Guided orthodontic regeneration: A tool to enhance conventional regenerative techniques in implant surgery.

Ó 2015 CEO Published by / E´dite´ par Elsevier Masson SAS All rights reserved / Tous droits re´serve´s

Original Article Article original

Guided orthodontic regeneration: A tool to enhance conventional regenerative techniques in implant surgery ge ne ration orthodontique guide e : un outil Re lioration des techniques re ge ne ratives d’ame conventionnelles en chirurgie implantaire Roberto KAITSAS,*, Maria Giacinta PAOLONE, Gaetano PAOLONE Viale dei Quattro Venti, 233-00152 Rome, Italy Available online: 23 October 2015 / Disponible en ligne : 23 octobre 2015

Summary

sume Re

A hopeless upper central incisor was subjected to forced eruption before implant substitution to improve and develop the amount of soft tissue. This involved a GBR to insert the implant and a GTR to regenerate the tissue around the dehiscence of the nearby lateral using a “Guided Orthodontic Regeneration” (GOR) approach. The extrusion was performed esthetically in lingual orthodontics. The GOR technique included a Guided Orthodontic “Bone” Regeneration (GOBR) and a Guided Orthodontic “Soft Tissue” Regeneration (GOTR). This developed a 3D implant site while correcting the osseous defects and increasing the amount of soft tissue, which was used for a subsequent regenerative technique.

Ó 2015 CEO. Published by Elsevier Masson SAS. All rights reserved

Une incisive centrale superieure fortement compromise a e soumise a` l’eruption avant remplacement par un et forcee implant afin d’ameliorer et de developper la quantite de en eration (ROG) tissus mous. Cette reg osseuse guidee en eration permet d’inserer l’implant et une reg tissulaire (RTG) permet de reg en erer guidee les tissus autour de la dehiscence de la laterale voisine utilisant une approche en eration dite de reg orthodontique guidee (ROrG). e conduite de fa¸c on esthetique ^ L’egression a et grace a` l’orthodontie linguale. La technique ROrG comprenait en eration deux phases : la reg osseuse orthodontique (ROOrG) et la reg en eration guidee tissulaire orthodontique (RTOrG). Ce proced e a permis de developper guidee le site implantaire en 3D tout en corrigeant les defauts osseux et en augmentant la quantite de tissus mous disponibles, e exploites pour des procedures en eratives qui ont et reg ulterieures. Ó 2015 CEO. E´dite´ par Elsevier Masson SAS. Tous droits re´serve´s

Keywords

s Mots cle

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Orthodontic extrusion. Orthodontic eruption. Forced eruption. Implant. Implant site development.

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Egression orthodontique. Eruption orthodontique. e. Eruption force Implant. veloppement du site implantaire. De

Correspondence and reprints / Correspondance et tires a` part. e-mail address / Adresse e-mail : [email protected] (Roberto Kaitsas) *

International Orthodontics 2015 ; 13 : 539-554 http://dx.doi.org/10.1016/j.ortho.2015.09.009

539

Roberto KAITSAS et al.

·· ·· ·· ·· ·

Lingual orthodontics. Bone regeneration. Tissue regeneration. Guided orthodontic regeneration. Guided bone regeneration. Guided tissue regeneration. GTR. GBR. GOR.

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Orthodontie linguale. ge ne ration osseuse. Re ge ne ration tissulaire. Re ge ne ration orthodontique guide e. Re ge ne ration osseuse guide e. Re ge ne ration tissulaire guide e. Re RTG. ROG. ROrG.

Introduction

Introduction

Orthodontic tooth movement can modify and improve the periodontal anatomy of the hard and soft tissue morphology even of periodontally damaged or fractured teeth [1–7], thus simplifying complex conventional regenerative techniques. The loss for fracture or periodontal reasons of an anterior tooth and the subsequent implant substitution is a challenging situation for both the surgeon and the prosthodontist due to the esthetic demands during and after treatment. Indeed, the vestibular cortical plate covering the roots of the maxillary teeth is very thin and its porosity makes it susceptible to resorption following periodontal and periapical infections. Preservation of the alveolar dimensions appears to be important in order to reduce the risk of further surgical procedures [8]. Being very often involved the anterior and esthetic zone of the mouth, it appears important an aesthetic attention not only at the end but also during the treatment. As the anterior esthetic zone is often involved, it is important to pay particular esthetic attention to this region not only at the end but also during treatment. This can be done using lingual appliances for orthodontic extrusion [9–12]. The aim of this study is to suggest a new approach to implant site development using “Guided Orthodontic Regeneration” by describing a clinical case and its relationship with GBR and GTR.

