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Continuing Education

Course Number: 175

Orthodontic Forced
Eruption:
A Team Approach in Aesthetic Treatment
Authored by
Ahmad Soolari, DMD, MS; Duane Erickson, DDS; and
Amin Soolari, CDRT
Upon successful completion of this CE activity 2 CE credit hours may be awarded

A Peer-Reviewed CE Activity by

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Continuing Education

Orthodontic Forced Eruption: Mr. Amin Soolari is a student in the pre-


dental program at the University of
A Team Approach in Aesthetic Treatment Maryland. He has been a dental assistant
for 6 years and has experience in
Effective Date: 7/1/2014 Expiration Date: 7/1/2017
orthodontics, periodontics, and assisting
LEARNING OBJECTIVES in general treatment and oral surgery,
After participating in this CE activity, the individual will learn: and he is currently taking courses to prepare for dental
• The literature-supported scientific basis for the clinical school. He started his career in a periodontal office, where
use of forced orthodontic eruption. he became a Certified Dental Radiation Technologist. He
• A team approach to treating a difficult periodontal- can be reached via e-mail at amin.soolari@gmail.com.
restorative challenge in the anterior maxilla for a patient
with extreme aesthetic concerns. Disclosure: Mr. Amin Soolari reports no disclosures.

ABOUT THE AUTHORS INTRODUCTION


Dr. Ahmad Soolari is a Diplomate of Extraction of maxillary anterior teeth with severe attachment
American Board of Periodontology. He has loss leaves an obvious defect that is difficult to reconstruct.
a certificate in periodontics from the The lost soft and hard tissues must be regenerated prior to
Eastman Dental Center and an MS degree implant therapy or fixed partial denture placement to replace
from the University of Rochester (New the missing tooth for the most aesthetically conscious
York). He earned his DMD degree from the patients. Orthodontic forced eruption (OFE) has been
University of Mississippi Medical Center. A former clinical practiced as one method of restoring the soft and hard
associate professor at the University of Maryland, Dental tissues lost due to periodontal disease.1-3
School in Baltimore, he operates a specialty practice in the This article illustrates a team approach to treating a
Silver Spring and Gaithersburg areas of Montgomery County, difficult periodontal-restorative challenge in the anterior
Md. He can be reached via e-mail at asoolari@gmail.com. maxilla for a patient with extreme aesthetic concerns. Her
gummy smile, midline diastema, and severe periodontal
Disclosure: Dr. Ahmad Soolari reports no disclosures. disease were successfully treated with periodontal therapy,
forced extrusion, and crown lengthening surgery prior to the
Dr. Erickson has been in private practice restorative phase. This method can be used in similar
in orthodontics for 25 years and has offices patients as a more conservative, predictable alternative to
in Silver Spring and Olney, Md. He earned achieve aesthetic harmony versus more invasive and time-
his dental degree at the University of consuming techniques such as ridge augmentation.
Maryland, Baltimore, and practiced general Periodontal disease causes loss of both hard and soft
and restorative dentistry for 9 years before tissues. The loss may be uniform throughout the dentition,
receiving his certification in orthodontics in 1988 from Fairleigh but more often it is asymmetric.4,5 Especially in the aesthetic
Dickinson University in New Jersey. He is past president of the zone (ie, the anterior jaws), asymmetry coupled with
Maryland State Orthodontic Society and has served as periodontal disease presents a challenge for dentists. In
chairman of the education committee of the Middle Atlantic addition, in patients with severe periodontal disease, a tooth
Association of Orthodontists. He can be reached at or teeth may be deemed unrestorable if attachment loss is
drerickson@ericksonorthodontics.com. significant.
When planning restoration of a tooth, dentists can
Disclosure: Dr. Erickson reports no disclosures. choose from many different techniques to regain the lost

