues that follow the tooth in its
gingival tissue and bone tissue of 2 mm and 1.5 mm, respectively. (Int J coronal trajectory, thus permitting
Periodontics Restorative Dent 2006;26:87–93.) appropriate prosthetic therapy.
The coronal migration of perio-
dontal tissues in dental extrusion is
induced by the tension provoked by
gingival fibers and by the periodon-
tal ligament.6 In clinical case reports,
*Resident, Division of Periodontics, Department of Stomatology, School of Edwards6 described the use of tat-
Dentistry, University of São Paulo, Brazil.
**Private Practice, São Paulo, Brazil.
tooing of gingival tissue as a refer-
***Assistant Professor, Division of Periodontics, Department of Stomatology, ence for measuring its deformation
School of Dentistry, University of São Paulo, Brazil. during dental movement and sug-
gested the application of gingival
Correspondence to: Dr Cássio Volponi Carvalho, Av. Professor Lineu Prestes
no. 2227, Cidade Universitária, CEP 05508–900, São Paulo, S.P., Brazil; fiberotomy to reduce the possibility
e-mail: volpcarv@terra.com.br. of relapse.
Volume 26, Number 1, 2006

88
Pontoriero et al7 described an Method and materials All measurements were taken by a
orthodontic extrusion technique asso- single trained blinded examiner and
ciated with supracrestal fiberotomy This study was approved by the Ethics were standardized to an acrylic resin
(SCF). During the period of forced Committee in Research, School of stent. Six marks were made around the
eruption, intrasulcular incisions were Dentistry, University of São Paulo, tooth to be extruded to serve as guides
performed weekly through the junc- Brazil. so that measurements would always
tional epithelium and connective tissue For this study, 20 single-root teeth be carried out at the same point: dis-
to eliminate the tension produced by (maxillary incisors), obtained from 18 tobuccal (DB), buccal (B), mesiobuccal
supracrestal fibers. In doing so, the patients (9 men and 9 women, mean (MB), distolingual (DL), lingual (L), and
authors reported that only minor cor- age 35.25 years), were used. A peri- mesiolingual (ML). A periodontal probe
rection of the gingival tissue outline apical radiograph of each selected (North Carolina, PCPUNC 15, Hu-
was necessary after extrusion, because tooth was obtained. Based on radi- Friedy) and a digital caliper (Absolute-
intra-sulcular incisions prevented the ographic and clinical evaluation, crown Digimatic model CD-6”C, Mitutoyo)
bone tissue from migrating coronally. lengthening was indicated. All patients were used to perform the measure-
Partial migration, especially that were nonsmokers and presented with ments. The measurements used were:
of gingival tissue, can be justified by no systemic factors that could com-
the study by Levine and Stahl,8 who promise their periodontal condition. 1. Guide mark–healthy tooth struc-
demonstrated that the supracrestal The selected teeth did not pre- ture (M-T)
fibers, when incised, remain inserted sent periodontal pockets, and their 2. Guide mark–gingival margin (M-
into the root surface and will reinsert adjacent teeth possessed a clinical GM)
into soft tissue, thus reconstructing the attachment of at least two-thirds of the 3. Guide mark–top of alveolar bone
gingival fiber apparatus. Kozlovsky et root length, thus permitting adequate crest (M-AC)
al9 studied a variation of the ortho- support for orthodontic movement.
dontic extrusion technique associated Teeth that presented with crown The third measurement (M-AC)
with SCF.7 During the process of extru- destruction received fixed provisional (Fig 1) was obtained via transsulcular
sion, teeth were submitted to SCF restorations, when clinical conditions probing (Jardini and Pustiglioni10). To
associated with root planing every 2 permitted, and only then were partial accomplish this, local anesthesia was
weeks. This technique prevented the fixed orthodontic appliances applied. applied to the papillae, and then, using
coronal migration of bone tissue and Movement was performed using a the fixed point of the stent, the peri-
gingival tissue. 0.14-mm stainless steel orthodontic odontal probe was introduced into the
The aim of the present random- wire, with a constant pressure of not gingival sulcus, and light pressure was
ized clinical trial was to carry out a bio- more than 50 g. All patients were pro- exerted until the top of the alveolar
metric comparison of the orthodontic vided with initial periodontal treatment bone crest was reached. The afore-
extrusion (OE) technique and the OE and received professional plaque con- mentioned parameters were mea-
technique combined with fiberotomy trol treatment every 2 weeks. sured three times: (1) at baseline (time
and root planing (OEFRP). 0), (2) after extrusion (21 days; time 1),
and (3) after retention (8 weeks after
the end of extrusion; time 2).
After the initial measurements, the
teeth were randomly assigned to 2
groups.

