Surgical extrusion with an atraumatic extraction system: A clinical study

Conventional avulsion versus less traumatic extraction of ankylosed roots with a magnetoelectric device in anterior maxillary areas

The analysis aimed to compare two different single-tooth extraction surgical approaches in anterior maxillary areas of the ankylosed teeth: less traumatic magneto-electrical (mag) versus conventional tooth extraction (con) in minimizing the adverse effects on post-extractive sockets. Parameters of clinical interest such as intra-surgical fracture of the buccal bone plate, presence of postoperative inflammation, and application of stitches were acquired from medical records. The data were subjected to Pearson's χ2 analysis or to Fisher's exact test with significance at 0.05. Sixty-six hopeless maxillary permanent ankylotic teeth were extracted in the same number of patients. In the mag group 2 incisors suffered a fracture. Two patients out of 40 had signs and symptoms of inflammation that resolved completely within 3 days. In the con group 18 out of 26 patients suffered from buccal alveolar fracture. Six of these patients experienced signs of inflamed tissue. The two groups showed significant differences with p-values ≤0.0009 with regards to fracture (2/38 vs. 18/8) and tissue inflammation variables (2/38 vs. 10/16). A significantly different distribution about the presence of sutures was registered between the mag (4/36) and the con (18/8) group with a p-value <0.0001. Mag group seemed to have reduced frequency of fractured and infected post-extractive sites.

Evaluating the prospective crown-root ratio after extrusion and crown lengthening procedures in vitro

For restoration of extensively damaged teeth preprosthetic treatment measures are necessary. Crown lengthening and extrusion affect the prospective crown-root ratio (CRR). The subject of this in vitro study was to compute CRRs for both treatment approaches. 120 human maxillary central extracted incisors were measured. Measurements were calculated for five treatment groups: C (control), E-2 mm (extrusion of 2 mm), E-4 mm (extrusion of 4 mm), CL-2 mm (crown lengthening of 2 mm), and CL-4 mm (crown lengthening of 4 mm). Tooth (TL), root (RL), and crown lengths (CL) were measured from mesial (m) and facial (f) cemento-enamel junction (CEJ), and respective anatomic (CRR) and effective crown-root ratios (eCRR) were calculated. Following CRR values were computed for C: CRR-m = 0.4 ± 0.1, CRR-f = 0.7 ± 0.1. All crown-root ratios were lower (more favourable) for extrusion compared to crown lengthening (p < 0.001). ECRRs were higher than anatomic CRRs. CRR at mesial CEJ was significantly lower than CRR with facial CEJ as reference (p < 0.001). Mesial measurement-based calculations of CRR typically based on radiographic images should be interpreted with caution as they underestimate the eCRR. CRR can be expected as lower, i.e. more favourable, when teeth are extruded than crown lengthened.

Clinical applications and outcomes of the surgical tooth extrusion technique: A bibliometric analysis from 1982 to 2023

STATEMENT OF PROBLEM

The surgical extrusion technique has been advocated for severely damaged teeth as well as for intruded and unerupted teeth. However, a quantitative literature analysis is lacking.

PURPOSE

The purpose of this bibliometric analysis was to provide a comprehensive overview of surgical extrusion, assess the applications and outcomes, and evaluate topics for future research.

MATERIAL AND METHODS

An electronic search was conducted in leading databases in April 2023. Human studies with surgical tooth extrusion or synonyms in titles or abstracts were included. A bibliographic analysis, co-occurrence analysis, and coupling of publications were performed. The analysis of variance was used to assess the characteristics of the subgroups based on indications. The survival rate was evaluated by using the Kaplan-Meier method in the R software program (α=.05).