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Continuing Education

Orthodontic Forced Eruption: A Team Approach in Aesthetic Treatment


hard and soft tissues. Guided tissue regeneration, bone
grafting with either blocks or particulated material, ridge
Figure 1. Initial
augmentation, gingival grafting, distraction osteogenesis, appearance of the
and sinus elevation are some of the most frequently used patient (June 7,
2010). Excessive
and documented methods of restoring tissue architecture. gingival display, a
However, these methods are invasive, time-consuming, and midline diastema,
gingival and
expensive. They are also associated with morbidity (for dental asymmetry,
example, at graft donor sites)6 and, occasionally, unpre- rotated maxillary left canine (No. 11), and short clinical crowns on most
teeth are apparent.
dictable resorption.7 Thus, noninvasive and more
predictable techniques have been sought.
In the mid-1970s, Ingber1,8 advocated forced eruption of
diseased teeth to treat one- and 2-wall defects. Salama and
Salama9 introduced forced eruption as a method of
developing/restoring tissues prior to implant treatment.
Subsequent studies reported success with this technique
prior to both conventional and implant therapies.2,10-13 The
method is predictable and can be done more quickly than
many other techniques, saving time and expense.
The current report details the treatment of a patient with
excessive gingival display, a midline diastema, asymmetry at
the maxillary central incisors, and significant attachment loss
caused by periodontal disease. Her disease activity was Figure 2. Initial
periapical view of
controlled, attachment levels were improved and stabilized, the maxillary
and a poor aesthetic appearance was corrected through central incisors
(June 7, 2010).
periodontal therapy, OFE, and crown lengthening surgery.

CASE REPORT
A 55-year-old female smoker was not happy with her smile
Figure 3. Palatal
and rejected a proposed treatment plan from another office view showing
that involved extraction of “2 upper front teeth” and placement significant
attachment loss,
of 2 adjacent implants. Clinical and radiographic evaluation dehiscence, and
heavy subgingival
disclosed excessive gingival display, incomplete passive calculus (October
eruption, asymmetry of the maxillary central incisors, a 9, 2010).
midline diastema, and significant attachment loss in the
anterior maxilla (Figures 1 to 4). The only tooth in her anterior
maxilla that showed aesthetic proportions was the left central Figure 4. Facial
incisor (No. 9); the other teeth had rather short crowns. view of teeth Nos.
8 and 9 showing
A treatment plan was recommended to harmonize the the buccal plate,
remaining teeth in the aesthetic zone with the maxillary left which was missing
on the palatal
central incisor. The proposal included OFE following aspect (October 9,
nonsurgical periodontal therapy (scaling and root planing) 2010).

and surgical treatment, which included flap surgery to treat crown lengthening surgery for the remaining maxillary
teeth No. 8 (maxillary right central incisor) and No. 9, and anterior teeth. The patient agreed to periodontic-

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Continuing Education

Orthodontic Forced Eruption: A Team Approach in Aesthetic Treatment


orthodontic-restorative therapy. The OFE was needed to
minimize the ridge deformity; these are hard to hide and
difficult to manage following the removal of maxillary Figure 5. Intraoral
view (April 25,
anterior teeth. The key to the success of this treatment plan 2011) after 8
was careful implementation of OFE to support the weeks of
orthodontic
restorative effort. treatment to rotate
The periodontal surgery disclosed severe bone loss on the maxillary left
canine (No. 11).
the palatal aspect of teeth Nos. 8 and 9 with heavy calculus
deposits. The bone loss was more severe on No. 9 than on
No. 8 (Figure 2). Following removal of infected tissue and
calculus, periodontal regenerative therapy (PRT) was
performed; this included bone grafting, application of
demineralized freeze-dried bone allograft (LifeNet Health),
and placement of a resorbable bilayer collagen membrane
(Geistlich Bio-Gide [Geistlich Pharma North America]).
The patient was referred to an orthodontist, and
examination and treatment were as follows: The orthodontic
exam revealed a good Class I occlusion with generalized
periodontitis; in particular, severe horizontal and vertical
bone loss around teeth Nos. 8 and 9. Teeth Nos. 8 and 9 had Figure 6.
Periapical
a hopeless prognosis due to severe periodontal defects, radiograph taken
mobility, poor crown-to-root ratios, and unaesthetic crowns. during orthodontic
forced eruption
The treatment plan was to remove Nos. 8 and 9 and replace (OFE) (July 6,
them with implant restorations. However, the periodontal 2011).

