CASE REPORT

Orthodontic tooth movement through the maxillary sinus in an adult with multiple missing teeth Heesoo Oh,a Kiri Herchold,b Stephanie Hannon,b Kelly Heetland,c Golnaz Ashraf,d Vince Nguyen,e and Heon Jae Chof San Francisco, Mill Valley, and Sunnyvale, Calif, Wichita Falls, Tex, and Seoul, Korea This case report describes the successful orthodontic tooth movement through the maxillary sinus in an adult patient. A 41-year-old Asian woman had severe lip protrusion and multiple missing posterior teeth. Her orthodontic treatment included the extraction of 2 teeth, maximum retraction of the incisors using the extraction spaces and the existing spaces from the missing molars, and closure of all remaining spaces. Even though the treatment time was extended because of the anatomic and biologic challenges associated with moving posterior teeth over a long distance through the maxillary sinus, a successful outcome was obtained, with significant bone modeling of the maxillary sinus. The results demonstrate that a carefully selected force system can overcome the anatomic limitations of moving tooth against the cortical bone of the maxillary sinus wall in adult patients. (Am J Orthod Dentofacial Orthop 2014;146:493-505)

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ith increased demand for adult orthodontics, orthodontists are often faced with the challenge of correcting occlusal problems that are related to anatomic limits, such as atrophy of the alveolar process, extension of the maxillary sinus into the alveolar process, and periodontally compromised supporting tissues. These anatomic limitations are attributed to cortical bone. Moving teeth through cortical bone is difficult in adults because it increases treatment complexity and treatment time.1-3 However,

a

Associate professor and program director, Department of Orthodontics, Arthur A. Dugoni School of Dentistry, University of the Pacific, San Francisco, Calif. Postgraduate student, Graduate Orthodontic Program, Arthur A. Dugoni School of Dentistry, University of the Pacific, San Francisco, Calif. c Postgraduate student, Graduate Orthodontic Program, Arthur A. Dugoni School of Dentistry, University of the Pacific, San Francisco, Calif; private practice, Wichita Falls, Tex. d Postgraduate student, Graduate Orthodontic Program, Arthur A. Dugoni School of Dentistry, University of the Pacific, San Francisco, Calif; private practice, Mill Valley, Calif. e Postgraduate student, Graduate Orthodontic Program, Arthur A. Dugoni School of Dentistry, University of the Pacific, San Francisco, Calif; private practice, Sunnyvale, Calif. f Private practice, Seoul, Korea. All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest, and none were reported. Address correspondence to: Heesoo Oh, Department of Orthodontics, University of the Pacific Arthur A Dugoni School of Dentistry, San Francisco, CA 94115; e-mail, hoh@pacific.edu. Submitted, January 2014; revised and accepted, March 2014. 0889-5406/$36.00 Copyright Ó 2014 by the American Association of Orthodontists. http://dx.doi.org/10.1016/j.ajodo.2014.03.025 b

previous investigators and clinicians have demonstrated successful tooth movement “with bone” into the compromised bone by applying a carefully planned force system that resulted in bodily movement with frontal bone resorption, rather than indirect bone resorption.1-4 Among dental professionals, this approach has been well established as a method to generate new bone for implant placement.3 In addition, a maxillary sinus lift procedure is commonly recommended for implant placement when the maxillary sinus extends into the alveolar process because of the loss of maxillary posterior teeth.5,6 Moving teeth through the maxillary sinus is considered one of the most challenging problems in orthodontics, since it requires compensatory new bone apposition, before bone resorption, in the direction of tooth movement to maintain the integrity of the sinus wall.1-4,7 In addition, unknown side effects, such as root resorption, pulp vitality, and perforation of the sinus membrane, can cause additional complications.8,9 Thus far, few reports are available in the literature.1,4,7 This case report presents the possibility of moving teeth over a long distance through the maxillary sinus to close posterior edentulous spaces. In addition, it demonstrates the generation of new bone after tooth movement, which, in turn, contributed to changes in the configuration of the maxillary sinus and the maxillary tuberosity region. 493

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Fig 1. Pretreatment facial and intraoral photographs.

