The International Journal of Periodontics & Restorative Dentistry © 2015 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
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Implant Site Development by Horizontal Tooth Movement to an Esthetic Area: A Case Report Yoshiyuki Wada, DDS, PhD1 Harunori Yoshimura, DDS, PhD2 Itaru Mikami, DDS, PhD3 Kousuke Matsuzawa, DDS, PhD4 Morimichi Mizuno, DDS, PhD1 This case report describes the treatment of a woman who lost a central incisor. The socket developed severe tissue defects. She rejected hard and soft tissue management and the use of biomaterials. The lateral incisor was moved mesially with orthodontic treatment. The tissue defects were filled with the alveolar bone of the moved tooth and adequate bone volume was generated behind it. An implant was placed in the space that was generated without any tissue augmentation. The moved tooth had sound periodontal tissue and was restored without preparation. The horizontal tooth movement enabled an esthetic outcome with minimal intervention. (Int J Periodontics Restorative Dent 2015;35:697–705. doi: 10.11607/prd.2019)
Institute of Hokkaido Plastic Dentistry; Adjunct Instructor, Laboratory of Oral Biochemistry, Graduate School of Dentistry, Hokkaido University, Sapporo, Japan; Private Practice, Sapporo, Japan. 2Private Practice, Bibai, Japan. 3Private Practice, Tomakomai, Japan. 4Private Practice, Sapporo, Japan. 1
Correspondence to: Dr Yoshiyuki Wada, 3-6, Fujino, Minami-ku, Sapporo, 061-2283, Japan. Fax: 011-593-8211. Email: [email protected] ©2015 by Quintessence Publishing Co Inc.
In implant treatment for esthetic sites, the implants should be exactly placed in three-dimensionally correct positions to achieve preferred clinical outcomes. Therefore, sufficient bone volume for implant placement is required. In addition, to avoid gingival recession after a long duration, sound, thick soft tissues are crucial factors for esthetic implant treatment. However, severe atrophy of the hard and soft tissues is frequently observed in esthetic sites. As a result, the bone and gingival volumes for proper implant treatment are often insufficient.1 Researchers have demonstrated that, after tooth extraction, bundle bone resorption affects the alveolar buccal plate, resulting in horizontal collapse.2,3 Furthermore, the soft tissue volume and thickness of the gingiva also decrease frequently.4 In the case of teeth in esthetic sites that have chronic inflammation for a long duration, the loss of hard and soft tissues makes it difficult for dentists to place implants. Such hard and soft tissue defects are serious risks for singletooth implant treatment.1 Augmentation of hard and soft tissues is often necessary when bone and gingival volumes for implant placement are insufficient, and surgical augmentation procedures are often performed together with implant treatment. Bone
Volume 35, Number 5, 2015 © 2015 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
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Fig 1 Frontal view of the patient.
augmentation procedures such as guided bone regeneration5 and cortical bone block grafts6 have been used successfully in esthetic sites, and soft tissue management techniques such as connective tissue grafts are often needed.1 However, patients may suffer from surgical stress and long-term treatment. In addition, the clinical outcomes are not always successful after hard and soft tissue augmentation because the grafted bone can be resorbed after a long duration,7 and gingival recession sometimes occurs. In addition, multiple soft tissue management procedures may cause scarring of the recipient site and esthetic problems.1,8 An alternative to surgical tissue augmentation is orthodontic treatment.9,10 It has been reported that tooth eruption by orthodontic force is effective to regenerate bone and soft tissue in esthetic implant sites.9,10 However, vertical tooth movement cannot provide sufficient tissue volume, and additional tissue augmentation is often necessary before implant placement.10 On the other hand, it was reported that horizontal (in the distal or mesial direction) tooth movement might also be effective to acquire sufficient tissue volume for implant placement.11
Several clinical reports and studies have shown that when a tooth is moved to an edentulous area with reduced bone width and height, the supporting periodontal tissue and alveolar bone move with it.11–14 Re et al11 reported that movement of teeth through the maxillary sinus and insertion of the implant in the alveolus of the moved tooth was effective for a patient exhibiting pneumatization of the maxillary sinus resulting from early extractions and that an osseointegrated implant could be used for anchorage. Furthermore, it was reported that the space where the moved tooth previously existed developed sufficient volumes of hard and soft tissues. Zachrisson12 reported that when a tooth (generally a premolar) was moved orthodontically into an edentulous space, an implant could be successfully placed in the position previously occupied by the tooth that was moved. In this case study, the authors speculated that horizontal tooth movement could be applied to implant treatment of esthetic sites, and that good clinical outcomes could be achieved.
