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DEVELOPMENTS IN
ORTHODONTICS
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2 C E C R E D I T S

ESTHETIC RIDGE AUGUMENTATION

Tridimensional Reconstruction of a Complex

Iatrogenic Defect Using Orthodontic Forced
Eruption and Minimally Invasive Bone Grafting
Ernesto A. Lee, DMD

C A S E R E P O R T

ORTHODONTIC TECHNIQUE

Frictionless Segmented Mechanics for

Controlled Space Closure
Ildeu Andrade, Jr., DDS, MS, PhD; Fernando Amaral Moreira Guimaraes, DDS;
and Giordani Santos Silveira, DDS, MS

SUPPORTED BY AN UNRESTRICTED GRANT FROM CLEARCORRECT • Published by AEGIS Publications, LLC © 2021
 The Next
Movement
of Continuing Education in Dentistry

W
MAY 2021 | www.compendiumlive.com

PUBLISHER
Matthew T. Ingram
of Continuing Education in Dentistry
SPECIAL PROJECTS DIRECTOR
elcome to another edition of the C. Justin Romano
Compendium eBook series focus- SPECIAL PROJECTS COORDINATOR
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ing on clinical topics addressing of Continuing Education in Dentistry
MANAGING EDITOR
the latest developments in oral Bill Noone

healthcare. CREATIVE
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General practice dentistry is expanding treatment offer-
EBOOK DESIGN
ings as more sophisticated digital technology becomes widely Jennifer Barlow

available and affordable. Orthodontics is one area of increas-

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disciplinary approach with a subperiosteal minimally invasive Printed in the U.S.A.

esthetic ridge augmentation technique for safer, more predict-

able results.
The accompanying case report explores a treatment plan
developed to improve the patient’s lateral profile and lip line,
obtain ideal inclination of anterior teeth, maintain class I molar
and canine relationships, achieve ideal overbite and overjet,
and attain a mutually protected functional occlusion. As the pa-
tient rejected more aggressive treatments, the authors describe
how their simple controlled segmented mechanical approach
Chairman & Founder
(differential moments without friction to minimize anchorage Daniel W. Perkins
loss and control incisor torque) produced excellent results in Vice Chairman & Co-Founder
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 CONTINUING EDUCATION ESTHETIC RIDGE AUGUMENTATION

Tridimensional Reconstruction of
a Complex Iatrogenic Defect Using
Orthodontic Forced Eruption and
Minimally Invasive Bone Grafting
Ernesto A. Lee, DMD

ABSTRACT: As the use of dental implants has become more common, so has the frequency
of complications and unforeseen outcomes. This article describes the treatment of a complex
iatrogenic defect secondary to a failed implant (No. 7) and multiple bone-grafting attempts in
the maxillary anterior region. The patient’s revealing smile line and high-risk circumstances
demanded the use of an interdisciplinary treatment approach with high potential for predict-
able esthetic results. Forced eruption was performed to restore the alveolar height deficit and
develop the compromised hard and soft tissues around teeth Nos. 6 and 8. The subperiosteal
minimally invasive (a)esthetic ridge-augmentation technique (SMART) was subsequently
used to provide horizontal bone augmentation while preserving the soft-tissue architecture.
After bone-graft integration, immediate postextraction implants were placed at Nos. 6 and
8 using a flapless approach, and a screw-retained long-term polymethylmethacrylate provi-
sional prosthesis was delivered during the same appointment. The synergy of these combined
therapies resulted in a complete tridimensional reconstruction of the defect. Gingival and
alveolar volumes and gingival margin levels were successfully restored.
LEARNING OBJECTIVES

• Discuss the rationale for • Describe the minimally • Explain how forced eruption
implant therapy in the esthetic invasive bone-grafting used in conjunction with min-
zone technique used for treating a imally invasive bone grafting
complex iatrogenic gingival- can enhance the reconstruction
alveolar defect of gingival-alveolar defects in

T
the esthetic zone

he use of dental implants has be- revealing smile, treatment of these complica-
come increasingly widespread tions represents a high-risk proposition for
and, along with it, the frequency clinicians, which is compounded by potential
of complications and unexpected medico-legal implications. The most difficult
outcomes has risen. In particular, endeavor in these situations is the recreation
iatrogenic sequelae from failed implant and of an ideal gingival architecture, particularly
bone-augmentation procedures in the esthetic when dental implants are involved.
zone pose a significant challenge because of Alveolar ridge defects have traditionally
the often catastrophic nature of the resulting been treated with surgical techniques that in-
gingival-alveolar defects. In the presence of a volve the reflection of a mucoperiosteal flap.
DISCLOSURE: “Subperiosteal Minimally Invasive Aesthetic Ridge Augmentation Technique” and “S.M.A.R.T.” are trademarks of the author.
The method and its associated devices are the subject of one or more pending patent applications.
3 COMPENDIUM EBOOK SERIES May 2021 | Volume 42 Number 5 www.compendiumlive.com
 CONTINUING EDUCATION ESTHETIC RIDGE AUGUMENTATION

Because these defects often require signifi- of combined therapies, including orthodontic
cant volume augmentation, a greater degree forced eruption and distraction osteogenesis,
of flap reflection and advancement is needed may provide more predictable alternatives to
to achieve adequate co-aptation. The risk of vertical bone augmentation while preserving
complications is also increased, including in- the soft-tissue architecture.3,4
complete wound closure and soft-tissue de- The purpose of this article is to demonstrate,
hiscences, which could lead to exposure of the through the presentation of a case report, the
membrane or graft material, infections, and use of an interdisciplinary approach that in-
compromised hard- and soft-tissue outcomes.1 cluded forced eruption and a novel subperi-
An evaluation of the predictability of bone- osteal minimally invasive (a)esthetic ridge-
augmentation procedures in the esthetic zone augmentation technique (SMART) for the
must take into account the resulting peri-im- treatment of a complex iatrogenic gingival-
plant soft-tissue architecture. This factor be- alveolar defect.
comes a crucial concern in high-risk scenarios
when improved esthetic outcomes are required Case Presentation
and minimally invasive surgical techniques A healthy 20-year-old woman presented to
need to be considered.2 Additionally, the use the author’s office requesting treatment for a

Fig 1. Fig 2.

Fig 3. Fig 4.

Fig 1. The patient presented with a large deformity stemming from a congenitally missing maxillary right
lateral incisor. Fig 2. A failed implant and bone-graft procedures had resulted in a substantial iatrogenic
gingival-alveolar defect. Fig 3 and Fig 4. Tomographic images revealed a tridimensional defect extend-
ing to the apical third of teeth Nos. 6 and 8, a buccal bone dehiscence on tooth No. 5, and associated
thin labial plates.

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 CONTINUING EDUCATION ESTHETIC RIDGE AUGUMENTATION

An evaluation of the predictability of

bone-augmentation procedures in the esthetic zone
must take into account the resulting peri-im­plant
soft-tissue architecture.
large defect in the area of missing tooth No. 7. keratinized gingiva was present and the soft
She exhibited a high smile line that revealed a tissues were acutely inflamed. Plaque removal
clearly visible deformity, associated with pain was difficult because of the soft-tissue defect,
and sensitivity on teeth Nos. 6 and 8 and in the gingival-margin location, and irregular soft-
area of tooth No. 7 (Figure 1). Although the tissue architecture. Additionally, bone seques-
patient wore a modified Essix retainer, the tration could be observed through the labial
defect was still visible because of the magni- mucosa (Figure 2).
tude of tissue loss and the revealing nature of Tomographic images revealed a large tridi-
her smile. mensional defect, with vertical and horizontal
The patient reported previous compre- loss of bone extending to the apical third of
hensive orthodontic therapy, part of which teeth Nos. 6 and 8. Additionally, a buccal bone
included the creation of adequate space for dehiscence was evident on tooth No. 5, and
replacement of the congenitally missing max- thin labial plates secondary to the orthodon-
illary right lateral incisor. After completion of tic movement were present in several areas
orthodontic therapy, implant placement and (Figure 3 and Figure 4).
bone grafting were performed in the area of
No. 7. Unfortunately, both procedures failed, Rationale for Implant Therapy in
resulting in a large hard- and soft-tissue de- the Esthetic Zone
fect. A subsequent attempt to perform bone Establishing esthetic and restorative objec-
augmentation was also unsuccessful and, in- tives is essential in treatment planning for
stead, resulted in a larger deficit and increased complex defects in the maxillary anterior
recession on teeth Nos. 6 and 8. After a recom- region. In the present case, teeth Nos. 6 and
mendation to attempt a third bone graft, the 8 required extraction and replacement with
patient decided to seek alternative options. implants due to their poor prognosis. The pa-
tient’s high smile line and esthetic demands
Clinical Examination precluded the use of any prosthesis incorpo-
The intraoral examination revealed a sub- rating pink restorative materials.
stantial deficit of alveolar bone and gingival Esthetic outcomes in implant therapy are
tissues in the maxillary right lateral incisor highly dependent on the architecture of the
area. The ridge defect exhibited vertical and peri-implant soft tissues.5 Additionally, the
horizontal components, which were associ- esthetic predictability of immediate postex-
ated with a severe loss of clinical attachment traction implant placement has been well-
on both the mesial aspect of tooth No. 6 and documented.6-13 Lee and coworkers reported
the distal aspect of tooth No. 8. Although prob- minimal changes in the thickness of the labial
ing depths were within normal limits, minimal plate 6 months after treatment,12 and Chu et

