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The International Journal of Periodontics & Restorative Dentistry

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 239

Esthetic Restoration with Orthodontic

Traction and Single-Tooth Implant:
Case Report

Santiago González López, PhD* The use of osseointegrated dental

Maria Victoria Olmedo Gaya, PhD** implants to replace a single man-
Manuel Vallecillo Capilla, PhD*** dibular tooth is one of the main chal-
lenges of esthetic odontology.1,2 The
This case re p o rtdescribes the use of orthodontic traction to recover soft tissue lost loss of a tooth is often associated
around a maxillary right central incisor with major external root resorption associat- with collapse of the alveolar process
ed with severe gingival recession. Traction of the residual root for 1 month pro- and alteration of the soft tissues,
duced a gingival appearance in harmony with the adjacent teeth. After the place- reflected in the absence of inter-
ment of an implant, a correct emergence profile was obtained, giving an optimal proximal papillae and in horizontal
esthetic outcome. After a 3-year follow-up, complete regeneration of soft tissue and vertical defects that compro-
persisted around the implant-supported crown. (Int J Periodontics Restorative
mise subsequent prosthetic re s t o r a-
Dent 2005;25:239–245.)
tion.3 The esthetic factor common to
all these restorations is the soft tissue
profile, which must be identical to
that of the contralateral tooth.
Gingival restoration includes the
inderdental papillae, arched form of
the free gingival margin, area of
attached gingiva, and root promi-
nence, which should all be similar to
the natural adjacent teeth.
Prevention of the alveolar col-
lapse associated with any dental
*Associate Professor of Dental Pathology and Therapeutics, School of extraction is now regarded to be of
Dentistry, University of Granada, Spain.
great importance for the enhance-
**Assistant Professor of Oral Surgery, School of Dentistry, University of
Granada, Spain.
ment of future implant treatment.
***Associate Professor of Oral and Maxillofacial Surgery, School of This can be achieved with the imme-
Dentistry, University of Granada, Spain. diate placement of implants or, if
these are not indicated, with alveo-
Correspondence to: Dr Santiago González López, Facultad de
Odontología, Patología y Terapéutica Dental, Universidad de lar grafts, tissue regeneration, or a
Granada, Campus Universitario de Cartuja s/n, Granada 18071, Spain. combination of both. 4 A highly