Case report A 40-year-old female patient required esthetic treatment. Her general condition and systemic condition were normal. Her left central incisor had been restored several years earlier and had become inflamed (Fig 1). Radiographic analysis indicated that the tooth had a periapical lesion and perforation (Fig 2a). Her right central incisor and
left lateral incisor were healthy. She wished to have the inflammation treated and to have a better esthetic profile with suitable occlusion adjusted with orthodontic treatment. The lip line of the patient was in the middle range (Fig 2b). It was suggested that the left central incisor be extracted because of tooth fracture. It was expected that the extraction socket would induce large bone and soft tissue defects. However, she would not accept any surgical hard or soft tissue augmentation such as an autograft using a bone block from the chin or ramus, except for placing a dental implant. In addition, she also rejected the usage of biomaterials such as bone filling materials or a collagen membrane originating from an animal or cadaver. The following three treatment options were offered to the patient. 1. A fixed partial denture using the right central incisor and left lateral incisor as supporting teeth. The patient was explained that intervention would be necessary for both teeth undergoing this treatment. 2. Implant placement in the site of the extracted left central incisor. However, it would be necessary to augment both hard and soft tissues to place an implant in this site. 3. Horizontal tooth movement of the left lateral incisor into the site where the left central incisor existed, and implant placement in the previous position of the left lateral incisor. An assumed set-up model after orthodontic
The International Journal of Periodontics & Restorative Dentistry © 2015 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
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Fig 2a Initial radiographs showing fracture of the left central incisor. The mandibular bilateral first molars and the maxillary left first molar were extracted instead of healthy premolars.
Fig 2b Initial facial view of the patient.
Fig 3 (left) The assumed set-up model after orthodontic and prosthetic treatment was shown to the patient. Fig 4 (right) At the start of the short leveling procedure.
and prosthetic treatment was shown to the patient (Fig 3). She selected the third treatment option using tooth movement. First, the lower bilateral first molars and the upper left first molar which had periapical lesions were extracted instead of healthy premolars and leveling was started (Fig 4). After the short leveling procedure and expansion of the palatal arch using palatine anchorage, extrusion of the left incisor was performed. A Nance holding arch was placed and the left central incisor was extracted (Fig 5). Following this, intermaxillary Class II
elastic was used on the left side to improve maxillary protrusion. Then the left lateral incisor was moved to the position where the central incisor had existed previously. Edgewise appliances were used to avoid tipping movement. A 0.016 × 0.022-L&H titanium archwire (Tommy International) and 0.022 × 0.025–inch stainless steel Hybrid archwire (Dentsply-Sankin) were used mainly, and nickel-titanium open-coil springs were later used to speed up the orthodontic movement. The bodily movement was performed as carefully as possible. After 18 months, the left lateral inci-
sor was settled at the site of the left central incisor (Fig 6). The moved tooth had healthy keratinized gingiva. The defect was filled with the alveolar bone of the moved tooth, and a space was created behind the tooth (Fig 7). The site where the lateral incisor had previously resided had a wide alveolar ridge and sufficient interdental spaces with a thick gingiva. Radiographic and cone beam computed tomographic analyses demonstrated that the amount of bone generated at this site was wide and high enough to place an implant (Fig 8). A narrow-diameter, tapered
Volume 35, Number 5, 2015 © 2015 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
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Figs 5a to 5c The left central incisor was extracted because of tooth fracture. A large bone defect was observed.
Fig 6a (left) Radiograph of the left lateral incisor moving into the site of the central incisor. Fig 6b (below) The left lateral incisor was settled in the site of the left central incisor and had healthy keratinized gingiva.
Fig 7 After 18 months, orthodontic treatment was almost finished.
The International Journal of Periodontics & Restorative Dentistry © 2015 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
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Fig 8a Panoramic radiograph at the end of the tooth movement.
Figs 8b and 8c Cone beam computed tomography demonstrated that the bone formation generated at this site was high and wide enough to place an implant.
Figs 9a and 9b Narrow-diameter tapered implant was placed using computer-guided surgery without any surgical bone augmentation and maintained sufficient distance from adjacent teeth.
implant (Replace Tapered Groovy, 3.5 mm in diameter and 13 mm in length, Nobel Biocare) was placed using computer-guided surgery (Surgi Guide Simplant) without any surgical bone augmentation, and with sufficient distance from adjacent teeth (Fig 9). The bone at this site was type 3 in the classification of Lekholm and Zarb and the insertion torque value was 35 N/cm).15 Three months later, a secondary operation was performed and a healing abutment was placed. A provisional restoration was placed on the implant with a retaining screw 1 week after the secondary operation. The implant was then used for orthodontic anchorage to complete the orthodontic therapy (Fig 10). Two years after starting orthodon-
tic treatment, the right incisor and lateral incisor that were moved into the site where the left central incisor had existed were restored using porcelain laminate veneer (IPS e.max Press, Ivoclar Vivadent) without any special preparation (Fig 11). Six months later, an impression was taken with a custom impression coping (Fig 12) and the ceramic definitive restoration was placed on a zirconia abutment (Procera, Nobel Biocare) (Fig 13). The patient was satisfied with the clinical and esthetic outcomes. The maintenance phase started after cementation of the restorations, which included prescribing a heat-cured night guard appliance. Final retention was done by fixation with lingual wire and a Hawley re-
tainer. Follow-up of this patient has been uneventful, and good oral hygiene and the esthetic profile have been maintained for 2 years after completion of the definitive restoration (Figs 14a and 14b). Though root resorption of the lateral incisor was observed on radiography (Fig 14c), tooth mobility remains normal and gingival recession has not been observed.
