Case Report Orthodontic extrusion of an impacted tooth

with a removable appliance and a bonded

attachment: A case report with relevant
biomechanics
Pramod Philip, Ashwin Rao1
Departments of Orthodontics and Dentofacial Orthopedics, and 1Paedodontics and Preventive Dentistry,
Manipal College of Dental Sciences, Manipal University, Mangalore, Karnataka, India

Address for correspondence: Dr. Ashwin Rao, E-mail: ashwinraopedo@gmail.com

ABSTRACT
This case report describes orthodontic extrusion of an impacted central incisor in a 9-year-old child with a removable appliance.
Though orthodontic extrusion with removable appliances has been described previously in literature, the aim of this paper
is to help the practicing clinician understand the biomechanics and biology of orthodontic extrusion and provide practical
tips for using this simple mode of treatment. This will aid the clinician practice orthodontic extrusion in his/her practice in a
predictable manner.

CLINICAL RELEVANCE TO INTERDISCIPLINARY DENTISTRY

The primary aim of this paper is to provide practical tips to the general dentist in carrying out orthodontic extrusion
predictably with a simple removable appliance.
Orthodontic extrusion is indicated in various clinical situations like management of impacted teeth, crown lengthening,
treatment of vertical bony defects, etc.

Key words: Impacted tooth, orthodontic extrusion, removable appliance

INTRODUCTION Impacted teeth: With the maxillary canine being

the most commonly affected tooth

E xtrusion is defined as the translation of a tooth

along its long axis in a coronal direction. If the
movement of the tooth is accelerated by an applied
traction it is called orthodontic extrusion. Application of
optimal traction forces will lead to a stress distribution
all around the periodontal ligament leading to marginal
apposition of bone at the alveolar crest.[1]
Orthodontic extrusion is a relatively common
procedure in clinical practice. It is indicated in the
following situations:
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DOI:
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46
Traumatically intruded permanent teeth, which
needs to be orthodontically repositioned into the
occlusal level
Restorative indications like the management of
sub-gingival restorations, tooth fractures at the
cervical margin, implant site development etc
Periodontal indications like management of
vertical bony defects.
Orthodontic extrusion can be carried out using fixed
or removable appliances. Orthodontic extrusion is
discouraging many times for a general practitioner
due to inadequate knowledge on the part of the
clinician about fixed orthodontic therapy and the
biomechanics involved. Insufficient number of teeth
could compromise the anchorage, thereby complicating
fixed appliance therapy. Though orthodontic extrusion
using removable appliances has been previously
described in literature,[2] the aim of this paper is to help
understand the biology and biomechanics behind the
Journal of Interdisciplinary Dentistry / Jan-Apr 2014 / Vol-4 / Issue-1
 Philip and Rao: Orthodontic extrusion with a removable appliance
procedure and aid the general dentist, practice orthodontic
extrusion with removable appliances predictably. This case
report therefore explains the effective use of a removable
appliance in conjunction with a single bonded attachment
in the extrusion of an impacted central incisor.
CASE REPORT
A 9-year-old girl was brought to the Department of
Pedodontics and Preventive Dentistry by her mother with
a chief complaint of an un-erupted upper front permanent
tooth. The medical history and the family histories were
noncontributory. Extra oral examination revealed nothing
significant.
Intra-oral examination revealed the presence of a
retained right primary central incisor (tooth no. 51) and a
supplementary supernumerary deciduous tooth adjacent to
it. An intra-oral peri-apical radiograph revealed the presence
of another un-erupted supernumerary tooth and right
permanent upper central incisor (tooth no. 11) [Figure 1a].
The un-erupted supernumerary tooth was extracted along
with the supplemental supernumerary tooth and the
retained tooth no. 51 under local anesthesia. The child
was put on a monthly recall to check for spontaneous
eruption of tooth no. 11.
At 6 months, there was no spontaneous eruption of tooth
no. 11. Examination revealed that her right upper premolar
had erupted and the left one was erupting. Upper right
central incisor was conspicuous by its absence, but the
space for the tooth was still intact. The bulge of the crown
was palpable clinically [Figure 1b-d].
b c
a d e
f
Figure 1: (a) Intra oral periapical: (1) Tooth no. 21, (2) tooth no. 51, (3)
tooth no. 52, (4) supplementary supernumerary deciduous tooth, (5) tooth
no. 53, (6) tooth no. 11, (7) un-erupted supernumerary tooth, (8) tooth no.
12, (9) tooth no.13, (b) pretreatment intra-oral pictures-right lateral view
(c) left lateral view (d) frontal view (e) maxillary occlusal view (f) tomogram
showing the mesio-distal and labio-lingual position of the incisor
Journal of Interdisciplinary Dentistry / Jan-Apr 2014 / Vol-4 / Issue-1
A tomogram revealed that the right upper central
incisor was present well above the adjacent incisor with
around 2-3 mm of soft tissue covering the tooth. It was
