prosthetic considerations for orthodontic implant site … · 2016-12-21 · of any orthodontic...

J6

Aicpt

D

O

v

o

D

r

t

h

s

H

I

p

G

u

©

0

d

Oral Maxillofac Surg7:82-88, 2009, Suppl 3

Prosthetic Considerations forOrthodontic Implant Site Development in

the Adult PatientAlexandra I. Holst, DMD,* Emeka Nkenke, MD, DDS, PhD,†

Markus B. Blatz, DMD, PhD,‡ Hans Geiselhöringer, CDT, MDT,§

and Stefan Holst, DMD, PhD�

Proper site development is a key factor for long-term clinical success of dental implants. Whereas surgicaland restorative techniques have been refined to ensure predictable functional and esthetic outcome,individual clinical prerequisites do not always allow proper placement of implants when prosthetic andmaterial properties are considered. Orthodontic tooth movement may be a viable and nonsurgical sitedevelopment treatment option. With the introduction and advancements of minimal invasive and lessvisible orthodontic appliances, a growing number of adult patients are willing to obtain orthodontictreatment. The spectrum of modern appliances is broad and ranges from clear aligners to lingualbrackets. Skeletal anchorage devices such as orthodontic mini-implants often eliminate unpopularexternal anchorage devices (ie, headgear) in adult patients, This article discusses the selection of anappropriate pretreatment approach by taking patient-specific criteria into account.© 2009 American Association of Oral and Maxillofacial Surgeons
J Oral Maxillofac Surg 67:82-88, 2009, Suppl 3
tocimttfaTfsardcp

udtiavtmtmp

lthough replacing missing single teeth with dentalmplants has become routine, in many cases the initiallinical situation does not provide for optimal implantositioning. Especially in adult patients with missingeeth, neighboring or opposing teeth may migrate,

*Associate Professor, University Clinic Erlangen, Dental Clinic 3,

epartment of Prosthodontics, Erlangen, Germany.

†Associate Professor, University Clinic Erlangen, Department of

ral and Maxillofacial Surgery, Erlangen, Germany.

‡Professor of Restorative Dentistry, Chairman, Department of Pre-

entive and Restorative Sciences, Robert Schattner Center, University

f Pennsylvania, School of Dental Medicine, Philadelphia, PA.

§Dental X Hans Geiselhöringer GmbH & Co, Munich, Germany.

�Associate Professor, University Clinic Erlangen, Dental Clinic 2,

epartment of Prosthodontics, Erlangen, Germany.

Drs Alexandra I. Holst and Emeka Nkenke state no financial ar-

angement or affiliation with a corporate organization or a manufac-

urer of a product discussed in this article. Dr Stefan Holst has received

onoraria from Nobel Biocare. Dr Markus B. Blatz has received re-

earch contracts and/or grants from Nobel Biocare, Ekton/Straumann,

eraeus Kulzer, 3M ESPE, Noritake, Kuraray, Coltene Whaledent, and

voclar Vivadent. Dr Hans Geiselhöringer has received governance and

aid consultantship from Nobel Biocare.

Address correspondence and reprint requests to Dr Holst:

lueckstrasse, 91054 Erlangen, Germany; e-mail: alexandra.holst@

k-erlangen.de

2009 American Association of Oral and Maxillofacial Surgeons

278-2391/09/6711-0310$36.00/0

coi:10.1016/j.joms.2009.07.010

82

ilt, or extrude over years, making correct placementf implants impossible, or jeopardizing the long-termlinical success of a restoration. This is especially truef material properties are not considered and mini-

um dimensions are ignored. In addition, the practi-ioner is challenged with increasing demands for es-hetic outcomes, which require that multiple biological,unctional, and biomechanical aspects be addressednd potential problems be identified preoperatively.he factors that have a direct influence on success or

ailure include the amount of available alveolar ridge,oft tissue type, correct positioning of the implant inll 3 dimensions, design and material of the selectedestorative components, and adequate space for theefinitive restoration.1-3 Depending on the overallondition, an interdisciplinary team approach is indis-ensable for a predictable long-term success.Recent advancements in new materials and man-