DIAGNOSIS AND ETIOLOGY

A 41-year-old Asian woman came to the graduate orthodontic clinic, Arthur A. Dugoni School of Dentistry, University of the Pacific, in San Francisco, with a chief complaint of lip protrusion and difficulty in lip closure. She had no significant past medical history but had a moderately restored maxillary dentition with several missing molars. She received regular periodontal checkups, and her oral hygiene was well maintained. The pretreatment facial photographs showed a convex profile and upper and lower lip protrusion with lip incompetence upon closure. Although a slight maxillary occlusal cant and a slight facial asymmetry were observed, the facial midline and dental midlines were coincident (Fig 1). Intraorally, the patient had normal overjet and overbite (4 and 3 mm, respectively), a Class II canine relationship bilaterally, a lingual crossbite, and a significant supraeruption of the maxillary right first molar because of the missing opposing mandibular right

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first molar (Fig 2). Loss of the mandibular right first molar also resulted in the mandibular right second molar's being mesially tipped and the mandibular right second premolar's being distally displaced toward the missing first molar space, which left about 6 mm of space. The loss of the maxillary left first and second molars resulted in a space of 16 mm, into which the maxillary left third molar was slightly mesially tipped. A moderate curve of Spee in the mandibular arch was observed. Figure 3 shows the pretreatment lateral cephalometric and panoramic views from the cone-beam computed tomography (CBCT) images. They showed that the dentition was moderately restored, including root canal treatments on the maxillary central incisors and the maxillary right second molar. The lateral cephalometric tracing and analysis (Table) demonstrated normal anteroposterior (ANB, 2 ) and vertical (normodivergency; MP-SN, 28 ; FMA, 21 ) relationships relative to the cranial base with severe proclination of the

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Fig 2. Pretreatment study casts.

maxillary and the mandibular incisors (U1-NA, 11 mm; U1-SN, 111 ; L1-NB, 10 mm; IMPA, 101 ) and lip protrusion beyond the E-line (upper lip, 1 mm; lower lip, 4 mm). The interincisal angle was 120 , and the nasolabial angle was less than 90 . Based on the cephalometric measurements, the patient was diagnosed as having a normal skeletal pattern with severe bimaxillary protrusion. Sagittal and coronal slices of the CBCT image showed that the floor of the maxillary sinus on the left side extended significantly toward the top of the alveolar crest, leaving only 1 mm of cortical bone in the edentulous space where the first and second molars were missing (Fig 4). The distal surface of the maxillary second premolar and the mesial surface of the third molar were directly contacting the cortical bone of the maxillary sinus wall. In addition, the maxillary left third molar had 3 roots that were unusually well developed, including a buccolingually wide mesial root that is more typical of mandibular molars (Fig 4, C). The floor of the maxillary sinus on the right side also extended into the roots of the posterior teeth, especially at the supraerupted first molar (Fig 4, A). The temporomandibular joint was asymptomatic, and radiographic evidence showed no abnormalities.

The patient reported a family history of lip protrusion. The etiology of the bimaxillary protrusion appeared to be primarily hereditary. TREATMENT OBJECTIVES

The treatment objectives for this patient were to (1) improve her facial profile and eliminate her lip incompetence through maximum retraction of the maxillary and mandibular incisors into the existing spaces and the extraction spaces (maxillary right first molar and mandibular left first premolar); (2) close the remaining space with protraction of the maxillary left third molar and the mandibular right second molar after using the spaces needed for incisor retraction; (3) obtain normal overjet and overbite; and (4) achieve ideal Class I canine relationships with good buccal occlusion. TREATMENT ALTERNATIVES

A combined orthodontic and restorative plan was presented as the preferred treatment option. This involved extracting all first premolars, except the maxillary left premolar because of the 2 missing molars, and retracting the anterior segments to reduce the lip

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Fig 3. Pretreatment lateral cephalogram, tracing, and panoramic radiograph.