defects and the likelihood of further alveolar resorption


following the extraction of teeth Nos. 8 and 9 meant that the
prognosis for placement of implants was poor. Therefore, Figure 7. Clinical
OFE would be accomplished in order to create new alveolar appearance on
July 6, 2011,
bone so that implants could be placed. during orthodontic
Orthodontic treatment in the presence of severe therapy, after 8
weeks of forced
periodontal disease is not recommended. Therefore, perio- eruption of the
dontal treatment was performed to control disease activity. Due incisors and
canines and reduction of the central incisor crowns from fremitus.
to the significant attachment loss and heavy subgingival
calculus on the palatal aspect of teeth Nos. 8 and 9 (Figure 2), On November 24, 2010, partial fixed orthodontic
periodontal surgery was performed to gain access to the roots appliances (0.018-inch Innovation-R [GAC International] self-
of the teeth and the bony defects to resolve the inflammation, ligating brackets) were placed on the anterior teeth (Nos. 6 to
stop bleeding on probing, reduce the pocket depth, and 11), and anchor tubes were placed on teeth Nos. 3 and 14
remove the calculus. After a flap was raised and the necrotic (0.022-inch) (Figures 5 to 7). A 0.016-inch Ni-Ti wire was
tissue and calculus were removed, PRT was performed to placed to align teeth Nos. 6 to 11; No. 11 in particular
prepare teeth Nos. 8 and 9 for OFE. The proposed orthodontic required derotation. Derotation of No. 11 took somewhat
therapy would slowly erupt teeth Nos. 8 and 9 to improve longer than expected but was accomplished by May 4, 2011
alveolar height and minimize bony defects in the alveolus that (Figure 5). At this time a 0.016- x 0.022-inch braided wire
would result from the extraction of these teeth. (Quad Cat) was placed with 1.5-mm step-down bends to

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Continuing Education

Orthodontic Forced Eruption: A Team Approach in Aesthetic Treatment


slowly super-erupt teeth Nos. 8 and 9.
During the next several months, the patient was seen
about every 3 to 4 weeks; at each appointment, the wire was
activated 0.5 to 1.0 mm to erupt teeth Nos. 8 and 9. In addition,
Figure 8. Clinical
at each appointment, the teeth were evaluated to eliminate any appearance on
September 29,
fremitus (traumatic occlusion) and the clinical crowns of teeth 2011, following
Nos. 8 and 9 were adjusted accordingly (Figures 6 and 7). The removal of
orthodontic
objective during this time was to slowly erupt the teeth so that appliances.
the tension on the periodontal ligament would stimulate
osteoblastic activity and the erupting tooth would bring bone
with it. Close monitoring and elimination of fremitus were
important so that untoward occlusal forces would not result in Figure 9. Final
appearance
the destruction of bone. During this time, teeth Nos. 8 and 9 (March 24, 2012)
after one year of
each erupted 4 to 5 mm, and the interproximal spaces were periodontic-
distributed for ideal restoration. On September 29, 2011, the orthodontic-
restorative
fixed appliances were removed. The patient was instructed to therapy.
wear a clear (Essix-type) retainer for 12 hours per day and to
return to the periodontist and general dentist to plan for the
replacement of teeth Nos. 8 and 9.
However, tooth No. 8 had responded positively to Figure 10. Final
appearance in the
periodontal-regenerative therapy; therefore the decision aesthetic zone.
The prosthesis is
was made to retain it and utilize it as an abutment for the supported by
definitive prosthesis. Tooth No. 9 remained hopeless. The healthy, pink, and
firm keratinized
original treatment plan included placement of an implant gingiva.
following the extraction of tooth No. 9, but the patient now
refused the implant, since the remaining teeth in the
aesthetic zone would still require prosthetic restoration to
achieve an acceptable appearance. The OFE improved
alveolar height for both Nos. 8 and 9. This approach
resulted in the creation of new alveolar bone. The
multidisciplinary treatment in this case significantly
improved the aesthetic appearance of a patient who was
not happy with her diastema, excessive gingival display,
midline asymmetry, tooth mobility, and significant bone loss.
The definitive prosthesis was placed a year later. Excellent
aesthetics and strong function were established for this patient, Figure 11.
Radiographic
who originally suffered from generalized moderate and appearance after
localized severe periodontitis. The patient was pleased with the OFE, extraction,
crown length-
final appearance of her smile (Figures 8 to 11) and stopped ening, and
smoking. The aesthetics of the definitive restoration may have prosthesis
placement.
been improved by moving the gingival margin of crown No. 8
apically to make it symmetrical with pontic No. 9. This highlights the treating professionals and the patient during all phases
the need for meticulous detailed communication between of this type of treatment.