facturing techniques integrating computer-aidedesign/computer aided manufacturing (CAD/CAM)echnology into everyday laboratory routine allowndustrial fabrication of prosthetic components forlmost any clinical situation. Despite their many ad-antages such as biocompatibility, strength, and es-hetic properties, several requirements apply whenaterials such as oxide ceramics are used. In situa-

ions where available space does not allow for mini-um required thickness of components, materialroperties can result in catastrophic failure under
linical function. This is especially important when
mailto:[email protected]

mailto:[email protected]

rsetpife

pcTotftpIdf2comdottsam

ota

OS

mtsrTmtgsprmidco

or3iatipscmaswwlaaftatsbtporltcort

shCfptfibcLossmcfisco

HOLST ET AL 83

estoring posterior implants where functional occlu-al loads are the highest. In many cases, long-termdentulism results in elongation of the opposingeeth, limiting the availability of vertical height forroper restorations.4,5 Meticulous treatment planning

s also a necessity in the anterior maxilla, where theunctional and esthetic outcome is significantly influ-nced by available hard and soft tissue morphology.The increasing acceptance of orthodontics in adult

atients enables the creation of more favorable clini-al conditions before dental implants are being placed.he advantages are not only an improved estheticutcome but more stable tissue architecture. Pre-pros-hetic tooth alignment may also prevent the necessityor root canal treatment in cases in which elongatedeeth have to be prepared for full-coverage crowns,roviding sufficient space for all-ceramic restorations.mplant site development is typically limited to aefined region in most patients. Therefore, extensiveull-arch bonding is not warranted in most cases. The

most easily applied orthodontic techniques for lo-alized orthodontic pretreatment are forced orth-dontic eruption and the application of orthodonticini-implants. An alternative approach is the use of

efinitive osseointegrated dental implants as orth-dontic anchors. Although various types of orthodon-ic appliances may be attached to an abutment inhese situations, the technique requires adequatepace for primary implant positioning and can bepplied predominantly for uprighting tilted molars oresiodistal movements of teeth.The aim of this article is to present and discuss

rthodontic options for implant site development ando discuss their limitations and potential risk factors indult patients.

rthodontic Miniscrews for Localizedite Development

The clinical use of orthodontic mini-implants oriniscrews is becoming increasingly popular. These

ools are used as bone-retained anchorage devices toupport orthodontic tooth movement and to resisteciprocal reaction to applied orthodontic forces.6,7

here are various screw systems available on thearket, with differing designs, dimensions, and inser-

ion techniques.8 Orthodontic mini-implants havereatly increased the treatment options for dental andkeletal malocclusions because of the simplicity oflacement and removal, minimal invasiveness, andelatively low cost.9 In addition, the option of im-ediate loading and the elimination of shortcom-

ngs frequently associated with extraoral anchorageevices (eg, patients’ noncompliance) result in in-reasing acceptance and clinical application in
rthodontics.10 Currently, the greatest shortcoming E
f mini-implants is an unpredictable clinical failureate, ranging from less than 10% to greater than0%.11 Multiple scientific studies report that success

s determined by a multitude of external factors, suchs bone quality and quantity and surrounding ana-omic structures,12-14 oral hygiene, insertion torque,15

nsertion angle, root proximity,16 involvement of theeriodontal ligament,17 applied loads, and screw de-ign.18 This unpredictability is confirmed by severallinical studies. Chuang et al19 reported that place-ent of screws in nonkeratinized mucosa was associ-

ted with clinical failure. In a study by Moon et al,20

ignificant differences in success rate in adult patientsas related to placement site. The lowest success rateas seen between the second premolar and first mo-

ar in young patients in both jaws. Although Park etl21 found better success rates in the maxilla, My-waki et al22 found no difference in the success rateor the maxilla and mandible. The underlying cause ofhe inconsistent results when comparing maxillarynd mandibular implants remains unclear. Reports inhe scientific literature agree that a predominant rea-on for failure of screws inserted into the alveolarone is excessive micromovement upon load applica-ion. Although theoretical ratios exist for dental im-lants,23 these values cannot be transferred to orth-dontic mini-implants because of the significantlyeduced size with resulting small surface area and theow horizontal forces being applied. The reason forhe lack of relevant data in orthodontic applications isaused by the difficulty in measuring displacementccurring in the low-micrometer range. This lack ofelevant data underlines the need for additional scien-ific research on this specific topic.