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240
promising technique using growth
factor–enriched plasma is also avail-
able.5 Under certain circumstances,
a nonsurgical approach may be
adopted, such as the ort h o d o n t i c
extrusion of nonviable teeth, de-
signed to increase the amount of
bone and soft tissue at proposed
implant sites.6
There is wide consensus that all
i n t e rventions should be sequentially
scheduled, deciding first on the final
f o rm of the restoration and subse-
quently planning all consequent pro-
c e d u re s .7 Soft tissue defects can
s e v e rely compromise the final
esthetic outcome, and numerous
mucogingival and regenerative sur-
gical techniques have been devel-
oped to reverse them.8 If, on the
other hand, bone and tissue loss is
presented before the tooth extrac-
tion, the forced orthodontic extru-
sion technique proposed by Salama
and coworkers4,9 can be used. This
technique improves the implant
recipient site by physiologically
i n c reasing bone and gingival
heights, pulling the tooth along with
the supporting bone tissue and the
soft tissues that cover the tooth. Dur-
ing implant site development, ortho-
dontic extrusion also improves the
emergence profile of implants and
restorations by increasing the thick-
ness of the tissues from the tissue
crest to the seating surface of the
implant, improving the implant an-
gulation in relation to the adjacent
dentition and the interarch distance
measured from the implant seating
s u rface to the opposing denti-
tion.10,11 The only requirement for
the satisfactory application of this
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procedure is that the apical third of
the root maintain an intact fiber
apparatus.
The present case report, which
includes a 3-year follow-up,
describes the authors’ clinical expe-
rience using the orthodontic trac-
tion technique. It demonstrates the
good esthetic outcome that can be
obtained in patients with major soft
tissue defects when pro s p e c t i v e
implant sites are adequately pre-
pared.
Case report
A 34-year-old woman visited the
authors’ clinic for the restoration of
her maxillary right central incisor. The
tooth presented advanced extern a l
root resorption, with a gingival reces-
sion of 6 mm in depth that did not
reach the mucogingival line, leaving
a 1-mm band of attached gingiva.
Examination with a dental probe
revealed that the entire root was
destroyed and replaced by granula-
tion tissue. Finally, a radiograph
showed major bone loss around the
whole root. The restoration of the
tooth was not a viable alternative, so
extraction and a prosthetic re p l a c e-
ment was the treatment of choice
(Fig 1).
The considerable gingival reces-
sion from the resorption and loss of
periodontal bone had produced a
major retraction of the gingiva, hin-
dering good esthetic restoration by
conventional fixed prosthesis or
i m p l a n t - s u p p o rted restoration. On
extraction of the tooth, the apical
third of the root was found to be
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completely separated from the coro-
nal two thirds; it was firmly joined to
a band of buccal attached gingiva
but not attached to the alveolar
bone (Fig 2). It was decided to apply
traction to this root fragment to coro-
nally displace the gingival tissues in
preparation for a future implant. The
gingival portion of the extracted
crown was remodeled for placement
as a provisional restoration, making
a mesiopalatal-distal cavity contain-
ing a strip of carbon fiber fixed with
adhesive techniques and fluid com-
posite. Dental pins were placed in
the residual root and bent apically
for use as anchors in the traction.
Subsequently, the extracted tooth
connected to the carbon fiber was
attached to the palatal parts of the
right canine and left central incisor,
given the agenesis of the maxillary
right lateral incisor. Traction was car-
ried out by anchoring a 6.4-mm elas-
tic band to the pins and incisal edge
of the provisional re s t o r a t i o n .
Chlorhexidine gel was applied to the
gingival cavity, and the patient was
instructed to apply the gel two or
three times daily.
At a follow-up session 1 week
later, it was observed that the pins
collided with the gingival part of the
provisional restoration, and a cavity
was drilled out so that the traction
could be continued (Fig 3). The size
of the cavity had to be continually
increased over a 3-week period to
allow the coronal displacement of
the root fragment. While the coronal
displacement of the keratinized gin-
giva was being achieved, forc e d
o rthodontic extraction of the re s i d-
ual root was being produced, and