RESULTS

Fifty-one studies from 1982 to 2023 were included. The Journal of Dental Traumatology and the Journal of Prosthetic Dentistry combined published approximately one-third of the papers and acquired the most citations. The burst detection of keywords revealed 4 popular research topics: the Benex extraction system, chlorhexidine for infection control, rigid or semi-rigid splints to decrease the risk of complications, and novel restorative materials to improve esthetics. An overall survival rate of 96.36% was reported among 316 participants with 330 extruded teeth. No significant differences were found in study types, geographic distribution, year of publication, or citation counts among the 4 subgroups (surgical extrusion for subgingival fractures, extensive caries, intruded teeth, and unerupted teeth). A significant difference was observed among the Kaplan-Meier curves of the 4 subgroups (P=.030).

CONCLUSIONS

Surgical extrusion may be used to save otherwise nonrestorable teeth, and the procedure has shown promising survival rates when teeth are properly selected and the procedure is well executed. Subgingival fractures and extensive caries near bone level are the predominant indications, as well as intruded and unerupted teeth. Surgical extrusion is a reliable treatment option to facilitate tooth restoration for severely damaged teeth, especially for maxillary anterior teeth.

Forced surgical extrusion using an axial tooth extraction system as a practicable technique for preserving severely destroyed teeth? - Clinical outcomes up to 4.8 years

OBJECTIVE

Several extrusion techniques have been described to restore teeth with insufficient coronal tooth structure and to avoid their extraction. Still, there is little evidence for a treatment concept combining surgical extrusion using an atraumatic axial extraction system.

MATERIALS AND METHODS

A total of nine patients, each with an iso- or subgingival fractured tooth, were retrospectively examined. Treatment of the damaged tooth comprised an atraumatic forced surgical extrusion performed with an axial tooth extraction system and a more coronal positioning within the socket. The teeth were initially splinted and subsequently restored. The follow-up period was up to 57.1 months and averaged 36.5 (SD: ±13.5) months.

RESULTS

All nine teeth were still in situ, without signs of inflammation. During the period of the provisional restoration, six prosthetic complications occurred, which were resolved with little effort, whereas, success rate for the definitive restoration was 100%. No biological complications were observed concerning the root apex or soft tissue. The radiographically measured mean extrusion distance was 3.4 (SD: ±1.0) mm, so that a sufficient prosthetic ferrule could be reestablished.

CONCLUSIONS

Surgical extrusions using an axial tooth extraction system demonstrate low biological and prosthetic complications rates over observation time.

CLINICAL SIGNIFICANCE

The presented extrusion approach preserves soft and hard tissue and is an efficient treatment option for severely destroyed teeth. Saving hopeless teeth by this relatively predictable and feasible procedure has hardly any disadvantages for patients, and in case of failure, an implant or fixed partial denture are still an option.

Root-analogue implants compared to forced orthodontic extrusion: a retrospective analysis of clinical, radiological and esthetic outcomes after restoration

OBJECTIVES

To assess clinical, radiological and esthetic outcomes of restorations supported by root-analogue implants (RAIs) or roots of severely damaged teeth after forced orthodontic extrusion (FOE).

MATERIALS AND METHODS

Clinical data regarding milled one-piece (titanium/zirconia roots and zirconia abutments) RAIs (REPLICATE™ System) and FOE were recorded and retrospectively evaluated for 40 patients by two investigators. Strict inclusion and exclusion criteria were applied. Functional and esthetic outcomes were assessed for n = 20 pre-molars and n = 20 anterior teeth via comparison of radiographic and digital images applying the novel Functional Implant Prosthodontic Score (FIPS). Krippendorff's alpha coefficient was calculated to assess inter-rater reliability. Mann-Whitney-U-Test was used to compare the assessed parameters. Level of significance was set to p < 0.05.

RESULTS

After a mean observation period of 18.4 ± 5.7 months for restorations supported by RAIs and 43.9 ± 16.4 months for restorations after FOE, mean FIPS scores were 9.2/8.8 ± 1.1/1.2 (RAIs) and 7.4/7.7 ± 1.3/1.5 (FOE), respectively. Krippendorff's alpha coefficients did not reveal unacceptable inter-rater reliabilities regarding the investigators and applicability of FIPS. Significant differences were documented when comparing restorations after FOE or supported by RAIs regarding bone loss (p < 0.01), presence of papillae (p < 0.05) and quality and quantity of mucosa (p < 0.02) in favor of FOE.