89
Fig 1 Transsulcular probing with acrylic Fig 2a Pretreatment clinical appearance Fig 2b Root planing performed after
resin stent. of maxillary right central incisor in group A. fiberotomy.
Fig 2c Before extrusion. Fig 2d After 3 weeks of extrusion and 8 Fig 2e Final appearance with provisional
weeks of stabilization. restoration.
Group A teeth the top of the alveolar bone crest using Group B teeth
curettes (Gracey 5/6, Hu-Friedy). The
In these teeth, the forced extrusion incisions were made under papillary In these teeth, only the forced extru-
technique was combined with circum- anesthesia, using the smallest possible sion technique was applied. Fixed
ferential supracrestal fiberotomy and quantity of anesthetic. Following the orthodontic appliances were activated
root planing,8 and fixed orthodontic active period of extrusion, the teeth weekly with a force of approximately
appliances were activated weekly, with were maintained for 8 weeks, using 50 g for 3 weeks. From this moment
a force of approximately 50 g, for 3 the same fixed orthodontic appliance on, the extruded teeth were main-
weeks. The weekly activations were with a 0.18-inch wire (Dentaurum) to tained for 8 weeks. After this stage,
performed with fiberotomy using a prevent relapse. In this group, there the teeth in this group received surgi-
scalpel and a 15C blade (Swann- was no need for complementary cal crown lengthening to re-establish
Morton) jointly with root planing from surgery (Figs 2a to 2e). biologic width (Figs 3a to 3d).

90
Fig 3a (left) Pretreatment clinical appear-

ance of maxillary right central incisor in
group B.
Fig 3b (right) After forced eruption.
Fig 3c (left) An osseous resection is per-

formed to establish normal biologic width.
Fig 3d (right) Final appearance with provi-

sional restoration.
Statistical analysis Results Negative values correspond to the

amount of tissue that drifted away from
The chi-squared association test was There was no statistically significant the probing guide in comparison to a
performed to determine whether there association between experimental previous measurement.
was an association between the group and sex (P = 1.00), which means Tables 1 and 2 reveal that statisti-
groups studied and the qualitative vari- that both groups were homogenous cally significant differences were seen
able gender. To analyze the difference as to this variable. According to the t between the groups in the three para-
between the mean ages of both test, the difference between the mean meters assessed from baseline. Group
groups, the Student t test was per- ages of each group (group A, 37.8 ± A teeth obtained a greater amount of
formed. The homogeneity of variances 7.3 years; group B, 32.7 ± 12.1 years) extrusion with respect to measure M-
was assessed by the Levene test, and was not considered to be significant T than did group B teeth. With respect
distribution normality was evaluated (P = .27). to other measurements (M-GM and
with the Komolgorov-Smirnov test.11 The differences between the initial M-AC), group A teeth did not show dif-
To determine whether there were dif- and final values for the time assessed ferences between the values for the
ferences between the values obtained are presented in Tables 1 to 3. We two time periods represented.
for the measurements taken at the chose to analyze the differences, Table 3 presents the values of the
three different time points, the Student because if we started off with the ini- differences found between times 1 and
t test was applied for two indepen- tial values for each tooth, the variabil- 2—that is, after the period of 8 weeks
dent groups (time 0 time 1, time 0 ity among the teeth would lead to a of retention for stabilization. Between
time 2, and time 1 time 2). A sta- mathematical difference that would those times, statistical testing did not
tistical software package was used not represent the reality from a clinical reveal significant differences between
(Statistical Package for the Social standpoint. The values in Tables 1 to 3 groups A and B for any of the mea-
Sciences, SPSS) and the criterion for represent how much dental, gingival, surements considered.
statistical significance was P < .05. and bone tissue was extruded.

