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Co-authors:
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Coordinating
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Ph.D.; Alan Cantor, Ph.D.; Roland Mais, M.S.; Barbara
Christine; Anne Horney; Jean Rowe.

Orthodontic
technique

extrusion

of premolar

D. L. Nappen,
D.D.S., M.S.D.,*
and D. J. Kohlan,
Naval Dental Clinic, San Diego, Calif.

teeth: An improved

D.D.S.**

Traditional
methods of tooth restoration
may be impossible
because of insufficient
crown length. This article describes a method to orthodontically
extrude nonrestorable
premolar
teeth. More than 100 patients who required
premolar
extrusion
before prosthetic
restoration
have been treated with this procedure.
Clinical
records of a typical patient are shown to demonstrate
the effects of the application
of this technique,
and a method of bracket placement
on a severely broken down
nonrestorable
tooth is described. The advantages
of the technique
recommended
in this article are described.
(J PROSTHET DENT 1989,61:549-54.)

nrestorable margins at or below the crestal height

of alveolar bone often result from root fractures,
root
resorption,
cervical caries, or iatrogenic
root perforation.
Each of these clinical situations may serve as an indication
for orthodontic
extrusion prior to the use of traditional
restorative procedures. Since Heithersayl
described a method
of orthodontically
extruding
teeth exhibiting
transverse
fractures in the coronal one third of the root, numerous authors have suggested
additional
indications
for the
procedure.2-4 The techniques
suggested for extruding
the
root fragment have varied depending upon the clinical situation as well as the materials
available to the authors.
*Captain, U.S. Naval Dental Corps, Department Head, Orthodontics.
**Lieutenant Commander, U.S. Naval Dental Corps, General Dentistry Fellow.
TAEJOURNALOFPROSTHETICDENTISTRY

Although
different techniques have been used, the various
authors agree on the benefit of extruding the root fragment
versus extraction
or exposure of the root via periodontal
surgery. Extrusion avoids the loss of a dental unit and simplifies the prosthetic restoration. Orthodontic
extrusion also
avoids the creation of unesthetic and uncleansable
gingival
contours that may result from surgical exposure of buried
tooth margins.
Most previously published techniques demonstrate extrusion of maxillary anterior teeth. The method popularized
by
several authors consists of passively attaching a piece of rigid
round wire to the teeth located mesial and distal to the tooth
fragment to be extruded.1-3 Another piece of straight wire
with a hook bent in one end is cemented into the coronal
portion of the root canal system of the tooth. Elastics are
connected between the rigid wire and the hook-shaped
wire,
thereby activating
the tooth. Positioning
of the two wires
549

NAPPENANDKOHLAN

Fig. 1. A, View of patients intact maxillary dentition with

obliquely fractured lingual cusp of right second premolar. B,
Gingival margin of fracture extends to alveolar crest at distolingual area.

must allow for clearance from occlusion, sufficient access for

placement of activated elastics, and enough distance to permit the anticipated
amount of extrusion.
Applying
this
technique to posterior teeth has been suggested but rarely
demonstrated
in the literature.
The ability to extrude premolars with this method is complicated
by the presence in
the posterior
dentition
of greater occlusal forces, more
occlusal interferences,
and shorter clinical crown lengths.
This article describes a technique
that simplifies
orthodontic extrusion of premolars and takes advantage of recent advances in orthodontic
materials. The technique provides for a high degree of control and predictability
of the
linear amount of extrusion. In addition it has the advantages
of minimizing
interference
from occlusion, simplifying
the
stabilization
of the extruded root fragment, and reducing
appointment
frequency and length.