CONCLUSIONS

Within the main limitations of sample size and the retrospective study design, both concepts seem to provide clinically acceptable results.

CLINICAL RELEVANCE

Bone- and tissue-preserving characteristics regarding the concept of FOE are promising. It could be applicable for socket preservation and subsequent conventional implant placements in an adapted workflow.

Health economic evaluation of forced orthodontic extrusion of extensively damaged teeth: up to 6-year results from a clinical study

OBJECTIVES

Clinical data on retaining extensively damaged teeth using forced orthodontic extrusion followed by restorative rehabilitation are scarce, and economic evaluations are basically absent. A health economic evaluation of this method was performed based on a clinical study.

MATERIALS AND METHODS

In a convenience sample of individuals recruited from routine care, extensively damaged teeth were orthodontically extruded prior to restoration. Patients were followed up for up to 6 years. The health outcome was tooth retention time. Direct medical, non-medical, and indirect initial and follow-up costs were estimated using the private payer's perspective in German healthcare. Association of initial direct medical treatment costs and cofounding variables was analyzed using generalized linear models. Success and survival were secondary outcomes.

RESULTS

A total of 35 teeth in 30 patients were followed over a mean ± SD of 49 ± 19 months. Five patients (14%) dropped out during that period. Median initial costs were 1941€ (range: 1284-4392€), median costs for follow-up appointments were 215€ (range: 0-5812€), and median total costs were 2284€ (range: 1453 to 7109€). Endodontic re-treatment and placement of a post had a significant impact on total costs. Three teeth had to be extracted and in three patients orthodontic relapse was observed. The survival and success rates were 91% and 83%, respectively.

CONCLUSIONS

Within the limitations of this clinical study, total treatment costs for orthodontic extrusion and subsequent restoration of extensively damaged teeth were considerable. Costs were by large generated initially; endodontic and post-endodontic therapies were main drivers. Costs for retreatments due to complications were limited, as only few complications arose.

CLINICAL RELEVANCE

The restoration of extensively damaged teeth after forced orthodontic extrusion comes with considerable initial treatment costs, but low follow-up costs. Overall and over the observational period and within German healthcare, costs are below those for tooth replacement using implant-supported crowns.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: DRK S00026697).

Quality of CAD-CAM inlays placed on aged resin-based composite restorations used as deep margin elevation: a laboratory study

OBJECTIVES

To assess the impact of the age of resin-based composite (RBC) restorations used for deep margin elevation (DME) on the marginal quality and fracture resistance of inlays.

MATERIALS AND METHODS

Permanent human molars with direct RBC restorations, involving the mesial, occlusal, and distal surface (MOD), were allocated to four groups (each n = 12). Half of the teeth underwent thermomechanical loading including 240,000 occlusal load cycles and 534 thermal cycles (TML, 5 °C/55 °C; 49 N, 1.7 Hz). With RBC left in one proximal box as DME, all teeth received MOD inlays, made from lithium disilicate (LDS) or a polymer-infiltrated ceramic network material (PICN). The restored teeth underwent TML including 1.2 million occlusal cyclic loadings and 2673 thermal cycles. The marginal quality was assessed at baseline and after both runs of TML. Load-to-fracture tests were performed. The statistical analysis comprised multiple linear regressions (α = 0.05).

RESULTS

Simulated aging of RBC restorations had no significant effect on the marginal quality at the interface between the RBC and the tooth and the RBC and the inlay (p ≥ 0.247). Across time points, higher percentages of non-continuous margin were observed between the inlay and the tooth than between the tooth and the RBC (p ≤ 0.039). The age of the DME did not significantly affect the fracture resistance (p ≥ 0.052).

CONCLUSIONS

Artificial aging of RBC restorations used for DME had no detrimental effect on the marginal quality and fracture resistance of LDS and PICN inlays.