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Continuing Education

Orthodontic Forced Eruption: A Team Approach in Aesthetic Treatment


DISCUSSION injured tooth/root must be intact to perform OFE and avoid
Dentists have been exploring the possibility of forced eruption surgical treatment.
of diseased teeth as a means of augmenting soft and hard As the use of implants has increased, clinicians have
tissue and eliminating infrabony defects since the 1970s.1,8 used OFE more frequently prior to implant placement to
Since then, many reports of successful forced prepare sites to receive implants. Makhmalbaf and Chee17
eruption/extrusion followed by retention and conservative cited forced eruption as a viable alternative to
restoration of what would have been hopeless teeth have been preimplantation bone augmentation in their treatment of a
published.2,10-12 In addition to its predictability, forced eruption woman with bone and gingiva loss. Mankoo and Frost12 used
can usually be completed fairly quickly; Biggerstaff et al2 OFE in 2 patients with advanced periodontal loss. The
completed treatment in 3 patients within about 4 weeks. procedure provided sufficient vertical augmentation for im-
Van Venrooy and Yukna3 provided proof of principle for plant placement. Mirmarashi et al18 showed that OFE could
OFE in an animal study. The attachment apparatus was assist in the transition to definitive implant prosthetic
damaged and periodontal disease was induced in beagle treatment. While the teeth to be extracted remained in situ,
dogs. Teeth extruded with orthodontic elastics were less they were used not only to assist in developing an
mobile and displayed shallower pockets, less bleeding, and appropriate soft- and hard-tissue profile, but they also
radiographic bone gain, whereas control (untreated) teeth supported a fixed provisional restoration so that a removable
showed no improvement after 21 days. provisional was not needed. Amato et al19 found that OFE
In clinical studies, many authors have investigated the prior to implant treatment was successful for bone
use of extrusion for teeth that would otherwise be regeneration about 70% of the time and for gingival
considered nonrestorable. Biggerstaff et al2 “reclaimed” augmentation in about 60% of cases. The implant survival
nonrestorable teeth with OFE in 3 patients with teeth with rate in their series19 of 11 patients (27 implants) was 96%.
compromised gingival margins caused by tooth fractures or Kan et al20 used an interdisciplinary approach (periodontics,
perforation of the gingiva. The authors2 found that the orthodontics, and prosthodontics) to modify the tissue
technique was relatively simple and quick, and bone support architecture in the aesthetic zone for multiple adjacent teeth.
was regained because the process resembled normal tooth Tarnow et al21 noted that there is about a one- or 2-mm
eruption. Camargo et al10 declared OFE the “technique of difference between the thickness of the peri-implant soft
choice” prior to crown lengthening in the aesthetic zone. tissue and that of the soft tissue around the natural
Fakhry11 also advocated OFE as a more conservative dentition, with implants being associated with thinner
method of restoring teeth, even in sites with minimal coronal tissue. The crest of bone at the implant neck should be 2
tooth structure in the aesthetic zone, but cautioned against mm coronal to the bone around the adjacent natural tooth
overaggressive use of the technique to prevent periodontal to ensure optimal control of soft-tissue aesthetics and avoid
damage and harm to coronal tooth structure. the “black triangle” caused by inadequate papillae.21
Many authors have reported on the use of OFE to Rokn et al13 noted that most attempts at vertical
restore fractured teeth or roots as a means of avoiding augmentation were unpredictable, whether done via sinus
more aggressive treatment, including extraction. Goenka et elevation, guided bone regeneration, or distraction
al14 discussed the use of OFE for teeth that had fractured osteogenesis; resorption might be minimal or very dramatic
at or coronal to the gingival level. They14 reported on the and uneven. In addition, these techniques are very invasive,
successful treatment of such a case with OFE followed by time consuming, and expensive. Periodontal treatment and
prosthetic treatment. Addy et al15 reviewed the literature on OFE followed by implant therapy in a woman with
treatment of root fractures, noting that sufficient root length generalized aggressive periodontitis was successful,
was needed to ensure success and avoid extraction of the resulting in shallower probing pocket depths, improved
injured tooth. Valerio et al16 stated that, in addition, the hard- and soft-tissue margins, and restoration with an
ferrule should be adequate and the biologic width of the implant-supported prosthesis.