91
Table 1 Mean differences (mm) between variables M-T (healthy tooth structure), M-GM (gingival
margin), and M-AC (top of alveolar bone crest) between time 0 (baseline) and time
1 (after extrusion)
Buccal measurements Lingual measurements
Parameter/
group Mesiobuccal Buccal Distobuccal P Mesiolingual Lingual Distolingual P
M-T
Group A 2.7 ± 0.47 2.73 ± 0.55 2.56 ± 0.49 2.76 ± 0.49 2.94 ± 0.67 2.91 ± 0.50
< .05 < .05
Group B 2.10 ± 0.42 2.11 ± 0.41 2.08 ± 0.27 2.10 ± 0.25 2.12 ± 0.42 2.18 ± 0.33
M-GM
Group A –0.01 ± 0.09 0.00 ± 0.14 0.10 ± 0.12 0.08 ± 0.22 0.00 ± 0.10 –0.06 ± 0.13
< .001 < .001
Group B 1.82 ± 0.38 2.10 ± 0.42 2.26 ± 1.27 1.79 ± 0.40 1.99 ± 0.53 1.94 ± 0.60
M-AC
Group A –0.09 ± 0.09 0.06 ± 0.17 0.00 ± 0.15 –0.02 ± 0.11 0.03 ± 0.16 –0.03 ± 0.19
< .001 < .001
Group B 1.51 ± 0.81 1.49 ± 0.74 1.50 ± 0.65 1.47 ± 0.65 1.31 ± 0.6 1.44 ± 0.69
margin), and M-AC (top of alveolar bone crest) between time 0 (baseline) and time
2 (after retention)
Parameter/
M-T
Group A 2.68 ± 0.52 2.78 ± 0.52 2.61 ± 0.48 2.75 ± 0.47 2.96 ± 0.66 2.93 ± 0.53
< .05 < .05
Group B 2.07 ± 0.38 2.15 ± 0.33 2.05 ± 0.22 2.03 ± 0.20 2.08 ± 0.35 2.17 ± 0.33
M-GM
Group A 0.01 ± 0.28 0.00 ± 0.19 0.04 ± 0.20 0.00 ± 0.07 –0.01 ± 0.17 –0.08 ± 0.19
< .001 < .001
Group B 1.78 ± 0.35 2.11 ± 0.42 2.34 ± 1.29 1.84 ± 0.38 2.00 ± 0.52 1.93 ± 0.64
M-AC
Group A –0.09 ± 0.13 –0.05 ± 0.21 0.06 ± 0.17 –0.03 ± 0.12 –0.07 ± 0.21 –0.02 ± 0.19
< .001 < .001
Group B 1.53 ± 0.77 1.56 ± 0.78 1.51 ± 0.61 1.49 ± 0.66 1.35 ± 0.65 1.47 ± 0.76
margin), and M-AC (top of alveolar bone crest) between time 1 (after extrusion) and time
2 (after retention)
Parameter/
M-T
Group A –0.01 ± 0.12 0.05 ± 0.15 0.05 ± 0.10 –0.01 ± 0.09 0.02 ± 0.07 0.02 ± 0.10
NS NS
Group B –0.03 ± 0.13 0.04 ± 0.18 –0.02 ± 0.11 –0.06 ± 0.12 –0.04 ± 0.2 –0.02 ± 0.12
M-GM
Group A 0.02 ± 0.22 0.00 ± 0.15 0.03 ± 0.15 –0.08 ± 0.16 –0.01 ± 0.08 –0.03 ± 0.12
NS NS
Group B –0.04 ± 0.15 0.02 ± 0.10 0.08 ± 0.31 0.05 ± 0.08 0.01 ± 0.10 –0.01 ± 0.10
M-AC
Group A 0.00 ± 0.10 0.02 ± 0.10 0.07 ± 0.09 –0.01 ± 0.07 –0.04 ± 0.08 0.00 ± 0.09
NS NS
Group B 0.02 ± 0.08 0.07 ± 0.08 0.00 ± 0.09 0.02 ± 0.06 0.04 ± 0.10 0.03 ± 0.11