Table. Cephalometric analysis Pretreatment Posttreatment Skeletal SNA ( ) SNB ( ) SNP( ) ANB ( ) MP-SN ( ) FMA (MP-FH) ( ) Dental U1-SN ( ) U1-NA ( ) U1-NA (mm) L1-NB ( ) L1-NB (mm) IMPA (L1-MP) ( ) FMIA (L1-FH) ( ) Interincisal angle (U1-L1) ( ) Soft tissue Upper lip to E-plane (mm) Lower lip to E-plane (mm) Nasolabial angle ( )

Norm

87 84.8 85.1 2.3 28.3 20.8

87.6 83.4 84.7 4.2 28.5 20.1

81 6 4.0 77.7 6 3.4 79.8 6 4.1 2.9 6 2.7 32.1 6 5.5 23.9 6 4.5

111.1 24.1 10.6 33.6 10.4 100.5 58.8 120.1

89 1.4 0.3 19.4 2.8 87.6 72.4 155

102.8 6 5.5 22.8 6 5.7 4.3 6 2.7 25.3 6 6.0 4 6 1.8 90 6 7.0 64.8 6 8.5 130 6 6.0

0.7

2.8

6 6 2.0

4.2

1.4

2 6 2.0

104.6

102 6 8.0

86

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protrusion. The remaining spaces would be restored with dental implants to replace the mandibular right first molar and the maxillary left molar, which would also require a maxillary sinus-floor augmentation. However, the patient declined the maxillary sinus lift procedure and implant option because of the surgical risks and high costs. An orthodontic-only approach with miniscrews to close all remaining spaces without dental restorations was also discussed. To reduce lip protrusion, maximum distal movement of the maxillary premolars and anterior teeth would be necessary. This option required extractions in the maxillary right and mandibular left quadrants, and also using the existing spaces in the maxillary left and mandibular right quadrants. Although the need for restorations was eliminated, a significantly longer orthodontic treatment time was expected, since the space from the 2 missing molars was about 16 mm. Moreover, because the maxillary sinus extended into the top of the alveolar crest in the missing molar space and the cortical bone of the sinus wall directly contacted the mesial surface of the unusually large

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Fig 4. Pretreatment CBCT images: A, sagittal slice at the middle of the alveolar ridge of the right buccal segment; B, coronal slice at the position of the maxillary right second molars and left edentulous space; C, axial slice at the middle of the maxillary posterior root level (arrow indicates the roots of the maxillary left third molar); D, sagittal slice at the lingual third of the alveolar ridge of the left buccal segment. Note the wide surface of the mesial root directly contacting the maxillary sinus wall. The edentulous space is completely pneumatized by the extension of the maxillary sinus.

mesial root of the third molar, protraction mechanics would require careful planning and accurate execution of force systems to achieve bodily tooth movement with bone (Fig 4). With mesial movement of the third molar and distal movement of the second premolar, modeling of the maxillary sinus wall (new bone on the wall of the maxillary sinus) must occur before bone resorption. Despite knowing that it would be a long treatment time, the patient still accepted the orthodontic treatment-only option to close all spaces. Therefore, extractions of the first premolars in the maxillary right and the mandibular left quadrants for retraction of the incisors were considered inevitable. A large amalgam filling also provided a practical reason for extracting the maxillary right first premolar. However, extraction of the first molar in the maxillary right quadrant was discussed because the alveolar bone level was above its furcation due to supraeruption (Fig 4, A). After considering the feasibility of intrusion and the prognosis of the periodontal status, we decided to extract the first molar in the maxillary right quadrant. TREATMENT PROGRESS

A periodontal examination and prophylactic procedures were performed, root canal retreatment was done on the maxillary right second molar, and new root canal treatment was done on the maxillary right

canine before orthodontic treatment. The patient was committed to regular dental and periodontal checkups throughout her orthodontic treatment. After extraction of the maxillary right first molar and the mandibular left first premolar, 0.022 3 0.028-in slot preadjusted brackets were bonded on the maxillary and mandibular teeth. Molar bands with lingual attachments were added to apply lingual intramaxillary forces to prevent molar rotation during space closure. Absolute anchorage using miniscrews was planned to achieve maximum retraction of the mandibular incisors. Two miniscrews were placed mesial to the mandibular first molars and were used for direct anchorage by connecting nickel-titanium closed-coil springs from the miniscrews to anterior hooks on the 0.019 3 0.025-in stainless steel archwire (Fig 5). In contrast, a reciprocal space-closure strategy was incorporated in the maxillary left quadrant, where half of the space was closed by retracting the incisors and the other half by protracting the third molar. After retraction of the mandibular incisors, gradual en-masse retraction of the maxillary incisors was achieved using elastic chains and nickel-titanium closed-coil springs in a 0.018 3 0.025-in stainless steel wire with a reverse curve. Throughout the space-closure mechanics, an accentuated curve and light forces were used to control the maxillary incisor inclination and to promote bodily tooth movement during protraction of the third molar in the maxillary arch.