The time of load application is discussed controver-ially in the literature. Recent reports conclude that aealing time seems unnecessary for mini-implants.oncluding from a review, Chen et al24 stated that

ailures also happened before loading and several ex-erimental studies revealed that immediate loading ofhe threaded implant does not necessarily lead tobrous tissue healing. The authors summarized that aone-to-implant contact developed over time and isomparable to that of conventionally loaded implants.oad application within generally accepted ranges forrthodontics does not negatively affect the overalluccess. Costa et al25 attributed failures to torsionaltress and concluded that a force system generating aovement to the implant in the unscrewing direction

aused an implant to fail. This statement is backed byndings of Wawrinek et al.26 The authors demon-trated more microstructural damage in cortical boneaused by overtightening with deep insertion of orth-dontic microscrews than with lower insertion depths.
xtensive osseous micro-damage and subsequent

bi

omTot(

CSO

vttloTa

crbrpl

FPgi

HS

Ft

HS

FdAu

84 PROSTHETIC CONSIDERATIONS FOR ORTHODONTIC IMPLANT SITES

one remodeling may detract from the stability ofmmediate-load microscrews and implants.26

Nevertheless, because of the reduction of peri-dontal tissues in many adult patients, orthodonticini-implants provide a valuable treatment option.he greatest benefit is the broad range of treatmentptions from mesial– distal tooth movements to in-rusion, extrusion, and uprighting of tilted teethFigs 1-4).

linical Implication forite Development Withrthodontic Mini-Implants

The current literature indicates an ongoing contro-ersy over several aspects of orthodontic mini-implantreatment. However, because of its many advantages,his treatment alternative should be considered whenocalized retention is needed to counteract appliedrthodontic forces or to provide additional retention.his is especially true when the periodontal anchor-ge potential, such as full-arch bonding, fails to ac-

IGURE 1. Orthodontic mini-implants (Ortho Easy, Forestadent,forzheim, Germany) can provide additional anchorage. A, Trans-ingival insertion of mini-implant with insertion tool. B, Mini-implant

mmediately after placement.

olst et al. Prosthetic Considerations for Orthodontic Implantites. J Oral Maxillofac Surg 2009.

HS

ommodate the treatment goal. In adult patients, theeduced reactivity of the cells and the decrease inone flexibility demand longer treatment times andeduced initial loading forces.13,27,28 Predominant as-ects for success are selection of the appropriate

ocation providing maximum cortical thickness and

IGURE 2. Uprighting of a tilted mandibular molar with orthodon-ic mini-implants before implant placement.


IGURE 3. Factors for ideal mini-implant positioning are adequateistance to neighboring roots and positioning in attached mucosa.and B, Simple orthodontic devices such as elastic bands can be

sed for intrusion of teeth.


asar

ltte

FE

stpe5bbsoo

Fv

HS

Fvwen

HS

FAm

HS

Fi

HOLST ET AL 85

ttached gingival tissues. Self-drilling mini-implantshould be used except for the posterior and inferiorspects of the mandible because of the high fractureates.24 Careful implant insertion and application of

IGURE 4. Intrusion of maxillary molars to provide adequateertical space for restoring the posterior mandibular implant.


IGURE 5. Preoperative situation: A, Intraoral view. B, Extraoraliew. Initial leveled cervical crown margins and a high smile lineith significant exposure of the maxillary alveolar process aresthetic risk factors. Extraction of the left central incisor wasecessary.