also evident that the tooth is oriented in the correct
labio-lingual inclination [Figure 1f].
A decision was made to orthodontically extrude tooth
no. 11. Though a 2 4 appliance was considered, it was
not feasible because of insufficient anchorage, as the
permanent lateral incisors had not fully erupted into the
arch. Hence, it was decided to use a removable appliance
for extrusion. The procedure was explained to the child
and good cooperation was ensured before attempting the
treatment with the removable appliance. Informed consent
was obtained from the mother for the same. The extrusion
was carried out in the Department of Orthodontics and
Dentofacial Orthopedics.
The removable appliance was fabricated with the
following design. A full acrylic plate spanning the
maxillary arch from the upper incisors to the first
permanent molars was made. Adams clasps on first
permanent molars and first premolars provided retention
of the appliance. A posterior bite-plane was added to
the acrylic plate to enhance the stability of the appliance.
A hook made with a 0.8 mm stainless steel wire was
incorporated into the acrylic plate. The tip of the hook
was positioned slightly labial to the center of the arch to
ensure that the line of action of the force stays along the
long axis. The anterior open bite created by the posterior
bite-plane allowed the hook to be positioned well below
the occlusal plane creating sufficient stretch of the elastic
to provide optimal force levels [Figure 2a and b].
The right permanent upper central incisor tooth was
surgically exposed and a bracket (Begg bracket) was
bonded to the labial surface using light cure composite
material. Elastic was stretched between the bracket
bonded on the incisor and the hook in the acrylic plate
a b
c d e
Figure 2: (a) Appliance - occlusal view (b) right lateral view
(c) schematic diagram explaining the force and the moment generated
(d and e) dontrix gauge used for measuring the force level by stretching
the elastic to the desired distance
47
 Philip and Rao: Orthodontic extrusion with a removable appliance
to deliver 20 g of force for the extrusion [Figure 3a]. The
elastic was chosen after measuring the force with a dontrix
gauge [Figure 2d and e].
The child was instructed to wear the appliance
throughout the day except during eating. The elastic
was changed once a day. The active tr eatment
continued for a period of 4 months, following which the
child wore the appliance for another 2 months with a
minimal force of 5 g to retain the tooth in the extruded
position [Figure 3b].
The vertical position of the lower incisors was carefully
monitored during the whole treatment period to ensure
that there is no supra-eruption.
DISCUSSION
Orthodontic extrusion has become a very common clinical
procedure with various indications. A clinician who is
attempting the same should have adequate understanding
of the biological and the biomechanical aspects of the
procedure.
Biology of orthodontic extrusion
Application of light forces lead to coronal migration of the
root along with the bony ridge leading to an increase in
the attached gingiva. The increase in the attached gingiva
is initially seen as an eversion of sulcular epithelium which
is nonkeratinized. It gets keratinized over a period of 28-
42 days.[1,3] The extrusion leads to bone deposition at the root
apex as well as the alveolar crest of the extruded tooth and a
normal relationship will be maintained between the alveolar
crest and the cement-enamel junction if the periodontium
is healthy.[1] The gingival tissue, which moves coronally
needs to be surgically excised for optimal esthetics (as in
a Biomechanics
b If fixed appliance is used for extrusion, addition of a
Figure 3: (a) Appliance in the mouth with elastic applied between the
bonded bracket and hook (b) posttreatment intra-oral frontal photograph
48
the case of anterior teeth) or for the placement of proper
margin of the restorations. Some researchers recommend
the weekly excision of the supra-crestal fibers where as
others recommend a single excision at the end of the whole
procedure depending on the amount of fibrotomy required.
[4]
A light continuous force is desirable for the remodeling
of the periodontal tissue and subsequent bony deposition
with in the alveolar socket.
Rapid extrusion with the application of heavy forces will
result in a less pronounced migration of supporting tissue as
the tooth tends to move faster than the rate of physiologic
adaptation of the soft tissue. Hence it requires an extended
period of retention to allow the investing tissues to adapt to
the new position of the tooth. There is a risk of periodontal
tear and resultant ankylosis of the tooth.[5] Heavy forces can
also lead to external root resorption.
Care should be taken to have minimal exposure of the
tooth surface for the purpose of bonding an attachment.[4]
As the crown bulge was visible through the gingiva, a
small window was created for the purpose of bonding
the bracket.
Optimal force needed for orthodontic
extrusion
Optimal force for the forceful extrusion depends on the
tooth involved and it can vary from 15 g for a lower
incisor to 60 g for a molar. The applied force should be
based on the physiologic response of the individual tooth
depending on its root size, root length root morphology