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Fig 5. Progress photos 2.5 years into treatment. Miniscrews were placed in the mandibular arch to provide maximum anchorage.

Progress photographs at 2.5 years into treatment showed an improved facial profile from retraction of the incisors (Fig 5). After 3.5 years of treatment, incisor retraction was completed, and the mandibular miniscrews were removed (Fig 6). It seems that having the maxillary right second molar and the maxillary left third molar against the cortical bone of the sinus wall provided for almost absolute anchorage; maximum incisor retraction was achieved, and about 5 mm of space still remained in the maxillary left quadrant. However, the panoramic radiograph showed that the maxillary third molar crown had tipped mesially, and the second premolar crown had tipped distally, so there was actually approximately 8 to 10 mm of space between their roots. There were signs of sinus wall modeling in the direction of tooth movement (distal surface of the second premolar and mesial surface of the third molar) and a significant amount of new bone deposition distal to the third molar.

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At this point in treatment, the remaining space needed to be exclusively closed by protracting the third molar. At 4.5 years into treatment, all spaces were closed clinically, including in the maxillary left quadrant (Fig 7). During an additional year of treatment, a tip-back bend was placed in a 0.017 3 0.025-in beta-titanium archwire with double helical loops to allow uprighting of the third molar and maxillary sinus modeling. The panoramic and periapical radiographs showed that the third molar still required more mesial root movement for uprighting. In addition, there were signs of modeling of the sinus wall and floor between the roots of the second premolar and the third molar (Fig 8). After confirming root parallelism and uprighting of the third molar (Fig 8), all orthodontic appliances were debonded, and wrap-around Hawley retainers were delivered in both arches to allow for further settling and closure of band spaces, while also preventing the

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Fig 6. Intraoral photographs and panoramic radiograph at 3.5 years into treatment. Spaces were all closed except in the maxillary left quadrant.

Fig 7. Intraoral photographs at 4.5 years into treatment. Clinically, all spaces were closed. Panoramic radiograph at 5.5 years. An extended sinus remained between the second premolar and the third molar, and the third molar crown was still mesially tipped toward the space.

spaces from opening up. The total treatment time was 70 months. TREATMENT RESULTS

Fig 8. Periapical radiographs at 5.5 and 5.9 years into treatment. The third molar is uprighted. The arrows indicate the radiographic sign of new bone formation followed by distal movement of the premolars.

The posttreatment records demonstrated that all treatment objectives were achieved with good esthetic and occlusal results (Figs 9 and 10). Protrusion of the upper and lower lips was corrected, and lip incompetence upon closure was relieved. As a result, facial convexity was significantly reduced, and a harmonious facial balance was achieved. In addition, ideal overjet and overbite, coincident dental and facial midlines,

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Fig 9. Posttreatment facial and intraoral photographs.

and Class I canine relationships with good buccal occlusion were obtained. All spaces were closed, with good root parallelism. The final panoramic radiograph confirmed that the maxillary left third molar was successfully moved mesially more than 10 mm and that modeling of the cortical bone of the maxillary sinus wall occurred along with new bone formation behind the molar (Fig 11). Since space closure required bodily tooth movement with light forces, the treatment time was significantly extended. The patient understood that her treatment involved the long and complex process of protracting the maxillary third molar, which also required maintaining healthy dental and periodontal tissues throughout treatment. No apparent root resorption was observed, and the alveolar bone level was maintained (Fig 11). Toward the end of treatment, the patient had her restorations (post and crown) on the maxillary central incisors replaced. The cephalometric measurements showed successful correction of bimaxillary protrusion without changing

