journal of prosthodontic research 60 (2016) 145–155

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Review

Orthodontic extrusion for pre-implant site

enhancement: Principles and clinical guidelines

Abdulaziz Alsahhaf BDSa,b,*, Wael Att DDS, Dr Med Dent, PhDa

a
Department of Prosthodontics, Dental School, Albert-Ludwigs University, Freiburg, Germany
b
Department of Prosthodontics, Dental School, King Saud University, Riyadh, Saudi Arabia

article info abstract

Article history: Purpose: The aim of this paper is to provide a concise overview about the principles of pre-
Received 13 September 2015 implant orthodontic extrusion, describe methods and techniques available and provide the
Received in revised form clinicians with guidelines about its application.
16 January 2016 Study selection: A number of reports describe orthodontic extrusion as a reliable method for
Accepted 26 February 2016 pre-implant site enhancement. However, no standard protocols have been provided about
Available online 12 March 2016 the application of this technique. The literature database was searched for studies involving
implant site enhancement by means of orthodontic extrusion. Information about the
Keywords: principles, indications and contraindications of this method, type of anchorage, force
Implant site enhancement and time were obtained from the literature.
Implant site development Result: Despite that the scarce data is largely limited to case reports and case series, implant
Orthodontic extrusion site enhancement by means of orthodontic extrusion seems to be a promising option to
Forced eruption improve soft and hard tissue conditions prior to implant placement.
Conclusion: Orthodontic extrusion is being implemented as a treatment alternative to
enhance hard and soft tissue prior to implant placement. While the current literature does
not provide clear guidelines, the decision making for a specific approach seems to be based
on the clinician’s preferences. Clinical studies are needed to verify the validity of this
treatment option.
# 2016 Japan Prosthodontic Society. Published by Elsevier Ltd. All rights reserved.

Contents

1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 146
2. Orthodontic extrusion or orthodontic extraction? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 146
3. Biological principles of orthodontic extrusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 146
4. Indications and contraindications for pre-implant orthodontic extrusion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147
5. Clinical guidelines for the application of orthodontic extrusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147
5.1. Case selection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147

* Corresponding author at: Albert-Ludwigs University Freiburg, Hugstetter Str. 55, 79106 Freiburg, Germany. Tel.: +49 15226971265;
fax: +49 76127049250.
E-mail address: Dr.sahhaf@gmail.com (A. Alsahhaf).
http://dx.doi.org/10.1016/j.jpor.2016.02.004
1883-1958/# 2016 Japan Prosthodontic Society. Published by Elsevier Ltd. All rights reserved.
146 journal of prosthodontic research 60 (2016) 145–155

5.2. Applied techniques for orthodontic extrusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147

5.2.1. Removable appliances for orthodontic extrusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147
5.2.2. Fixed appliances for orthodontic extrusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 150
6. Forces applied for orthodontic extrusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 150
7. Duration and retention of orthodontic extrusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 150
8. Fiberotomy during orthodontic extrusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 150
9. Considerations on orthodontic extrusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 152
10. Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 152
11. Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 153
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 153