Les mouvements dentaires orthodontiques peuvent modifier liorer la morphologie anatomique parodontale des tiset ame ^me des dents fracture es ou pre sentant sus durs et mous, me se [1–7] tout en simplifiant les techniques un parodonte le ge ne ration conventionnelle. La perte d’une complexes de re rieure suite a` une fracture ou a` une le sion parodondent ante tale et son remplacement par un implant constitue une dure difficile pour le chirurgien comme pour le prosthoproce tiques des patients dontiste en raison des exigences esthe s le traitement. En effet, l’os alve olaire vestipendant et apre s bulaire recouvrant les racines des dents maxillaires est tre le rend tre s susceptible a` la re sorption mince et sa porosite riapicales. La consersuite a` des infections parodontales ou pe olaires paraıˆt donc importante pour vation des dimensions alve duire le risque de nouvelles interventions chirurgicales [8]. re gion ante rieure du point de En raison de l’importance de la re tique, il est essentiel de faire attention a` l’esthe tique vue esthe de cette zone, non seulement a` la fin du traitement mais aussi ` cette fin, des appareils linguaux en cours de traitement. A ^tre utilise s pour re aliser des e gressions orthodonpeuvent e tude est de proposer une tiques [9–12]. L’objectif de cette e veloppement des sites implantaires nouvelle technique de de ge ne ration orthodontique guide e en de crivant un utilisant la re cas clinique et sa relation avec la ROG et la RTG.

Case report

Etude de cas

The patient was a 41-year-old woman. She had suffered several traumas on the central left incisor. The tooth displayed external resorption (fig. 1) which had been treated by apical surgery and filling of the resorption two years previously. There was presence of a sinus tract (fig. 2) and deep probing on the palatal and distal site of the tooth (fig. 3). The central incisor was unrecoverable and needed to be replaced by an implant. Due to the bone lesion, the implant treatment needed a GBR technique and, for this reason, a large amount of soft tissue was required (fig. 4). The orthodontic extrusion was performed despite the presence of an endodontic lesion. We were aware that the lesion was a contraindication for extrusion and that perhaps a smaller amount of bone could be regenerated. Despite these considerations, the decision to extrude was

La patiente de 41 ans avait subi plusieurs traumatismes au sentait une niveau de l’incisive centrale gauche. La dent pre sorption exte rieure (fig. 1) qui avait e te traite e deux ans re auparavant par chirurgie apicale et comblement de la sorption. On a note la pre sence d’une fistule (fig. 2) et la re ne trait profonde ment des co ^ te s palatin et distal de la sonde pe tait irre cupe rable et ne cessitait son dent (fig. 3). La centrale e sion osseuse, remplacement par un implant. En raison de la le cessitait une technique ROG. Pour le traitement implantaire ne importante de tissu mou e tait essencette raison, une quantite gression orthodontique a e te re alise e malgre tielle (fig. 4). L’e sence d’une le sion endodontique. Nous e tions consla pre sion constituait une contre-indication cients que la le gression et que, de ce fait, une moindre quantite d’os a` l’e ^tre re ge ne re e. Malgre ces conside rations, nous pourrait e

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International Orthodontics 2015 ; 13 : 539-554

Guided orthodontic regeneration: A tool to enhance conventional regenerative techniques in implant surgery

ge ne ration orthodontique guide e : un outil d’ame lioration des techniques re ge ne ratives conventionnelles en chirurgie implantaire Re

[(Fig._1)TD$IG]

Fig. 1: X-ray of the external resorption. sorption externe. Fig. 1 : Radiographie de la re

made primarily to regenerate the soft tissue required for the regenerative technique.

cide d’e gresser surtout pour re ge ne rer le tissu mou avons de ge ne rative. requis par la technique re

Orthodontic extrusion

Egression orthodontique

The patient received a full-mouth bonded appliance on the upper teeth using lingual brackets (Ormco 7th generationÒ)

complet aux dents maxLa patiente a re¸cu un appareil colle ne rationÒ) illaires utilisant des brackets linguaux (Ormco 7e ge

[(Fig._2)TD$IG]

Fig. 2: Pretreatment aspect of the 21 with the sinus tract. traitement de la 21 montrant la fistule. Fig. 2 : Vue en pre


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[(Fig._3)TD$IG]

Fig. 3: Palatal periodontal probing of the bone defects. fauts osseux. Fig. 3 : Sondage parodontal palatin des de

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Fig. 4: The vestibular and palatal appearance of the tooth and bone defects. fauts dentaires et Fig. 4 : L’aspect vestibulaire et palatin des de osseux.