PATIENT

SELECTION

Evaluation of patients for possible premolar extrusion include the parameters of occlusion, oral hygiene, periodontal

Fig. 2. A, Enough facial enamel remains to allow for direct

bonding to fractured tooth with orthodontic
brackets. Initially nickel-titanium
wire is deflected 3 to 4 mm gingivally.
B, Following extrusive tooth movement brackets are vertically leveled by nickel-titanium
wires active memory.

status, restorability,
endodontic
status, and patient desires
(Fig. 1). It is important that sufficient centric and functional
occiusal clearance exist to allow for the desired amount of
extrusion. The patients oral hygiene and periodontal
health
must be stable and the root not ankylosed. Successful endodontic treatment should be completed before the extrusion procedure. Assessment of the restorability
of the tooth
must include an estimate of the crown/root
ratio after
extrusion and restoration. Because the extrusion procedure
and postextrusion
stabilization
require approximately
12 to
16 weeks, the patients availability
for follow-up evaluation
must also be assessed.

CLINICAL

TECHNIQUE

The teeth mesial and distal to the premolar to be extruded

are isolated with a rubber dam to permit clear access, optimal bonding,5 and increased patient comfort. Orthodontic
brackets are bonded to the facial surfaces of the involved
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Fig. 3. A, Maxillary second premolar was extruded approximately 4 mm to obtain access for marginal integrity in
distolingual area. B, Coronal movement of attached tissue on
facial side of extruded premolar.

Fig. 4. A, Intact mandibular dentition with left second

premolar exhibiting recurrent caries to level of alveolar crest
in distolingual area. B, Short clinical crown and lack of facial enamel preclude direct placement of orthodontic bracket.

tooth and each tooth me&al and distal to it. Prior to bonding, the teeth are acid-etched for 1 to 1.5 minutes with 37%
orthophosphoric acid. Either self-curing or light-cured composite resin bonding paste is applied to the back of the orthodontic brackets. Brackets are immediately placed and
aligned to allow for occlusal clearance. The bracket on the
tooth fragment to be extruded is positioned more apically
than the adjacent brackets (Fig. 2, A). The distance this
bracket is apically offset is determined by the estimated
amount of extrusion desired. The offset should not exceed 5
mm from the adjacent brackets. If greater than 5 mm of extrusion is desired, the extrusion should be planned in phases
with the bracket repositioned more apically after the first 5
mm of extrusion have been accomplished. A straight segment of .016 inch round nickel-titanium wire (Nitinol wire,
Unitek Corp., Monrovia, Calif.) is adapted into the three
bracket slots and ligated in place. The resilient nickel-titanium wire (Ni-Ti) has a wide working range and can be elastically deformed the 2 to 5 mm to engage the bracket on the
tooth to be extruded without the wire taking on a permanent

bend. The elastic memory of the wire provides the extrusive

force to the involved tooth. After the Ni-Ti wire has returned
to its original straight form (Fig. 2, B), the amount of extrusion achieved is assessed clinically and radio~aphically. The
extrusive movement generally occurs over a Z- to d-week period, Following extrusion, the 0.016 inch round wire or a segment of passive rectangular wire can be used to retain the
tooth in the final desired position. The stabilization period
should be at least 12 weeks to allow for reorganization of the
periodontal membrane and alveolar osseous tissue. Following stabilization, the orthodontic brackets and segmental
archwire are removed and the appropriate prosthetic restoration is accomplished (Fig. 3).
Frequently the root fragment lacks enough clinical crown
to permit bonding an orthodontic bracket (Fig. 4). In such
situations a pin- or pulp chamber-retained light-cured composite resin buildup is recommended (Fig. 5). A dentinal
bonding composite resin provides a temporary facial surface
onto which the bracket can be fastened. Following the
extrusion and stabilization (Fig. 6, A) the brackets and tem-

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551

NAPPEN

5. A, Isolation of remaining clinical crown and pin

placement allow for temporary restoration of facial surface.
B, Placement of orthodontic bracket subsequentto restoration of facial surface to contour consistentwith adjacent facial contours.