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 CONTINUING EDUCATION ESTHETIC RIDGE AUGUMENTATION

al similarly reported negligible remodeling of procedures needed to be considered. In the

labial soft-tissue profiles.14 results of an initial study, Merli and coworkers
Although different protocols have been ad- reported a 54% total complication rate in ver-
vocated, recent publications show consensus tical augmentation procedures comparing the
on the importance of clinician experience use of autogenous bone grafts with resorbable
and adequate site selection in achieving pre- membranes and titanium plates versus tita-
dictable esthetic outcomes with immediate nium-reinforced barriers.23 In a subsequent
postextraction flapless implant placement study of vertical GBR outcomes using resorb-
and provisionalization.13,15,16 Therefore, a ra- able and nonresorbable membranes, Merli re-
tionale for the predictable treatment of severe ported a total complication rate of 41%.24 The
gingival-alveolar defects in the esthetic zone complications included membrane exposure,
may require development of compromised infections, and loss of the graft. Both studies
sites into ideal sites before implant placement. were limited to posterior sites, and all surgical
In the present case, site development of Nos. procedures were performed by a highly skilled
6 and 8 with predictable soft-tissue esthet- clinician with more ➀ than 20 years of experi-
ics would be a complex endeavor requiring ence with dental implant surgery.
the use of interdisciplinary therapy. Whether Because of the high-risk scenario in the pres-
subsequent immediate implant placement ent case, based on the iatrogenic nature and
➁
and provisionalization would result in abso- complexity of the defect, its location in the
lute preservation of the hard and soft tissues anterior maxilla, and the revealing smile line,
is less relevant than a comparison between traditional surgical bone-augmentation pro-
the esthetic outcomes of this approach ver- cedures (horizontal or vertical) were likely to
sus those achieved with traditional flap-based present an unacceptable rate of complications
surgical augmentations. and lack of esthetic predictability. Therefore,
they were not considered as options for resolv-
Esthetic Predictability of Bone- ing the clinical challenges of this case.
Grafting Procedures
Bone-grafting procedures have been shown Orthodontic Forced Eruption
to be efficacious in providing adequate bone Bone remodeling associated with orthodon-
volumes for dental implant placement.4,17-19 tic movement follows the basic principles
However, the effect of these procedures on the described by Reitan. When a tooth is moved
peri-implant soft-tissue profiles is an impor- in a certain direction, bone resorption occurs
tant consideration in the esthetic zone. Several on the side where pressure is applied to the
authors have reported that bone augmenta- periodontal ligament, while bone apposition
tion, guided bone regeneration (GBR), and is stimulated by the tension generated on the
flap-based techniques exhibit an increased opposite side.25 In 1973, Brown reported the
risk of complications and compromised peri- effect of orthodontic therapy on periodontal
implant esthetics, frequently resulting in se- defects and the potential for changes in the
quelae ranging from scar formation and gingi- hard- and soft-tissue architecture.26 In a clas-
val defects to recession and deficient papillae, sic report, Ingber described the use of orth-
particularly in thin-biotype scenarios.2,20-22 odontic forced eruption and the resulting bone
In addition, the patient in this case report ex- remodeling to treat periodontal infrabony
hibited a large iatrogenic defect with a substan- defects.27 Pontoriero et al demonstrated how
tial vertical component, and, therefore, the this technique could also be used to alter in-
predictability of vertical bone-augmentation terproximal crest levels.28 Ingber subsequently

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 CONTINUING EDUCATION ESTHETIC RIDGE AUGUMENTATION

reported on the benefits of soft-tissue remod-

eling associated with forced eruption in the
treatment of cosmetic soft-tissue deformi-
ties.29 Salama and coworkers later described
the use of forced eruption in hopeless teeth
and how the resulting orthodontic extrusive
Fig 5. remodeling of hard and soft tissues could be
used to develop extraction-site defects before
implant placement.30
Due to its predictability in achieving bone re-
modeling and developing alveolar ridge height
while preserving or improving soft-tissue ar-
chitecture, forced eruption was included as
part of the interdisciplinary approach to treat
Fig 6. the patient in the present case (Figure 5). Only
stretching forces are applied to the periodon-
tal ligament during the forced-eruption move-
ment. This provides the stimulus for bone ap-
position within the socket walls. Generally, the
orthodontic movement should be controlled
so the root is extruded without impinging on
the socket walls. In the presence of periodon-
Fig 7. tal health, bone apposition and gingival re-
modeling will result in coronal proliferation
of the attachment apparatus.29,30
Occlusal management during the forced-
eruption process is essential to avoid prema-
ture contacts that may displace the teeth labi-
ally and cause resorption of the buccal plate.
Fig 8. Fig 9. The author recommends providing 2.5 mm of
occlusal clearance at the start of forced erup-
Fig 5. Start of orthodontic forced eruption to de-
velop sites Nos. 6 and 8 before implant placement.
tion and performing weekly occlusal adjust-
A denture tooth was common-tied to the archwire ments to re-establish this distance through
to serve as a pontic. Anchorage requirements deter- the duration of the forced eruption. The rate
mined the extent of bracket placement. Fig 6 and Fig of extrusion may vary, so patients should be
7. Eruption of tooth No. 6 to the apical third and tooth
No. 8 beyond its alveolus was needed to achieve ideal
instructed to contact the office for ad hoc
site development. This degree of forced eruption adjustments at any point where contact with
often results in lingual displacement that needs to be the opposing dentition may be perceived.
managed with root-torquing auxiliaries. Sulcular epi- Additionally, supracrestal fiberotomy may be
thelium eversion can be observed on tooth No. 8. Fig
8 and Fig 9. Compared to the preoperative view seen performed to sever the periodontal ligament
in Fig 2, adequate alveolar height and gingival profile fibers and control the coronal migration of the
were achieved with forced eruption (Fig 8). Direct attachment apparatus.28 In the present case,
composite splint would remain for 3 months. Residual
cleft was a visible remnant of iatrogenic defect. Post-
supracrestal fiberotomies were performed bi-
orthodontically, keratinization of sulcular epithelium weekly on the mesial half of tooth No. 8 and
on tooth No. 8 was evident (Fig 9). the distal half of tooth No. 6.