and a 0.01600 CuNiTi wire was applied for the first month (fig. 5). The bracket on the resorbed incisor was positioned apically with a sectional set-up in indirect lingual bonding. The patient was checked every two weeks to activate the appliance with a controlled bone movement of 1 mm per month. The patient was under strict periodontal control during the whole extrusion and the crown was kept out of occlusal contact to prevent jiggling movements. During the second month, the extrusion was performed with a 0.01600 TMA wire, followed by a 0.017 0.01700 TMA. At the very beginning, the first movement was a pure extrusion along the long axis of the tooth. Then, the objective was to enhance the mesial and distal bone peaks, tipping the tooth first distally to overcorrect the mesial peak and then mesially to raise the distal peak. The surgeon needed interproximal bone peaks to perform a GBR on the implant and a GTR on the lateral incisor. The fourth phase required vestibular root torque while including compensatory lingual bending to torque the crown lingually. The 3-D movement of the tooth was guided by the endoperiodontal lesion and was closely monitored and reevaluated by the

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te inse re pour le premier mois (fig. 5). et un fil 0,01600 CuNiTi a e sorbe es ont e te positionne s Les brackets sur les incisives re apicalement avec un set-up segmentaire par collage indirect. te contro ^ le e toutes les deux semaines pour La patiente a e placement osseux contro ^ le activation de l’appareil avec un de tait e troitement surveille de 1 mm par mois. Son parodonte e riode de l’e gression et tout contact de la pendant toute la pe te e vite pour pre venir les mouvements de va-etcouronne a e me mois, l’e gression s’est faite avec vient. Au cours du deuxie un fil TMA 0,01600 , suivi d’un 0,017 0,01700 TMA. Au tout but, le mouvement initial e tait une e gression pure le long de tait d’ame liorer les de l’axe long de la dent. Ensuite, l’objectif e ^ tes osseuses distales et me siales en inclinant la dent cre ^ te me siale et ensuite d’abord en distal pour surcorriger la cre sial pour relever la cre ^ te distale. Le chirurgien avait en me ^ tes osseuses interproximales pour re aliser une besoin de cre rale. ROG sur le site implantaire et une RTG sur l’incisive late me phase exigeait du torque vestibuloradiculaire La quatrie grant une pliure linguale de compensation pour tout en inte torquer la couronne en lingual. Le mouvement 3D de la dent




[(Fig._5)TD$IG]

Fig. 5: Orthodontic lingual appliance. Fig. 5 : Appareil orthodontique lingual.

periodontist. The amount of extrusion was not determined by the final hard tissue enhancement, but by the soft tissue increment. This was the periodontist’s main request in order to allow future surgical regenerative procedures. Lingual orthodontics allows these movements while maintaining good esthetics. When the esthetics was no longer acceptable due to the increase in the soft tissue, the patient was given a removable Essix with a resin tooth to cover the redundant soft tissue. This allowed us to work behind the teeth on the lingual side. Each month, during the entire treatment, an intraoral radiograph was taken. A 0.017 0.02200 SS wire was used to stabilize the tooth before the implant surgery (fig. 6).

te guide par la le sion endoparodontale. Il a e te suivi de pre s ae e value par le parodontiste. La quantite d’e gression n’a et re te de termine e par l’ame lioration finale des tissus durs pas e de mais par l’augmentation des tissus mous. Ce proce pondait a` la demande principale du parodontiste afin de re dures re ge ne ratives futures. permettre de nouvelles proce L’orthodontie linguale permet ces mouvements tout en maintique. Lorsque l’esthe tique n’e tait plus tenant une bonne esthe acceptable en raison de l’augmentation des tissus mous, la te e quipe e d’un Essix amovible avec une dent en patiente a e sine pour couvrir les tissus mous redondants. Ainsi, nous re re les dents du co ^ te lingual. Chaque avons pu travailler derrie du traitement, une radiographie mois et pendant la totalite te re alise e. Un fil 0,017 0,02200 SS a e te place intraorale a e pour stabiliser la dent avant la chirurgie implantaire (fig. 6).

[(Fig._6)TD$IG]

Fig. 6: a–c: radiographic and clinical (lingual and vestibular aspect) sequences of orthodontic extrusion. quences radiographiques et cliniques (vues linguales et vestibulaires) de l’e gression orthodontique. Fig. 6 : a–c Se


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Fig. 7: The soft tissue at the end of extrusion at implant surgery time. gression au moment de la Fig. 7 : Les tissus mous en fin d’e chirurgie implantaire.