Discussion Before starting the treatment, the patient was presented with three possible options. First, for the fixed partial denture, the left lateral incisor and right central incisor needed to be restored. However, this
Volume 35, Number 5, 2015 © 2015 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
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Figs 10a and 10b Completion of the orthodontic therapy using the implant for orthodontic anchorage.
Figs 11a and 11b Placement of the provisional restoration on the left lateral incisor and laminate veneers on the central incisors.
Figs 12a and 12b Impression taking using a custom impression coping.
Fig 13a Placement of the zirconia abutment.
Fig 13b Ceramic definitive cement-retained restoration was placed on the abutment.
The International Journal of Periodontics & Restorative Dentistry © 2015 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
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Figs 14a and 14b Lateral and frontal views at 2-year follow-up.
patient would not accept any tooth preparation. On the other hand, if an implant were to be placed into the site where the left central incisor existed, surgical bone augmentation would be necessary for a good esthetic appearance. However, the patient also rejected any surgical treatment, such as a bone graft, and use of a bone filling material originating from an animal or a cadaver. Bone augmentation methods such as guided bone regeneration have proven successful, but flap release and a lack of vascularization, together with a low supply of keratinized tissue, are obstacles that need to be overcome for predictable results. The bone formed in the implant site might not be stable and this could result in a lower success rate for implant treatment. In addition, in the esthetic site, further surgical treatment might be needed to improve the biotype.16 Therefore, a less invasive surgical approach was proposed, which was chosen in this case. It is re-
ported that bone and connective tissue are generated and maintain their original height and width on the tension side with orthodontic treatment, leaving behind an area in which an implant can be placed adequately without any grafting.17 Therefore it was hypothesized that horizontal tooth movement into the edentulous area would restore the missing bone of the large bone defect in the esthetic site, and a good clinical outcome could be achieved using the site for implant treatment. However, moving a tooth into a narrow alveolar ridge is clinically challenging, risky, and potentially slow.18 In this case, on the tension side behind the orthodontically moved lateral incisor, a wide bony ridge having the same width as the tooth was formed. This observation corresponded with findings of a previous report.12 A narrow, tapered implant could be placed with sufficient insertion torque, which affects osseointegration,19 and the implant could be placed into an ideal threedimensional position using guided
Fig 14c Radiograph showing a stable bone level at 2-year follow-up.
surgery without surgical bone augmentation. In addition, the bone formed behind the lateral incisor was accompanied by thick gingiva. This might have occurred because of the distal gingiva of the lateral incisor maintaining its thickness and sufficient volume. No ugly scar was left in the implant recipient site because of the treatment without any soft tissue graft. In addition, implant treatment at the site of lateral incisor may have a lower esthetic risk than that at the site of central incisor. In this case, flapless surgery, a less invasive method, was not chosen, because the buccal bone shape needed to be evaluated visually and the implant had to be placed very carefully. Moreover, the moved lateral incisor had normal periodontal tissue with keratinized epithelium and a well-ordered marginal line. In addition, the bone heights of adjacent teeth were the same as the preoperative level. The risk of inflammatory lesions, which affect osseointegration, was diminished by the tooth
Volume 35, Number 5, 2015 © 2015 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
704 movement.20 Lindskog-Stokland et al21 reported that, by slow and bodily movement of teeth into edentulous areas of reduced bone height, the periostea on the labial and lingual surfaces of the alveolus would normally form bone. However, it has also been reported that if the teeth are moved too rapidly there is a risk of dehiscence.21,22 Tooth movement also faces the problem of root resorption.23 It was reported that root resorption was more severe for upper incisors than for other teeth.24,25 In this case, an acceptable level of root resorption of the lateral incisor was observed but serious problems such as marked tooth mobility were not observed. This was considered to occur because of the long treatment period and the long moving distance.26,27 Moreover, jiggling forces may also induce root resorption. Thus, clinicians should take care to minimize the treatment period, distance of movement, and degree of orthodontic force.28 Orthodontic treatment takes a long time in general. In this case, a long period of orthodontic treatment was needed compared with conventional orthodontic treatment because tooth movement was performed very carefully to minimize tipping movement and root resorption. In this study, the patient agreed with the long treatment time. However, a detailed treatment plan should always be presented to the patient before beginning the treatment. Horizontal movement of the upper lateral incisor into the edentulous space was planned to fill the
