orthodontic consideration of the old extraction site

Mansoura UniversityFaculty of Dentistry

Orthodontic Department

BONE RESORPTION

Dental Traumatology 2003; 19: 19–29

Alveolar bone is resorbed after tooth extraction most rapidly during the first years.

Extraction of anterior maxillary teeth is associated with a progressive loss of bone mainly from the labial side.

The cause for resorption of alveolar bone has been assumed to be due to disuse atrophy, decreased blood supply, localized inflammation or prosthesis pressure

The loss is estimated to be 40-60% during the first 3 years and decreases to 0.25-0.5% annual loss there after.

Intra alveolar changes

When a tooth is removed the entire socket is filled by blood clot which is formed within 24 hours.

Baltic Dental and Maxillofacial Journal, 2012, Vol. 14, No. 1

Post-extraction socket

Within 2 to 3 days, the clot changes – it contracts and starts to break down as granulation tissue.After 4 to 5 days the granulation tissue covers alveolar bone ridge and epithelium

Intra alveolar changes

Baltic Dental and Maxillofacial Journal, 2012, Vol. 14, No.1

After 6 weeks trabecular bone formation is observed. The bone deposition in the socket is seen well after two months.

Stages of bone loss

Bone deposition is decelerating after 4 to 6 months, but still will continue for a few months.

Complete healing of the extraction socket is generally accomplished in about 100 days after the removal of a tooth.

Natural Healing

Asian Journal of Oral Health & Allied Sciences - Volume 1, Issue 3, Jul-Sep 2011

How can I do socket preservation ?

soft Tissue Graft

Socket Preservation

Grafting is the replacement or augmentation of the bone around the teeth. It is performed to reverse the bone loss / destruction caused by periodontal disease, trauma, or ill fitting removable dentures.

A. Destruction caused by periodontal disease

B. 6 months after graft placed

Socket Preservation

Guided Tissue Regeneration (GTR)

The goal of regenerative surgery is to create an environment where the body rebuilds structures lost due to the disease process that attach a tooth to the jaw, including the bone. This therapy is recommended when the pattern of bone loss is more vertical in nature

Immediate Implant Placement as Socket Preservers:

Immediate implantation is accepted treatment for the rehabilitation of the completely or partially edentulous mandible or maxilla.

Asian Journal of Oral Health & Allied Sciences - Volume 1, Issue 3, Jul-Sep 2011

Socket ready for implant

Socket Preservation

Platelet Rich Plasma (PRP) is one potential source of concentrated platelets that could be used in boneregeneration

Studies related with socket preservation techniques

Systematic Reviews

The orthodontic molar uprighting, one of the most common orthodontic procedures done as an aid to restorative therapy will improve the local alveolar morphology and the periodontal health.

Biology of the Alveolar Bone:

At patients with agenesis or previous extractions of permanent teeth (frequent) the alveolar bone is atrophic with reduced height and labiolingual thickness.

In this situations when you move orthodontically a tooth (generally a premolar) through the alveolus new bone will build up the alveolar process.

Distal movement of a premolar creates a wide area of new alveolar bone


One of the greatest specialists in this domain, prof. Birte Melsen mentioned:”When I want to move a tooth through an edentulous area it is important to avoidtipping the tooth into the region; the roots should, in principal, be moved ahead of the crown. This builds up bone by exerting a slight pressure, thereby increasing the density of the bone ahead of the tooth”.

When teeth have to be moved into areas with an atrophic alveolar process due to extraction of teeth, a balance between resorption and apposition has to be kept, and the tooth is, so to speak, “carrying its alveolus along”.


Alveolar bone loss

Implant site development between two lower premolars after extraction of a temporary canine and moving the permanent canine in class I relationship


When we use the orthodontic tooth movement to regenerate alveolar bone we must always take into consideration the lag time when we are planning theretention, because the lag time increases with increasing age.

The lag time (the time between the formation of osteoid to the formation of mineralizing bone) on successive radiographies made at an interval of 8 month

Biology of the Alveolar Bone: Also in vertical dimension the orthodontic tooth movement has a great osteogenic potential. For example at patients with periodontal disease andvertical alveolar defects the orthodontic extrusion fills the vertical defect with newly formed alveolar bone.