Fig 1 Initial view of case shows major
gingival recession caused by external root
resorption, making tooth nonviable.
Fig 4 After extraction of remaining root,
provisional restoration is restored to same
cervical level as other central incisor. A gin-
gival space still persists.
Fig 7 Ceramic core screwed in place.
Initially, soft tissues became ischemic when
displaced by core modeled with appropri-
ate emergence form.
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241
Fig 2 On extraction of tooth, apical third Fig 3 At 1 week, cavity is drilled into
of root is completely separated from coro- neck of provisional restoration to allow
nal two thirds and firmly attached to band continuation of orthodontic traction.
of vestibular gingiva but unattached to
alveolar bone.
Fig 5 Within 1 week, gingiva is com- Fig 6 Vestibular displacement of flap
pletely adjusted to emergence profile of after placing 5-mm healing abutment and
provisional restoration. replacing provisional restoration.
Fig 8 Ceramic core restored with resin Fig 9 Crown and soft tissues immediate-
composite and adhesive techniques in ly after completion of treatment.
preparation for impression taking.
Vestibular convexity of gingiva is compen-
sated for by palatally displaced flap. Note
correct profile of ceramic core.
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242
the root was extracted 1 month after
traction was started. The cavity in
the provisional dental crown was
restored by placing a strip of acetate
below the pontic using microfilled
resin composite. By means of this
technique, a polished surface that
did not retain plaque was obtained,
and a gingival cavity that was deeper
than its width was produced (Fig 4).
Through negative pressure, the gin-
giva was completely adapted to the
pontic after 1 week (Fig 5).
Two weeks later, the provisional
fixed partial denture was removed,
and a full-thickness flap was lifted
by means of two vertical releasing
incisions, without including papillae
of adjacent teeth. A thre a d e d
implant was then placed. Although
designed to be left exposed at the
first surg e ry, the implant was in this
case completely covered by gingiva
after suturing of the flap because of
the depth of the bone.
Six months later, the second sur-
gical intervention was perf o rm e d ,
making a U-shaped palatal-to-
vestibular flap, without including
papillae and without the vestibular
releasing incisions reaching beyond
the attached gingiva. In this way, the
vestibular convexity was compen-
sated for by the vestibular displace-
ment of the tissue. An impression
coping was fitted and stabilized
using light-curing resin, including the
incisal edges of adjacent teeth. In
this way, it was possible to transfer
the position of the implant hexagon
to the laboratory, where a ceramic
core and provisional crown were cre-
ated on a previous model. A 5-mm
healing abutment was inserted, and
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the provisional prosthesis was
replaced (Fig 6).
I n s t ructions were given to the
laboratory to make a ceramic core
with the shoulder at the level of the
cementoenamel junction (CEJ) of
the adjacent teeth; no account was
taken of the soft tissues because the
resin key does not re p roduce their
position. The laboratory was also
asked to create a provisional resin
crown on the core.
When the piece was received
f rom the laboratory, the recipient
site was anesthetized, the healing
abutment was removed, and the
ceramic core was screwed in place.
The soft tissues were observed to
be ischemic when displaced by the
core modeled for the appropriate
e m e rgence profile (Fig 7). Perf e c t
seating with the implant was radi-
ologically demonstrated, and the
p rovisional restoration was probed
to confirm its correct fit with
respect to the hexagon. Subse-
q u e n t l y, it was tightened at a
t o rque of 25 N/cm 2 us ing a
dynamometric wrench. The core
was etched with fluorhydric acid
for 3 minutes and washed, followed
by an application of silane. After
placing Optibond Solo dental
adhesive (Kerr), Heliotin opaque
resin composite (Ivoclar Vivadent)
was applied, and the sealing was
completed by applying Herculite
XRV resin composite (Kerr). The
final contour of the shoulder and
core was completed using a ball-
shaped bur (Fig 8). Addition-cure d
silicone-based impressions were
made for the production of an IPS
E m p ress ceramic crown (Ivoclar