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 CONTINUING EDUCATION ESTHETIC RIDGE AUGUMENTATION

Successful outcomes with forced eruption 8 and Figure 9 depict the treatment progres-
require the establishment of treatment end- sion with forced eruption. The restoration of
points, which may include overcompensa- adequate alveolar height was achieved while
tion beyond the desired soft- and hard-tissue enhancing the soft-tissue architecture, and
changes. For the present case, achieving ideal the everted sulcular epithelium on tooth No. 8
gingival-alveolar socket architecture required proceeded to develop keratinization. However,
force-erupting tooth No. 6 to the level of the the pre-existing defect still manifested itself
apical third and tooth No. 8 beyond the con- in the form of a residual cleft.
fines of its alveolus. As the gingival sulcus is After 3 months of post-orthodontic stabi-
everted through the eruption process, a gin- lization, a cone-beam computed tomogra-
gival red patch corresponding to the nonke- phy scan was taken to re-evaluate the results
ratinized sulcular epithelium may appear, as and plan the future treatment sequence.
shown around tooth No. 8 in Figure 8 and Tomographic images clearly showed verti-
Figure 9. This tissue will develop into keratin- cal gains in alveolar height, including in the
ized gingiva when exposed to the oral environ- edentulous area corresponding to tooth No.
ment.31,32 Additionally, when forced eruption 7 (Figure 10 through Figure 12). The apex of
of this magnitude is performed, there may be a tooth No. 8 was forced-erupted beyond its
tendency for lingual displacement that needs socket and could be visibly located within the
to be addressed with root-torquing orthodon- soft tissue.30,33
tic auxiliaries (Figure 6 and Figure 7).
When forced eruption is completed, the Minimally Invasive Bone Grafting
teeth should be splinted for a 3-month sta- The effect of complications secondary to tra-
bilization period,30 which will allow miner- ditional bone-augmentation procedures on
alization of osteoid tissue and settling of the the peri-implant soft-tissue architecture is
gingival remodeling process. The degree of an important consideration. Evidence sug-
forced eruption in the present case was such gests that flap-based surgical techniques, such
that extreme mobility precluded the use of as bone augmentation and GBR, may have a
a provisional restoration. Instead, a metal- deleterious effect on implant esthetics.2,20-22
reinforced direct composite splint extending Minimally invasive procedures offer the po-
from teeth Nos. 6 to 8 was fabricated in situ tential to decrease postoperative complica-
(Figure 8 and Figure 9). When compared with tions and morbidity. Although a variety of
the preoperative condition (Figure 2), Figure tunneling techniques with particulate bone

Fig 10. Fig 11. Fig 12. Fig 13. Fig 14. Fig 15.

Fig 10 through Fig 12. Tomographic images of teeth Nos. 6 (Fig 10), 7 (Fig 11), and 8 (Fig 12) clearly
showed vertical gains in alveolar height, including in the edentulous area corresponding to tooth No.
7. The apex of tooth No. 8 was located within the soft tissue because it was force-erupted beyond its
socket. Fig 13 through Fig 15. Flapless horizontal bone augmentation in the areas of teeth Nos. 6 (Fig
13), 7 (Fig 14), and 8 (Fig 15), using SMART method.

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 CONTINUING EDUCATION ESTHETIC RIDGE AUGUMENTATION

Gingival volume, margin level, and architecture

were successfully restored while avoiding
multiple hard- and soft-tissue
grafting procedures.
grafting have been attempted, they have not to maintain the contours of the augmentation
been widely accepted in clinical practice.34-39 (Figure 13 through Figure 15).55-57 The recom-
Recent interest has focused mainly on soft- binant platelet-derived growth factor BB was
tissue tunneling applications.40-47 used to stimulate bone formation and favor
The author recently published a case series soft-tissue healing.58-60
reporting the use of the SMART minimally in- The SMART method does not require the
vasive bone-grafting method. Bone augmenta- use of tenting screws or other space-main-
tion was achieved in 60 sites within five treat- taining devices. The degree of horizontal aug-
ment categories, with a maximum 30-month mentation is a result of the ability to establish
follow-up and human histology. The results the confines of the tunnel and subperiosteal
demonstrated predictable and consistent pouch, so that particle aggregation can be
bone augmentation, with a reduction in mor- achieved while controlling the dispersion of
bidity and complications.48 The mean hori- the graft material.
zontal augmentation in edentulous ridges was Contrary to traditional GBR techniques, cell
6.47 mm with the SMART approach, while occlusive membranes are not required in the
the average gain in ridge width for all treat- SMART method. The author previously con-
ment categories was 5.11 mm. These results ducted a pilot study that demonstrated mem-
compare favorably with previously reported branes to be unnecessary for graft integration
horizontal augmentation outcomes using tra- and mineralization. In addition, Simion and
ditional GBR techniques.49-54 coworkers have reported that growth fac-
For the present case, the SMART method tor–mediated bone regeneration benefited
was used to achieve horizontal bone augmen- when access to the periosteum was not pro-
tation while preserving the soft-tissue profiles hibited by a barrier membrane.58 Because no
developed using forced eruption. Flap eleva- decortication or intramarrow penetration was
tion would have resulted in loss of gingival ar- performed in the present case, the role of the
chitecture and the residual root of tooth No. periosteum as a potential source of osteopro-
8. A confined subperiosteal tunnel and pouch genitor cells in growth factor–mediated bone
were developed using the SMART instrumen- regeneration needs to be considered.61,62
tation and surgical technique to allow the de- Because recession was already present on
livery of an anorganic bovine-derived bone tooth No. 5, the scope of the SMART proce-
mineral and platelet-derived growth factor dure was extended to horizontally augment
combination and horizontally augment the adjacent areas that exhibited dehiscences and
labial alveolar bone in area Nos. 6, 7, and 8. thin buccal plates (Figure 16). The augmented
The rationale for selecting the biomaterial was areas evident in Figure 16 (which can be com-
based on its low substitution rate and ability pared to the preoperative imaging in Figure

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 CONTINUING EDUCATION ESTHETIC RIDGE AUGUMENTATION

4) were accomplished using two remote inci- predictable outcomes require training and ex-
sions. It must be emphasized, however, that perience. Unlike lateral subperiosteal tech-
this procedure may be technique sensitive, and niques, the SMART method is based on the
development of a laparoscopic tunnel from a
remote incision to access the graft site. A sub-
periosteal pouch is subsequently created to
confine the biomaterial particles (Figure 17
and Figure 18). This approach ensures that
surgical trauma to the subperiosteum and the
associated inflammatory reaction do not inter-
fere with healing of the bone graft. Specially
Fig 16. designed instruments are required to control
the elevation of the periosteum, reach the graft
site, and develop the subperiosteal pouch.
The bone graft underwent a 6-month matu-
ration period to allow integration of the bio-
material. At this point, teeth Nos. 6 and 8 were
atraumatically removed, and implants were
immediately placed into the extraction sites
without elevating a flap (Figure 19 through
Figure 21). The gingival tissues exhibited a
moderate degree of inflammation as a result
of the difficult access for oral hygiene pro-
Fig 17. cedures under the post-orthodontic splint,
which at the time had remained in place for 9
months. Implants featuring a tapered design
were selected, and excellent primary stabil-
ity was achieved (Figure 22 and Figure 23).
Insertion torque values in excess of 45 Ncm
were recorded for both implants, which al-
lowed an immediate loading protocol.6,7,63,64
A screw-retained three-unit provisional pros-
thesis from teeth Nos. 6 through 8 was deliv-
ered during the same appointment (Figure 20).
Fig 18. Additionally, direct composite occlusal over-
Fig 16. The SMART bone-graft procedure was lays were bonded to the central fossae of the
extended to horizontally augment adjacent ar- maxillary bicuspids and first molars to open the
eas that exhibited dehiscences and thin buccal bite and disengage the maxillary anterior teeth,
plates. This augmentation is clearly evident when
compared with the preoperative condition shown
thus avoiding centric and excursive contacts
in Fig 4. Fig 17 and Fig 18. Illustration of SMART during the osseointegration period.6-8,10,12
method. A full-thickness incision is made at a At the patient’s return visit 3 months after
remote location, and a subperiosteal tunnel is implant placement, the composite overlays
developed to provide laparoscopic access to the
site (Fig 17). A subperiosteal pouch is then created
were removed and the incisal edges of the pro-
to confine the graft without damaging the perios- visional restoration were modified to approxi-
teum (Fig 18). mate the length of the contralateral teeth. The

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 CONTINUING EDUCATION ESTHETIC RIDGE AUGUMENTATION

Fig 19. Fig 20.

Fig 19 through Fig 21. After extraction of teeth

Nos. 6 and 8, implants were placed and a screw-
retained immediate three-unit provisional was
delivered.