HS

ow initial forces are crucial to prevent micro damageo the surrounding bone.26,27 Immediate load applica-ion, however, does not seem to increase screw loos-ning.24

orced Orthodonticxtrusion—Basic Principles

Orthodontic eruption or forced orthodontic extru-ion (FOE) is a noninvasive method to improve thehree-dimensional topography of the periodontal com-lex and can be used to optimize the implant recipi-nt site before extraction of nonrestorable teeth (Figs-7). FOE was first documented by Ingber and haseen suggested for the management of an inadequateiologic width resulting from root fractures or exten-ive subgingival defects.29-31 The underlying principlef any orthodontic tooth movement is the remodelingf periodontal ligament (PDL) and alveolar bone in

IGURE 6. Forced orthodontic eruption of left central incisor.pplication of low forces (50gN) is ideal for subsequent coronaligration of hard and soft tissues.


IGURE 7. Immediate implant placement following a minimallynvasive approach.


rmpbaayfhmd

mirpfoamvpsedPosfgtgcte

t

Fat

HS

FnZ


esponse to mechanical loading.32 Eruptive toothovement causes a stretching of the gingival anderiodontal fibers, which leads to a coronal shift ofone and gingiva. The mechanical loading patternsre quite complex because of the intricate anatomynd tissue structure, as shown by finite element anal-sis investigations.33 The transduction of mechanicalorces to the cells triggers a biologic response, whichas been described as an aseptic inflammation. It isediated by a variety of inflammatory cytokines and

IGURE 8. A-C, Extraoral, occlusal, and frontal views of soft tissuerchitecture after a 5-month healing period. Note the excess of soft

issue in the vertical dimension.


oes not represent a pathological condition.34,35 TheHS

ain difference to chronic inflammatory responses,n which stimuli sustain a long-lasting inflammatoryesponse and result in tissue damage, is that the ex-ression of inflammatory mediators after orthodontic

orce application is temporary and essential for orth-dontic movement. Walker and Burin showed thatnti-inflammatory drugs are capable of blocking toothovement.36 The tissue response initially involves

ascular changes, followed by cell mediators (eg,rostaglandins, cytokines, growth factors). Finally,uch mediators are believed to activate tissue remod-ling, characterized by selective bone resorption oreposition in compression and tension regions of theDL.32-34,37 An investigation by Kajiyama et al38 dem-nstrated that upon FOE, the gingiva moved in theame direction in which the teeth were extruded. Theree gingiva moved about 90% and the attached gin-iva moved about 80% as far as the teeth were ex-ruded. At the same time, the width of the attachedingiva on the labial surface increased (Figs 8, 9). Nolinical or histologic problems were encountered inhe gingival tissues if the teeth were extruded prop-rly.38

With these biologic reactions, both the hard andhe soft tissue components of the anticipated implant

IGURE 9. A and B, Frontal view of definitive custom-made zirco-ia abutment (NobelProcera Abutment Zirconia, Nobel Biocare,urich, Switzerland) and provisional restoration.


srn

COA

mrfapsscaaepVsvt

gtet

mts

R

1

1

1

1

1

1

1

1

1

1

2Fi

HS

HOLST ET AL 87

ite can be optimized to compensate for subsequentemodeling after implant insertion and abutment con-ection.39

linical Implications of Forcedrthodontic Extrusion fordult Patients

The application of FOE for implant site develop-ent is simple but requires consideration of other

elated aspects. The extra time and cost requiredor FOE is justified only when the clinical situationllows for minimally invasive extraction and im-lant placement without the necessity for exten-ive bone augmentation (eg, vertical root fracture,evere subgingival caries). One key factor for suc-ess of FOE when applied in adult patients is thepplication of appropriate orthodontic forces andn appropriate length of retention period after thextrusion to stabilize the tissues (Fig 10).40 Anotherarameter is the potential for periodontal disease.an Venrooy and Yukna41 showed that when as-essing orthodontic extrusion of teeth with ad-anced periodontal disease in beagle dogs, ex-ruded teeth had shallower pocket depths, less

IGURE 10. A and B, Extraoral and intraoral views of the defin-tive restoration and stable soft tissue at 36-month recall.


ingival inflammation, and no bleeding on probinghan control teeth. These findings, however, do notliminate the risk of peri-implantitis around defini-ive implants without adequate pretreatment.

