Orthodontic consideration of the old extraction site

Mansoura University
Faculty 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 bone
regeneration

Studies related with socket preservation techniques

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 avoid
tipping 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 the
retention, 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

Also in vertical dimension the orthodontic tooth movement has a great
osteogenic potential. For example at patients with periodontal disease and
vertical 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 reality
and orthodontic tissue regeneration (OTR) is a useful method in many clinical
situations where we have to deal with an insufficient alveolar bone. This
technique 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 arises
because 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

KJO-March 22 ,2013
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 Report 1
Diagnosis 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
KJO-March 22 ,2013
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.

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
KJO-March 22 ,2013
RESULTS

Case Report 1
KJO-March 22 ,2013
RESULTS
Post treatment facial and intraoral photographs.

Case Report 1
KJO-March 22 ,2013
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 2
Management 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 .

Orthodontic consideration of the old extraction site

Orthodontic consideration of the old extraction site

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