CLINICAL RELEVANCE

This laboratory study suggests that-in select cases-intact, direct RBC restorations not placed immediately before the delivery of an indirect restoration may be used for DME.

Forced orthodontic extrusion to restore extensively damaged anterior and premolar teeth as abutments for single-crown restorations: Up to 5-year results from a pilot clinical study

STATEMENT OF PROBLEM

Clinical data on orthodontic extrusion to restore teeth deemed unrestorable because of their defect size are scarce. It remains unclear for which defects forced orthodontic extrusion and tooth retention is preferred to extraction.

PURPOSE

The purpose of this pilot clinical study was to investigate the survival, frequency, and type of complications of extensively damaged teeth requiring single-crown restorations after forced orthodontic extrusion.

MATERIAL AND METHODS

Participants were recruited from consecutive patients in need of restorative treatment of extensively damaged teeth at a university clinic. The teeth were orthodontically extruded to reestablish the biologic width and to ensure a 2-mm ferrule preparation before restoration. The primary endpoint was restoration success and survival. At recall, survival was defined as the tooth being in situ and success as a symptom-free tooth with an intact, caries-free restoration and with physiological pocket probing depths, no signs of intrusion, ankylosis, root resorption, or periapical radiolucency. Recalls were performed every 6 months; the outcome was assessed by radiographic and clinical evaluation after up to 5 years of clinical service. Quantitative parameters were described with mean values and standard deviations.

RESULTS

Thirty-four participants were assessed for eligibility and enrolled (mean ±standard deviation age: 53.4 ±18.9 years). Four participants were premature dropouts. Data were analyzed for 35 teeth in 30 participants. The amount of extrusion varied between 2 and 6 mm (mean ±standard deviation 3.4 ±0.9 mm). The mean duration of extrusion was 18.9 ±12.6 days and the mean duration of retention was 126.94 ±88.1 days. The mean ±standard deviation crown-to-root ratio after treatment was 0.8 ±0.1 (range: 0.5 to 1.0). Three participants exhibited orthodontic relapse before restoration. Teeth were successfully restored after repeated extrusion. After a mean observation period of 3.3 years (range: 1 to 5.2 years), 29 of 31 teeth were still in situ. Two teeth were fractured, and 4 participants were not available for recall. Thus, the survival rate was 94%. No resorption or periapical translucencies were observed radiographically. Clinical examinations revealed physiological probing depths and absence of ankyloses. One tooth presented with marginal bone loss. The most frequent type of complication was orthodontic relapse at recall (n=3). A total of 84% of teeth were considered a success.

CONCLUSIONS

Forced orthodontic extrusion allowed for the restoration of anterior and premolar teeth deemed as nonrestorable because of their defect size. Tooth retention of extensively damaged teeth and their use as abutments for single-crown restorations can be recommended.

Are Physics Forceps Less Traumatic than Conventional Forceps for Tooth Extraction? A Systematic Review and Meta-Analysis of Randomized Controlled Trials

This systematic review and meta-analysis studied the clinical outcomes with physics forceps compared to those with conventional forceps for closed dental extraction. A systematic literature search was performed to identify all the published randomized clinical trials that compared the relevant clinical outcomes with physics forceps to those with conventional forceps for closed dental extraction. A total of 11 studies were included. The adverse events were significantly lower with physics forceps (n = 48) compared to with conventional forceps (n = 120), with an odds ratio of 0.42 [0.25, 0.70], Z = 3.78 (p = 0.0002), and I² = 21%. There were statistically significant differences in the incidence of GL (p = 0.04), and tooth or root fracture (p = 0.0009). Operating time was significantly lower in physics forceps than that of conventional forceps, mean difference (−20.13 (−30.11, −10.15)), Z = 3.78 (p = 0.0001), I² = 79%. The available evidence is limited by a high risk of bias and low evidence certainty. Based on the current evidence, physics forceps might be better than the conventional extraction forceps in terms of the extraction duration, pain after extraction, trauma to both hard and soft tissue, and complications. Physics forceps are newer instruments that have not yet been introduced in the teaching of dental graduates. The introduction of physics forceps can be time saving, less invasive and reduce post-extraction complications.