Orthodontic site development with orthodonticini-implants or FOE can significantly improve a po-

ential implant site to increase functional and estheticuccess.

eferences

1. Belser UC, Schmid B, Higginbottom F, et al: Outcome analysisof implant restorations located in the anterior maxilla: A reviewof the recent literature. Int J Oral Maxillofac Implants 19:30,2004 (suppl)

2. Sadan A, Blatz MB, Salinas TJ, et al: Single-implant restorations:A contemporary approach for achieving a predictable out-come. J Oral Maxillofac Surg 62:73, 2004 (suppl 2)

3. Kois JC: Predictable single tooth peri-implant esthetics: Fivediagnostic keys. Compend Contin Educ Dent 22:199, 2001

4. Miskinis SB, Snyder M, Sierraalta M, et al: Effect of varyingcoping thickness on early load-to-fracture strength of proceraAllCeram copings cemented with 2 resin-modified glass-iono-mer cements. Quintessence Int 39:501, 2008

5. Quek CE, Tan KB, Nicholls JI: Load fatigue performance of asingle-tooth implant abutment system: Effect of diameter. IntJ Oral Maxillofac Implants 21:929, 2006

6. Huang LH, Shotwell J, Wang HL: Dental implants for orthodon-tic anchorage. Am J Orthod Dentofac Orthop 127:713, 2005

7. Buchter A, Wiechmann D, Gaertner C, et al: Load-related bonemodelling at the interface of orthodontic microimplants. ClinOral Implants Res 17:714, 2006

8. Leung MT, Lee TC, Rabie AB, et al: Use of miniscrews andminiplates in orthodontics. J Oral Maxillofac Surg 66:1461, 2008

9. Kitai N, Yasuda Y, Takada KA: Stent fabricated on a selectivelycolored stereolithographic model for placement of orthodonticmini-implants. Int J Adult Orthodon Orthognath Surg 17:264,2002

0. Kravitz N, Kusnoto B: Risks and complications of orthodonticminiscrews. Am J Orthod Dentofac Orthop 131:43, 2007

1. Cheng SJ, Tseng IY, Lee JJ, et al: A prospective study of the riskfactors associated with failure of mini-implants used for orthodon-tic anchorage. Int J Oral Maxillofac Implants 19:100, 2004

2. Hernández LC, Montoto G, Puente Rodríguez M, et al: Bonemap for a safe placement of miniscrews generated by com-puted tomography. Clin Oral Implants Res 19:576, 2008

3. Ono A, Motoyoshi M, Shimizu N: Cortical bone thickness in thebuccal posterior region for orthodontic mini-implants. IntJ Oral Maxillofac Surg 37:334, 2008

4. Kim HJ, Yun HS, Park HD, et al: Soft tissue and cortical–bonethickness at orthodontic implant sites. Am J Orthod DentofacOrthop 130:177, 2006

5. Motoyoshi M, Hirabayashi M, Uemura M, et al: Recommendedplacement torque when tightening an orthodontic mini-im-plant. Clin Oral Implants Res 17:109, 2006

6. Kuroda S, Yamada K, Deguchi T, et al: Root proximity is amajor factor for screw failure in orthodontic anchorage. Am JOrthod Dentofac Orthop 131:68, 2007

7. Asscherickx K, Vannet BV, Wehrbein H, et al: Root repair afterinjury from mini-screw. Clin Oral Implants Res 16:575, 2005

8. Serra G, Morais LS, Elias CN, et al: Sequential bone healing ofimmediately loaded mini-implants. Am J Orthod Dentofac Or-thop 134:44, 2008

9. Chuang SK, Cai T, Douglass CW, et al: Frailty approach for theanalysis of clustered failure time observations in dental re-search. J Dent Res 84:54, 2005

0. Moon CH, Lee DG, Lee HS, et al: Factors associated with thesuccess rate of orthodontic miniscrews placed in the upper
and lower posterior buccal region. Angle Orthod 78:101,2008