The orthodontic extrusion does not create a new attachment; it merely relocates the existing attachment in a coronal direction. The relationship between the cementoenamel junction and the bone crest is maintained; in other words, the bone follows the tooth.

After extrusion of the left mandibular premolars that initially have wide vertical bone defects around the apex.

New bone was formed around the teeth

Conclusion

The remodeling of the alveolar bone during orthodontic treatments is a realityand orthodontic tissue regeneration (OTR) is a useful method in many clinical situations where we have to deal with an insufficient alveolar bone. Thistechnique requires sound knowledge of biology of the alveolar bone and special biomechanics.

Adult Room

Rainbow Room

Imaging Room

Timing and Sequence of Treatment

Adjunctive Orthodontic Treatment

The sequence of steps in the treatment of patients requiring adjunctive orthodontics. Orthodontics is used to establish occlusion, but only after disease control has been accomplished, and the occlusion should be stabilized before definitive restorative treatment is carried out.

Proffit WR, Contemporary Orthodontics, Fifth edition

which would reduce or even close the edentulous space?

Adjunctive Orthodontic Treatment


As a general rule, treatment by distal tipping of the second molar and a bridge or implant to replace the first molar is preferred.

If extensive ridge resorption has already occurred, particularly in the buccolingual dimension, closing the space by mesial movement of a wide molar root into the narrow alveolar ridge will proceed very slowly.

If uprighting with space closure is to be done successfully, skeletal anchorage in the form of a temporary skeletal anchorage often is needed, and the treatment time is likely to be around 3 years.

Panoramic radiograph of a 32-years-old patient who lost mandibular first molars years ago and now desired treatment to correct her malocclusion. She chose comprehensive fixed appliance treatment, including uprighting of both the second and third molars, opening space for replacement of the missing first molars with either implants or fixed bridges.

Treatment time was 30 months. But uprighting two molars on each side takes much longer than uprighting only one molar, and it is difficult to maintain the occlusal relationships without a maxillary appliance.


A

Distal tipping for bilateral uprighting of second and third molars

Post treatment radiograph. Uprighting the second molar does not create new bone but does tend to improve the periodontal condition.


B

Missing Teeth: Space Closure versus Prosthetic Replacement

Old Extraction Sites.

In adults, closing an old extraction site is likely to be difficult. The problem arisesbecause of resorption and remodeling of alveolar bone.


After several years, resorption results in a decrease in the vertical height of the bone, but more importantly, remodeling produces a buccolingual narrowing of the alveolar process as well.

When this has happened, closing the extraction space requires a reshaping of the cortical bone that comprises the buccal and lingual plates of the alveolar process. Cortical bone will respond to orthodontic force in most instances, but the response is significantly slower.


An old first molar extraction site often poses a particular problem, because mesial drift of the second and third molars and distal drift of premolars has partially closed it, and the molars have tipped mesially.

In adjunctive treatment, a mesially tipped second molar usually is uprighted by tipping it distally, and then a bridge is placed.



A, At age 48, this woman sought treatment to replace missing teeth and improve her appearance, especially her "crooked smile.

B, The maxillary left lateral incisor and all four first molars were missing. The left canine had a composite buildup to close the remaining lateral incisor space. The maxillary posterior teeth were in a crossbite relationship, especially on the left side.


Areas of periodontal bone loss were present, but at this point, active periodontal disease had been brought under control. The key questions in planning treatment revolved around whether to close old extraction spaces or open them for prosthetic replacements.

To improve symmetry in the maxillary arch and obtain better smile esthetics, opening space for replacement of the missing lateral incisor was needed, and space closure in the maxillary left molar area would facilitate opening the anterior space. The mandibular third molars would be extracted so the second molars could be uprighted and rolled lingually to improve the crossbite.

D to F, Treatment Progress. Note the acrylic pontic tied to the maxillary archwire in the lateral incisor space. In the mandibular arch, the teeth adjacent to the space that was opened for a replacement for the first molars required restorations, and ridge augmentation would be required on the left side for an implant, so the decision was bridges rather than implants in the lower arch.