92
Discussion ies by Ingber.3,4 This is very important, root planing that the subjacent bone
because if a clinical situation demands tissue suffered some kind of modifica-
The purpose of this study was to mea- surgical crown lengthening and the tion. Naturally, during the period eval-
sure possible morphologic alterations area has important esthetic involve- uated, there remains some doubt
in dental and periodontal tissues after ment, coronal dislocation from the gin- about whether this result is associated
the execution of the two different tech- gival margin will lead to the need for with an actual loss or if the tissue was
niques employed, as in the studies by surgical crown lengthening. still in a process of reparation; also, a
Pontoriero et al7 and Kozlovsky et al.9 However, when we carried out probing error is possible.
All parameters evaluated (M-T, M- SCF without root scaling, there was no Ruben et al13 reported that by 14
GM, and M-AC) were separately mea- significant accompanying migration. to 18 days after gingivectomy, which is
sured at six points on each tooth. To Nonetheless, Pontoriero et al7 drew a far more invasive procedure than that
reduce the possibility of error inherent attention to the fact that in some situ- carried out in the current study, a well-
in the procedure of probing, we used ations, there may be a need for gingi- defined osteoblastic layer had been
a guide made specifically for each val plastic surgery, which would require formed. When this happens, osseous
patient. The use of this apparatus has additional treatment time. remodeling starts somewhere around
an advantage over the use of radio- Our results show that if we con- that period. Hill et al14 compared four
logic evaluation, because the latter sider the amount of exposed dental tis- different root treatments in shallow
does not permit the analysis of the sue (M-T) after 21 days of movement, pockets and observed that there was
free surfaces of each tooth; in addition group A (OEFRP group) had a greater clinical loss of insertion with all four
there are distortions inherent in the exposure than group B (OE group). treatments.
radiographic technology itself. When we analyze the amount of bone The possibility of these values
The statistical analysis of our tissue that followed dental movement being related to an eventual osseous
results highlighted the changes that in a coronal direction, the results we resorption is justifiable, because neg-
occurred in the position of the struc- obtain are the same as those reported ative values appeared only in the
tures evaluated at the three studied elsewhere.7,9 In group B, we observed group where the invasive procedure
times—that is, the amount of struc- an osseous dislocation of approxi- was carried out (group A). If a probing
ture, if any, that moved within each mately 1.48 mm (mean of all sites) dur- error was in fact responsible, one
increment of time. The results regard- ing the period studied. This result cor- would expect more surfaces to pre-
ing the first time period (Table 1) clearly roborates those of van Venrooy and sent a positive value.
indicate that teeth were extruded more Yukna,12 who evaluated the potential In group B, coronal migration of
in group A, in which OEFRP was car- of orthodontic movement for the gain the gingival and bone tissues was
ried out. Moreover, it is clear that the of osseous structure in teeth with approximately 1.5 and 2.0 mm,
gingival margin maintained itself unal- advanced periodontal disease and respectively. Recent studies have
tered in this group, demonstrating that reported a mean of 2.00 mm (for all demonstrated the importance of this
the procedure is capable of dissociat- sites) of crestal bone deposition. technique when executed on hope-
ing movement of teeth from peri- An important finding of this study less teeth prior to the placement of
odontal support structures. was that in the group who received osseointegrated implants, resulting in
One of the most important points OEFRP, there was a small osseous a more esthetic rehabilitation.15,16
is the analysis of the position of the gin- resorption (represented by negative Another important aspect is that
gival margin in the studied procedures. values in Tables 1 and 2). From a clini- between time 1 and time 2 (retention),
Tables 1 and 2 clearly show that when cal standpoint, the values found are there were no statistically significant
OEFRP was not carried out, there was not very significant. However, some changes for all the parameters. This is
coronal migration of the gingival tissue, histologic considerations could be in agreement with the findings of
as had been demonstrated in the stud- made, since it was only after SCF and Simon et al,2 who recommend a min-

93
imum of 8 to 12 weeks of retention to 8. Levine HL, Stahl SS. Repair following peri-
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ening is desired without alteration in eruption combined with gingival fiberoto-
the position of the gingival margin. my. A technique for clinical crown length-
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can be used with success when aiming Statistics. Oxford: Blackwell, 1988.
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with advanced periodontal disease. Am J
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13. Ruben M, Smukler H, Shulman S, Kon S,
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The International Journal of Periodontics & Restorative Dentistry

COPYRIGHT © 2005 BY QUINTESSENCE PUBLISHING CO, INC.