bony defect and leave the area previously occupied by the central incisor full of newly generated bone. Amato et al29 reported an excellent method combining horizontal tooth movement and bone splitting in the case of the mandible. However, bone splitting was not used because the esthetic aspect was important in this case and no scar was to be left on the gingiva. In addition, the patient wished for limited surgical treatment. In this case, prosthetic treatment was necessary for the right central incisor and the moved left lateral incisor to achieve a good esthetic outcome. Full porcelain laminate veneer for the left lateral incisor and partial veneer for the right central incisor were applied. Thus, the preparation of these teeth was expedited by using veneers of pressed ceramics, because the lateral incisor was considerably smaller than the central incisor. Porcelain laminate veneers of pressed ceramics have sufficient hardness and can be made thinner than conventional products. The result of our treatment indicated that horizontal tooth movement was useful to minimize surgical treatments, as was the use of biomaterials in a case in which bone volume was insufficient for esthetic implant treatment. However, it was necessary for the patient to agree to the long treatment duration, and risks such as root resorption and dehiscence needed to be considered. Moreover, it was necessary to carefully observe the tissue changes made by tooth movement.
Conclusion In this case, horizontal tooth movement was used for implant treatment of a patient who lost a central incisor to reduce the surgical burden as much as possible. The adjacent lateral incisor was moved into the extraction socket site, which had a large bone defect, resulting in sound periodontal tissue and a space for implant placement. The implant was placed in the site formed after the tooth movement, and a desirable esthetic outcome was obtained without any surgical tissue augmentation. Horizontal tooth movement is useful for implant treatment also in the esthetic area. An interdisciplinary approach using orthodontic and prosthodontic treatments should produce a predictable and maintainable situation. However, deliberate case selection based on the indication is important.
References 1. Buser D, Martin W, Belser UC. Optimizing esthetics for implant restorations in the anterior maxilla: anatomic and surgical considerations. Int J Oral Maxillofac Implants 2004;19:43–61. 2. Cardaropoli G, Araújo M, Lindhe J. Dynamics of bone tissue formation in tooth extraction sites. An experimental study in dogs. J Clin Periodontol 2003;30: 809–18. 3. Araújo MG, Lindhe J. Dimensional ridge alterations following tooth extraction. An experimental study in the dog. J Clin Periodontol 2005;32:212–218. 4. Esposito M, Maghaireh H, Grusovin MG, Ziounas I, Worthington HV. Soft tissue management for dental implants: What are the most effective techniques? A Cochrane systematic review. Eur J Oral Implantol 2012;5:221–238.
The International Journal of Periodontics & Restorative Dentistry © 2015 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
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5. Nevins M, Mellonig JT. Enhancement of the damaged edentulous ridge to receive dental implants: a combination of allograft and the GORE-TEX membrane Int J Periodontics Restorative Dent 1992;12: 96–111. 6. Garg AK. Bone biology, harvesting, and grafting for dental implants: rationale and clinical applications. Chicago: Quintessence, 2004. 7. Zitzmann NU, Schärer P, Marinello CP. Long-term results of implants treated with guided bone regeneration: A 5-year prospective study. Int J Oral Maxillofac Implants 2001;16:355–366. 8. Evian CI, al-Maseeh J, Symeonides E. Soft tissue augmentation for implant dentistry. Compend Contin Educ Dent 2003;24:195–198, 200–202, 204–206; quiz 208. 9. Salama H, Salama M. The role of orthodontic extrusive remodeling in the enhancement of soft and hard tissue profiles prior to implant placement: a systematic approach to the management of extraction site defects. Int J Periodontics Restorative Dent 1993;13:312–333. 10. Amato F, Mirabella AD, Macca U, Tarnow DP. Implant site development by orthodontic forced extraction: A preliminary study. Int J Oral Maxillofac Implants 2012;27:411–420. 11. Re S, Cardaropoli D, Corrente G, Abundo R. Bodily tooth movement through the maxillary sinus with implant anchorage for single tooth replacement. Clin Orthod Res 2001;4:177–181. 12. Zachrisson BU. Implant site development by horizontal tooth movement. World J Orthod 2003;4:266–272. 13. Fontanelle A. Lingual orthodontics in adults. In: Melsen B (ed). Current Controversies in Orthodontics. Chicago: Quintessence, 1991:219–268.