Surgical phase

Phase chirurgicale

After the stabilization period, the remaining fragment was extracted (fig. 7). A trapezoidal full-thickness flap was raised with two oblique “hockey-stick” [13] releasing incisions from the distal aspect of 11 and 22 connected with a horizontal intrasulcular incision, preserving the amount of soft tissue (fig. 8) and taking into consideration the huge bone defect in the implant site and a dehiscence on the 22 root surface (fig. 9). After implant insertion (4.5/15 mm FRIALIT-2 Dentsply FRIADENTÒ root-form fixture) (fig. 10), the bone defect was filled with autologous particulated bone scraped from the same site, without opening a second surgical site, using a manual scraper (Safescraper METAÒ); the 22 root dehiscence was also treated (fig. 11). The graft was covered with a nonresorbable titanium-reinforced e-PTFE membrane (GoreTEXÒ) previously adapted and fixed by a single titanium pin (Dentsply FRIADENTÒ) at the apical portion. The root

s la pe riode de stabilisation, le fragment re siduel a e te Apre zoı¨dal pleine e paisseur a e te extrait (fig. 7). Un lambeau trape avec deux incisions obliques de de charge en « ba ^ton de leve es par hockey » [13] a` partir de l’aspect distal des 11 et 22 relie servant la quantite une incision intrasulculaire horizontale pre norme de faut de tissus mous (fig. 8) et tenant compte de l’e hiscence a` la surface de la osseux au site implantaire et une de s insertion de l’implant (4,5/15 mm racine de la 22 (fig. 9). Apre FRIALIT-2 Dentsply FRIADENTÒ dispositif en forme de faut osseux a e te comble avec de l’os racine) (fig. 10), le de es au me ^me site, sans ouvrir un autologue en particules gratte me site chirurgical, utilisant un grattoir manuel deuxie hiscence radiculaire a` la 22 a (Safescraper METAÒ). La de galement e te traite e (fig. 11). La greffe a e te recouverte e sorbable en e-PTFE renforce de titane d’une membrane non re e avec une pointe en titane (Dentsply (Gore-TEXÒ) fixe

[(Fig._8)TD$IG]

Fig. 8: The design of the trapezoidal flap. zoı¨dal. Fig. 8 : La conformation du lambeau trape

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[(Fig._9)TD$IG]

Fig. 9: The extruded fragment with the regenerated attached tissue. gresse avec le tissu attache ne oge ne re . Fig. 9 : Le fragment e

[(Fig._10)TD$IG]

Fig. 10: Fixture insertion with the defect and the dehiscence of the root of 22. faut et la de hiscence Fig. 10 : Insertion de l’implant avec le de radiculaire a` la 22.

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Fig. 11: Autologous particulated bone placed on implant and root. sur l’implant et la racine. Fig. 11 : Os autologue particulaire place


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[(Fig._12)TD$IG]

Fig. 12: Fixation of the non-resorbable membrane. sorbable. Fig. 12 : Fixation de la membrane non re

surface of 22 was covered with the same membrane to achieve deep tissue regeneration (fig. 12). The cortical bone was drilled with a low-speed round bur with sterile irrigation to access the bone marrow cavities and increase vascularization at the recipient site. The periosteal mesiodistal release incision at the base of the flap was performed to allow the coronally passive sliding of the flap. The crestal incision was sutured with two suture lines (Polyglactin 910 resorbable – VICRYL 5/0Ò): — a horizontal “U”-shaped mattress suture 4 mm from the incision line to allow a greater contact of connective surfaces; — interrupted sutures along the eversion line. The vertical releasing incisions were sutured with interrupted sutures with e-PTFE suture (Gore-Tex 5/0Ò). The flap was stabilized with a Cornick suture at its apical level (Gore-Tex 5/0Ò) to avoid the apical displacement and the opening of the crestal incision (fig. 13). An Essix appliance was chosen to enhance esthetics during the whole orthoperiodontal

FRIADENTÒ) dans la partie apicale. La surface radiculaire de te recouverte de la me ^me membrane pour re aliser la la 22 a e ge ne ration des tissus profonds (fig. 12). La corticale a e te re e avec une fraise ronde a` basse vitesse avec irrigation fore rile pour donner acce s aux cavite s de moelle osseuse et ste cepteur. Cette incision augmenter la vascularisation au site re charge me siodistale du pe rioste a` la base du lambeau a de de te re alise e pour permettre le glissement coronal passif du e te suture e avec deux lignes de lambeau. L’incision crestale a e sorbable – VICRYL 5/0Ò) : sutures (Polyglactin 910 re — une suture horizontale de 4 mm a` points de matelassier en U a` partir de la ligne d’incision afin de permettre un meilleur contact avec les surfaces conjonctives ; pare s le long de la ligne d’e version. — des sutures a` points se charge verticales ont e te suture es avec des Les incisions de de pare s avec une suture e-PTFE (Gore-Tex 5/0Ò). Le points se te stabilise avec une suture Cornick au niveau lambeau a e viter le de placement et l’ouverapical (Gore-Tex 5/0Ò) pour e te ture de l’incision crestale (fig. 13). Un appareil Essix a e liorer l’esthe tique pendant tout le traitement choisi pour ame

[(Fig._13)TD$IG]

Fig. 13: Suture of the flap. Fig. 13 : Suture du lambeau.