Fig.

porary restoration are removed before definitive restoration

of the now accessiblemargins (Fig. 6, B).
DISCUSSION
The orthodontic extrusion procedure is indicated in various clinical situations. According to Simon et al2 and others, horizontal or oblique root fractures, internal or external
resorption, caries,perforation, or estheticsmay be indicating factors394,6,7 Simply stated, any subgingival or subosseousextension of a pathologic or traumatic defect that
precludesthe traditional restorative approach is a possible
indication for orthodontic extrusion.2
The evaluation of each casemust include both the interpersonalfactors and the physical factors. The patient should
be aware of cost, time commitments, and necessaryplaque
control procedures.Physical factors include the following.
Crown-to-root
ratio. The posttreatment crown-to-root
lengths must support the final restoration.2 Heithersayi
552

AND

KOHLAN

suggestsa ratio of 1:l must be maintained with a residual

root segmentof 12 to 15 mm. However, healthy periodontium and effective plaque control may allow morelatitude in
this respect. Even where an initial infrabony defect has
compromisedthe crown-to-root ratio, Ingbe& g has shown
that orthodontic extrusion improvesthe ratio. This occursas
the alveolar bone and attached gingiva move with the root
segment, thereby maintaining periodontal support. The
coronal segment,meanwhile, becomesshorter as it must be
adjusted to the new occlusal level.
Severe trauma. There is little tendency for ankylosis to
involve erupted teeth with a history of slight to moderate
trauma.O However, according to Turley et al.,ll when the
trauma producesintrusion greater than 1 mm, ankylosis is
likely to occur. If a tooth is ankylosed, orthodontic extrusion
will be unsuccessfuland will only produce intrusive movement of the anchor teeth.
Restorability.
The term biologic width describesthe
dimension of gingival connective tissue attachments, and
epithelial attachment. Potashnick and RosenbergI and
Schneider and Binderi relate to range of 0.71to 1.35mm of
epithelial attachment, and they suggesta 3 to 4 mm distance
from the alveolar crest to the coronal extension of the
remaining tooth structure to maintain optimum periodontal
health. Taper of the erupted tooth will be increasedin most
casesbecauseof the narrower tooth segmentpositioned into
a more coronal location.
Rate of eruption.
The faster the tooth is erupted forcibly
from the alveolus, the greater will be the lag between the
movement of the tooth and its attachment apparatus.12This
may be desirablefrom a restorative point of view. Too rapid
extrusion, however, may necessitate longer stabilization
times and marked periodontal inflamation.7
Stabilization
time. Nasjleti et a1.14have shown that
shorter splinting times with a nonrigid material may reduce
inflammatory resorption and ankylosisin reimplanted teeth.
Several authors2-4,l5 have reported using stabilization periodsafter orthodontic extrusion ranging from 6 to 12 weeks.
Stabilization must allow a rehyalinization processto occur to
prevent reintrusion.Complete healing and mature bone formation need not have occurred during the stabilization period.
Postorthodontic
surgery. The attached gingival width
may increaseduring orthodontic extrusion.12Esthetics may
be compromiseddue to disrupted alveolar and gingival contour. The biologic width may be encroachedupon by the
final restoration.i5 Any or all of these factors may dictate
post-orthodontic osseoussurgery or gingivoplasty.
Since multiple disciplines and factors are involved in
orthodontic extrusion, it follows that control and simplicity
are essentialfor reaching a predictable tooth position. Most
descriptionsof this subject have included the useof elastics
for the application of force.2-4*7,16-18
Someauthors have advocated usinga modified Hawley appliancefor extrusionigp2o
and others have used direct bonded brackets and flexible
wire.15v21