14. Diedrich PR, Fuhrmann RA, Wehrbein H, Erpenstein H. Distal movement of premolars to provide posterior abutments for missing molars. Am J Orthod Dentofacial Orthop 1996;109:355–360. 15. Lekholm U, Zarb GA, Arbrektsson T. Patient selection and preparation. Tissue integrated prostheses. Chicago: Quintessence, 1985;199–209. 16. Fiorellini JP, Nevins ML. Localized ridge augmentation/preservation. A systematic review. Ann Periodontol 2003;8: 321–327. 17. Spear FM, Mathews DM, Kokich VG. Interdisciplinary management of singletooth implants. Semin Orthod 1997;3: 45–72. 18. Lindskog-Stokland B, Wennström JL, Nyman S, Thilander B. Orthodontic tooth movement into edentulous areas with reduced bone height. An experimental study in the dog. Eur J Orthod 1993; 15:89–96. 19. Sennerby L, Thomsen P, Ericson LE. A morphometric and biomechanic comparison of titanium implants inserted in rabbit cortical and cancellous bone. Int J Oral Maxillofac Implants 1992;7:62–71. 20. Lindeboom JA, Tjiook Y, Kroon FH. Immediate placement of implants in periapical infected sites: a prospective randomized study in 50 patients. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2006;101:705–710. 21. Lindskog-Stokland B, Hansen K, Ekestubbe A, Wennström JL. Orthodontic tooth movement into edentulous ridge areas —a case series. Eur J Orthod 2013;35: 277–285. 22. Thilander B, Odman J, Lekholm U. Orthodontic aspects of the use of oral implants in adolescents: a 10-year follow-up study. Eur J Orthod 2001;23: 715–731.
23. Reitan K. Initial tissue behavior during apical root resorption. Angle Orthod 1974; 44:68–82. 24. Lupi JE, Handelman CS, Sadowsky C. Prevalence and severity of apical root resorption and alveolar bone loss in orthodontically treated adults. Am J Orthod Dentofacial Orthop 1996;109: 28–37. 25. Beck BW, Harris EF. Apical root resorption in orthodontically treated subjects: analysis of edgewise and light wire mechanics. Am J Orthod Dentofacial Orthop 1994;105:350–361. 26. Maltha JC, van Leeuwen EJ, Dijkman GE, Kuijpers-Jagtman AM. Incidence and severity of root resorption in orthodontically moved premolars in dogs. Orthod Craniofac Res 2004;7:115–121. 27. Segal GR, Schiffman PH, Tuncay OC. Meta analysis of the treatment-related factors of external apical root resorption. Orthod Craniofac Res 2004;7:71–78. 28. McFadden WM, Engstrom C, Engstrom H, Anholm JM. A study of the relationship between incisor intrusion and root shortening. Am J Orthod Dentofacial Orthop 1989;96:390–396. 29. Amato F, Mirabella AD, Borlizzi D. Rapid orthodontic treatment after the ridgesplitting technique—A combined surgical-orthodontic approach for implant site development: case report. Int J Periodontics Restorative Dent 2012 ;32: 395–402.
Volume 35, Number 5, 2015 © 2015 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
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Implant Site Development by Horizontal Tooth Movement to an Esthetic Area: A Case Report Yoshiyuki Wada, DDS, PhD1 Harunori Yoshimura, DDS, PhD2 Itaru Mikami, DDS, PhD3 Kousuke Matsuzawa, DDS, PhD4 Morimichi Mizuno, DDS, PhD1 This case report describes the treatment of a woman who lost a central incisor. The socket developed severe tissue defects. She rejected hard and soft tissue management and the use of biomaterials. The lateral incisor was moved mesially with orthodontic treatment. The tissue defects were filled with the alveolar bone of the moved tooth and adequate bone volume was generated behind it. An implant was placed in the space that was generated without any tissue augmentation. The moved tooth had sound periodontal tissue and was restored without preparation. The horizontal tooth movement enabled an esthetic outcome with minimal intervention. (Int J Periodontics Restorative Dent 2015;35:697–705. doi: 10.11607/prd.2019)
Institute of Hokkaido Plastic Dentistry; Adjunct Instructor, Laboratory of Oral Biochemistry, Graduate School of Dentistry, Hokkaido University, Sapporo, Japan; Private Practice, Sapporo, Japan. 2Private Practice, Bibai, Japan. 3Private Practice, Tomakomai, Japan. 4Private Practice, Sapporo, Japan. 1
Correspondence to: Dr Yoshiyuki Wada, 3-6, Fujino, Minami-ku, Sapporo, 061-2283, Japan. Fax: 011-593-8211. Email: [email protected] ©2015 by Quintessence Publishing Co Inc.