Fig 21.

patient reported no complaints, discomfort, outcomes from bone-augmentation proce-

or symptomatology throughout the osseoin- dures must also be evaluated with regard to
tegration period. The implants were stable, the achievement of adequate peri-implant
and all discernable clinical parameters were soft-tissue architecture.
within normal limits. The radiographic as- In this case report, the tridimensional recon-
sessment revealed adequate bone-to-implant struction of a complex iatrogenic defect was
contact and osseous crest levels. Similarly, the accomplished using orthodontic forced erup-
peri-implant soft tissues displayed a healthy tion to restore the vertical height and minimal-
appearance and satisfactory gingival margin ly invasive bone grafting to achieve horizontal
architecture (Figure 24 through Figure 27). augmentation.27,29,48 This interdisciplinary ap-
The patient subsequently enrolled in medi- proach allowed the predictable development
cal school, limiting her availability to continue and preservation of favorable peri-implant
treatment because of academic commitments soft tissues. Gingival volume, margin level,
and geographic location. As a result, she has and architecture were successfully restored
been maintained with a long-term milled while avoiding multiple hard- and soft-tissue
polymethylmethacrylate temporary restora- grafting procedures. The only shortcoming
tion for an 18-month period and is currently was the length of the papillae adjacent to the
scheduled to return for final impressions and area of the defect, which did not match the
completion of the definitive restoration. contralateral side.
The technique used provided adequate
Discussion bone volume, while the soft-tissue disfigure-
Predictability is essential when consider- ments, complications, and morbidity associ-
ing the treatment of high-risk scenarios in ated with traditional GBR procedures were
the esthetic zone. Therefore, the potential avoided.48 This procedure, however, may be

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 CONTINUING EDUCATION ESTHETIC RIDGE AUGUMENTATION

Fig 22. Fig 23. Fig 24. Fig 25.

Fig 26. Fig 27.

Fig 22 and Fig 23. The implants selected for teeth Nos. 6 (Fig 22) and 8 (Fig 23) featured a tapered de-
sign. Fig 24. At 3 months post immediate implant placement and provisionalization, complete regenera-
tion of the defect and adequate osseous crest levels and bone-to-implant contact were evident radio-
graphically. Fig 25. Three months post-treatment, peri-implant soft tissues appeared healthy. Fig 26 and
Fig 27. Three months post-treatment, favorable gingival architecture was preserved.

technique sensitive, and predictable out- ABOUT THE AUTHOR

comes require the use of specially designed Ernesto A. Lee, DMD
Clinical Professor and Director Postdoctoral Periodontal
instruments, a specific surgical methodology,
Prosthesis Program, University of Pennsylvania School of
training, and experience. Dental Medicine, Philadelphia, Pennsylvania, Private Practice,
Bryn Mawr, Pennsylvania
Conclusion Queries to the author regarding this course may be submit-
Forced eruption in conjunction with mini- ted to [email protected].
mally invasive bone grafting may provide
synergistic advantages for the predictable REFERENCES
1. Jensen AT, Jensen SS, Worsaae N. Complications
and efficient reconstruction of gingival-al- related to bone augmentation procedures of local-
veolar defects in the esthetic zone. Further ized defects in the alveolar ridge. A retrospective
research and development are required to clinical study. Oral Maxillofac Surg. 2016;20(2):115-
determine the full potential and limitations 122.
2. Lei Q, Chen J, Jiang J, et al. Comparison of soft
of this approach. tissue healing around implants in beagle dogs: flap
surgery versus flapless surgery. Oral Surg Oral Med
ACKNOWLEDGMENT Oral Pathol Oral Radiol. 2013;115(3):e21-e27.
The author would like to thank LynAnn Mas- 3. Chiapasco M, Romeo E, Casentini P, Rimondini L.
Alveolar distraction osteogenesis vs. vertical guided
taj, DMD, for her expert orthodontic advice bone regeneration for the correction of vertically
and assistance with root torque mechanics. deficient edentulous ridges: a 1-3-year prospective

12 COMPENDIUM EBOOK SERIES May 2021 | Volume 42 Number 5 www.compendiumlive.com

 CONTINUING EDUCATION ESTHETIC RIDGE AUGUMENTATION

study on humans. Clin Oral Implants Res. 2014;29(suppl):216-220.

2004;15(1):82-95. 16. Cosyn J, Eghbali A, Hermans A, et al. A 5-year
4. Jensen SS, Terheyden H. Bone augmentation prospective study on single immediate im-
procedures in localized defects in the alveolar ridge: plants in the aesthetic zone. J Clin Periodontol.
clinical results with different bone grafts and bone- 2016;43(8):702-709.
substitute materials. Int J Oral Maxillofac Implants. 17. Becker W, Dahlin C, Lekholm U, et al. Five-year
2009;24(suppl):218-236. evaluation of implants placed at extraction and with
5. Fürhauser R, Florescu D, Benesch T, et al. Evalu- dehiscences and fenestration defects augmented
ation of soft tissue around single-tooth implant with ePTFE membranes: results from a prospec-
crowns: the pink esthetic score. Clin Oral Implants tive multicenter study. Clin Implant Dent Relat
Res. 2005;16(6):639-644. Res.1999;1(1):27-32.
6. Wöhrle PS. Single-tooth replacement in the 18. Aghaloo TL, Moy PK. Which hard tissue augmen-
aesthetic zone with immediate provisionalization: tation techniques are the most successful in furnish-
fourteen consecutive case reports. Pract Periodon- ing bony support for implant placement? Int J Oral
tics Aesthet Dent. 1998;10(9):1107-1114. Maxillofac Implants. 2007;22(suppl):49-70.
7. Kan JY, Rungcharassaeng K. Immediate place- 19. Chiapasco M, Zaniboni M. Clinical outcomes
ment and provisionalization of maxillary anterior sin- of GBR procedures to correct peri-implant dehis-
gle implants: a surgical and prosthodontic rationale. cences and fenestrations: a systematic review. Clin
Pract Periodontics Aesthet Dent.2000;12(9):817-824. Oral Implants Res. 2009;20(suppl 4):113-123.
8. De Rouck T, Collys K, Cosyn J. Immediate single- 20. Santing HJ, Raghoebar GM, Vissink A, et al.
tooth implants in the anterior maxilla: a 1-year case Performance of the Straumann bone level implant
cohort study on hard and soft tissue response. J system for anterior single-tooth replacements in
Clin Periodontol. 2008;35(7):649-657. augmented and nonaugmented sites: a prospective
9. Degidi M, Nardi D, Daprile G, Piatelli A. Buccal cohort study with 60 consecutive patients. Clin Oral
bone plate in the immediately placed and restored Implants Res. 2013;24(8):941-948.
maxillary single implant: a 7-year retrospective 21. Cosyn J, Eghbali A, Hanselaer L, et al. Four mo-
study using computed tomography. Implant Dent. dalities of single implant treatment in the anterior
2012;21(1):62-66. maxilla: a clinical, radiographic, and aesthetic evalu-
10. Chu SJ, Salama MA, Salama H, et al. The dual- ation. Clin Implant Dent Relat Res. 2013;15(4):517-
zone therapeutic concept of managing immediate 530.
implant placement and provisional restoration in 22. Cosyn J, Sabzevar MM, De Bruyn H. Predic-
anterior extraction sockets. Compend Contin Educ tors of inter-proximal and midfacial recession
Dent. 2012;33(7):524-532. following single implant treatment in the anterior
11. Cooper LF, Reside GJ, Raes F, et al. Immedi- maxilla: a multivariate analysis. J Clin Periodontol.
ate provisionalization of dental implants placed in 2012;39(9):895-903.
healed alveolar ridges and extraction sockets: a 23. Merli M, Migani M, Esposito M. Vertical ridge
5-year prospective evaluation. Int J Oral Maxillofac augmentation with autogenous bone grafts: resorb-
Implants. 2014;29(3):709-717. able barriers supported by ostheosynthesis plates
12. Lee EA, Gonzalez-Martin O, Fiorellini J. Lingual- versus titanium-reinforced barriers. A preliminary
ized flapless implant placement into fresh extrac- report of a blinded, randomized controlled clinical
tion sockets preserves buccal alveolar bone: a cone trial. Int J Oral Maxillofac Implants. 2007;22(3):373-
beam computed tomography study. Int J Periodon- 382.
tics Restorative Dent. 2014;34(1):61-68. 24. Merli M, Moscatelli M, Mariotti G, et al. Bone level
13. Rieder D, Eggert J, Krafft T, et al. Impact of variation after vertical ridge augmentation: resorb-
placement and restoration timing on single-implant able barriers versus titanium-reinforced barriers. A
esthetic outcome—a randomized clinical trial. Clin 6-year double-blind randomized clinical trial. Int J
Oral Implants Res. 2016;27(2):e80-e86. Oral Maxillofac Implants. 2014;29(4):905-913.
14. Chu SJ, Salama MA, Garber DA, et al. Flapless 25. Reitan K. Clinical and histologic observations on
postextraction socket implant placement, part 2: tooth movement during and after orthodontic treat-
the effects of bone grafting and provisional res- ment. Am J Orthod. 1967;53(10):721-745.
toration on peri-implant soft tissue height and 26. Brown IS. The effect of orthodontic therapy on
thickness—a retrospective study. Int J Periodontics certain types of periodontal defects. I. Clinical find-
Restorative Dent. 2015;35(6):803-809. ings. J Periodontol. 1973;44(12):742-756.
15. Morton D, Chen ST, Martin WC, et al. Consen- 27. Ingber JS. Forced eruption. I. A method of treat-
sus statements and recommended clinical proce- ing isolated one and two wall infrabony osseous
dures regarding optimizing esthetic outcomes in defects—rationale and case report. J Periodontol.
implant dentistry. Int J Oral Maxillofac Implants. 1974;45(4):199-206.