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TEETH

Control of tooth movement with direct bonded brackets

and a segmental arch wire is superior to elastics. Lack of patient cooperation
and broken elastics can increase clinical
treatment time by allowing intrusion of the moving tooth. A
technique that uses elastics stretched between the brackets
of the anchor teeth may cause tipping of those teeth toward
the extruding tooth.
The occlusion becomes a factor when orthodontic
extrusion is attempted on posterior teeth. Brackets bonded to facial surfaces of posterior teeth avoid the occlusal interferences that are common in occlusally positioned acid-etched
arch wires and hook-shaped
pulpally retained temporary
posts.i6 Stabilization
can be accomplished
with the same
appliance as used in activation when using direct bonded
brackets and wire. In contrast, after using elastics for activation, stabilization
must be accomplished
with an alternate
technique or appliance. Desired physiologic splinting is attained with the brackets and wires, whereas an acid-etch or
ligature stabilization
may be too restrictive to the healing
periodontium.
The public has accepted orthodontic
brackets and arch
wires in an esthetic sense. Their appearance and cleansibility may be more desirable than techniques that use elastics,
temporary posts, and acid-etch splints. Shiloah16 has pointed
out that on posterior teeth adequate distance from a temporary hook to a spanning wire must exist preoperatively
so
that elastic thread can function properly. It must also avoid
occlusal interferences.
These difficulties are minimized
by
using direct bonded brackets and arch wire.
Nickel-titanium
wire has been widely used in orthodontics
since 1981. K~sy~~r 23 tested this material in various parameters and described its high strength, excellent range, and
low stiffness as compared with beta-titanium,
stainless steel,
and multitwist
wires. Nickel-titaniums
outstanding
springiness and flexibility results in lighter forces and larger tooth
displacements.
These properties
recommend
it for orthodontic extrusion techniques.
The dilemma of fastening an orthodontic
bracket to a
badly fractured or carious tooth must be met with some
forethought.
Sabalaj has noted that each tooth has its own
special problems, and the dentists ingenuity
is taxed in
finding solutions. A composite resin buildup, as illustrated in
Figs. 5, B and 6, A, offers one solution to the dilemma. It also
provides the realistic advantage of allowing extrusion of the
tooth before attempting
post and dowel fabrication.
This
technique minimizes involvement
of the preprosthetic
root
canal system and thus reduces the potential for root perforation or fracture.

SUMMARY
Insufficient
clinical crown length may sometimes make
traditional
methods of tooth restoration impossible. Extraction or crown-lengthening
procedures may produce less desirable results than those obtained from orthodontic
extrusion. Previously
reported
methods of extruding
anterior
teeth have not provided consistent results when applied to

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JOURNAL

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Fig. 6. A, Following extrusion of second premolar, passive

nickel-titanium
wire is left in place for 12 weeks to retain
vertical position while periodontium
remodels. B, Radiograph of extruded tooth reveals sufficient biologic width to
allow for restoration
and healthy connective tissue attachment.

posterior teeth. A method is described to orthodontically

extrude nonrestorable
premolar
teeth by using direct
bonded brackets and a nickel-titanium
segmental arch wire.
This suggested technique provides the following advantages.
1. There is minimal violation of the root-canal space during extrusion and thus less risk of root fracture or perforation.
2. There is more precise control of the linear amount of
extrusion with fewer patient appointments.
3. The extrusion appliance also serves as the retaining
appliance for the extruded tooth.
4. The temporary
composite resin buildup
before the
placement of orthodontic
brackets may provide improved
esthetics during the extrusion process.
5. Definitive prosthetic restoration is accomplished at the
time of maximal access to the remaining tooth structures.
This article presented two clinical examples to demon-