In implant treatment for esthetic sites, the implants should be exactly placed in three-dimensionally correct positions to achieve preferred clinical outcomes. Therefore, sufficient bone volume for implant placement is required. In addition, to avoid gingival recession after a long duration, sound, thick soft tissues are crucial factors for esthetic implant treatment. However, severe atrophy of the hard and soft tissues is frequently observed in esthetic sites. As a result, the bone and gingival volumes for proper implant treatment are often insufficient.1 Researchers have demonstrated that, after tooth extraction, bundle bone resorption affects the alveolar buccal plate, resulting in horizontal collapse.2,3 Furthermore, the soft tissue volume and thickness of the gingiva also decrease frequently.4 In the case of teeth in esthetic sites that have chronic inflammation for a long duration, the loss of hard and soft tissues makes it difficult for dentists to place implants. Such hard and soft tissue defects are serious risks for singletooth implant treatment.1 Augmentation of hard and soft tissues is often necessary when bone and gingival volumes for implant placement are insufficient, and surgical augmentation procedures are often performed together with implant treatment. Bone
Volume 35, Number 5, 2015 © 2015 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
698
Fig 1 Frontal view of the patient.
augmentation procedures such as guided bone regeneration5 and cortical bone block grafts6 have been used successfully in esthetic sites, and soft tissue management techniques such as connective tissue grafts are often needed.1 However, patients may suffer from surgical stress and long-term treatment. In addition, the clinical outcomes are not always successful after hard and soft tissue augmentation because the grafted bone can be resorbed after a long duration,7 and gingival recession sometimes occurs. In addition, multiple soft tissue management procedures may cause scarring of the recipient site and esthetic problems.1,8 An alternative to surgical tissue augmentation is orthodontic treatment.9,10 It has been reported that tooth eruption by orthodontic force is effective to regenerate bone and soft tissue in esthetic implant sites.9,10 However, vertical tooth movement cannot provide sufficient tissue volume, and additional tissue augmentation is often necessary before implant placement.10 On the other hand, it was reported that horizontal (in the distal or mesial direction) tooth movement might also be effective to acquire sufficient tissue volume for implant placement.11
Several clinical reports and studies have shown that when a tooth is moved to an edentulous area with reduced bone width and height, the supporting periodontal tissue and alveolar bone move with it.11–14 Re et al11 reported that movement of teeth through the maxillary sinus and insertion of the implant in the alveolus of the moved tooth was effective for a patient exhibiting pneumatization of the maxillary sinus resulting from early extractions and that an osseointegrated implant could be used for anchorage. Furthermore, it was reported that the space where the moved tooth previously existed developed sufficient volumes of hard and soft tissues. Zachrisson12 reported that when a tooth (generally a premolar) was moved orthodontically into an edentulous space, an implant could be successfully placed in the position previously occupied by the tooth that was moved. In this case study, the authors speculated that horizontal tooth movement could be applied to implant treatment of esthetic sites, and that good clinical outcomes could be achieved.
Case report A 40-year-old female patient required esthetic treatment. Her general condition and systemic condition were normal. Her left central incisor had been restored several years earlier and had become inflamed (Fig 1). Radiographic analysis indicated that the tooth had a periapical lesion and perforation (Fig 2a). Her right central incisor and
left lateral incisor were healthy. She wished to have the inflammation treated and to have a better esthetic profile with suitable occlusion adjusted with orthodontic treatment. The lip line of the patient was in the middle range (Fig 2b). It was suggested that the left central incisor be extracted because of tooth fracture. It was expected that the extraction socket would induce large bone and soft tissue defects. However, she would not accept any surgical hard or soft tissue augmentation such as an autograft using a bone block from the chin or ramus, except for placing a dental implant. In addition, she also rejected the usage of biomaterials such as bone filling materials or a collagen membrane originating from an animal or cadaver. The following three treatment options were offered to the patient. 1. A fixed partial denture using the right central incisor and left lateral incisor as supporting teeth. The patient was explained that intervention would be necessary for both teeth undergoing this treatment. 2. Implant placement in the site of the extracted left central incisor. However, it would be necessary to augment both hard and soft tissues to place an implant in this site. 3. Horizontal tooth movement of the left lateral incisor into the site where the left central incisor existed, and implant placement in the previous position of the left lateral incisor. An assumed set-up model after orthodontic
The International Journal of Periodontics & Restorative Dentistry © 2015 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
699
Fig 2a Initial radiographs showing fracture of the left central incisor. The mandibular bilateral first molars and the maxillary left first molar were extracted instead of healthy premolars.
Fig 2b Initial facial view of the patient.