1. Introduction 2. Orthodontic extrusion or orthodontic

The replacement of missing teeth by dental implants has
proven to be a successful and a predictable treatment
modality. Long-term clinical studies have shown excellent
survival rates for implants placed in edentulous and
partially edentulous jaws [1,2]. For single tooth replacement,
a number of treatment protocols have been proposed with
the goal to improve the esthetic and functional outcomes
and to accelerate the overall treatment duration [3–6]. One
of the available treatment options is immediate implant
placement, which denotes the installation of the implant at
the time of tooth extraction [7,8]. Nevertheless, immediate
implant placement is indicated only in cases where soft and
hard tissue conditions are considered ideal at the time of
implant placement [4]. Here, it is well known that the
majority of implant cases lack a sufficient quantity of soft
tissue and underlying bone structure. The lack of these
tissues is mainly due to site-specific anatomical limitations,
namely a thin buccal plate [9–11]. Therefore, most implant
procedures, such as immediate implant procedures in the
esthetic zone, necessitate pre-implant, simultaneous and/or
post-implant site enhancement procedures, specifically
tissue augmentation procedures [12,13]. The ultimate goal
of such procedures is to furnish a peri-implant tissue
architecture that facilitates the establishment of close-to-
nature functional and esthetic outcomes. For this purpose,
several techniques and procedures have been proposed [14].
One of the suggested approaches is orthodontic extrusion.
While this approach has been originally introduced to save
traumatized teeth from extraction, it has been suggested as
a method to manipulate soft and hard tissues via gradual
extrusion of a ‘‘hopeless’’ tooth and its periodontal
apparatus; thereby enhancing the predictability of the
implant site [3]. A number of reports are available in the
literature that describes orthodontic extrusion as a reliable
method for pre-implant site enhancement [3,5,15]. However,
no standard protocols have been provided about the
application of this technique. An overview about orthodon-
tic extrusion would enhance the knowledge about different
techniques as well as provide the clinicians with guidelines
that can aid in decision-making and application of this
approach.
The aim of this review was to provide an overview about
the principles of pre-implant orthodontic extrusion, de-
scribe methods and techniques available and provide
clinicians with guidelines about its application based on
the current evidence.
extraction?
For a successful orthodontic treatment, time and force are
considered as important factors [16]. Based on these, the terms
orthodontic extrusion and orthodontic extraction were exten-
sively discussed in the literature and are summarized
elsewhere in this paper [3,17,18]. The term ‘‘orthodontic
extrusion’’ indicates coronal shifting of the entire attachment
apparatus along with the tooth utilizing light eruptive forces
[17,19,20]. Here, the gingival margin maintains the same
relationship with the erupted tooth prior to and following
extrusion [17]. The procedure is considered as a conservative
exercise, where the dimensions of the attached gingiva and
bone are increased [21]. Different terms have been used in the
literature to describe orthodontic extrusion, such as ‘‘con-
trolled vertical extrusion’’, ‘‘forced eruption’’ and ‘‘slow
eruption’’ [22]. On the other hand, the term ‘‘orthodontic
extraction’’ indicates coronal shifting of the tooth without the
attachment apparatus and the crestal bone using ‘‘high’’ and
‘‘rapid’’ eruptive forces [17]. This results in a more coronally
positioned tooth, with unchanged gingival margins at the
pretreatment levels [22]. Orthodontic extraction is often used
in the esthetic zone to coronally position cervical or
subgingival caries, thereby bypassing the need for crown
lengthening procedure that may compromise the esthetic
outcome [23,24]. In contrast, orthodontic extrusion is indicat-
ed in cases where esthetics are a primary goal, such as
achieving a harmonious gingival course [25]. In addition, it is
indicated as a non-surgical approach to enhance soft and hard
tissue architecture prior to implant placement [3]. For
consistency and to avoid confusion, the term orthodontic
extrusion will be used throughout this review.
3. Biological principles of orthodontic
extrusion
Histologically, pressure and tension zones are distinguished in
the areas where an orthodontic movement is active [16,26]. In
the pressure zone, several biological events take place. These
are characterized by disturbance of blood flow in the
compressed periodontal ligament (PDL), followed by cell
death, termed as hyalinization, as well as subsequent
resorption of the hyalinized tissue by macrophages and
resorption of the undermining bone through osteoclast
activity, which eventually leads to tooth movement [27]. In
the tension zone, stretching of the PDL activates blood flow,
 journal of prosthodontic research 60 (2016) 145–155
promoting thereby osteoblast activity and leading to osteoid
formation [28].
The formation and extent of the hyalinized zone ‘‘necrotic
zone’’ is an important indicator during the process of tooth
movement [26], where it must be kept as minimal as possible,
as hyalinization has been shown to limit the tooth movement
[29]. An interesting finding was that an initially light and
gradually increasing force resulted in less hyalinization when
compared to a greater initial force that increased to the same