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the skeletal jaw relationship. The mandibular incisors were uprighted from 101 to 88 relative to the mandibular plane (IMPA), the maxillary incisors were uprighted from 111 to 89 with respect to SN (SN to U1), and the mandibular plane angle (SN-MPA, FMA) was maintained (Table). Overall, the inclination of the maxillary incisors could have been better controlled; however, significant root movement was limited because of concern that the central incisors would be weakened, since they had endodontic treatment with post crowns. The cephalometric superimposition showed that the maxillary and mandibular incisors were retracted approximately 9.5 and 8.5 mm, respectively, mainly through controlled distal tipping and intrusive movement of the mandibular incisors (Fig 12). This resulted in the upper and lower lips placed behind the E-line. In addition, the maxillary left third molar moved forward, and the mandibular right second molar was uprighted with a slight mesial movement. Since the patient wanted to orthodontically close all spaces to eliminate the need for restorations, she was

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Fig 10. Posttreatment study casts.

satisfied with the results, despite the unusually long treatment time. An acceptable occlusion and normal overjet and overbite were maintained after 18 months of retention (Fig 13). The follow-up CBCT images confirmed that some portion of the interradicular space between the maxillary left third molar and the second premolar was filled in with new bone, but the rest was filled with sinus pneumatization (Fig 14, C and D). DISCUSSION

The floor of the maxillary sinuses is a layer of compact bone lined with periosteum that is formed by the alveolar process of the maxilla and maintains contiguity with the maxillary posterior teeth throughout life.10,11 A few experimental and radiographic studies have shown maxillary sinus pneumatization in adult patients after the extraction of posterior teeth.11-13 This phenomenon is caused by a type of disuse atrophy that occurs with replacement with functionless bone.11,14 Sharan and Madjar11 reported that sinus expansion was greater in cases that involved second molar extractions and when 2 or more adjacent posterior teeth were extracted. Studies also showed that postextraction pneumatization occurred during the 4- to

6-month socket healing period.11,15 In addition, the pneumatization process was reduced after mature bone developed in the extraction socket. Therefore, if dental implant placement is planned in such cases, the clinician should consider preserving as much bone height as possible through immediate implantation or immediate bone grafting at the time of extraction to prevent or decrease pneumatization of the sinus.11,16,17 In severe cases, such as this patient, sinus pneumatization can extend entirely into the alveolar process of the edentulous space between the roots of the neighboring teeth; this makes it not only difficult to move teeth through the sinus (Fig 4), but also impossible to place a restorative implant without also needing sinus lift surgery. In this patient, in lieu of premolar extractions, the clinicians attempted to orthodontically close the edentulous space by moving the teeth through the maxillary sinus to allow for retraction of the maxillary incisors to eliminate the need for dental restorations and a relatively complicated sinus-lift surgical augmentation procedure.18,19 It is well established that bone follows tooth movement and that teeth can be moved “with the bone” or “through the bone.” To produce a “with the bone” type of tooth movement, direct bone resorption in the direction of tooth movement must take place, and there

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Fig 11. Posttreatment lateral cephalogram and tracing, and panoramic and periapical radiographs.

must be a balance between resorption and apposition.1-4 Recently, Kuroda et al20 demonstrated that new bone formation on the surface of the maxillary sinus was evoked by mechanotransduction of mechanical stress applied to a tooth in an experimental tooth movement model. Osteogenesis was induced ahead of bone resorption on the periodontal ligament side, and the bone thickness of the sinus was generally consistent throughout the period of tooth movement. In adult patients, it is crucial to maintain light and continuous forces with bodily tooth movement to prevent any hyalinization that can cause indirect resorption, a situation in which the tooth moves through the bone without apposition.1-4 Melsen1,2 and others have emphasized the importance of increasing the momentto-force ratio to achieve bodily movement.3,4 In addition, several experimental studies suggested that orthodontically induced translation movements depend on the speed of the movement.21 Wingard and Bowers22 pointed out that movement at low speeds is a prerequisite