G, An implant was placed in the lateral incisor area, and the maxillary appliance was retained during initial healing as the best way to supply a temporary pontic. Note that fixed retainers are in place in the mandibular arch, where bridges are to be placed. H, Crown on implant; I, Post-treatment smile.




Often, it is better judgment to open a partially closed old extraction site and replace the missing tooth with a bridge or implant. This decision should be considered carefully in consultation between the orthodontist and prosthodontist.

If it is desired to move lower molars forward into an old first molar or second premolar extraction site, a temporary implant in the ramus can be used to provide the necessary anchorage and avoid retracting the lower anterior teeth. This technique, pioneered by Roberts, offers a level of control that cannot be obtained in any other way.

If comprehensive treatment is planned, should the space be closed by bringing the first molar mesially? That depends very much on the specific problems of an individual patient.


A to D, Use of an implant in the ramus for anchorage to move the mandibular Second and third molars mesially when it is desired to close an old first molar extraction site. Note that a wire extending forward from the implant stabilizes the premolar and through it the anterior teeth, so that they are not pulled posteriorly in reaction to anterior movement of the second and third molars


Mesial root movement is technically much more difficult than distal tipping, but the larger problem is that cortical bone remodeling usually is required to close the space because of atrophy after the old extraction.


panoramic radiograph of a 39-year-old patient who also lost mandibular first molar years ago. Comprehensive orthodontics was planned to align the anterior teeth in both arches, correct the supereruption of the maxillary first molars, and close the old extraction spaces.


Bilateral space closure with mesial root movement.

After completion of treatment, which required 36 months because tooth movement into old extraction spaces like this requires remodeling of cortical bone. Note that the periodontal situation on the mesial of the second molars remains less than ideal and that fixed retainers are being used to maintain closure of the extraction spaces, as well as incisor alignment.


Space closure of extraction site

A clinical experience is that cases after orthodontical space closure of extraction gaps have a tendency to reopen. The orthodontic force creates a compressed gingival tissue in the extraction site.

Current principle and technique (Graber – Fifth edition ).

Fixed appliance for closure of an extraction space. A, With gingivitis of the incisors (small arrows) and invagination (large arrow) in the extraction area. B, Histologic appearance of the invagination

Because active periodontitis enhances resorption and inhibits apposition, orthodontics in patients with this condition often results in a severe loss of alveolar bone support.

A, The mechanics of using a retromolar implant with an external abutment as anchorage to stabilize the premolar anterior to an extraction site. B, Using buccal and lingual mechanics to balance the load and shield the periosteum in the extraction site, the atrophic extraction site is closed without periodontal compromise of any of the adjacent teeth.

Current principle and technique (Graber – Fifth edition ).

Closing old edentulous spaces in the mandibular posterior region is a major challenge.

KJO-March 22 ,2013

space closure in the mandibular posterior region

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Spaces longer than 10 mm have been successfully closed in young patients, although problems with root parallelism and gingival dehiscence still occur.

The possibility of complications such as root resorption and periodontal defects also increase with the age of the patient and length of the space to be closed.

KJO-March 22 ,2013

Kessler suggested that if the buccolingual width of the alveolar ridge is narrower than the alveolus of the second molar, then edentulous spaces should not be closed because this would result in the loss of periodontal tissue.

Orthodontic tooth movement into edentulous areas (Reduced alveolar bone height):

In patients with partially edentulous dentitions, due to congenitally absent or the extraction of the teeth there is a reduced alveolar bone height with tooth movement :

1.on tension side original height and width of the supporting bone were fully maintained.

2.On the pressure side, supporting alveolar bone was also present with a limited reduction in vertical bone height, averaging(-1.3mm)

3.On pressure side histological sections showed that the supporting bone on the pressure side was much thinner than the original bone .

International journal of dental and medical research-Nov-Dec2014 Issue 4

So a tooth with normal periodontal support can be orthodontically moved into an area of reduced bone height with maintenance of height of connective tissue attachment level and alveolar bone support .