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 CONTINUING EDUCATION ESTHETIC RIDGE AUGUMENTATION

28. Pontoriero R, Celenza F Jr, Ricci G, Carnevale 1999;19(2):199-206.

G. Rapid extrusion with fiber resection: a combined 42. Mahn DH. Treatment of gingival recession with a
orthodontic-periodontic treatment modality. Int J modified “tunnel” technique and an acellular dermal
Periodontics Restorative Dent. 1987;7(5):30-43. connective tissue allograft. Pract Proced Aesthet
29. Ingber JS. Forced eruption: alteration of soft tis- Dent. 2001;13(1):69-74.
sue cosmetic deformities. Int J Periodontics Restor- 43. Tözüm TF, Dini FM. Treatment of adjacent gingi-
ative Dent. 1989;9(6):416-425. val recessions with subepithelial connective tissue
30. Salama H, Salama M. The role of orthodontic ex- grafts and the modified tunnel technique. Quintes-
trusive remodeling in the enhancement of soft and sence Int. 2003;34(1):7-13.
hard tissue profiles prior to implant placement: a 44. AlGhamdi AS, Buhite RJ. A new tunnel tech-
systematic approach to the management of extrac- nique with acellular dermal matrix for soft tissue
tion site defects. Int J Periodontics Restorative Dent. preparation prior to symphyseal block graft—a
1993;13(4):312-333. description of technique and case report. J Oral
31. Van Venrooy JR, Vanarsdall RL. Tooth eruption: Implantol. 2008;34 (5):274-281.
correlation of histologic and radiographic findings 45. Modaressi M, Wang HL. Tunneling procedure
in the animal model with clinical and radiographic for root coverage using acellular dermal matrix:
findings in humans. Int J Adult Orthodon Orthog- a case series. Int J Periodontics Restorative Dent.
nath Surg. 1987;2(4):235-247. 2009;29(4):395-403.
32. Mantzikos T, Shamus I. Forced eruption and 46. Zadeh HH. Minimally invasive treatment of
implant site development: soft tissue response. Am maxillary anterior gingival recession defects by
J Orthod Dentofacial Orthop. 1997;112 (6):596-606. vestibular incision subperiosteal tunnel access and
33. Amato F, Mirabella AD, Macca U, Tarnow DP. platelet-derived growth factor BB. Int J Periodontics
Implant site development by orthodontic forced Restorative Dent. 2011;31(6):653-660.
extraction: a preliminary study. Int J Oral Maxillofac 47. Chao JC. A novel approach to root coverage:
Implants. 2012;27(2):411-420. the pinhole surgical technique. Int J Periodontics
34. Kent JN, Quinn JH, Zide MF, et al. Alveolar ridge Restorative Dent. 2012;32(5):521-531.
augmentation using nonresorbable hydroxylapatite 48. Lee EA. Subperiosteal minimally invasive aes-
with or without autogenous cancellous bone. J Oral thetic ridge augmentation technique (SMART): a
Maxillofac Surg. 1983;41(10):629-642. new standard for bone reconstruction of the jaws.
35. Vanassche BJ, Stoelinga PJ, de Koomen HA, et Int J Periodontics Restorative Dent. 2017;37(2):165-
al. Reconstruction of the severely resorbed man- 173.
dible with interposed bone grafts and hydroxylapa- 49. Proussaefs P, Lozada J. Use of titanium mesh for
tite. A 2-3 year follow-up. Int J Oral Maxillofac Surg. staged localized alveolar ridge augmentation: clini-
1988;17(3):157-160. cal and histologic-histomorphometric evaluation. J
36. Block MS, Degen M. Horizontal ridge augmenta- Oral Implantol. 2006;32(5):237-247.
tion using human mineralized particulate bone: pre- 50. Pieri F, Corinaldesi G, Fini M, et al. Alveolar ridge
liminary results. J Oral Maxillofac Surg. 2004;62(9 augmentation with titanium mesh and a combina-
suppl 2):67-72. tion of autogenous bone and anorganic bovine
37. Hasson O. Augmentation of deficient lateral bone: a 2-year prospective study. J Periodontol.
alveolar ridge using the subperiosteal tunneling 2008;79(11):2093-2103.
dissection approach. Oral Surg Oral Med Oral Pathol 51. Hämmerle CH, Jung RE, Yaman D, Lang NP.
Oral Radiol Endod. 2007;103(3):e14-e19. Ridge augmentation by applying bioresorbable
38. Kfir E, Kfir V, Eliav E, Kaluski E. Minimally inva- membranes and deproteinized bovine bone min-
sive guided bone regeneration. J Oral Implantol. eral: a report of twelve consecutive cases. Clin Oral
2007;33(4):205-210. Implants Res. 2008;19(1):19-25.
39. Dibart S, Sebaoun JD, Surmenian J. Piezocision: 52. Urban IA, Nagursky H, Lozada JL, Nagy K.
a minimally invasive, periodontally accelerated orth- Horizontal ridge augmentation with a collagen
odontic tooth movement procedure. Compend Con- membrane and a combination of particulated au-
tin Educ Dent. 2009;30(6):342-344,346,348-350. togenous bone and anorganic bovine bone-derived
40. Blanes RJ, Allen EP. The bilateral pedicle flap- mineral: a prospective case series in 25 patients. Int
tunnel technique: a new approach to cover connec- J Periodontics Restorative Dent. 2013;33(3):299–307.
tive tissue grafts. Int J Periodontics Restorative Dent. 53. Meloni SM, Jovanovic SA, Urban I, et al. Hori-
1999;19(5):471-479. zontal ridge augmentation using GBR with a native
41. Zabalegui I, Sicilia A, Cambra J, et al. Treat- collagen membrane and 1:1 ratio of particulated
ment of multiple adjacent gingival recessions with xenograft and autologous bone: a 1-year prospec-
the tunnel subepithelial connective tissue graft: a tive clinical study. Clin Implant Dent Relat Res.
clinical report. Int J Periodontics Restorative Dent. 2017;19(1):38-45.