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[(Fig._14)TD$IG]

Fig. 14: The soft tissue at second-stage surgery. me phase chirurgicale. Fig. 14 : Les tissus mous lors de la deuxie

treatment. Systemic antibiotics (amoxicillin + clavulanic ac. 1 g every 8 hours for 4 days) were prescribed and 0.12% chlorhexidine mouth rinses were prescribed 3 times a day until removal of the sutures (14 days later). Every month, the site was checked to prevent any accidental uncovering of the membrane and avoid site infection. After 12 months (fig. 14), the membrane was removed and the second surgical phase was attempted. The implant was activated with a healing abutment with a height of 5 mm. At the same time, a vestibular graft was obtained rolling the palatal pedicle of the flap. It was performed to increase the width of the vestibular tissue to be used during the prosthetic phase [14,15]. A trapezoidal flap was raised with two vertical releasing incisions continuing intrasulcularly on the adjacent teeth (fig. 15). No crestal incision was made. The incision continued palatally intrasulcularly with 2 vertical incisions and a horizontal one in the palatal tissue to create a pedicle (fig. 16). This pedicle was disepithelializaed (fig. 17) to create a roll-flap that was vestibulary packed to increase the thickness of the vestibular soft

miques (amoxicilline orthoparodontal. Des antibiotiques syste te + clavulanic ac. 1 g tous les 8 heures pendant 4 jours) ont e prescrits et un rince-bouche a` base de chlorhexidine a` 0,12 % te prescrit 3 fois par jour jusqu’a` enle vement des sutures ae te contro ^ le pour 14 jours plus tard. Tous les mois, le site a e venir tout de placement de la membrane et pour empe ^cher pre s 12 mois (fig. 14), la membrane a e te le site de s’infecter. Apre e et la deuxie me phase chirurgicale a e te initie e. enleve te active avec un pilier de cicatrisation de 5 mm L’implant a e ^me temps, une greffe vestibulaire re alise e de hauteur. En me dicule palatin du lambeau a e te effectue e afin d’augavec le pe ^tre utilise menter la largeur du tissu vestibulaire qui allait e tique [14,15]. Un lambeau pendant la phase prosthe zoı¨dal a e te leve avec deux incisions de de charge vertitrape es dans le sulcus jusqu’aux dents cales, qui se sont prolonge te faite. voisines (fig. 15). Aucune incision crestale n’a e te poursuivie dans le sulcus jusqu’au palais gra ^ce L’incision a e a` deux incisions verticales ainsi qu’une incision horizontale er un pe dicule (fig. 16). Ce dans le tissu palatin pour cre

[(Fig._15)TD$IG]

Fig. 15: The roll flap vestibular incision. . Fig. 15 : L’incision vestibulaire pour le lambeau roule


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[(Fig._16)TD$IG]

Fig. 16: The roll flap palatal incision. . Fig. 16 : L’incision palatine pour le lambeau roule

tissue. The membrane was checked to ensure no infection had developed (fig. 18). After removal of the membrane, the new regenerated bone at the implant site and the tissue regeneration on the root surface of 22 were checked (fig. 19). After sliding the palatal pedicle of the flap under the vestibular envelope, a ramp mattress suture [16] was used to maintain the vestibular flap coronally positioned and the palatal portion of the flap apically positioned with polypropylene sutures (PROLENE 4/0Ò) (figs. 20 and 21). Mesiodistal and apical dissections were performed to release residual muscle tension and facilitate the displacement of the flap for suturing. After 7 days, the suture was removed. A 0.12% chlorhexidine mouth rinse was prescribed 3 times a day until suture removal. To reduce visibility of the healing abutment the patient used the same Essix appliance.