Fig 3 (left) The assumed set-up model after orthodontic and prosthetic treatment was shown to the patient. Fig 4 (right) At the start of the short leveling procedure.
and prosthetic treatment was shown to the patient (Fig 3). She selected the third treatment option using tooth movement. First, the lower bilateral first molars and the upper left first molar which had periapical lesions were extracted instead of healthy premolars and leveling was started (Fig 4). After the short leveling procedure and expansion of the palatal arch using palatine anchorage, extrusion of the left incisor was performed. A Nance holding arch was placed and the left central incisor was extracted (Fig 5). Following this, intermaxillary Class II
elastic was used on the left side to improve maxillary protrusion. Then the left lateral incisor was moved to the position where the central incisor had existed previously. Edgewise appliances were used to avoid tipping movement. A 0.016 × 0.022-L&H titanium archwire (Tommy International) and 0.022 × 0.025–inch stainless steel Hybrid archwire (Dentsply-Sankin) were used mainly, and nickel-titanium open-coil springs were later used to speed up the orthodontic movement. The bodily movement was performed as carefully as possible. After 18 months, the left lateral inci-
sor was settled at the site of the left central incisor (Fig 6). The moved tooth had healthy keratinized gingiva. The defect was filled with the alveolar bone of the moved tooth, and a space was created behind the tooth (Fig 7). The site where the lateral incisor had previously resided had a wide alveolar ridge and sufficient interdental spaces with a thick gingiva. Radiographic and cone beam computed tomographic analyses demonstrated that the amount of bone generated at this site was wide and high enough to place an implant (Fig 8). A narrow-diameter, tapered
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Figs 5a to 5c The left central incisor was extracted because of tooth fracture. A large bone defect was observed.
Fig 6a (left) Radiograph of the left lateral incisor moving into the site of the central incisor. Fig 6b (below) The left lateral incisor was settled in the site of the left central incisor and had healthy keratinized gingiva.
Fig 7 After 18 months, orthodontic treatment was almost finished.
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Fig 8a Panoramic radiograph at the end of the tooth movement.
Figs 8b and 8c Cone beam computed tomography demonstrated that the bone formation generated at this site was high and wide enough to place an implant.
Figs 9a and 9b Narrow-diameter tapered implant was placed using computer-guided surgery without any surgical bone augmentation and maintained sufficient distance from adjacent teeth.
implant (Replace Tapered Groovy, 3.5 mm in diameter and 13 mm in length, Nobel Biocare) was placed using computer-guided surgery (Surgi Guide Simplant) without any surgical bone augmentation, and with sufficient distance from adjacent teeth (Fig 9). The bone at this site was type 3 in the classification of Lekholm and Zarb and the insertion torque value was 35 N/cm).15 Three months later, a secondary operation was performed and a healing abutment was placed. A provisional restoration was placed on the implant with a retaining screw 1 week after the secondary operation. The implant was then used for orthodontic anchorage to complete the orthodontic therapy (Fig 10). Two years after starting orthodon-
tic treatment, the right incisor and lateral incisor that were moved into the site where the left central incisor had existed were restored using porcelain laminate veneer (IPS e.max Press, Ivoclar Vivadent) without any special preparation (Fig 11). Six months later, an impression was taken with a custom impression coping (Fig 12) and the ceramic definitive restoration was placed on a zirconia abutment (Procera, Nobel Biocare) (Fig 13). The patient was satisfied with the clinical and esthetic outcomes. The maintenance phase started after cementation of the restorations, which included prescribing a heat-cured night guard appliance. Final retention was done by fixation with lingual wire and a Hawley re-
tainer. Follow-up of this patient has been uneventful, and good oral hygiene and the esthetic profile have been maintained for 2 years after completion of the definitive restoration (Figs 14a and 14b). Though root resorption of the lateral incisor was observed on radiography (Fig 14c), tooth mobility remains normal and gingival recession has not been observed.
Discussion Before starting the treatment, the patient was presented with three possible options. First, for the fixed partial denture, the left lateral incisor and right central incisor needed to be restored. However, this
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Figs 10a and 10b Completion of the orthodontic therapy using the implant for orthodontic anchorage.
Figs 11a and 11b Placement of the provisional restoration on the left lateral incisor and laminate veneers on the central incisors.
Figs 12a and 12b Impression taking using a custom impression coping.
Fig 13a Placement of the zirconia abutment.
Fig 13b Ceramic definitive cement-retained restoration was placed on the abutment.