Orthodontic tooth movement into edentulous areas (Reduced alveolar bone height):

International journal of dental and medical research-Nov-Dec2014 Issue 4

Determined height of resorped ridge by 3D

Average buccolingual width of the lower second mandibular molar = 10.4

In other patient width of lower second molar = 10.2

Average buccolingual width of the lower first mandibular molar = 10.3

In other patient width of lower first molar = 10.2

CASE CASE REPORTREPORT

Case Report 1Diagnosis and Etiology:

A female patient aged 18 years and 9 months was referred to our clinic because of a complaint of spaces between her teeth.

Pretreatment facial photographs showed a straight profile, with competent lips and a slightly prominent chin.

KJO-March 22 ,2013

The maxilla had a 5-mm space excess. The patient had diastemas between her maxillary central incisors and distal to the maxillary canines. Her maxillary right second premolar was missing and the maxillary right first premolar was rotated by 90 degrees.

KJO-March 22 ,2013

Case Report 1

In the mandibular dentition, 15- and 14-mm spaces were present between the first and the second premolars on the right and left sides, respectively, caused by either congenital absence or early loss of the first molars. All the existing second premolars were inclined mesially. Although the canines showed a Class I relationship, all the anterior teeth were slightly retroclined.

KJO-March 22 ,2013

Case Report 1

The patient had no relevant medical history. Her oral hygiene was satisfactory, and no periodontal problems were observed.

A panoramic radiograph showed that her mandibular first and third molars were missing and the mandibular second molars were impacted. The maxillary first and third molars were also missing.

KJO-March 22 ,2013

Case Report 1

KJO-March 22 ,2013

The patient was diagnosed with skeletal Class III malocclusion, hypodontia, and polydiastemas.

Case Report 1

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Treatment Progress

Surgical phase:

One week before the orthodontic treatment was to be started, 9-mm-deep horizontal osteotomies were performed bilaterally with a piezoelectric device on the mandibular alveolar crest 2 mm away from each tooth to facilitate faster mesial movement of the second premolars.

Schematic of the corticotomy procedure. A, Sagittal view. B, Occlusal view.

Case Report 1

KJO-March 22 ,2013

Intraoperative phase. A, Corticotomy lines. B, Cylindrical bone -block placement.

Two vertical osteotomies and one horizontal osteotomy were then performed on the buccal side, and two 3-mm diameter cylindrical bone blocks were removed from this horizontal osteotomy site. The bone blocks were placed in the space on the alveolar crest.

Case Report 1

KJO-March 22 ,2013

Orthodontic phase

Mandibular orthodontic treatment was started with segmental fixed appliances ( 0.022 - inch slot brackets with MBT prescription ) and a lingual arch between the first premolars. After anchorage of the anterior teeth was reinforced by the lingual arch, two mini-anchorage screws were placed between the first premolar and the canine bilaterally.

Case Report 1

KJO-March 22 ,2013

The second premolars were banded, and 0.017 × 0.025-inch stainless steel guidance wires were passively placed between the first and the second premolars. Light closed coil springs were employed for space closure

After alignment of the mandibular second premolars, space closure was continued with tiebacks, which were changed every 4 weeks.

Alberta , Canada

Case Report 1

KJO-March 22 ,2013

When the mandibular left and right second molars erupted into the oral cavity, after 6 and 8 months of orthodontic treatment, respectively, the teeth were bonded with thinner nickel-titanium wires

Case Report 1

KJO-March 22 ,2013

The mandibular second premolars were moved into the edentulous spaces over 19 months. After the spaces between the first and the second premolars were fully closed, tiebacks were used to move the second molars mesially.

Case Report 1

KJO-March 22 ,2013

Maxillary fixed orthodontic treatment was started 6 months after the mandibular treatment began. Anterior diastemas were closed with power chains. The maxillary right first premolar was stabilized in its rotated position. Class II elastics were used, together with rectangular stainless steel archwires on the maxillary teeth, to protrude the mandibular anterior teeth.

Case Report 1

KJO-March 22 ,2013

RESULTS

The entire fixed orthodontic treatment period was 2 years and 10 months. Maxillary Hawley and mandibular bonded retainers were used for retention.