dicule a e te de se pithe lialise (fig. 17) pour cre er un lambeau pe qui e tait regroupe du co ^ te vestibulaire pour augmenter roule paisseur du tissu mou. La membrane a e te contro ^ le e pour l’e tait pas infecte (fig. 18). Une fois la s’assurer que le site ne s’e e, le nouvel os re ge ne re au site implantaire membrane enleve ge ne re a` la surface radiculaire de la 22 ont e te et le tissu re rifie s (fig. 19). Le pe dicule palatin du lambeau a e te glisse ve sous l’enveloppe vestibulaire et une suture a` points de mate te utilise e avec des sutures en polypropyle ne lassier [16] a e (PROLENE 4/0Ò) pour maintenir le lambeau vestibulaire dans une direction coronale et la portion palatine du lambeau e en apical (fig. 20 et 21). Des dissections positionne siodistale et apicale ont e te re alise es pour libe rer la tension me siduelle et pour faciliter le de placement du lammusculaire re te enleve e 7 jours plus tard. beau avant la suture. La suture a e te preDes bains de bouche a` 0,12 % de chlorhexidine ont e vement des points de suture. scrits 3 fois par jour jusqu’a` enle duire la visibilite du pilier de cicatrisation, le patient a Pour re un appareil Essix. utilise

[(Fig._17)TD$IG]

Fig. 17: The roll flap palatal disepithelialization. se pithe lialisation palatine du lambeau roule . Fig. 17 : La de

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[(Fig._18)TD$IG]

Fig. 18: Second surgical phase flap raised to access the membrane. pendant le deuxie me temps chirurgical Fig. 18 : Lambeau leve s a` la membrane. pour donner acce

[(Fig._19)TD$IG]

Fig. 19: The regenerated bone on the implant (GBR) and on the root (GTR). ge ne re sur l’implant (ROG) et sur la racine (RTG). Fig. 19 : L’os re

[(Fig._20)TD$IG]

Fig. 20: Suture of the flap (vestibular view). Fig. 20 : Suture du lambeau (vue vestibulaire).


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[(Fig._21)TD$IG]

Fig. 21: Suture of the flap (occlusal view) with the vestibular soft tissue augmentation. Fig. 21 : Suture du lambeau (vue occlusale) montrant l’augmentation des tissus mous vestibulaires.

Prosthetic phase

tique Phase prothe

After a healing period of 4 months, a temporary crown was cemented using a customized titanium abutment to guide tissue maturation [17,18]. During the following 8 months the temporary crown was modified, changing the contact point, the mesial and distal aspect of the tooth and the emergence profile in order to obtain the definitive morphology of the soft tissues. When papillae maturation was complete, the provisional crown was removed and, using a transfer coping, an impression with polyether (Permadyne polyether-impression material, ESPEÒ) was taken. A maxillary and a mandibular cast were prepared and, after being mounted on an articulator, the

s une pe riode de cicatrisation de 4 mois, une couronne Apre te scelle e en utilisant un pilier en titane temporaire a e pour guider la maturation tissulaire [17,18]. personnalise te Pendant les 8 mois suivants, la couronne temporaire a e e pour changer le point de contact, les aspects me sial modifie mergence afin d’obtenir la et distal de la dent et le profil d’e finitive des tissus mous. Une fois termine e la morphologie de te de pose e maturation des papilles, la couronne provisoire a e de transfert, une empreinte au polye ther et, a` l’aide d’une cle te (Permadyne polyether-impression material, ESPEÒ) a e te prise. Des moulages maxillaire et mandibulaire ont e

[(Fig._2)TD$IG]

Fig. 22: Three years control. ^ le a` trois ans. Fig. 22 : Contro

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[(Fig._23)TD$IG]

Fig. 23: Radiographic control at three years. ^ le radiographique a` trois ans. Fig. 23 : Contro

definitive restoration was manufactured. Great attention was paid while transferring the information concerning the soft tissue and the emergency profile from the patient to the laboratory cast to produce the final restoration [19,20]. The definitive restoration was made using a titanium abutment and a porcelain-fused-to-metal (PFM) crown (figs. 22 and 23).

pare s et monte s sur un articulateur pour permettre la fabpre finitive. Beaucoup d’attention a rication de la restauration de te porte e a` la production de cette restauration finale pendant e le transfert depuis les moulages de la patiente aux moulages es concernant les tissus mous et le du laboratoire des donne mergence [19,20]. La restauration de finitive a e te profil d’e alise e en utilisant un pilier en titane et une couronne PFM re ramome tallique) (fig. 22 et 23). (ce