2

2

2

2

2

2

2

2

2

3

3

3

3

3

3

3

3

3

3

4

4


1. Park HS, Jeong SH, Kwon OW: Factors affecting the clinicalsuccess of screw implants used as orthodontic anchorage. Am JOrthod Dentofac Orthop 130:18, 2006

2. Miyawaki S, Koyama I, Inoue M, et al: Factors associated withthe stability of titanium screw placed in the posterior region fororthodontic anchorage. Am J Orthod Dentofac Orthop 124:373, 2003

3. Pilliar RM: Quantitative evaluation of the effect of movement ata porous coated implant–bone interface, in Davies, EJ (ed):The Bone–Biomaterial Interface. Toronto, ON, University ofToronto Publishing, 1991, pp 380-387

4. Chen Y, Kyung HM, Zhao WT, et al: Critical factors for thesuccess of orthodontic mini-implants: A systematic review.Am J Orthod Dentofac Orthop 135:284, 2009

5. Costa A, Raffainl M, Melsen B: Miniscrews as orthodontic an-chorage: A preliminary report. Int J Adult Orthodon Orthog-nath Surg 13:201, 1998

6. Wawrzinek C, Sommer T, Fischer-Brandies H: Microdamage incortical bone due to the overtightening of orthodontic micro-screws. J Orofac Orthop 69:121, 2008

7. Motoyoshi M, Inaba M, Ono A, et al: The effect of cortical bonethickness on the stability of orthodontic mini-implants and onthe stress distribution in surrounding bone. Int J Oral Maxillo-fac Surg 38:13, 2009

8. Devlin H, Horner K: A study to assess the relative influence ofage and edentulousness upon mandibular bone mineral densityin female subjects. Oral Surg Oral Med Oral Pathol Oral RadiolEndod 104:117, 2007

9. Ingber JS: Forced eruption. Part I. A method of treating isolatedone and two-wall intrabony osseous defect—Rationale andcase report. J Periodontol 45:199, 1974

0. Ingber JS: Forced eruption. Part II. A method of treating non-restorable teeth—Periodontal and restorative considerations. J
Periodontol 47:203, 1976
1. Ogihara S, Marks MH: Enhancing the regenerative potential ofguided tissue regeneration to treat an intrabony defect andadjacent ridge deformity by orthodontic extrusive force. J Peri-odontol 77:2093, 2006

2. Krishnan V, Davidovitch Z: Cellular, molecular, and tissue levelreactions to orthodontic force. Am J Orthod Dentofac Orthop129:1, 2006

3. Cattaneo PM, Dalstra M, Melsen B: The finite element method:A tool to study orthodontic tooth movement. J Dent Res 84:428, 2005

4. Meikle MC: The tissue, cellular, and molecular regulation oforthodontic tooth movement: 100 Years after Carl Sandstedt.Eur J Orthod 28:221, 2006

5. Wang XJ, Han G, Owens P, et al: Role of TGFbeta-mediatedinflammation in cutaneous wound healing. J Invest Dermatol126:112, 2006

6. Walker JB, Buring SM: NSAID impairment of orthodontic toothmovement. Ann Pharmacother 35:113, 2001

7. Hughes FJ, Turner W, Belibasakis G, et al: Effects of growthfactors and cytokines on osteoblast differentiation. Periodontol2000 41:48, 2006

8. Kajiyama K, Murakami T, Yokota S: Gingival reactions afterexperimentally induced extrusion of the upper incisors inmonkeys. Am J Orthod Dentofac Orthop 104:36, 1993

9. Small PN, Tarnow DP: Gingival recession around implants: A1-year longitudinal prospective study. Int J Oral MaxillofacImplants 15:527, 2000

0. Owman-Moll P, Kurol J, Lundgren D: Effects of a doubledorthodontic force magnitude on tooth movement and rootresorptions. An inter-individual study in adolescents. EurJ Orthod 18:141, 1996

1. van Venrooy JR, Yukna RA: Orthodontic extrusion of single-rooted teeth affected with advanced periodontal disease. Am J
Orthod 87:67, 1985

prosthetic considerations for orthodontic implant site … · 2016-12-21 · of any orthodontic...

Documents