end force level [30]. Therefore, to avoid or minimize any
complication that may occur, it is highly recommended to
apply a light orthodontic extrusive movement. The force
applied can be controlled by different factors, namely by its
type and magnitude [31–34] as well as by the duration of
treatment [35].
Basically, orthodontic extrusion for implant site enhance-
ment contributes to the emergence profile of implant and
restoration [36]. This is achieved by increasing tissue depth as
measured from tissue crest to the implant platform; thus
facilitating optimization of implant angulation in relation to
the adjacent dentition and improving the inter-arch distance
as measured from the implant platform to the opposing
dentition [37].
4. Indications and contraindications for pre-
implant orthodontic extrusion
Hopeless teeth are not necessarily considered as useless teeth,
as they offer resides in their remaining attachment apparatus,
namely periodontal ligament, bone and cementum [3,16,19]. A
proper case selection is important for a predictable outcome.
The indication of a pre-implant tooth extrusion usually is in
the anterior region of dentition, where esthetics is a major
concern [38]. Although the literature does not provide clear
information about when to apply this approach, the selected
cases generally include a tooth that is deemed hopeless and
need to be extracted due to severe attachment and bone loss,
endodontic lesions, root fractures, failed root canal fillings,
failed apicoectomies or severe root caries [25]. A pre-implant
orthodontic extrusion of such teeth induces the formation of
buccal and coronal bone as well as soft tissue enhancement,
thereby bypassing the need for additional pre-implant site
enhancement surgical procedures. On the other hand, severe
hard and soft tissue defects, such as excessive soft tissue
recession and/or severe buccal bone resorption are contra-
indications for orthodontic extrusion, but rather for guided
bone regeneration [3,5].
Although orthodontic extrusion is considered as a safe and
a predictable procedure, complications such as bone dehis-
cence and gingival recession might occur in cases were the
buccal bone is thin and strategically unfavorable for implant
placement [28,39]. For this reason, the indications for
orthodontic extrusion are limited to moderate bony defects
characterized by moderate resorption of the buccal bone and
overall recession of up to the middle third of the root [3].
Nevertheless, a number of case reports demonstrated the
success of pre-implant extrusion procedure of a severe
periodontally compromised tooth [39,40]. Here, it should be
mentioned that the absence of the attachment apparatus is a
147
contraindication of orthodontic extrusion, as orthodontic
extrusion will only coronally relocate the existing attachment
[5]. Further contraindications include root ankylosis or
hypercementosis [25], chronic uncontrolled inflammatory
lesions [41] or whenever bone augmentation is indicated [42].
5. Clinical guidelines for the application of
orthodontic extrusion
5.1. Case selection
Generally, the success of orthodontic extrusion mainly
depends on a careful clinical and radiographic evaluation of
the existing anatomic structures, namely the tooth itself, the
periodontal support as well as occlusal condition. The
evaluation should be carried out as a standardized measure
before, during and after the extrusion procedure. Further, the
patient’s acceptance and cooperation to undergo this thera-
peutic approach is a prerequisite.
For a proper case selection, a classification system that
focuses on the residual defect morphology and the regenera-
tive potential of the extraction site was introduced [3]. Here,
the potential extraction sites are classified in 3 types; a type 1
site has adequate regenerative potential and is highly
amenable to orthodontic extrusion and immediate implant
placement. On the other hand, the residual bone morphology
in type 2 site is moderately compromised. An orthodontic
extrusion may transform this type into a type 1 site. In
contrast, the residual bone morphology in a type 3 site is
severely compromised with pronounced vertical and bucco-
lingual osseous inadequacies. Therefore, the severe loss of soft
and hard tissue dimensions requires other means of augmen-
tation intervention. As such sites are not indicated for
immediate implant placement, an orthodontic extrusion is
not recommended [28].
5.2. Applied techniques for orthodontic extrusion
A number of techniques using different types of orthodontic
appliances have been described to perform orthodontic
extrusion. In general, the appliances can be categorized into
either removable or fixed.
5.2.1. Removable appliances for orthodontic extrusion
To perform orthodontic extrusion by means of a removable
appliance, magnets, rubber bands or other mechanisms can be
utilized.
Magnets for orthodontic applications are composed of dual
magnetic parts that are pre-defined in ‘N’ force and vary in
shapes such as disks, cylinders or balls. The selection of the
desired shape depends mainly on the amount of the
remaining tooth structure. While one component of the
magnet is luted using a resin cement in the remaining tooth
structure, the other component is accommodated within the
intaglio surface of the removable appliance (usually a denture
or a splint) using a hard relining material or cement (Figs. 1–3).
To facilitate free tooth movement and avoid interferences, it is
important to maintain enough space between the tooth and
the orthodontic appliance. More, an exact fit of the appliance
148 journal of prosthodontic research 60 (2016) 145–155