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Figs 14a and 14b Lateral and frontal views at 2-year follow-up.
patient would not accept any tooth preparation. On the other hand, if an implant were to be placed into the site where the left central incisor existed, surgical bone augmentation would be necessary for a good esthetic appearance. However, the patient also rejected any surgical treatment, such as a bone graft, and use of a bone filling material originating from an animal or a cadaver. Bone augmentation methods such as guided bone regeneration have proven successful, but flap release and a lack of vascularization, together with a low supply of keratinized tissue, are obstacles that need to be overcome for predictable results. The bone formed in the implant site might not be stable and this could result in a lower success rate for implant treatment. In addition, in the esthetic site, further surgical treatment might be needed to improve the biotype.16 Therefore, a less invasive surgical approach was proposed, which was chosen in this case. It is re-
ported that bone and connective tissue are generated and maintain their original height and width on the tension side with orthodontic treatment, leaving behind an area in which an implant can be placed adequately without any grafting.17 Therefore it was hypothesized that horizontal tooth movement into the edentulous area would restore the missing bone of the large bone defect in the esthetic site, and a good clinical outcome could be achieved using the site for implant treatment. However, moving a tooth into a narrow alveolar ridge is clinically challenging, risky, and potentially slow.18 In this case, on the tension side behind the orthodontically moved lateral incisor, a wide bony ridge having the same width as the tooth was formed. This observation corresponded with findings of a previous report.12 A narrow, tapered implant could be placed with sufficient insertion torque, which affects osseointegration,19 and the implant could be placed into an ideal threedimensional position using guided
Fig 14c Radiograph showing a stable bone level at 2-year follow-up.
surgery without surgical bone augmentation. In addition, the bone formed behind the lateral incisor was accompanied by thick gingiva. This might have occurred because of the distal gingiva of the lateral incisor maintaining its thickness and sufficient volume. No ugly scar was left in the implant recipient site because of the treatment without any soft tissue graft. In addition, implant treatment at the site of lateral incisor may have a lower esthetic risk than that at the site of central incisor. In this case, flapless surgery, a less invasive method, was not chosen, because the buccal bone shape needed to be evaluated visually and the implant had to be placed very carefully. Moreover, the moved lateral incisor had normal periodontal tissue with keratinized epithelium and a well-ordered marginal line. In addition, the bone heights of adjacent teeth were the same as the preoperative level. The risk of inflammatory lesions, which affect osseointegration, was diminished by the tooth
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704 movement.20 Lindskog-Stokland et al21 reported that, by slow and bodily movement of teeth into edentulous areas of reduced bone height, the periostea on the labial and lingual surfaces of the alveolus would normally form bone. However, it has also been reported that if the teeth are moved too rapidly there is a risk of dehiscence.21,22 Tooth movement also faces the problem of root resorption.23 It was reported that root resorption was more severe for upper incisors than for other teeth.24,25 In this case, an acceptable level of root resorption of the lateral incisor was observed but serious problems such as marked tooth mobility were not observed. This was considered to occur because of the long treatment period and the long moving distance.26,27 Moreover, jiggling forces may also induce root resorption. Thus, clinicians should take care to minimize the treatment period, distance of movement, and degree of orthodontic force.28 Orthodontic treatment takes a long time in general. In this case, a long period of orthodontic treatment was needed compared with conventional orthodontic treatment because tooth movement was performed very carefully to minimize tipping movement and root resorption. In this study, the patient agreed with the long treatment time. However, a detailed treatment plan should always be presented to the patient before beginning the treatment. Horizontal movement of the upper lateral incisor into the edentulous space was planned to fill the
bony defect and leave the area previously occupied by the central incisor full of newly generated bone. Amato et al29 reported an excellent method combining horizontal tooth movement and bone splitting in the case of the mandible. However, bone splitting was not used because the esthetic aspect was important in this case and no scar was to be left on the gingiva. In addition, the patient wished for limited surgical treatment. In this case, prosthetic treatment was necessary for the right central incisor and the moved left lateral incisor to achieve a good esthetic outcome. Full porcelain laminate veneer for the left lateral incisor and partial veneer for the right central incisor were applied. Thus, the preparation of these teeth was expedited by using veneers of pressed ceramics, because the lateral incisor was considerably smaller than the central incisor. Porcelain laminate veneers of pressed ceramics have sufficient hardness and can be made thinner than conventional products. The result of our treatment indicated that horizontal tooth movement was useful to minimize surgical treatments, as was the use of biomaterials in a case in which bone volume was insufficient for esthetic implant treatment. However, it was necessary for the patient to agree to the long treatment duration, and risks such as root resorption and dehiscence needed to be considered. Moreover, it was necessary to carefully observe the tissue changes made by tooth movement.
Conclusion In this case, horizontal tooth movement was used for implant treatment of a patient who lost a central incisor to reduce the surgical burden as much as possible. The adjacent lateral incisor was moved into the extraction socket site, which had a large bone defect, resulting in sound periodontal tissue and a space for implant placement. The implant was placed in the site formed after the tooth movement, and a desirable esthetic outcome was obtained without any surgical tissue augmentation. Horizontal tooth movement is useful for implant treatment also in the esthetic area. An interdisciplinary approach using orthodontic and prosthodontic treatments should produce a predictable and maintainable situation. However, deliberate case selection based on the indication is important.
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