Case Report 1

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RESULTS

Case Report 1

KJO-March 22 ,2013

RESULTS

Post treatment facial and intraoral photographs.

Case Report 1

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Post treatment lateral head film and cephalometric tracing.

Case Report 1

KJO-March 22 ,2013

Superimposition of the pretreatment (dotted line) and post treatment (solid line) cephalometric tracings. A, Maxillary segmental superimposition. B, Mandibular segmental superimposition.

Case Report 1

KJO-March 22 ,2013

CONCLUSION

The results show that orthodontic space closure assisted by alveolar ridge expansion is a viable treatment option especially for old edentulous spaces.

This alternative is valuable because it eliminates most of the risks associated with corticotomy.

Case Report 2Management of severely resorbed maxillary anterior ridge complicated by traumatic bite using a ridge splitting technique

A 19-year-old female patient presented to our University Dental Center with the chief complaint of deficient maxillary anterior edentulous ridge. The patient wanted the esthetic rehabilitation of missing upper front teeth.

Journal of Indian society of periodontology –vol 19 ,issue 1, Jan-Feb 2015

Case Report 2

On clinical examination, there was deficient maxillary anterior edentulous ridge complicated by the traumatic deep bite.


Case Report 2


After the oral prophylaxis and hygiene maintenance instructions patient was referred to the orthodontist for bite opening. It took 12 months to open the bite.

The patient was then referred to the periodontist for the management of deficient maxillary anterior edentulous ridge.


Surgical procedure

On reflection of mucoperiosteal flap, it was found that the palatal cortical bone was mostly absent due to traumatic deep bite from mandibular anterior teeth.

Case Report 2


The graft material was then placed into the surgically prepared site with an amalgam carrier followed by firm pressure with amalgam condenser.

Primary soft tissue closer was done using 3–0 black braided silk suture by simple interrupted sutures. Periodontal dressing was given for the wound stabilization for 7 days.

Case Report 2


Post treatment photograph of the patient; (a) After 1 week; (b and c) After 2 weeks frontal and maxillary occlusal view; and (d) With prosthesis

Case Report 3

The international journal of periodontics & Restorative Dentistry, volume 32,Number 4, 2012

Rapid Orthodontic Treatment After the Ridge – Splitting Technique

A 32-year-old woman presented to the private with a chief complaint of an unesthetic smile and a desire to replace her missing teeth.

Case Report 3


Intraoral examination revealed an adequate overbite and overjet, transverse discrepancy, multiple-tooth agenesis, mesial tipping of the molars, absent anterior and lateral guidance, and severe atrophy of the edentulous areas.

Case Report 3


Specifically, the second premolar / first molar area presented with severe atrophy of the soft and hard tissues, a residual bone crest that was knife-edged with an advanced horizontal component, and a defect that yielded a moderate vertical component.

Case Report 3


Treatment plan:

The treatment plan included aligning the dental arches, leveling the occlusal plane, and correcting the occlusal scheme through use of orthodontics.

A channel was created using piezosurgery instruments in the edentulous areas to aid in the movement of adjacent teeth. The defects were filled with the alveolar bone of the moved teeth.

Orthodontic appliances were placed in the maxilla and mandible; 10 months later, surgery was performed .

Knife-edged ridge of the mandibular edentulous area.

Case Report 3


Separated cortical plates created a channel to allow orthodontic-guided migration of the first premolars.

Case Report 3


Elastic chain was used extending from the second molar to the first premolar to allow movement in the newly created path.

Case Report 3


CT scan showing the quality and quantity of the generated bone, which appears dense and cortical.

Case Report 3


Implants used for orthodontics anchorage to complete the alignment.

Case Report 3


conclusions

The technique presented is a valid alternative to regenerate bone and soft tissue in a knife-edged ridge. In clinical cases that need orthodontic treatment, the rapid orthodontics after ridge splitting technique could be a successful option.

Please, don’t forget :

AT THE END

Don’t leave the extraction site without preservation to prevent alveolar bone resorption.

Every year the anterior alveolar ridge reduces from 0.5-1 mm and the posterior reduces from 0.25-0.5 mm .

Sleeping Sleeping time time

orthodontic consideration of the old extraction site

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