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 CONTINUING EDUCATION ESTHETIC RIDGE AUGUMENTATION

54. Urban IA, Monje A, Lozada JL, Wang HL. Long- Periodontics Restorative Dent. 2009;29(3):245-255.
term evaluation of peri-implant bone level after re- 59. Cardaropoli D. Vertical ridge augmentation with
construction of severely atrophic edentulous maxilla the use of recombinant human platelet-derived
via vertical and horizontal guided bone regeneration growth factor-BB and bovine bone mineral: a
in combination with sinus augmentation: a case case report. Int J Periodontics Restorative Dent.
series with 1 to 15 years of loading. Clin Implant Dent 2009;29(3):289-295.
Relat Res. 2017;19(1):46-55. 60. Nevins M, Camelo M, Nevins ML, et al. Growth
55. Nevins ML, Camelo M, Nevins M, et al. Minimally factor-mediated combination therapy to treat large
invasive alveolar ridge augmentation procedure local human alveolar ridge defects. Int J Periodon-
(tunneling technique) using rhPDGF-BB in combina- tics Restorative Dent. 2012;32(3):263-271.
tion with three matrices: a case series. Int J Peri- 61. Zhu SJ, Choi BH, Huh JY, et al. A comparative
odontics Restorative Dent. 2009;29(4):371-383. qualitative histological analysis of tissue-engineered
56. Buser D, Chappuis V, Bornstein MM, et al. Long- bone using bone marrow mesenchymal stem
term stability of contour augmentation with early cells, alveolar bone cells, and periosteal cells. Oral
implant placement following single tooth extraction Surg Oral Med Oral Pathol Oral Radiol Endod.
in the esthetic zone: a prospective, cross-sectional 2006;101(2):164-169.
study in 41 patients with a 5- to 9-year follow-up. J 62. Ceccarelli G, Graziano A, Benedetti L, et al.
Periodontol. 2013;84(11):1517-1527. Osteogenic potential of human oral-periosteal cells
57. Jensen SS, Bosshardt DD, Gruber R, Buser D. (PCs) isolated from different oral origin: an in vitro
Long-term stability of contour augmentation in the study. J Cell Physiol. 2016;231(3):607-612.
esthetic zone: histologic and histomorphometric 63. Ottoni JM, Oliveira ZF, Mansini R, Cabral AM.
evaluation of 12 human biopsies 14 to 80 months Correlation between placement torque and sur-
after augmentation. J Periodontol. 2014;85(11):1549- vival of single-tooth implants. Int J Oral Maxillofac
1556. Implants. 2005;20(5):769-776.
58. Simion M, Nevins M, Rocchietta I, et al. Vertical 64. Greenstein G, Cavallaro J. Implant insertion
ridge augmentation using an equine block infused torque: its role in achieving primary stability of
with recombinant human platelet-derived growth restorable dental implants. Compend Contin Educ
factor-BB: a histologic study in a canine model. Int J Dent. 2017;38(2):88-95.

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 CONTINUING EDUCATION 1 QUIZ 2 Hours CE Credit
Tridimensional Reconstruction of a Complex Iatrogenic
Defect Using Orthodontic Forced Eruption and
Minimally Invasive Bone Grafting
Ernesto A. Lee, DMD

TAKE THIS FREE CE QUIZ BY CLICKING HERE: COMPENDIUMLIVE.COM/GO/CCEDORTHOTRIRECON

ENTER PROMO CODE: TRIDIMENSIONAL

1. Alveolar ridge defects have traditionally been C. flap-based techniques

treated with: D. All of the above
A. orthodontic repositioning of adjacent teeth.
B. s urgical techniques that involve the 6. In a subsequent study of vertical
reflection of a mucoperiosteal flap. GBR outcomes using resorbable and
C. o rthotic appliances to remodel adjacent nonresorbable membranes, Merli reported a
bone into a better architecture. total complication rate of:
D. electromagnetic stimulation of local  A. 14%. B. 41%.
osteoblasts. C. 73%. D. 91%.

2. Why is a greater degree of flap reflection and 7. When a tooth is moved in a certain direction,
advancement is needed to achieve adequate bone resorption occurs on the side where:
coadaptation for failed implants? A. heat is applied to the periodontal ligament.
A. because these defects often require B. cold is applied to the periodontal ligament.
significant volume augmentation C. p ressure is applied to the periodontal
B. because these defects are infected ligament.
C. b ecause these defects have virtually no D. vibration is applied to the periodontal
blood supply of their own after an implant ligament.
has failed
D. because these defects have approximately 8. For orthodontic forced eruption, bone
25% shrinkage of the flap within 30 days apposition is stimulated by:
A. the compression generated on the opposite
3. Establishing esthetic and restorative side.
objectives is essential in treatment planning B. the tension generated on the opposite side.
for complex defects in the C. t he compression generated on the same
A. mandibular premolar region. side.
B. mandibular molar region. D. the tension generated on the same side.
C. maxillary molar region.
D. maxillary anterior region. 9. What type of forces are applied to the
periodontal ligament during the forced
4. The patient’s high smile line and esthetic eruption movement?
demands precluded the use of: A. vertical B. lateral
A. a traditional metal framework removable C. stretching D. rotational
partial denture.
B. a
 provisional acrylic removable partial 10. Forced eruption in conjunction with
denture. minimally invasive bone grafting may provide
C. a
 ny prosthesis incorporating pink what type of advantages for the predictable
restorative materials. and efficient reconstruction of gingival-
D. metal copings. alveolar defects in the esthetic zone?
A. commensal
5. Several authors have reported that which B. synergistic
of the following exhibit an increased risk of C. parasitic
complications and compromised peri-implant D. esthetic
esthetics?
A. bone augmentation
B. guided bone regeneration (GBR)

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 CASE REPORT ORTHODONTIC TECHNIQUE

Frictionless Segmented Mechanics

for Controlled Space Closure
Ildeu Andrade, Jr., DDS, MS, PhD; Fernando Amaral Moreira Guimaraes, DDS; and Giordani Santos Silveira, DDS, MS

ABSTRACT: The treatment of incisor protrusion by means ABOUT THE AUTHORS

Ildeu Andrade, Jr., DDS, MS,
of tooth extraction can be challenging for orthodontists, PhD
especially during the space closure phase. Moreover, the level Associate Professor, Department of
Orthodontics, Pontifícia Universidade
of difficulty may increase when anterior movement of the Católica de Minas Gerais, Belo
posterior teeth is not desirable. Treatment alternatives may Horizonte, Minas Gerais, Brazil.

include the use of mini implants, mini plates, and extraoral Fernando Amaral Moreira
devices to reinforce anchorage; however, some patients may Guimaraes, DDS
Private Practice, Itaúna, Minas Gerais,
oppose these aggressive methods. This article describes the Brazil
use of frictionless segmented mechanics that provide dif-
Giordani Santos Silveira,
ferential moments for controlled space closure during full DDS, MS
retraction of the incisors without using extraoral forces or PhD Student, Department of

I
Orthodontics, Pontifícia Universidade
temporary anchorage devices. Católica de Minas Gerais, Belo
Horizonte, Minas Gerais, Brazil
ncisor protrusion is a fairly common condition that often
results in lip protrusion and increased facial convexity.1 A
prevalent treatment strategy for this circumstance involves
the extraction of the first premolars to immediately create
the necessary space for incisor retraction.2 However, the
space closure phase can be challenging for clinicians, because in
cases where the mesialization of posterior teeth is undesirable it
needs to be avoided or at least minimized during the retraction of
anterior teeth.
Alveolar or extra-alveolar temporary anchorage devices
(TADs) and extraoral forces have played important roles in
cases that require maximum anchorage,1 but patients may
not be receptive to further surgical treatment in addition
to the extraction itself and may be reluctant to use external
devices. Therefore, clinicians should be cognizant of alter-
native clinical strategies for anchorage control. Attention
should also be especially given to incisor torque control since
uncontrolled tipping of the incisor crowns may result in sag-
ittal and vertical problems.3
The following case report describes a relatively simple, con-
trolled segmented mechanical approach that utilizes differen-
tial moments without friction to minimize anchorage loss and
control incisor torque. This treatment option enabled definable