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Continuing Education

Orthodontic Forced Eruption: A Team Approach in Aesthetic Treatment


extrusive remodeling in the enhancement of soft and
CONCLUSION hard tissue profiles prior to implant placement: a
OFE may allow for retention and restoration of otherwise systematic approach to the management of extraction
hopeless teeth, and it may also provide an alternative to site defects. Int J Periodontics Restorative Dent.
ridge augmentation surgery to regenerate lost hard and soft 1993;13:312-333.
tissues prior to implant placement or delivery of a fixed 10. Camargo PM, Melnick PR, Camargo LM. Clinical
crown lengthening in the esthetic zone. J Calif Dent
partial denture. Extrusion will decrease periodontal pocket
Assoc. 2007;35:487-498.
depths, and in the case presented, it saved tooth No. 8. In 11. Fakhry A. Enhancing restorative, periodontal, and
conjunction with conventional periodontal treatment of esthetic outcomes through orthodontic extrusion. Eur
maxillary anterior teeth, OFE is a viable and noninvasive J Esthet Dent. 2007;2:312-320.
solution to a patient’s aesthetic concerns when dealing with 12. Mankoo T, Frost L. Rehabilitation of esthetics in
management of a nontreatable tooth in the aesthetic zone. advanced periodontal cases using orthodontics for
vertical hard and soft tissue regeneration prior to
Most patients, if given a choice, will prefer quicker, less
implants—a report of 2 challenging cases treated with
aggressive, and more cost-effective treatment, and OFE an interdisciplinary approach. Eur J Esthet Dent.
should be considered in appropriate cases. 2011;6:376-404.
13. Rokn AR, Saffarpour A, Sadrimanesh R, et al.
ACKNOWLEDGMENT Implant site development by orthodontic forced
The assistance of Jennifer Ballinger, ELS, in drafting this eruption of nontreatable teeth: a case report. Open
Dent J. 2012;6:99-104.
manuscript is gratefully acknowledged.
14. Goenka P, Marwah N, Dutta S. A multidisciplinary
approach to the management of a subgingivally
REFERENCES fractured tooth: a clinical report. J Prosthodont.
1. Ingber JS. Forced eruption: part II. A method of treating 2011;20:218-223.
nonrestorable teeth—Periodontal and restorative 15. Addy LD, Durning P, Thomas MB, et al. Orthodontic
considerations. J Periodontol. 1976;47:203-216. extrusion: an interdisciplinary approach to patient
2. Biggerstaff RH, Sinks JH, Carazola JL. Orthodontic management. Dent Update. 2009;36:212-218.
extrusion and biologic width realignment procedures: 16. Valerio S, Crescini A, Pizzi S. Hard and soft tissue
methods for reclaiming nonrestorable teeth. J Am management for the restoration of traumatized anterior
Dent Assoc. 1986;112:345-348. teeth. Pract Periodontics Aesthet Dent. 2000;12:143-150.
3. van Venrooy JR, Yukna RA. Orthodontic extrusion of 17. Makhmalbaf A, Chee W. Soft- and hard-tissue
single-rooted teeth affected with advanced periodontal augmentation by orthodontic treatment in the esthetic
disease. Am J Orthod. 1985;87:67-74. zone. Compend Contin Educ Dent. 2012;33:302-306.
4. Papapanou PN, Wennström JL. The angular bony 18. Mirmarashi B, Torbati A, Aalam A, et al.
defect as indicator of further alveolar bone loss. J Clin Orthodontically assisted vertical augmentation in the
Periodontol. 1991;18:317-322. esthetic zone. J Prosthodont. 2010;19:235-239.
5. Greenstein B, Frantz B, Desai R, et al. Stability of 19. Amato F, Mirabella AD, Macca U, et al. Implant site
treated angular and horizontal bony defects: a development by orthodontic forced extraction: a
retrospective radiographic evaluation in a private preliminary study. Int J Oral Maxillofac Implants.
periodontal practice. J Periodontol. 2008;80:228-233. 2012;27:411-420.
6. Pandit N, Pandit IK, Malik R, et al. Autogenous bone 20. Kan JY, Rungcharassaeng K, Fillman M, et al. Tissue
block in the treatment of teeth with hopeless architecture modification for anterior implant esthetics:
prognosis. Contemp Clin Dent. 2012;3:437-442. an interdisciplinary approach. Eur J Esthet Dent.
7. Schallhorn RG. Postoperative problems associated 2009;4:104-117.
with iliac transplants. J Periodontol. 1972;43:3-9. 21. Tarnow D, Elian N, Fletcher P, et al. Vertical distance
8. Ingber JS. Forced eruption. I. A method of treating isolated from the crest of bone to the height of the
one and two wall infrabony osseous defects—rationale interproximal papilla between adjacent implants. J
and case report. J Periodontol. 1974;45:199-206. Periodontol. 2003;74:1785-1788.
9. Salama H, Salama M. The role of orthodontic