and the periodontal support. It should also be based on
the rate of tooth movement in individual cases. A rate of
1 mm of extrusion per week is considered physiologic for
slow extrusion.[1,3]
In the present case, a force of 20 g was applied and the
tooth moved at a very slow rate of 1.5 mm/month. This
could be attributed to the presence of scar tissue formed
secondary to the surgical extraction of supernumerary
tooth. As the tooth was an immature permanent tooth, it
was decided to keep the force levels minimum enough to
bring about extrusion without undue damage to the root
and the investing tissues.
Extrusion can be achieved by the application of a single
force with a point contact of application delivered from an
appropriate anchorage unit with a desired line of action.
The biomechanics of extrusion varies with the design of
the appliance used. Care should be taken to minimize
the effects of reactionary forces on the anchorage unit.
sufficient number of teeth in the anchorage unit prevents
the reciprocal effects on the anchor unit.
Journal of Interdisciplinary Dentistry / Jan-Apr 2014 / Vol-4 / Issue-1
 Philip and Rao: Orthodontic extrusion with a removable appliance
A removable appliance usually provides anchorage from
the palate. Retention of the appliance in the mouth is more
critical in case of a removable appliance as the reciprocal
force tends to dislodge the appliance from the mouth.
Properly designed appliance with adequate retentive
clasps ensures the stability of the appliance in the mouth
when traction is applied for orthodontic extrusion.
The applied force creates a clockwise moment which tends
to rotate the tooth. The moment is created because the
point of force application of force (elastic is applied to the
bracket) is away from the center of resistance (as shown
by a dot in the root) of the tooth. The force extrudes
the tooth while the moment brings about a lingual
tipping [Figure 2c].
Stability of the procedure
Questions are raised regarding the stability when the
extrusions are carried out at a very rapid rate. That is
attributed to a lag in the coronal migration of the tissue as
against the pace at which the tooth has moved. Mostly,
orthodontic extrusion is carried out over a period of
4-6 weeks with 1 mm of tooth movement per week. This is
followed by a stabilization period of 6-8 weeks during which
the remodeling of the supporting structures occur. Prolonged
retention for a period of 6 months is recommended by some
researchers in cases of the implant site development as the
quality and the density of the bone formed improves with
such a prolonged period of retention.[3,6]
The incisor in the present case was brought down at
a very slow rate of 1.5 mm/month and retained for an
additional period of 2 months with the help of elastics.
Clinical examination at that time revealed that the
patient presented with a mild bi-maxillary dento-alveolar
proclination which might require a fixed appliance
therapy at an appropriate time because of which the final
leveling of the four incisors was not attempted.
Clinical considerations
Certain clinical guidelines need to be followed while
attempting orthodontic extrusion with a removable
appliance:
Ensure adequate patient compliance
Journal of Interdisciplinary Dentistry / Jan-Apr 2014 / Vol-4 / Issue-1
The periodontal status and the quality and the quantity
of the attached gingiva to be evaluated carefully
The design of the appliance should be contusive for
optimal biomechanics and good retention of the
appliance
The area of surgical exposure should be kept to the
bare minimum to bond an attachment
The force applied should be light and continuous in
nature and should bring about frontal resorption
Adequate period of retention should be provided to
prevent any relapse.
CONCLUSION
Orthodontic extrusion is commonly carried out by
trained specialists. A simple removable appliance along
with a bonded attachment has been used successfully
in this case to bring about the required extrusion. This
should encourage more general practitioners to attempt
an orthodontic extrusion with a removable appliance
therapy.
REFERENCES
1. Reitan K. Clinical and histologic observations on tooth
movement during and after orthodontic treatment. Am J Orthod
1967;53:721-45.
2. Cuoghi OA, Bertoz FA, De Mendona MR, Santos EC, An TL.
Extrusion and alignment of an impacted tooth using removable
appliances. J Clin Orthod 2002;36:379-83.
3. Bach N, Baylard JF, Voyer R. Orthodontic extrusion: Periodontal
considerations and applications. J Can Dent Assoc 2004;70:775-80.
4. Quirynen M, Op Heij DG, Adriansens A, Opdebeeck HM, van
Steenberghe D. Periodontal health of orthodontically extruded
impacted teeth. A split-mouth, long-term clinical evaluation.
J Periodontol 2000;71:1708-14.
5. Oesterle LJ, Wood LW. Raising the root. A look at orthodontic
extrusion. J Am Dent Assoc 1991;122:193-8.
6. Mantzikos T, Shamus I. Case report: Forced eruption and implant
site development. Angle Orthod 1998;68:179-86.
How to cite this article: Philip P, Rao A. Orthodontic extrusion of an impacted
tooth with a removable appliance and a bonded attachment: A case report
with relevant biomechanics. J Interdiscip Dentistry 2014;4:46-9.
Source of Support: Nil, Conflict of Interest: None declared.
49
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