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Applying extrusive orthodontic force without

compromising the obturated canal space
David Keinan, Jerard Szwec, Avital Matas,
Joshua Moshonov and Oded Yitschaky
JADA 2013;144(8):910-913
10.14219/jada.archive.2013.0208

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CLINICAL PRACTICE CASE REPORT

Applying extrusive orthodontic force

without compromising the obturated
canal space
David Keinan, DMD, MSc, PhD, MHA; Jerard Szwec, DMD; Avital Matas, DMD;
Joshua Moshonov, DMD; Oded Yitschaky, DMD, MA

O
rofacial trauma can result
in a wide spectrum of dental
injuries, ranging from
AB STRACT
enamel crown fractures with Background. Complicated tooth fractures can be the unfor-
good prognosis to complex injuries tunate result of orofacial trauma and can offer a therapeutic
with a less favorable long-term challenge for the dentist. A conservative solution for gaining
prognosis.1-5 To restore a tooth with supragingival sound tooth structure often includes orthodontic
a complicated crown fracture below forced eruption. Usually, this procedure is carried out by apply-
the cementoenamel junction, the ing extrusive force after placing a provisional acrylic Richmond
treatment alternatives may include crown on the tooth. However, this long-lasting dental treatment
orthodontic extrusion with or with- may jeopardize the coronal seal of the root canal space, leading to
out surgical crown lengthening.6-12 microleakage and endodontic failure.
This technique requires a multi- Case Description. Orthodontic forced eruption demands ap-
disciplinary approach combining plication of force to an attachment connected to the remaining
short clinical crown. In this article, the authors describe a case in
endodontic treatment, orthodontic
which they used a new technique for orthodontic forced eruption
extrusion (also called “forced erup-
of a traumatized tooth, using an extracanal attachment to apply
tion”) and prosthodontic coronal
extrusion force, and discuss its possible advantages and
restoration.7,11,13,14 Orthodontic
limitations.
extrusion facilitates exposure of the
Conclusions. An extracanal attachment approach for orthodon-
sound tooth margin with a healthy
tic forced eruption without compromising the obturated canal
biological width and usually is indi-
space can be a solution for posttraumatic crown fracture.
cated when the supragingival sound Practical Implications. The described procedure for forced
tooth structure is minimal.15-18 This eruption by using an extracanal pin attachment is efficient and
procedure emphasizes the practical convenient and does not require the clinician to apply force di-
problem of finding a reliable point rectly to the provisional crown. Therefore, during the application
of application of force to the remain- of force, there is less risk of loosening the provisional crown, and
ing root structure. If the clinically the canal space is kept intact with either the final restoration or
exposed tooth structure is large dressing material.
enough, the clinician can bond an Key Words. Forced eruption; crown-root fracture; orthodontic
orthodontic attachment (that is, an extrusion; dental trauma.
orthodontic bracket or button) to JADA 2013;144(8):910-913.
it, but this is not always possible.
When this article was written, Dr. Keinan was the head, Department of Endodontics, Medical Corps, Dental Center, Sheba Medical Center, Tel-Hashomer,
Israel, and an instructor, Department of Endodontics, Faculty of Dental Medicine, Hebrew University of Jerusalem and Hadassah Medical Center, Jerusalem.
He now is a visiting scholar, Department of Periodontics and Endodontics, University at Buffalo, State University of New York. Address reprint requests
to Dr. Keinan at Department of Endodontics, Faculty of Dental Medicine, Hebrew University of Jerusalem and Hadassah Medical Center, Jerusalem, Israel
91120, e-mail iendo4u@gmail.com.
Dr. Szwec is an instructor, Department of Prosthodontics, Faculty of Dental Medicine, Hebrew University of Jerusalem and Hadassah Medical Center,
Jerusalem. He also maintains a private practice in Jerusalem.
Dr. Matas is an instructor, Department of Endodontics, Faculty of Dental Medicine, Hebrew University of Jerusalem and Hadassah Medical Center,
Jerusalem.
Dr. Moshonov is the acting chairman, Department of Endodontics, Faculty of Dental Medicine, Hebrew University of Jerusalem and Hadassah Medical
Center, Jerusalem. He also maintains a private practice in Tel Aviv.
Dr. Yitschaky is an instructor, Department of Orthodontics, Faculty of Dental Medicine, Hebrew University of Jerusalem and Hadassah Medical Center,
Jerusalem. He also maintains a private practice in Jerusalem.