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for compensatory regeneration of fibrous bone. When teeth are moved at excessive rates, resorption of the periodontal ligament and periosteal apposition becomes uncoordinated in such a way that adequate bone regeneration in front of the tooth might be prevented. In our patient, light constant forces and a force system for bodily movement were attempted throughout tooth movement. However, it was impossible to accurately measure the moment-to-force ratios and force levels at each moment. When space was closed at the crown level, radiographs showed that further root movement was required for both the second premolar and the third molars. In addition, the extension of the sinus space was narrowed between the roots, and there were typical radiographic signs of a denser new bone trail and lamina dura surrounding the roots (Fig 7). Light continuous forces with a beta-titanium archwire with double helical loops were applied until the roots became parallel to each other. It took a considerable amount of time to move the third molar against the cortical wall of the sinus. Since

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Fig 12. Cephalometric superimposition.

the third molar forms distal to the posterior wall of the sinus, it seems that moving the maxillary third molar mesially through the sinus was much more difficult than moving the second molars. Previous studies have suggested that the morphologic structure of the sinus itself is an important factor in influencing the type of tooth movement that occurs—tipping or bodily movement.12,23 It has been shown that if there is more vertical extension of the basal maxillary sinus in front of the tooth that needs to be moved, it becomes harder to achieve bodily movement. Moreover, Roberts et al24 reported that after the mandibular second molar was moved mesially a few millimeters, there was a dramatic decrease in the rate of tooth movement that was related to the trailing root's being engaged in the denser, immature alveolar bone formed by the leading root. This concept can similarly be applied to maxillary third molar mesial movement through the sinus. In our patient, the 18-month posttreatment CBCT images showed that sinus floor modeling was obtained between the roots, and more than 10 mm of new bone was left behind the third molar. This would have been an ideal location for dental implant placement, but it was unnecessary for this patient. There also appeared to be no noticeable root resorption for both the premolars and the third molars, even though they traveled more than 10 mm through the sinus. It also seems that through modeling of the floor, some part of the extended sinus between the roots was

completely recessed to a level above the maxillary root, and new bone was located between the roots (Fig 14). This patient's main concern was to reduce her severe lip protrusion. Maximum anchorage was planned to achieve maximum retraction of the incisors, and 8 to 9 mm of incisor retraction was achieved. Miniscrews were placed in the mandibular arch, but no special anchorage methods were incorporated in the maxillary arch, even though the anchor unit was composed of only 1 last molar, which was pitted against the 5 teeth that needed to be retracted on each side. Therefore, it seems that it was possible to achieve maximum anchorage in the maxillary arch by carrying out bodily movement through the sinus wall in front of the molars to be moved. CONCLUSIONS

This case report demonstrates that successful tooth movement through the maxillary sinus can be achieved without noticeable side effects. New bone formation followed tooth movement, and changes in the size and shape of the maxillary sinus were observed. Maintaining light continuous forces and moving teeth at a slower rate were keys in accomplishing bodily movement and direct bone resorption. Overall, the patient's chief complaint was successfully resolved through maximum retraction of the incisors and use of the existing edentulous spaces.

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Fig 13. Posttreatment facial and intraoral photographs at 18 months. REFERENCES 1. Melsen B. Limitations in adult orthodontics. In: Melsen B, editor. Current controversies in orthodontics. Chicago: Quintessence; 1991. p. 147-80. 2. Melsen B. Biological reaction of alveolar bone to orthodontic tooth movement. Angle Orthod 1999;69:151-8. 3. Zachrisson BU. Current trends in adult treatment, part 2. J Clin Orthod 2005;34:285-96. 4. Cacciafesta V, Melsen B. Mesial bodily movement of maxillary and mandibular molars with segmented mechanics. Clin Orthod Res 2001;4:182-8. 5. Vitral RW, da Silva Campos MJ, de Andrade Vitral JC, Santiago RC, Fraga MR. Orthodontic distalization with rigid plate fixation for anchorage after bone grafting and maxillary sinus lifting. Am J Orthod Dentofacial Orthop 2009;136: 109-14. 6. Iturriaga MT, Ruiz CC. Maxillary sinus reconstruction with calvarium bone grafts and endosseous implants. J Oral Maxillofac Surg 2004;62:344-7.