Fig. 1 – Clinical example of hopeless teeth; #13, 23 (a–d) that were extruded using dual magnets for pre-implant site
enhancement. First part of the magnet was cemented in the tooth surface; the second part was attached in an essix
appliance (e and f). The orthodontic extrusive phase was followed by 3 months of stabilization using the same appliance.
The amount of papilla height gain compared to the neighboring teeth is noticeable (f–h).

on the neighboring teeth is required to avoid any tipping
movements. At an inter-component distance of 1 mm, the
magnets provide usually an extrusion force of 0.13 N. The
force increases to 0.3 N at a distance of 0.5 mm and reaches
0.65 N when the magnets components are in contact [43]. To
set the inter-component distance at the beginning of therapy,
a 1-mm thick thermo-formed foil spacer is usually placed
between the two components. Once the two components
come into contact during extrusion, a more distant reposi-
tioning of the magnet component that is accommodated
within the appliance from the within-tooth component is
necessary for further extrusion. An alternative option is to
 journal of prosthodontic research 60 (2016) 145–155 149

Fig. 2 – Images show bone level gain prior to implant placement (a and b). Extraction of teeth #13, 23 was followed by
immediate implant placement 3 mm apical to the neighboring CEJ (c). The excess bone coronal to the platform of the
implants was used to fill up the void between the extraction socket and the implant surface, bypassing the need for bone
substitute materials.

Fig. 3 – Post-operative clinical images showing a healthy soft tissue profile around the implants (a and b). Post-delivery
radiograph showing the amount of bone level maintained around the implants (c and d).