Orthodontic Forced Eruption of Permanent Anterior Teeth with Subgingival Fractures: A Systematic Review

(1) Background: To assess orthodontic forced eruption (OFE) as a pre-restorative procedure for non-restorable permanent teeth with subgingival dental hard tissue defects after dental trauma. (2) Methods: A systematic electronic search of three databases, namely, MEDLINE, Cochrane Library, and EMBASE, revealed a total of 2757 eligible publications. Randomized controlled clinical trials (RCT), retro- and prospective clinical studies, or case series (with a minimum of three patients) were reviewed. (3) Results: Thirteen full-text papers were included: one RCT, one prospective clinical trial, two retrospective cohort studies, and nine case series. Within case series, statistical significance between age and cause of fracture (p < 0.03) was determined. The mean extrusion rate of OFE was 1.5 mm a week within a four to six weeks treatment period followed by retention. Three OFE protocols for maxillary single teeth are available: 1. OFE without migration of gingiva and alveolar bone, 2. OFE with gingival migration and slight alveolar bone migration, and 3. OFE with migration of both gingiva and alveolar bone. (4) Conclusions: The current state of the evidence suggests that OFE is a feasible pre-treatment option for non-restorable permanent teeth. OFE can promote the migration of tooth surrounding hard and soft tissues in the esthetic zone. Root resorption does not seem to be a relevant side effect of OFE.

Pre-endodontic restoration of structurally compromised teeth: current concepts

Teeth that require endodontic treatment are often structurally compromised and this considerably complicates endodontic procedures. Therefore, pre-endodontic restoration is a key approach that dentists should consider for such teeth. This article discusses current concepts of pre-endodontic restoration, with a focus on adhesive restorative methods and surgical/orthodontic techniques, and provides a relevant decision-making flowchart.

Highlights the importance of pre-endodontic restoration for the predictability of endodontic treatment.

Discusses restorability aspects for structurally compromised teeth.

Reviews current restorative and surgical/orthodontic techniques for pre-endodontic restoration and provides a decision-making flowchart.

Orthodontic Extrusion vs. Surgical Extrusion to Rehabilitate Severely Damaged Teeth: A Literature Review

The need to rehabilitate severely compromised teeth is frequent in daily clinical practice. Tooth extraction and replacement with dental implant represents a common treatment choice. However, the survival rate for implants is inferior to teeth, even if severely damaged but properly treated. In order to reestablish a physiological supracrestal tissue attachment of damaged teeth and to arrange an efficient ferrule effect, three options can be considered: crown lengthening, orthodontic extrusion and surgical extrusion. Crown lengthening is considered an invasive technique that causes the removal of part of the bony support, while both orthodontic and surgical extrusion can avoid this inconvenience and can be used successfully in the treatment of severely damaged teeth. The aim of the present narrative review is to compare advantages, disadvantages, time of therapy required, contraindications and complications of both techniques.

Effects of different splinting times on surgically extruded teeth with a crown-root fracture: A randomized controlled trial

BACKGROUND/AIM

Clinical studies evaluating the splinting time for surgically extruded teeth with crown-root fractures are lacking. The aim of this study was to compare 2-week splinting versus functional splinting times after surgical extrusion.

MATERIAL AND METHODS

Children aged 8-13 years who presented with crown-root fractures were included. Surgical extrusion was performed, and teeth were splinted either for 2 weeks or until normal Periotest values were achieved (functional splinting time). The outcome measures were tooth mobility, tooth loss, root resorption, marginal bone resorption and ankylosis. Measurements were taken at baseline, weekly after splint removal, and after 1, 3, 6 and 12 months.