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 CASE REPORT ORTHODONTIC TECHNIQUE

and predictable force systems to be applied so or the periodontal and periapical aspects. She
that the intended treatment outcome could be had no notable medical history.
predictably achieved.
Treatment Objectives and Options
Case Report The treatment objectives were fivefold: im-
Diagnosis and Etiology prove the lateral profile and lip line, obtain
The patient was a 31-year-old woman whose ideal inclination of the anterior teeth, main-
chief complaint was that her maxillary and tain the class I molar and canine relationships,
mandibular front teeth were "forwardly placed" achieve ideal overbite and overjet, and attain
and her smile was "unesthetic." Facial photo- a mutually protected functional occlusion.6
graphs taken by the clinician demonstrated a Four treatment plan options were identified
convex facial profile and a slightly asymmetric and presented. The first was to extract the four
face (Figure 1 through Figure 3). She also pre- first premolars and retract the six anterior
sented with lip incompetence and was unable teeth in each arch simultaneously with TADs.
to close her lips without mentalis strain. The second treatment option was to extract
She was diagnosed with an Angle class I mal- the mandibular first molars, each of which had
occlusion,4 mild crowding in the mandibular a large amalgam filling, and the maxillary first
arch, bimaxillary protrusion, and lack of ca- premolars, and to fully retract the entire max-
nine guidance (Figure 4 through Figure 6). A illary and mandibular dentitions using TADs.
lateral cephalometric analysis showed a steep The third alternative was to perform an ante-
mandibular plane (SN-GoGn 37°) with severe rior segmental osteotomy combined with ge-
labioversion of the anterior teeth (1.SN 109°, nioplasty. The fourth option was to retract the
IMPA 100°, 1.1 109°) (Table 1). Her lips were anterior teeth with a two-step space closure
protrusive, with the upper lip to Ricketts "E" without using TADs, instead using frictionless
line at 2 mm and the lower lip to "E" line at 8 controlled segmented mechanics that utilize
mm (Figure 7 and Table 1).5 A panoramic ra- differential moments with power arms for
diograph showed no abnormalities in the bone anchorage control. The patient declined the

Fig 1. Fig 2. Fig 3.

Fig 4. Fig 5. Fig 6.

Fig 1 through Fig 3. Pretreatment facial photographs. Fig 4 through Fig 6. Pretreatment intraoral
photographs.

18 COMPENDIUM EBOOK SERIES May 2021 | Volume 42 Number 5 www.compendiumlive.com

 CASE REPORT ORTHODONTIC TECHNIQUE

surgical treatment plan and the use of TADs stainless steel wire passing through the slots of
and did not want her mandibular first molars the incisors, which created an incisor segment.
extracted. Therefore, the fourth treatment The anterior and posterior power arms were
plan was selected. positioned as close as possible to the center
of rotation of the molar and incisor segments.
Progression of Treatment To address the treatment objectives for
A transpalatal bar and lower lingual arch were space closure, the power-arm heights were
placed to avoid molar rotations and undesir- adjusted to be 3 mm to 5 mm apical to the
able transverse changes. Standard edgewise bracket position (shortening of the anterior
brackets and tubes were passively bonded to power arms provided controlled but not ex-
the teeth to allow the prompt distalization of cessive lingual/palatal torque).7 Segmented
the canines after the extractions. The distal- mechanics were used to slightly intrude the
ization of the canines was initiated 1 week after mandibular incisors during the retraction of
extraction of the premolars using a "T-loop" the maxillary incisors (Figure 10).
spring made with a 0.016-in x 0.016-in chro- Once the retraction of the incisors was
mium-cobalt wire, to achieve closure of up to completed, a panoramic x-ray and maxillary
two-thirds of the spaces (Figure 8). and mandibular impressions were taken to
After retraction of the canines, the next step evaluate root parallelism and possible mar-
was to retract the incisors using two power ginal ridge discrepancy. The patient was then
arms on each quadrant connected with a power debonded and rebonded for final alignment
chain, which delivered a force of 100 g on each and leveling. When both arches had been lev-
side (Figure 9). The posterior power arms on eled and aligned, continuous 0.019-in x 0.025-
the molars were made with 0.017-in x 0.025-in in stainless steel arch wires were inserted for
stainless steel wires and were distally placed torquing control (Figure 11). The archwires
in the auxiliary tubes of the first molars. The were sectioned distal to the canines and verti-
anterior ones were part of a 0.019-in x 0.025-in cal elastics were utilized in the posterior teeth
TABLE 1

Lateral Cephalometric Analysis

MEASUREMENT PRETREATMENT POST-TREATMENT

SNA° 83° 82°

SNB° 77.5° 77°
ANB° 5.5° 5°
SN-GoGn° 37° 36.5°
FMA° 23.5° 22°
1-NA mm 7 2
1-NA° 29° 15.5°
1-NB mm 11.5 5.5
IMPA° 100° 90°
1.SN 109° 96°
1.1 109° 134°
E-line +2s/+8i 0s/+4.5i Fig 7.

ANB = A point–nasion–B point angle; FMA = Frankfort mandibular plane angle; Gn = gnathion; Go = gonion; Fig 7. Pretreatment lateral cephalo-
IMPA = incisor mandibular plane angle; SNA = sella–nasion–A point angle; SNB = sella–nasion–B point angle
metric radiograph and tracing.

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 CASE REPORT ORTHODONTIC TECHNIQUE

for 1 week to hone and settle the occlusion. the maxillary lateral incisors for composite
The appliances were removed after a build-ups because of a tooth size discrepancy.
24-month treatment period, at which point
a maxillary wraparound and a mandibular Treatment Results
bonded premolar-to-premolar fixed retainer Facial photographs showed the improve-
were installed. A slight space was left distal to ment of the patient's profile after lip

Fig 8. Fig 9.

Fig 10. Fig 11.

Fig 8. Canine retraction with T-loop segmented mechanics. Fig 9. Power arms used for retraction of
mandibular incisors. Fig 10. Power arms for retraction of maxillary incisors, and cantilevers for intrusion
of mandibular incisors. Fig 11. Torquing control with 0.019-in x 0.025-in stainless steel arch wires.

Fig 12. Fig 13. Fig 14.

Fig 15. Fig 16. Fig 17.

Fig 12 through Fig 14. Post-treatment facial photographs. Fig 15 through Fig 17. Post-treatment intraoral
photographs.

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 CASE REPORT ORTHODONTIC TECHNIQUE

retraction, a balanced face with propor- Discussion

tional vertical thirds, and a more appeal- Bimaxillary protrusion is characterized by
ing smile (Figure 12 through Figure 14). severe buccal tipping of the anterior teeth; it
The protrusive incisors were retracted as results in lip protrusion and increased facial
needed. Intraoral photographs showed an convexity.1 Conventional treatment includes
Angle class I occlusion with normal overjet the extraction of the first premolars to modi-
and overbite (Figure 15 through Figure 17). fy the facial profile by retracting the anterior
The mutually protected functional occlusion teeth and keeping the canines and first molars
was achieved with stable and simultaneous in class I relationship.2 The retraction stage of
occlusal contacts of all teeth in centric rela- the anterior teeth is a highly critical phase of
tion and eccentric contacts guided by the the orthodontic therapy and requires precise
anterior teeth. mechanics to avoid unwanted movements and
The post-treatment cephalometric (Figure anchorage loss during treatment.
18) and panoramic radiograph demonstrated Two methods have been reported in the lit-
the positive changes achieved with the treat- erature for this purpose.8 One is the en-masse
ment. The cephalometric numbers confirmed retraction of incisors and canines; the other is
that the maxillary and mandibular incisors a two-step retraction that begins with the dis-
were considerably uprighted (Table 1). The talization of the canines, which is followed by
superimpositions revealed no extrusion of the incisor retraction. Both methods may involve
maxillary and mandibular molars (Figure 19). complex techniques,9 complicated spring
As anticipated, the preferred molar positions (force system) designs,10 excessive friction,11
were maintained almost unchanged, with and the use of TADs12 and may create an inde-
minimal anchorage loss. terminate system. Controlling the force sys-
At the 2-year follow-up, the final result had tem is essential to precise tooth movement.
remained stable. Force direction, magnitude, and constancy,

Fig 18. Post-treatment lateral cephalometric radiograph and tracing.

Fig 19. Pretreatment (black tracing) and post-treatment (red tracing)
superimpositions. Fig 20. System of forces and moments created by
the segmented mechanics for incisor retraction. (1) The applied force
at the power arms produces a clockwise moment in the center of
resistance (Cr) of the incisors and a counterclockwise moment in the
Cr of the molars. (2) The applied force at the molar tube produces a
clockwise moment in the Cr of the molars. (3) The applied force at
the bracket produces a counterclockwise moment in the Cr of the
Fig 18. incisors. (d = distance between the line of force to Cr)

Fig 19. Fig 20.