910 JADA 144(8) http://jada.ada.org August 2013

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CLINICAL PRACTICE CASE REPORT

Other alternatives include using different types

of temporarily cemented posts or intracanal
attachments.8,13,14,19-22
The clinician’s main challenge during orth-
odontic extrusion of endodontically treated teeth
is to prevent microleakage during tooth move-
ment because the commonly used temporarily
cemented post harbors great risks of microleak-
age and post dislocation.23 In this article, we
describe a new technique for forced eruption
involving the use of a buccal extracanal attach-
ment for applying extrusion force.
CASE REPORT
A 23-year-old man with a noncontributory medi-
cal history was admitted to a private dental
clinic in Jerusalem after experiencing dental
trauma resulting from a skiing accident. The
clinical examination revealed a crown-root frac-
ture of the maxillary right central incisor, with
pulpal exposure to the oral cavity (Figure 1).
The fractured tooth had not received any previ-
ous dental treatment.
At the first appointment, a clinician (A.M.)
isolated the tooth by using a rubber dam (Hy-
genic, Coltène Whaledent, Cuyahoga Falls,
Ohio) with the coronal access mainly at the
level of the fracture line. She established the
canal working length at 1 millimeter from the
radiographic apex with a no. 70 maillefer k-file.
During instrumentation, she irrigated the canal
with 20 milliliters of 4 percent sodium hypo-
chlorite (Sigma-Aldrich, St. Louis). In the final
irrigation, she used 2 mL of 17 percent ethyl-
enediaminetetraacetic acid (Ultradent, South
Jordan, Utah) for three minutes, followed by 2
mL of 4 percent sodium hypochlorite. The clini-
cian obturated the canal by using a lateral con-
densation technique with AH Plus Root Canal
Sealer (Dentsply DeTrey, Konstanz, Germany)
and gutta-percha cones (ROEKO Guttapercha
Points, Coltène Whaledent). She placed a cotton
pellet and a 3- to 5-mm layer of temporary fill-
ing, Coltosol F (Coltène Whaledent), and then
smoothed down sharp edges (Figure 2).
After 48 hours, another clinician (J.S.) made
a new provisional crown and cemented it to the
tooth with temporary luting cement (TempBond,
Kerr, Orange, Calif.). He made no gingival ad-
justments. The orthodontic treatment included
three components.
d On the labial side, 2 mm apical to the denti-
noenamel junction, the clinician inserted a tita-
nium handpiece–driven, self-shearing dental pin
(Stabilok, Fairfax Dental, Miami) about 2 mm
into the dentin, with 2 mm protruding from the
tooth surface. He inserted the pin after prepar-
Figure 1. A labial view obtained immediately after the patient’s
first admission to the dental clinic. Note the extensive coronal
tooth structure loss.
ing an orifice with a
0.027-inch titanium
drill (Stabilok, Fair-
fax Dental).
d He placed an
orthodontic wire,
stainless steel 18/25
(Dentsply GAC,
Islandia, N.Y.), by
using a composite
(Transbond XT, 3M
Unitek, Monrovia,
Calif.).
d He placed an elas-
tic orthodontic chain
(AlastiK chain, 3M
Unitek) between the Figure 2. A radiograph obtained
titanium dental pin immediately after completion of
the endodontic treatment of the
and the orthodontic maxillary right central incisor.
wire, over the maxil-
lary right central incisor (Figure 3).
This clinician recalled the patient for a follow-
up examination after five days. The incisal edge
of the provisional crown was 1.5 mm coronal to
the incisal edge of the maxillary right central
incisor. He smoothed the incisal edge by using a
high-speed turbine with an extra-fine diamond
bur (C1, Strauss, Ra’anana, Israel). During the
next three weeks, the patient visited the clinic
every week for reactivation of force, which the
clinician accomplished by replacing the elastic
chain and making occlusal adjustments. After
this period, he secured the pin passively to the
orthodontic wire with a 0.010-inch stainless
ligature (Dentaurum, Ispringen, Germany) for
an additional month of retention to prevent rein-
trusion. On removal of the orthodontic wire, the
fracture line was 3 mm coronal to the marginal
alveolar bone. The clinician then removed the