Discussion

Discussion

Rehabilitation of the esthetic zone of the dentition requires an interdisciplinary approach from diagnosis to subsequent therapy. Orthodontic extrusion or forced eruption is a non-surgical technique performed not only to increase the amount of available alveolar bone and soft tissue for implant site development and fixture placement [21,22], but also to extract teeth by squeezing the resulting regenerated tissues or to recover a safe dental structure to restore them. The periodontal ligament can be used as a means of distraction-osteogenesis. The periodontal ligament fibers are inserted into the periosteum of the alveolar bone. If tension is applied, new bone is deposited so the implant site can be modified and improved if the force, speed and inflammation are under control. The biologic potential of the periodontal ligament orthodontically stimulated by

habilitation de la zone esthe tique dentaire requiert une La re approche interdisciplinaire depuis le diagnostic jusqu’au traicoule. L’e gression orthodontique ou e ruption tement qui en de e est une technique non chirurgicale re alise e non seuleforce d’os alve olaire et de tissu ment pour augmenter la quantite veloppement du site implantaire mou disponibles en vue du de galement pour et de l’insertion du dispositif [21,22], mais e tablir une structure dentaire suˆre permettant de restaurer re ^tre utilise les dents. Le ligament parodontal (LPD) peut e ogene se. Les fibres du comme moyen de distraction-oste re es dans le pe rioste de l’os alve olaire. Si une LPD sont inse e, de l’os nouveau est de pose permettant tension est applique liorer le site implantaire si la force, la de modifier et d’ame ^ le. Le potentiel vitesse et l’inflammation sont sous contro


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extrusive forces can enhance the regenerative potential of future periodontal surgery including guided regeneration techniques modifying the morphology of an intrabone defect, increasing a vertically reduced alveolar ridge deformity [23] and increasing the amount of soft tissue. From this point of view, an unrecoverable tooth must not be extracted as first choice since, using adjunctive procedures it can be extremely helpful in improving the bone and tissue anatomy thus allowing better and more predictable implant surgery to be performed and providing an enhanced esthetic prosthetic result [24–26]. Orthodontics played an integral and multidisciplinary role in the treatment of this challenging patient contributing to the esthetics during treatment and to the final esthetic result. Lingual orthodontics becomes a means through “orthodontic extrusion” to develop and improve the final implant site, both the bone [27] and the soft tissues, as we can observe in this case. The lingual appliance can solve the patient’s esthetic demand during the first phase of the extrusion, and during the entire orthodontic treatment. When the esthetics is compromised by soft tissue enhancement, a removable Essix can preserve the integrity of the smile and minimize changes to the anatomy of the tooth, which being extruded, is no more than a root or an abnormal quantity of gingival tissue. Thus, Guided Orthodontic Regeneration (GOR), designed to enhance the orthodontic implant site by means of orthodontic extrusion, includes two aspects: — Guided Orthodontic “Bone” Regeneration (GOBR), i.e. the standard approach to orthodontic extrusion [27]; — Guided Orthodontic “Soft Tissue” Regeneration (GOTR) to improve the soft tissue and prepare the site for other regenerative techniques. When there is an adequate amount of soft tissue, it is possible to perform GOBR on implants and GOTR on teeth, all using GOR at the same surgical site and in one surgical procedure with no additional surgical treatment. The advantage of using lingual orthodontics to regenerate hard and soft tissue instead of other pure regenerative therapies are multiple. First of all, using unrestorable teeth condemned to extraction can assist whole mouth rehabilitation [28,29]. Then, during bone distraction and development, the lingual appliance can resolve orthodontic malocclusions. The use of GOR makes it possible to limit or even eliminate more complex regenerative techniques such as complex vertical GBR, ERE (Edentolous Ridge Expansion), and bone grafts. Last but not least, GOR facilitates the subsequent surgical phases such as fixture insertion (GOR Bone) and mucogingival correction (GOR Soft Tissue). Nevertheless, the disadvantages must be considered. These include the length duration of treatment, due to the nonresorbable membranes and the orthodontic extrusion, the poor esthetic appearance during orthodontics, solved by using the lingual approach, the external vestibular Essix and the reluctance of patients to accept and manage orthodontic treatment.