21 COMPENDIUM EBOOK SERIES May 2021 | Volume 42 Number 5 www.compendiumlive.com

 CASE REPORT ORTHODONTIC TECHNIQUE

in addition to moment-to-force ratio, are cru- may create distal crown tipping (Figure 20).
cial variables determined by the orthodontist The use of a more determinate system and
during treatment.11 The force systems should differential moments for space closure may
move teeth at an ideal rate (0.8 mm to 1.2 mm also allow the orthodontist to minimize side
per month)13 in an extended range of activa- effects, such as anchorage loss, without the
tion while producing a relatively constant use of TADs and extraoral devices. TADs have
force system. This reduces tissue injury and shown to be a stable source of anchorage for
the number of appointments and, at the same retraction of maxillary and mandibular ante-
time, results in tooth movement with a nearly rior teeth.10,11 However, as seen in the case pre-
constant center of rotation.10 sented here, patients sometimes decline the
This case report describes a mechanical sys- use of invasive methods or extraoral devices
tem that provides definable and predictable that would provide anchorage control. With
orthodontic forces. Moreover, constant force this in mind, the use of frictionless segmented
levels can be maintained, and the moment- mechanics with differential moments can be
to-force ratio at the centers of resistance can a beneficial clinical alternative to produce a
easily be regulated to produce the desired predictable force system between the poste-
tooth movement. The estimated position of rior and anterior segments, enabling the mag-
the center of resistance for the incisor segment nitude of the moments and forces delivered to
was located within the mid-sagittal plane, ap- be well controlled in the three planes of space
proximately 6 mm apical and 4 mm posterior and yielding minimum anchorage loss.1
to a line perpendicular to the occlusal plane Anchorage preservation is a critical fac-
extending from the labial alveolar crest of the tor in treating patients with alveolar dental
central incisor.14 The resulting force system protrusion. As observed in the superimposi-
can easily be modified by altering the magni- tions presented in this case, anchorage loss
tude and direction of force in relation to the was minimal but the result was comparable
center of resistance of the anterior segment; with traditional methods of achieving maxi-
this can be done by changing the height of the mum anchorage.11 Moreover, as stated in the
anterior or posterior power arms. literature, when first premolars are extracted,
Excessive retroinclination of the incisors can the posterior teeth can be expected to move
be moderated by the shorter distance from the forward approximately one-third of the space,
force line of action to the center of resistance leaving the other two-thirds for crowding re-
of the four incisors and by the buccal crown lief and incisor retraction.16 Therefore, abso-
torque created by the binary of forces gener- lute anchorage of the posterior teeth may not
ated by the rectangular wire in the bracket be essential to retract the anterior teeth as
slot.10 The power arms inserted in the auxil- long as the orthodontist maintains approxi-
iary tubes of the maxillary first molars play an mately two-thirds of the extraction space,
important role in anchorage for two reasons. which can be achieved easily with this seg-
First, this allows the placement of the vector mented technique.
of force close to the center of resistance of the Another advantage of the method presented
teeth (in the trifurcation of the roots),15 which here is the lack of friction during retraction
minimizes the mesial crown tipping created of the incisors. It is estimated that 50% of an
by the counter-clockwise moment. Second, applied orthodontic force is dissipated due to
the applied force causes a clockwise couple of friction.4 Therefore, the total force applied in
force in the molar tube due to the gap between an orthodontic treatment should be twice the
the wire and the inner walls of the tube, which force necessary to produce an effective force

22 COMPENDIUM EBOOK SERIES May 2021 | Volume 42 Number 5 www.compendiumlive.com

 CASE REPORT ORTHODONTIC TECHNIQUE

in the absence of friction. Excessive force, E. Soft tissue changes following the extraction of
however, may increase bracket friction and premolars in nongrowing patients with bimaxillary
protrusion. A systematic review. Angle Orthod. 2010;
escalate the potential loss of posterior anchor- 80(1):211-216.
age. Additionally, positive correlations likely 3. Isaacson RJ, Lindauer SJ, Rubenstein LK. Mo-
exist between increased force levels and root ments with the edgewise appliance: incisor
torque control. Am J Orthod Dentofacial Orthop.
resorption.17 In this segmented method, the 1993;103(5):428-438.
anterior and posterior segments are connected 4. Proffit WR, Fields HW. Contemporary Orthodon-
only by power chains or nickel-titanium coil tics. 6th ed. St. Louis, MO: Mosby; 2018.
springs, which eliminate friction. 5. Saxby PJ, Freer TJ. Dentoskeletal determi-
nants of soft tissue morphology. Angle Orthod.
An excellent final result was achieved with 1985;55(2):147-154.
frictionless segmented mechanics, differential 6. Okeson J. Management of Temporomandibular
moments, no anchorage devices, and strategic Disorders and Occlusion. 7th ed. St. Louis, MO: Else-
planning of the relationship between the force vier Mosby; 2012.
7. Sia S, Shibazaki T, Koga Y, Yoshida N. Experimen-
line of action and the centers of resistance of tal determination of optimal force system required
the anterior and posterior segments. Taken all for control of anterior tooth movement in slid-
together, a controlled retraction of the incisors ing mechanics. Am J Orthod Dentofacial Orthop.
2009;135(1):36-41.
into the extraction space was achieved with 8. Felembam NH, Al-Sulaimani FF, Murshid ZA,
minimum anchorage loss in a relatively short Hassan AH. En masse retraction versus two-step re-
period of time. traction of anterior teeth in extraction treatment of
bimaxillary protrusion. J Orthod Sci. 2013;2(1):28-37.
Conclusion 9. Ribeiro GL, Jacob HB. Understanding the basis
of space closure in orthodontics for a more effi-
This frictionless segmented mechanics meth- cient orthodontic treatment. Dental Press J Orthod.
od with differential moments and strategic 2016;21(2):115-125.
planning of the relationship between the force 10. Burstone CJ. The segmented arch approach to
space closure. Am J Orthod. 1982;82(5):361-378.
line of action and the centers of resistance of 11. Burstone CJ, Koenig HA. Optimizing anterior and
the anterior and posterior segments can be canine retraction. Am J Orthod. 1976;70(1):1-19.
used for patients who require anchorage con- 12. Upadhyay M, Yadav S, Patil S. Mini-implant
anchorage for en-masse retraction of maxillary
trol, such as for bialveolar protrusion cases. anterior teeth: a clinical cephalometric study. Am J
This approach may permit the application of Orthod Dentofacial Orthop. 2008;134(6):803-810.
definable and predictable force systems to en- 13. Buschang PH, Campbell PM, Ruso S. Accelerat-
able clinicians to predictably and confidently ing tooth movement with corticotomies: is it pos-
sible and desirable? Semin Orthod. 2012;18(4):286-
achieve the desired treatment outcome. 294.
14. Matsui S, Caputo AA, Chaconas SJ, Kiyomura H.
ACKNOWLEDGMENT Center of resistance of anterior arch segment. Am J
The authors acknowledge Coordenação de Orthod Dentofacial Orthop. 2000;118(2):171-178.
15. Dermaut LR, Kleutghen JP, De Clerck HJ. Experi-
Aperfeiçoamento de Pessoal de Nível Superior mental determination of the center of resistance
- Brasil (CAPES), which contributed a scholar- of the upper first molar in a macerated, dry human
ship to Dr. Silveira's PhD residency. skull submitted to horizontal headgear traction. Am
J Orthod Dentofacial Orthop. 1986;90(1):29-36.
16. Williams R, Hosila FJ. The effect of different ex-
REFERENCES traction sites upon incisor retraction. Am J Orthod.
1. Upadhyay M, Yadav S, Nanda R. Vertical-di- 1976;69(4):388-410.
mension control during en-masse retraction with 17. Roscoe MG, Meira JBC, Cattaneo PM. Association
mini-implant anchorage. Am J Orthod Dentofacial of orthodontic force system and root resorption: a
Orthop. 2010;138(1):96-108. systematic review. Am J Orthod Dentofacial Orthop.
2. Leonardi R, Annunziata A, Licciardello V, Barbato 2015;147(5):610-626.

23 COMPENDIUM EBOOK SERIES May 2021 | Volume 42 Number 5 www.compendiumlive.com

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