JADA 144(8)  http://jada.ada.org  August 2013 911

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 Downloaded from jada.ada.org on September 30, 2014
CLINICAL PRACTICE CASE REPORT
Figure 3. The elastic orthodontic chain, as seen during the ortho-
dontic extrusion of the maxillary right central incisor.
Figure 4. The incisor after cementation of the porcelain-fused-
to-metal crown.
pin with orthodontic pliers (Weingart Utility
Plier, Ormco, Orange, Calif.) and filled the pin-
hole with a resin-modified glass ionomer cement
(Fuji IX GP, GC, Tokyo). A prefabricated post
and porcelain-fused-to-metal crown completed
the treatment (Figure 4). The patient was satis-
fied by the treatment’s esthetic result and had
no complaints when the provisional crown was
removed.
Discussion
For decades, dentists have used forced erup-
tion with the aid of orthodontic appliances as a
relatively easy way to overcome a wide range
of complicated clinical situations.6 The fracture
resistance of anterior teeth that have received
endodontic treatment with a post and core can
be improved by using a ferrule design of 2 mm.
However, cases that involve sublingual fracture
do not allow use of this design without damaging
the supporting tissues.24 Two common modalities
of treatment that may help effectively overcome
the clinical problems associated with having a
912 JADA 144(8) http://jada.ada.org August 2013
Copyright © 2013 American Dental Association. All Rights Reserved.
short clinical crown are surgical resection and
forced eruption with or without corrective
surgery.15-18,25,26
Using a forced-eruption procedure enables the
clinician to preserve a better crown-to-root ratio
than is possible after a crown-lengthening pro-
cedure by preserving the alveolar bone height
of both the restored tooth and the neighboring
teeth.27 From the perspective of endodontics,
applying the orthodontic extrusive force as an
extracanal attachment prevents microleakage
because it eliminates the need for placing a pro-
visional Richmond crown28 and also may help
keep the root canal obturation intact in most
cases.29 The use of a titanium pin for attachment
is simple, reliable, time saving and inexpensive,
and it reduces the risk of the provisional crown’s
loosening. Contrary to most intracanal attach-
ments, the pin can be installed predictably even
if the root canal obturation is not completed be-
fore the orthodontic extrusion is performed. The
clinician also can cement the permanent post
without the risk of leakage, as in the case of pro-
visional cementing of a Richmond crown.28 How-
ever, the prudent clinician also should be aware
of the risks of doing minor damage to the tooth
during drilling and pin insertion. The described
technique applies a force vector that passes
buccally to the tooth’s center of resistance, thus
leading to a minor tilt of the tooth—that is, of
the crown toward the palate—whereas the root
apex is tilted labially in an opposite direction to
the crown. Ideally, the vector of orthodontic force
application for pure translational movement,
such as extrusion with no tooth tilt, must pass
through the tooth’s center of resistance.27,30 The
minor crown tilt described here actually may
enable the clinician to build an esthetic crown,
with proper preparation for adequate porcelain
bulk.31 However, the potential risk of causing
tooth tilt must not be overlooked, especially if
the tooth crown is located palatally before the
orthodontic extrusion or if the root apex is pal-
pable outside the alveolar bone at the height of
the labial vestibulum. Better control of the vec-
tor of movement, if indicated, can be obtained
when orthodontic brackets are used.27
The long-term prognosis of endodontically
treated teeth after traumatic injuries depends
on both the endodontic success and the heal-
ing capability of the periodontal ligament space
after the trauma.4 In general, this success rate
may be decreased for teeth with periapical ra-
diolucency.32 Results of epidemiologic studies
also have shown that coronal microleakage may
lead to a reduced success rate for endodontically
treated teeth.33,34 Other factors that may affect
 Downloaded from jada.ada.org on September 30, 2014
the long-term success rate are remaining tooth
structure and fracture resistance.35-37 Research-
ers have demonstrated that the duration of
intracanal dressing, especially with calcium hy-
droxide, also may affect fracture resistance.38,39
The prudent clinician should consider all these
aspects while planning treatment.
ConclusionS
This multidisciplinary technique of using an ex-
tracanal pin attachment to achieve orthodontic
forced eruption of a traumatized tooth appears
to be a promising procedure because it helps
keep intact the sealing of the endodontic filling
material. n
Disclosure. None of the authors reported any disclosures.
The authors thank Dr. Yehuda Zadik, chief dental officer, Israel
Defense Forces Medical Corps, and attending clinician, Department
of Oral Medicine, Hebrew University of Jerusalem and Hadassah
School of Dental Medicine, Jerusalem, for critically reading the
manuscript of this article before its submission and Dr. Ofer Sarne,
Department of Orthodontics, The Maurice and Gabriela Goldschleger
School of Dental Medicine, Tel Aviv University, Israel, for his clinical
advice.
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