RESULTS

Nineteen patients were included in the analysis. Surgically extruded teeth splinted for 2 weeks showed significantly higher mobility directly after splint removal and at 1 month after splinting compared with the functional splinting time group. The mean differences for horizontal Periotest values were 14.96 (95% confidence interval: 8.52, 21.39) and 6.63 (95% confidence interval: 0.25, 13), respectively. The vertical Periotest values were 10.47 (95% confidence interval: 1.95, 18.99) and 4.81 (95% confidence interval: -1.57, 11.18), respectively. At the 3-, 6- and 12-month follow-up intervals, there were no statistically significant differences between the groups. One tooth in the 2-week splinting group was lost. None of the teeth had ankylosis, marginal bone resorption or root resorption.

CONCLUSIONS

Although both groups showed neither statistical nor clinically significant differences after 12 months, there was a significant difference immediately after splint removal, with greater tooth mobility in the 2-week splinting group. Thus, a functional splinting time (4-6 weeks) can be suggested for better healing and optimal stability to allow placement of the final restoration directly after splint removal.

Surgical extrusion: A dental technique

This article describes a technique for surgically extruding severely compromised roots needing prosthetic rehabilitation. Unlike previously described approaches, the technique does not require advanced clinical skills or equipment, may reduce the risk of tooth or bone fracture during the luxation maneuvers, and does not seem to interfere with the alveolar socket healing process.

Long-term outcome of adhesive fragment reattachment in crown-root fractured teeth

BACKGROUND/AIMS

Adhesive fragment reattachment (AFR) is one treatment option for crown-root fractured teeth. However, there are no studies investigating the long-term outcome of this approach. The aim of this retrospective study was to evaluate the long-term outcome of AFR and periodontal health in crown-root fractured teeth by assessing complications and periodontal status.

MATERIALS AND METHODS

Data regarding 41 patients with 51 traumatized teeth (TT) were included. Periodontal health was assessed by recording the pocket probing depth (PPD), clinical attachment level (CAL), bleeding on probing (BoP), gingival index (GI), and plaque index (PI) in the TT and in one unaffected control tooth (CT). Complications were classified as "restorative," "endodontic," and "additional root fracture." Based on these complications, the outcome was graded as "success," "partial success," "survival," and "failure." Statistics was performed by t test, chi-square test and logistic regression models.

RESULTS

After 8.5 ± 4.6 years, 76.5% (39/51) of the TT had functionally survived. Functional survival of the reattached fragments was 66.7% (26/39) after 9.5 ± 3.7 years. PPD (TT: 4.11 ± 2.03; CT: 2.08 ± 0.65), CAL (TT: 4.78 ± 2.19; CT: 2.42 ± 1.03), and BoP values (TT: 77.4%; CT: 22.6%) were higher in TT than in CT. GI scores > 0 were found in 83.3% of the TT and in 27.8% of the CT. PI scores did not differ between TT and CT. Of the complications, 56.8% were "restorative," 22.7% "endodontic," and 20.5% "additional root fractures." Eleven (27.5%) TT were without complications and rated as "success."

CONCLUSIONS

AFR in crown-root fractured teeth showed a high survival rate and occasionally compromised periodontal health. However, due to the high complication rate, it should be considered as a long-term temporary treatment to postpone other invasive therapy options. AFR can be a valuable way to avoid early loss of crown-root fractured teeth, especially in young patients. Moisture control and additional root fractures significantly influenced the outcome.

Restoring the unrestorable! Developing coronal tooth tissue with a minimally invasive surgical extrusion technique

Surgical extrusion is a recognised treatment option for teeth that have insufficient coronal tooth structure remaining due to deep caries, resorption or traumatic injury. However, the technique has not been widely adopted, arguably because extraction of a severely compromised tooth may be difficult to achieve in a gentle and predictable way. In this paper, we present our novel approach to surgical extrusion and subsequent management of teeth using a vertical extraction system (Benex), which has become the method of choice in the authors' practice for many teeth that would otherwise be deemed unrestorable. We describe the clinical procedure in detail and discuss the advantages and disadvantages compared to alternative approaches, including surgical crown lengthening and orthodontic extrusion.