Vivadent), and the shades of the
c o re and neighboring teeth were
re c o rded. Provisional acrylic resin
was again applied to the base of
the provisional crown. The margins
w e re checked and cleaned to pre-
vent gingival inflammation. The
modifications re q u i red for the
definitive crown were noted, in-
cluding a reduction of the distance
between contact point and gingiva
to enhance the generation of papil-
lae and avoid black areas.
After acceptance of the esthetic
appearance of the definitive crown,
it was cemented in place with adhe-
sive techniques (Fig 9). Patient fol-
low-up included clinical and radio-
logic examinations at 1 week and
then annually (Fig 10). After 3 years,
the esthetic outcome and stability
of the peri-implant tissues were pre-
served.
Discussion
The esthetic success of implants in
the anterior sector is at least as
dependent on an appropriate muco-
gingival appearance as on an es-
thetic prosthetic re h a b i l i t a t i o n .
N u m e rous mucogingival flap sur-
g e rytechniques have been used to
achieve an esthetically acceptable
gingival outcome, such as coronal or
lateral displacements, grafting (eg,
free gingival graft or Langer tech-
nique), and guided soft tissue regen-
eration.8,12 There must be a clear
indication for any of these pro c e-
d u res, which are not exempt from
complications that can harm the
esthetic outcome.
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243
Orthodontic extrusion of the
root in cro w n - root fractures pro-
duces coronal displacement of the
gingival margin and bone, so the
technique must be combined with a
gingivectomy and sometimes
osteotomy, allowing the surface of
the fracture to be accessed for
restoration.13 Salama and Salama4
used this technique to increase the
amount of bone at the implant recip-
ient site. Mantzikos and Shamus14
describe several patients who under-
went forced eruption prior to tooth
extraction, increasing in all thre e
dimensions the implant recipient site
and enabling optimal implant place-
ment 1 to 3 mm apical to the CEJ of Fig 10 Final radiograph.
the adjacent tooth. They conclude
that bone modification of the im-
plant recipient site by orthodontic
restoration is always preferable to
mechanical and surgical modifica-
tions, which pay insufficient atten-
tion to the biologic situation.
The length of time required to
achieve an adequate bone and
mucogingival situation is an impor-
tant issue, and treatments should
not be excessively long. Bone
remodeling with autografts or
guided tissue regeneration takes 6
to 9 months before implants can be
placed. In contrast, mucogingival
flap and grafting techniques require
30 to 40 days for the gingival tissues
to mature, and forced eruption can
be perf o rmed within a similar time
period.4 In the present case, ort h o-
dontic traction alone was used to
remodel gingival tissues because
the root had no bone support. We
w e re able to regenerate the
attached gingiva to the level of the
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244
marginal gingiva within 30 days. The
modification of the pro v i s i o n a l
restoration enabled progression of
the traction and the maturation of
the gingival tissues.
We could have chosen to treat
this patient with a subepithelial con-
nective tissue graft after placement
of the implant. However, we re c o m-
mend the orthodontic traction
approach, always on the condition
that a tooth is available for the
replacement with no need for an
extraction, because it entails only
one surgical intervention. 14 Graft
treatment requires two operations:
one to place the graft for the buc-
colingual restoration of the soft tis-
sues, and another to place a wide
healing abutment for the coro n a l
displacement of buccal soft tissues,
producing the correct gingival mar-
gin height for an optimal esthetic
o u t c o m e . 3,15,16 F u rt h e rm o re, no
more time is required for orthodon-
tic traction than for other techniques;
in the present case, the procedure
was completed within 30 days.
The vestibular displacement of
the U flap at the second surg e ryalso
favored the development of ade-
quate soft tissue, compensating for
the vestibular convexity. Deeply
placed implants allow a more grad-
ual development of the emergence
profile and a flat emergence profile
for the crown, with the drawback
that the restoration-abutment inter-
face is at a deeper level. The creation
of a ceramic core allows a correct
emergence profile to be achieved
and means that the interface is at a
gingival or slightly subgingival level
so that the fit of the definitive crown
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can be well-controlled and excess remodeling of the gingiva and
resin cement can be readily re- achievement of an appro p r i a t e
moved. emergence profile were produced
For a restoration to have an opti- by the construction of the ceramic
mal esthetic outcome, the inter- c o re. During the 3 years in which
proximal papillae must regenerate this patient has been followed up,
and completely fill the interdental the initial soft tissue regeneration
a reas to avoid unesthetic black achieved with orthodontic traction
a reas. This re q u i res a distance persisted.
between the bone crest and contact
point of 6 mm or less.17,18 Among
published techniques to enhance Acknowledgments
p a p i l l a ry regeneration, 8 the most
widely used is the placement of a The authors are grateful to Juan José
Torrecillas for his invaluable work in the lab-
p rovisional crown to obtain an oratory and to Richard Davies for his assis-
a p p ropriate profile and pro d u c e tance with English translation.
papillae formation.3 Jemt19 reports
that provisional crowns placed dur-
ing surg e ry for abutment connec-
tion can guide soft tissue wound
healing and restore the gingival con-
tour in the initial stages of this
process. On the other hand, the
long-term effect of this treatment
appears to be the same as when soft
tissue is left to heal around a provi-
sional abutment before the definitive
crown is inserted.
O v e rc o n t o u red crowns with
small spaces allow better filling with
papillary tissue. The pro g re s s i v e
increase in this tissue by modifica-
tion of the provisional restoration,
combined with a slight hygienic
negligence in the early stages, may
p roduce the re o rganization and
maturation of the hyperplastic soft
tissue in the form of natural papil-
lae.19 In the present case, the pro-
visional crown was used to discern
the modifications necessary in the
definitive crown and to reduce the
interdental spaces, thus facilitating
their filling by the gingiva. The
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