552

orthodontiquement avec des forces biologique du LPD stimule gressives peut ame liorer la capacite de re ge ne ration de e dures chirurgicales futures, y compris les techniques proce ge ne ration guide e susceptibles de modifier la morpholode re ficit intraosseux, d’augmenter une de ficience vertigie d’un de ^ te alve olaire [23] et d’accroıˆtre la quantite de tissu cale de la cre cupe rable ne doit pas e ^tre mou. Pour ces raisons, une dent irre re intention puisqu’elle peut s’ave rer tre s extraite en premie lioration de l’anatomie osseuse et tissulaire utile pour l’ame alisation d’une chirurgie implantaire et ainsi permettre la re visible tout en fournissant un re sultat prothe tique plus plus pre tique [24–26]. L’orthodontie a joue un ro ^ le essentiel et esthe interdisciplinaire dans le traitement complexe de cette tique en cours de traitement patiente en contribuant a` l’esthe sultat esthe tique final. L’orthodontie linguale ainsi qu’au re de re aliser une « e gression orthodontique » offre la possibilite velopper et ame liorer le site implantaire final, l’os [27] pour de montre le cas pre sente . ainsi que les tissus mous, comme le de tiques du L’appareil lingual peut satisfaire les exigences esthe re phase de l’e gression, ainsi que patient pendant la premie du traitement. Lorsque l’esthe tique est compendant la totalite lioration des tissus mous, un dispositif Essix promise par l’ame grite du sourire et minimiser les amovible peut maintenir l’inte modifications anatomiques au niveau de la dent qui, une fois gresse e, ne ressemble plus qu’a` une racine ou a` une accue mulation anormale de tissu gingival. ge ne ration orthodontique guide e (ROrG), con¸cue Ainsi, la re liorer les sites implantaires au moyen d’une pour ame gression orthodontique, comprend deux phases : e ge ne ration « osseuse » orthodontique guide e — la re gression orthodontique (ROOrG), la technique standard d’e [27] ; ge ne ration tissulaire orthodontique guide e (RTOrG) — la re liorer les tissus mous et pre parer le site pour d’autres pour ame ge ne ratives. techniques re suffisante de tissus mous, il est Lorsqu’il existe une quantite aliser une ROOrG au niveau d’un site implanpossible de re taire et une RTOrG sur les dents, les deux techniques utilisant ^me site chirurgical et en une seule proce dure la ROrG au me mentaire. Les chirurgicale sans traitement chirurgical supple ge ne rer les avantages d’utiliser l’orthodontie linguale pour re ge ne ratifs tissus durs et mous au lieu d’autres traitements re plus conventionnels sont multiples. D’abord, l’exploitation de cupe rables condamne es a` l’extraction peut contridents irre habilitation de la bouche entie re [28,29]. Ensuite, buer a` la re veloppement de l’os, l’appareil pendant la distraction et le de orthodontique peut corriger des malocclusions orthodontiques. Le recours a` la ROrG permet de limiter, voire d’exclure, ge ne ratives plus complexes telles que la des techniques re ^ te e dente e), et les ROG verticale, l’ERE (Expansion de la cre greffes osseuses. Enfin, mais tout aussi important, la ROrG rieures telles que l’inserfacilite les phases chirurgicales ulte tion de l’implant (ROrG osseux) et la correction mucogingivale anmoins tenir compte des incon(ROrG tissulaire). Il faut ne nients. Parmi ceux-ci, on compte l’allongement de la dure e ve sorbables et du traitement duˆ aux membranes non re




gression orthodontique, l’esthe tique compromise pendant a` l’e solue en utilisant la technique linguale), l’Essix l’orthodontie (re ticence des patients face au besoin vestibulaire externe et la re rer leur traitement orthodontique. d’accepter et de ge

Conclusion

Conclusion

Forced eruption is a well-documented technique to enhance the implant site and to increase the amount of hard and soft tissues. Awareness of the potential of GOR (Guided Orthodontic Regeneration) enables simplification and greater effectiveness of regenerative techniques making GBR easier and avoiding failures due to the membrane uncovering. The GOR technique with the two approaches (“Bone” GOR and “Soft Tissue” GOR) enhances a 3D implant site by correcting bone defects and by increasing the amount of soft tissue that can be used for subsequent regenerative techniques and mucogingival corrections. Finally, lingual orthodontics can ensure acceptable esthetics during the entire treatment while allowing excellent development of the implant site.

ruption force e est une technique bien documente e pour L’e lioration du site implantaire et l’augmentation de la l’ame de tissus durs et mous. Bien comprendre le potentiel quantite ge ne ration orthodontique guide e (ROrG) permet de de la re ge ne ratives tout en augmentant simplifier les techniques re . Elle pre vient e galement les e checs dus a` la leur efficacite couverture incorrecte de la membrane. La technique ROrG, avec ses deux approches (ROrG « osseux » et ROrG tissuliore le site implantaire dans les trois dimensions en laire), ame fauts osseux et en augmentant la quantite corrigeant les de ^tre utilise s lors de proce dures des tissus mous qui peuvent e ge ne ratives ulte rieures et de corrections mucogingivales. re tique Enfin, l’orthodontie linguale peut garantir une esthe e du traitement tout en permettant acceptable pendant la dure veloppement du site implantaire. un excellent de

Disclosure of interest

claration de liens d’inte re ^ts De

The authors declare that they have no competing interest.

clarent ne pas avoir de liens d’inte re ^ ts. Les auteurs de

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