stack several magnets with spacers within the removable
appliance that can be removed sequentially until the desired
level of extrusion is reached. Once achieved, the retention can
be carried out via subsequent wearing of the magnet-
containing appliance. As the direction of extrusion is difficult
to control 3 dimensionally, the use of magnets in the anterior
zone, where teeth are tilted buccally, is not recommended.
Rubber bands for orthodontic extrusion are used by
engaging two projecting buttons that are usually cemented
buccally and lingually to the extruded tooth. In this approach,
150 journal of prosthodontic research 60 (2016) 145–155
the patient is instructed to wear a removable retainer and
connect the two projection buttons by attaching the rubber
band from the lingual to the buccal-cemented buttons (Fig. 4).
In addition to magnets and rubber bands, a further option
to fabricate a removable appliance for orthodontic extrusion is
to use the hock and ring method. In this approach, the post
with a ring or a hock head is fabricated and cemented in the
tooth canal. The other part of either the hock or the ring is part
of an extended arm made of a flexible wire or spring that is
usually made of b-titanium wire (TMA) and attached to the
removable retainer of the acrylic stent (Fig. 5). The patient is
then instructed to wear the retainer and place the end of the
flexible arm with the end that is cemented in the tooth. For the
best extrusion action, it is recommended to wear the
removable appliance for up to 16 h/day.
5.2.2. Fixed appliances for orthodontic extrusion
Orthodontic extrusion using a fixed appliance is usually
indicated whenever neighboring teeth are present. Here, it
is important to note that the bone surface area is larger than
the tooth to be orthodontically extruded. Therefore, in
order to avoid or minimize tipping of the anchorage teeth, at
least 3 neighboring teeth should be included for the
anchorage.
Several designs of fixed appliances for orthodontic extru-
sion have been suggested. The conventional fixed orthodontic
appliance is the simplest option, where a spring of orthodontic
arch wire is fitted to the bonded brackets on the neighboring
teeth and a more apically positioned bracket on the extruded
tooth is fixed. This creates a force directed along the root axis
of the tooth to be extruded, thus moving the tooth in a coronal
direction (Fig. 6). Retention is then achieved by bonding the
extruded tooth to the neighboring teeth, and maintaining a
passive extrusion mechanism [44].
A further option includes a combined approach using
conventional brackets with post/hock or magnetics. When
using a rubber band, it has to run around the wire to achieve
anchorage and attached to the hock headed post (Fig. 7).
Modifications of this technique can be achieved by using two
magnets; one is cemented on the tooth, while the other is a
part of a fixed provisional restoration. Mini-implants as an
anchorage tools have been also described as an alternative
bracket-less method for tooth extrusion and stabilization,
where it does not need high patient’s compliance during the
treatment [45,46].
6. Forces applied for orthodontic extrusion
While applied successfully, the efficacy of orthodontic extru-
sion depends on the technique implemented, namely the forces
applied. More, the direction of the applied forces must be
controlled to ensure that the root is moved vertically within the
bone without tipping or penetrating the buccal plate [17]. In
addition, the amount of force necessary to extrude a tooth
depends on the amount of periodontal support [25]. The range of
force must overcome the tone of the ligaments and insure an
optimal tissue response [28]. As a general rule, the less
periodontal support, the less force needed for extrusion. Here,
It is well known that the application of excessive forces may
Fig. 4 – Example of rubber bands for orthodontic extrusion.
An interocclusal appliance was used for anchorage. The
patient is instructed to connect the two-cemented
projecting buttons ‘buccally and lingually’ regularly with a
rubber band.
lead to bone resorption [21,29]. Also, an accelerated movement
rate may result in a risk of tissue damage and ankylosis [47,48].
Although there are no specific guidelines, the current knowl-
edge suggests the application of light and constant forces of 15 g
for the anterior teeth and 50 g for posterior teeth are optimal to
extrude a tooth for implant site enhancement [49].
7. Duration and retention of orthodontic
extrusion
The duration of tooth extrusion for pre-implant site enhance-
ment depend solely on the desired amount of extrusion. As a
general rule, the rate of orthodontic extrusion should not
exceed 1–2 mm per month [5,49]. In cases where soft tissue
deficiency is a major finding for a hopeless tooth, the concept
of ‘‘overcorrection’’ is a proper approach to enhance soft
tissues before implant placement (Figs. 3–5). Here, the post-
extrusion buccal soft tissue level should be at least 2 mm more
coronal than the desired final position, compensating thereby
later recession of soft tissues after implant placement [25,50].
This is of a greater importance whenever a thin biotype is
present, where a higher risk exists for the development of a
recession following implant placement [41].
After successful application of orthodontic extrusion, the
stabilization phase takes place. This phase is important to
allow for proper reorganization of the soft tissue and
remodeling of the bone in the so-called ‘‘osteoid formation’’
phase, thus discouraging relapse [28]. As the highest level
of relapse occurs shortly after extrusion, the retention
period should be applied immediately after orthodontic
extrusion [16].
Following extrusion, the tooth may be retained in the new
position for a period of 3–6 months. This period has been
previously suggested to facilitate bone growth in the apical
area around the root of the extruded tooth [17,51].
8. Fiberotomy during orthodontic extrusion
An intrasulcular incision or so-called ‘‘fiberotomy’’ is usually
performed while orthodontically extruding a tooth. The
incision is performed through the junctional epithelium and
 journal of prosthodontic research 60 (2016) 145–155 151

Fig. 5 – Example on hock and ring method for extrusion of a hopeless tooth. Flexible arm is attached on an acrylic stent with
a conventional bracket (a). Ring or hock projection is cemented in the tooth to be extruded (b). The patient is instructed to
connect the flexible arm with the ring (c).

