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Orthodontic Extraction Space Closure with and Without Socket Preservation: a Comparative Case Analysis

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Orthodontic Extraction Space Closure with and Without Socket Preservation: a Comparative Case Analysis ORTHODONTICS Orthodontic extraction space closure with and without socket preservation: a comparative case analysis Edlira Zere, DMD, PhD/Shmuel Einy, DMD, MSc/Thabet Asbi, DMD/Yuval Aizenbud, B Med Sc/ Zvi Gutmacher, DMD/Eyal Katzhandler, DMD, MSc/Dror Aizenbud, DMD, MSc Preorthodontic socket preservation after tooth extraction is in- 60%, and β-TCP 40%). The 3-year multidisciplinary treatment tended to enhance favorable dentoalveolar ridge morphology approach resulted in Class I relationships on the right side and and architecture, and facilitate orthodontic tooth movement Class II on the left side, improved facial appearance, and dento- (OTM) and extraction space closure. This 13-year-old skeletal skeletal jaw relationships. However, a 3-mm residual alveolar Class II case presents a unique opportunity to evaluate and space remained unclosed on the grafted left-site, along with an compare the OTM extraction space closure by means of a split- unerupted left third molar. This split-mouth comparative ana- mouth analysis in a single patient. The comprehensive ortho- lysis of the orthodontic space closure demonstrated a signifi- dontic-periodontal treatment included nonsimultaneous ex- cant clinical difference in the outcome. Preorthodontic place- traction of the bilateral periodontally compromised mandibular ment of HA-β-TCP grafting material on the left segment, proved first molars and the eruption of bilateral impacted mandibular to be an obstacle for OTM extraction space closure, hindering canines. While the right post-extraction space underwent a the establishment of good occlusion. (Quintessence Int 2019;50: natural healing process, the left one was grafted using 4BONE 306–314; doi: 10.3290/j.qi.a42161) BCH (hydroxyapatite β-tricalcium phosphate [HA-β-TCP], HA Key words: beta-tricalcium phosphate, calcium phosphate, extraction, orthodontics, socket preservation, tooth movement The alveolar process contains the tooth sockets and is consid- immediately after tooth extraction,11-14 facilitating implant ered a unique part of the jaw bone. It develops during the placement15-18 or OTM and tooth eruption through the grafted active tooth eruption process and is affected by tooth germ bone at the extraction site.19-21 Furthermore, reconstruction of development. The congenital absence of teeth (anodontia) appropriate alveolar bone mass has been reported crucial to results in underdevelopment of the alveolar ridge structure.1 facilitate and enhance orthodontic movement and teeth Similarly, the alveolar ridge dimensions affected by the retraction during extraction space closure,22,23 and proper extraction technique2 are reduced simultaneously with tooth orthodontic alignment of neighboring teeth at the extraction extraction as an expected outcome of the horizontal and verti- site.24 Therefore, preorthodontic socket preservation may pre- cal bone resorptive remodeling, especially in the coronal seg- vent insufficient bone structure and unsightly gingival reces- ment of the buccal bone plate.3-7 This may lead to a compro- sion, and facilitate optimal orthodontic-periodontic results in mised successor extraction space closure by orthodontic tooth compromised extraction orthodontic cases and prevent root movement (OTM).8,9 exposure.20,24-27 A socket preservation technique is aimed to minimize the A variety of biologically and synthetically derived bone alveolar socket residual resorption,10 reduce bone modeling augmentation materials, such as autografts, allografts, xeno- and remodeling rate, and maintain alveolar socket architecture grafts, and alloplasts, are currently being used to enhance new 306 QUINTESSENCE INTERNATIONAL | volume 50 • number 4 • April 2019 Zere et al Fig 1 Preliminary panoramic radiograph performed during initial admission screening. 1 bone formation.28-30 These serve as a bioactive resorbable foun- dation for the new bone to grow.31,32 Alloplastic materials including ceramics and polymers are natural, synthetic bio- compatible bone-graft substitutes that eliminate the need for donor site autogenous surgical bone harvesting procedures associated with morbidity and contamination.30,33,34 Calcium phosphate (CaP) crystals are bone apatite-like 2 material with a similar composition to natural bone minerals. CaP crystals are bioactive and can promote cellular function Fig 2 Periapical radiograph taken and expression, leading to the formation of a uniquely strong immediately after left first mandibular molar extraction and HA-β-TCP graft bone-CaP biomaterial interface and osteoconductivity.35 placement. Hydroxyapatite (HA) is one of the most widely used CaP graft biomaterials.36 Beta-tricalcium