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7. Re S, Corrente G, Abundo R, Cardaropoli D. Bodily tooth movement through the maxillary sinus with implant achorage for single tooth repalcement. Clin Orthod Res 2001;4:177-81. 8. Daimaruya T, Takahashi I, Nagasaka H, Umemori M, Sugawara J, Mitani H. Effects of maxillary molar intrusion on the nasal floor and tooth root using the skeletal anchorage system in dogs. Angle Orthod 2003;73:158-66. 9. Wainwright WM. Faciolingual tooth movement: influence on the root and cortical plate. Am J Orthod 1973;64:278-88. 10. Mc Growan DA, Baxter PW, James J. The maxillary sinus and its dental implications. 1st ed. London, United Kingdom: Wright; 1993. 11. Sharan A, Madjar D. Maxillary sinus pneumatization following extraction: a radiographic study. Int J Oral Maxillofac Implants 2008;23:48-56. 12. Rosen M, Sarnat B. Change of volume of the maxillary sinus of the dog after extraction of adjacent teeth. Oral Surg Oral Med Oral Pathol 1955;8:420-9. 13. Harorh A, Bocutoglu O. The comparison of vertical height and width of maxillary sinus by means of Waters' view radiograms taken from dentate and edentulous cases. Ann Dent 1995;54:47-9.

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Fig 14. Posttreatment CBCT images at 18 months: A, sagittal slice at the middle of the alveolar ridge of the right buccal segment; B, coronal slice at the position of the maxillary right second molar and left third molar; C, axial slice at the middle of the maxillary posterior root level; D, sagittal slice at the middle of the alveolar ridge of the left buccal segment. Note that an extension of the maxillary sinus remained between roots of the second premolar and the third molar. Arrows indicate that an extended maxillary sinus still partially remained between the maxillary second premolars and the last molars on both sides. 14. Wehrbein H, Bauer W, Wessing G, Diedrich P. The effect of the maxillary sinus floor on orthodontic tooth movement. Fortschr Keiferorthop 1990;51:345-51. 15. Misch C. Contemporary implant dentistry. 2nd ed. St Louis: Mosby; 1999. 16. Fugazzotto P. Sinus floor augmentation at the time of maxillary molar extraction: technique and report of preliminary results. Int J Oral Maxillofac Implants 1999;14:536-42. 17. Fugazzotto P. Immediate implant placement following a modified trephine/osteotome approach: success rates of 116 implants to 4 years in function. Int J Oral Maxillofac Implants 2002;17:113-20. 18. Wiltfang J, Schultze-Mosgau S, Nkenke E, Thorwarth M, Neukam FW, Schlegel KA. Onlay augmentation versus sinus lift procedure in the treatment of the severely resorbed maxilla: a 5-year comparative longitudinal study. Int J Oral Maxillofac Surg 2005;34:885-9. 19. Zijderveld SA, Zerbo IR, van den Bergh JP, Schulten EA, ten Bruggenkate CM. Maxillary sinus floor augmentation using a

20.

21.

22. 23.

24.

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beta-tricalcium phosphate (Cerasorb) alone compared to autogenous bone grafts. Int J Oral Maxillofac Implants 2005;20:432-40. Kuroda S, Wazen R, Moffatt P, Tanaka E, Nanci A. Mechanical stress induces bone formation in the maxillary sinus in a shortterm mouse model. Clin Oral Investig 2013;17:131-7. Wehrbein H, Fuhrmann R, Diedrich P. Human histologic tissue response after long-term orthodontic tooth movement. Am J Orthod Dentofacial Orthop 1995;107:360-71. Wingard CE, Bowers GM. The effects of facial bone from facial tipping of incisors in monkeys. J Periodontol 1976;47:450-4. Livas C, Halazonetis D, Booij J, Pandis N, Tu Y, Katsaros C. Maxillary sinus floor extension and posterior tooth inclination in adolescent patients with Class II Division 1 malocclusion treated with maxillary first molar extractions. Am J Orthod Dentofacial Orthop 2013;143:479-85. Roberts WE, Arbuckle GR, Analoui M. Rate of mesial translation of mandibular molars using implant-anchored mechanics. Angle Orthod 1996;66:331-8.

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Orthodontic tooth movement through the maxillary sinus in an adult with multiple missing teeth.

This case report describes the successful orthodontic tooth movement through the maxillary sinus in an adult patient. A 41-year-old Asian woman had se...
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