Fig. 6 – Clinical case on using fixed appliance for an

extrusive action of a hopeless tooth.

connective tissue around the tooth on a regular basis during

the period of extrusion. The aim of this procedure is to
eliminate any tension produced by supracrestal fibers, thus
minimizing the risk of relapse. Here, the stretched state of
marginal periodontal fibers is considered as the main cause
[16,31]. To minimize the risk of relapse, fiberotomy before and
immediately after the extrusion has been recommended [52].
Fig. 7 – Combined method of a rubber band and a fixed wire
Despite fiberotomy, partial migration of the gingival tissue
used for extrusion (a). The rubber band runs around the
coronally or toward the extrusive force seems to be unavoid-
wire and attaches to the hock of the cemented post (b).
able [53]. This is due to the supracrestal fibers that remain
embedded in the root surface and reinsert into the soft tissue
[54]. An additional root planning can aid to avoid such
migration [55]. These findings were confirmed in a randomized
clinical trial where extruded teeth showed 2 mm less coronal [56]. On the other hand, repeated fiberotomy during the
tissue migration with supracrestal fiberotomy and root extrusion period seems to provide more reliable results [57].
planning compared to teeth that did not undergo this Therefore, fiberotomy when applied is better performed on a
procedure [52]. regular basis during an active extrusive movement as well as
The optimal timing for performing fiberotomy is still shortly throughout the retention phase.
controversial. In a previous report, a single fiberotomy proce- While fiberotomy is usually a technique done in order to
dure immediately prior to extrusion has been recommended minimize the need for gingival correction at the end of an
152 journal of prosthodontic research 60 (2016) 145–155
extrusion phase in cases were gingival level of the extruded
tooth is of a normal relation to the neighboring teeth.
However, for implant site enhancement, performing fiber-
otomy on a hopeless tooth deemed for extraction is still
uncertain. As dissecting the supracrestal fibers might have
a negative impact on the amount of soft and hard tissue
gain [53,57].
9. Considerations on orthodontic extrusion
The need for endodontic therapy of teeth undergoing
orthodontic extrusion is not a universal procedure. In fact,
no difference has been found in term of bone regain after
orthodontic extrusion between endodontically treated
and untreated teeth [58]. Thus, endodontic treatment of
teeth undergoing extrusion should only be performed in
cases when the pulp becomes symptomatic or when the
incisal/occlusal reduction can be associated with pulp
exposure.
In regards to orthodontic extrusion and periodontal
disease, there has been a debate on whether extrusion could
be performed on a periodontally involved tooth or not. It is
important to notice that even after the loss of periodontally
compromised teeth, the remaining defects may compromise
the treatment outcome when implants are utilized [59].
Generally, it has been accepted that orthodontic extrusion
should not be performed in cases where periodontal disease is
active. Therefore, it is imperative that periodontitis is treated
before any orthodontic treatment [60]. For many years,
orthodontic extrusion has been recommended in order to
avoid further advancement of periodontal disease [20].
However, a number of reports stated that the application of
orthodontic extrusion during the course of periodontal
therapy could improve the treatment outcome. In fact, studies
have shown that orthodontic extrusion can be utilized to
reduce, eliminate or alter the nature of the osseous defects
resulting from periodontitis [61]. In a clinical study, successful
remodeling of soft and hard tissues were reported after tooth
extrusion procedure for implant site enhancement in patients
with advanced periodontal disease [59]. In an animal study,
the inflammation of the gingival tissue were found to be less
pronounced and the osseous defects were less deep and
associated with apposition of crestal bone in orthodontically
extruded teeth [62].
Based on these findings, it is suggested that the orthodontic
extrusion in periodontally involved teeth, when applied
correctly, does not jeopardize the periodontal condition. In
fact orthodontic extrusion may have a therapeutic effect on