553

NAPPENANDKOHLAN

skate an improved method of orthodontically extruding

isolated nonrestorable premolar teeth. This technique uses
recent advances in orthodontic wire metallurgy and provides
significant benefits to both the patient and dentist.
REFERENCES
1. Heithersay
GS. Combined endodontic-orthodontic
treatment of transverse root fractures in the region of the alveolar crest, Oral Surg
1973;36:404.
2. Simon JHS, Kelly WH, Gordon DG, Ericksen GW. Extrusion of endodontically treated teeth. J Am Dent Assoc 1978;97:17-21.
3. Cronin RJ, Wardle WL. Prosthodontic
management of vertical root extrusion. J PROSTHET DENT 1981;46:498-504.
4. Lemon RR. Simplified
esthetic root extrusion techniques. Oral Surg
1982;54:93-9.
5. Gwinnet Ad. State of the art and science of bonding in orthodontic treatment. J Am Dent Assoc 1982;105:844-50.
6. Sabala CL. Vertical extrusion of endodontically
treated teeth. Navy Dental Corps Clinical Updates, Vol 3(3), 1981.
7. Antrim DD. Vertical extrusion of endodontically
treated teeth. US Navy
Med 1981;72:23-8.
8. Ingber JS. Forced eruption: part 1. a method of treating isolated one and
two wall infrabony osseous defects-rationale
and case report. J Periodontal 1974;45:199-206.
9. Ingber JS. Forced eruption: part II. a method of treating nonrestorable
teeth-periodontal
and restorative
considerations.
J Periodontol
1976;47:203-16.
10. Malmgren 0, Goldson L, Hill C, Orwin A, Petrini L, Lundberg M. Root
resorption after orthodontic treatment of traumatized teeth. Am J Orthod
1982;82:487-91.
11. Turley PK, Joiner MJW, Hellstrom S. The effect of orthodontic extrusion
on traumatically
intruded teeth. Am J Orthod 1984;85:47-56.

ANNOUNCING

A NEW

12. Potashnick SR, Rosenberg ES. Forced eruption: principles in periodontics and restorative dentistry. J PROSTHET DENT 1982;48:141-8.
13. Schneider AR, Binder H. Periodontal
considerations relevant to treating
the fractured tooth. J PROSTHET DENT 1984;51:624-7.
14. Nasjleti CE, Castelli WA, Caffesse RG. The effects of different splinting
times on replantation
of teeth in monkeys. Oral Surg 1982;53:557-66.
15. lvey DW, Calhoun RL, Kemp WB, Dorfman HS, Wheless JE. Orthodontic extrusion:
its uses in restorative
dentistry.
J PROSTHEI
DENT
1980;43:401-7.
16. Shiloah J. Clinical crown lengthening
by vertical root movement.
THET DENT 1981;45:602-5.
17. Delivanis P, Delivanis H, Kuftinec MM. Endodontic-orthodontic

J PROS-

management of fractured anterior teeth. J Am Dent Assoc 1978;97:483-5.

18. Elias SA, DePaola LG. Restoration
of an extensively
decayed tooth
through forced eruption. Gen Dent 1983;31:310-2.
19. Fournier A. Orthodontic
management of subgingivally
fractured teeth. J
Clin Ort,hod 1981;15:502-3.
20. Mandel RC, Binzer WC, Withers JA. Forced eruption in restoring severely
fractured teeth using removable orthodontic
appliances. J PROSTHET
DENT 1982;47:269-74.
21. Ross S, Dorfman HS, Palcanis

KG. Orthodontic
extrusion: a multidisciplinary treatment approach. J Am Dent Assoc 1981;102:189-91.
22. Kusy PP, Greenberg AR. Comparison of the elastic properties of nickeltitanium and beta titanium arch wires. Am J Orthod 1982;82:199-205.
23. Kusy RP. Comparison of nickel-titanium
and beta titanium wire sizes to
conventional
orthodontic
arch wire materials. Am J Orthod 1981;79:
625-9.
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requests

to:

CAPTAIN DENNIS L. NAPPEN

NAVAL DENTAL CLINIC
Box 147, NAVAL STATION
SAN DIEGO, CA 92136-5147

SECTION-CLINICAL

REPORTS

The JOURNAL OF PROSTHETIC

DENTISTRY
is pleasedto announcea new section-Clinical
reports. This section will contain reports of the clinical treatment proceduresof a patient
that will be of specialinterest to our readers.A CLINICAL REPORT should be no longer
than three to four double-spaced,typewritten pagessupplementedby no more than eight
good-quality, descriptive color illustrations. CLINICAL REPORTS will be evaluated in
the same manner as all other manuscripts that are submitted to the JOURNAL
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PROSTHETIC
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for possiblepublication.

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