phosphate (β-TCP) has been shown to exhibit good biocompatibility and osteoconductivity However, the current scientific literature has not yet indicated in both animal and clinical studies.37,38 Its regenerative potential a specific preferable grafting material applied prior to the pre- is similar to that of autogenous bone, demineralized freeze- planned OTM in situations following extractions, based on micro- dried bone allograft (DFDBA), and collagen sponge.30,38 Nery et mechanical properties of the bone regenerative materials,44-47 al39 demonstrated the advantages of using a composite of and the consequences following OTM in extracted grafted sites these two materials, HA and β-TCP, compared to the use of using different bone graft materials.48 either material alone when treating infrabony defects. While The aim of this report is to present a split-mouth compara- HA alone showed a 3.9-mm attachment gain and β-TCP showed tive analysis of mandibular first molars’ orthodontic extraction a 3.3-mm attachment gain, the composite of the two materials space closure, with and without HA-β-TCP bone graft material, with a ratio of 65% HA and 35% β-TCP demonstrated a 5.4-mm within a single patient. attachment gain. A fully synthetic bone graft material composed of HA (60%) CASE REPORT and β-TCP (40%) is presented by 4BONE BCH (Mis Implant Technologies), which mimics natural bone apatites for ridge Initial admission screening preservation purposes.40 This material has been proven clini- cally efficient, safe, and supportive for new vital bone tissue A healthy 13-year-old male patient was referred to the multidis- regeneration during the healing process and gradually ciplinary Orthodontic – Surgery Clinic at Rambam Health Care becomes completely resorbable.41 It is used as a bone augmen- Campus, Haifa, Israel, due to large swelling of the right mandib- tation material in oral, periodontal, or maxillofacial defects and ular area. The initial panoramic radiograph (Fig 1) revealed also for bone reconstruction.42,43 bilateral impaction of mandibular second molars and canines. QUINTESSENCE INTERNATIONAL | volume 50 • number 4 • April 2019 307 ORTHODONTICS 3a 3b 3c 3d 3e Figs 3a to 3e Intraoral photographs prior to orthodontic treatment. In the right mandibular posterior segment, a large deep caries Preliminary dental care lesion was detected on the occlusal surface of the first molar. A large radiolucent lesion extended between its distal root and Four months later, the patient was evaluated by a multidisci- the horizontally impacted second molar’s crown. On the left plinary team (maxillofacial surgeon, orthodontist, endodontist, posterior mandibular segment, a large caries lesion was and periodontist) who recommended extraction without detected on the occlusal surface of the horizontally impacted socket preservation of the hopeless right first molar, due to the second molar’s crown. A periodontal bone defect between the severely resorbed distal root involved in the DC and the large endodontically restored mandibular first molar’s distal root and occlusal caries lesion. the second molar’s crown (Fig 1) was detected as well. Success- Following a normal healing process of the right extraction ful marsupialization of the right large infected cystic lesion site, the left mandibular first molar’s condition was deemed resulted in spontaneous eruption of the right mandibular sec- questionable. A surgical exploration revealed severe bone loss ond molar. The biopsy confirmed a dentigerous cyst (DC). around the distal root that made it hopeless. As a result, the 308 QUINTESSENCE INTERNATIONAL | volume 50 • number 4 • April 2019 Zere et al Fig 4 Panoramic radiograph taken during orthodontic treatment showing sponta- neously erupted and orthodontically aligned right third mandibular molar resulting from complete first molar extraction space closure and second molar mesialization on the right side. 4 team decided to extract the left first molar with socket preser- and the required space for the bilateral impacted mandibular vation using HA-β-TCP (4BONE BCH) (Fig 2). canine eruption was gained. The horizontally positioned mandib- ular second molars gradually and spontaneously erupted, incor- porated into the fixed appliance system, and were mesialized Orthodontic evaluation and treatment during the mandibular first molars’ extraction space closure, facil- Six months post-surgery, proper healing was clinically and itating the mandibular third molars’ spontaneous eruption (Fig 4). radiographically observed and the patient was referred for orthodontic evaluation. The patient exhibited a pleasant sym- Results metric face, convex profile, Class II, division 1 malocclusion associated with an increased overjet and overbite (OJ = 11 mm; The enlarged osseous defect associated with DC on the right OB = 9 mm), and constricted dental arches with severe crowd- molars and the deep residual
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