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Continuing Education

Orthodontic Forced Eruption: A Team Approach in Aesthetic Treatment


POST EXAMINATION INFORMATION POST EXAMINATION QUESTIONS
To receive continuing education credit for participation in 1. Hard- and soft-tissue loss due to periodontal disease
this educational activity you must complete the program may be uniform throughout the dentition, but more
post examination and receive a score of 70% or better. often it is asymmetric.
a. True.
Traditional Completion Option:
b. False.
You may fax or mail your answers with payment to Dentistry
Today (see Traditional Completion Information on following 2. The following is/are the most frequently used and
page). All information requested must be provided in order documented methods of restoring tissue
architecture:
to process the program for credit. Be sure to complete your
“Payment,” “Personal Certification Information,” “Answers,” a. Ridge augmentation.
and “Evaluation” forms. Your exam will be graded within 72 b. Distraction osteogenesis.
hours of receipt. Upon successful completion of the post- c. Gingival grafting.
exam (70% or higher), a letter of completion will be mailed d. All of the above.
to the address provided. 3. Orthodontic treatment in the presence of severe
Online Completion Option: periodontal disease is not recommended.
Use this page to review the questions and mark your a. True.
answers. Return to dentalcetoday.com and sign in. If you b. False.
have not previously purchased the program, select it from
4. In the clinical case presented, orthodontic forced
the “Online Courses” listing and complete the online eruption (OFE) of teeth Nos. 8 and 9 resulted in
purchase process. Once purchased the program will be _______ of eruption for each tooth.
added to your User History page where a Take Exam link a. 2 to 3 mm.
will be provided directly across from the program title. b. 3 to 4 mm.
Select the Take Exam link, complete all the program c. 4 to 5 mm.
questions and Submit your answers. An immediate grade d. 5 to 6 mm.
report will be provided. Upon receiving a passing grade,
complete the online evaluation form. Upon submitting 5. Forced eruption of diseased teeth as a means of
augmenting soft/hard tissue and eliminating
the form, your Letter of Completion will be provided
infrabony defects has been explored by dentists
immediately for printing. since:
General Program Information: a. The 1950s.
Online users may log in to dentalcetoday.com any time in b. The 1960s.
the future to access previously purchased programs and c. The 1970s.
view or print letters of completion and results. d. The 1980s.

6. Biggerstaff et al completed OFE treatment in 3


patients within approximately ________.
a. 4 weeks.
b. 8 weeks.
c. 12 weeks.
d. 16 weeks.

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Continuing Education

Orthodontic Forced Eruption: A Team Approach in Aesthetic Treatment


7. The following factor(s) is/are necessary to ensure 10. OFE may allow for retention and restoration of
successful OFE treatment and tooth restoration: otherwise hopeless teeth. OFE may also provide an
a. Sufficient root length. alternative to ridge augmentation surgery to
regenerate lost hard/soft tissues prior to implant
b. Adequate ferrule.
placement.
c. Intact biologic width.
a. The first statement is true, the second is false.
d. All of the above.
b. The first statement is false, the second is true.
8. Amato et al found that OFE prior to implant treatment c. Both statements are true.
was successful for bone regeneration approximately d. Both statements are false.
______ of the time.
a. 50%.
b. 60%.
c. 70%.
d. 80%.

9. The crest of bone at the implant neck should be


_________ the bone around the adjacent natural
tooth to ensure optimal control of soft-tissue
aesthetics.
a. Level with.
b. 2 mm coronal to.
c. 1 mm apical to.
d. 2 mm apical to.

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Continuing Education

Orthodontic Forced Eruption: A Team Approach in Aesthetic Treatment

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