ORTHODONTIC EXTRUSION: AN AESTHETIC AND PROPRIOCEPTIVE ALTERNATIVE TO IMPLANT - AN INTERDISCIPLINARY CASE REPORT.

Justin Jolly 1 , Sajith Sudevan 2 ,Vaishnavi Gowda 3 , Joshil D T 2 and Junu Henry 3 . 1. MDSPost Graduate Student, Department of Orthodontics, Coorg Institute of Dental Sciences, Coorg, Karnataka, India. 2. MDSPost Graduate Student, Department of Endodontics, Coorg Institute of Dental Sciences, Coorg, Karnataka, India. 3. MDSPost Graduate Student, Department of Prosthodontics, Coorg Institute of Dental Sciences, Coorg, Karnataka, India. ...................................................................................................................... Manuscript Info Abstract ......................... ........................................................................ Manuscript History Received: 10 February 2019 Final Accepted: 12 March 2019 Published: April 2019

Case report describes a multidisciplinary approach using orthodontic forced eruption to facilitate prosthetic restoration of a maxillary permanent lateral incisor with poor restorability. On examination, patient had a root stump in the region of 12. We decided to treat the patient by orthodontic extrusion followed by endodontic post and crown as patient was not wiling for extraction of 12 followed by prosthetic implant. The case was treated in a much easier way without the help of brackets and wire components. At 2 weeks, there was a clear radiolucent area filled with immature bone, osteoid and a normal periodontal ligament. Temporary anchorage device allowed the clinician to rehabilitate the smile easily and conveniently without extensive prosthodontic restorative work.

…………………………………………………………………………………………………….... Introduction:-
Replacing the maxillary incisor remains the most challenging procedure in implant dentistry. Factors impacting success include the amount of available bone, the type of soft tissue, correct positioning of the implant, the provisional restoration, the design and material of the implant abutment, and the final restoration. 1,2,3 Treatment approaches with mini-implants can be considered standard today in modern orthodontic practices because they treat conditions that are difficult to correct with conventional mechanics. 4,5 The purpose of this case report was to analyze the changes when forced eruption is used for endodontic post and crown development. Restoration after orthodontic eruption may present a more conservative treatment choice in all patients compared with the prosthetic restoration after extraction.

Case Report
A 50 year old female patient reported to the department of orthodontics with a chief complaint of spacing in the upper right front tooth region. On examination, patient had a root stump in the region of 12 ( Figure 1). It was decided to treat the patient by orthodontic extrusion followed by endodontic post and crown as patient was not willing for extraction of 12 followed by prosthetic implant. The case was treated in a much easier way without the help of brackets and wire components.

Discussion:-
This case presents the clinician with a difficult restorative problem and is complicated by the need to maintain the periodontal tissues in good health. The treatment options up to now have usually been limited to extrusion of the remaining root with a conventional orthodontic appliance or extraction with bridge replacement. In this report, a new method of orthodontic extrusion with mini-implant (1.6*0.8 mm) is presented (Figure 4). The roots were 655 extruded 3 to 4 mm with a force range from 10 to 40 grams during a treatment period of 5 to 6 weeks ( Figure 5,6). Good force control at short distances, no friction, and no material fatigue of titanium mini-implants resulted in successful rapid extrusion. No evidence of soft tissue dehiscences, aberrant tooth mobility, or root resorption was found. 6 Also it was important to achieve an acceptable crown-root ratio for a better prognosis of the post and crown. Crown root ratio, this ratio is a measure of the length of the tooth occlusal to the alveolar crest of bone co mpared with the length of root embedded in the bone. Optimum crown root ratio for a tooth to be utilized as a abutment is 2:3. A ratio of 1:1 is the minimum ratio that is acceptable for a prospective abutment under normal circumstances. If the occlusion opposing a proposed fixed partial denture is composed of artificial teeth the occlusal force will be diminished with less stress on the abutment teeth.

Figure 4:-Mini implant with green elastics
Orthodontic tooth extrusion was able to move the soft tissues when the sulcular attachment apparatus is intact. 7 Bone formation as the tooth is extruded is dependent on the vector of the movement and the force applied on to the tooth. 8 The rate of tooth extrusion is effected by the bone-tooth attachment. A tooth that would have been extracted routinely was thus saved and restored through the use of a collaborative approach using mini-implants.
Teeth with a poor restorability was extruded for 6 weeks with the help of an implant in the opposing arch and retained an additional 4 weeks prior to post and core buildup. At 2 weeks, there was a clear radiolucent area filled with immature bone, osteoid and a normal periodontal ligament.

Conclusion:-
Extrusion using miniscrew is a conservative treatment modality for root stumps with poor restorability. Temporary anchorage device allows orthodontist to rehabilitate the smile easily and conveniently without extensive prosthodontic restorative work. We could achieve good aesthetic results in just 6 weeks while maintaining proprioceptive sensation.