periodontitis [28,62,63].
10. Discussion
Based on the findings of this review, it is obvious that the
current knowledge about pre-implant orthodontic extrusion is
mostly based on case reports and case series, which managed
the cases using different techniques and tools.
The establishment of a successful esthetic outcome in
implant treatment depends upon a thorough understanding
of the relationship between hard and soft-tissue profiles as
well as an accurate diagnosis, treatment planning and
implementation of the treatment procedures. In regards to
bone healing, a post-extraction healing period of up to one
year was recommended in the late 80s prior to implant
placement [64]. Nevertheless, bone resorption of the labial
plate may result in a collapse of a significant part of the
ridge, leading thereby to hard and soft tissue deficiencies
that may compromise the treatment outcome [9]. To
overcome such problems, tooth extraction followed by
immediate implant placement has been proposed as a
reliable treatment method that may preserve the anatomi-
cal structures and reduce the overall treatment time [7]. Due
to the anatomical nature of bone in the anterior region,
namely thin buccal plate, the majority of cases involving
placement of immediate implants necessitate enhancement
of soft and hard tissue structures [11]. Furthermore, the
selection of a treatment modality to manage such cases by
delayed or immediate implant placement seems not to have
any specific criteria. Rather, the decision for a specific
treatment modality is mainly based on the clinician’s
preferences. It is noticeable today that clinicians are more
inclined to implement immediate implant procedures
rather than the delayed approach. In this context, pre-
implant orthodontic extrusion procedures may represent a
non-surgical treatment approach to furnish sufficient hard
and soft tissue structures, facilitating thereby easier and
more predictable implant placement. However, due to the
lack of sufficient evidence it is difficult to determine
whether a surgical intervention through hard and soft
tissue grafting following a tooth extraction is superior to
orthodontic extrusion for pre-implant site enhancement.
Both techniques were considered reliable and efficient for
enhancing a planned implant site [15]. On the other hand,
orthodontic extrusion can still be expensive, time consum-
ing and requires an experienced team. Furthermore,
orthodontic extrusion is only applicable when the attach-
ment apparatus of the hopeless tooth is still present, failure
to attain these attachments would eventually lead to the
failure of the procedure and further surgical approach is
recommended for the management of the surrounding
tissue deficiencies. Obviously, no evidence is available to
whether use a removable or a fixed appliance for orthodon-
tic extrusion. Nevertheless, force and direction seem to be
more controllable with fixed appliances. Regardless of the
type of appliance, the optimal extrusive force applied is
suggested to be light and constant not exceeding 2 mm per
month. While ‘‘over-extrusion’’ is a recommended proce-
dure, a stabilization for at least two to three months has to
be implemented to avoid any relapse and allow proper
reorganization of the soft and hard tissue complex before
implant placement can take place.
In addition, little information was identified in the
literature about a sequential step-by-step procedure on the
application of this method. It is therefore of great interest to
introduce a workflow about the application of orthodontic
extrusion as a technique for pre-implant site enhancement
(Fig. 8). In turn, such a workflow would facilitate the
application of standardized outcome measures and reduce
the rate of complications.
 journal of prosthodontic research 60 (2016) 145–155 153

Fig. 8 – Summary of workflow for implant-site enhancement by means of orthodontic extrusion.

references
11. Conclusion

Based on the current knowledge, orthodontic extrusion
can be considered as a treatment alternative to enhance
hard and soft tissue prior to implant placement. While
the current literature does not provide clear guidelines,
the decision making for a specific approach in orthodon-
tic extrusion seems to be based on the clinician’s
preferences.
Conflict of interest
No conflict of interest.
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