International Journal of

Environmental Research
and Public Health

Review
Orthodontic Extrusion vs. Surgical Extrusion to Rehabilitate
Severely Damaged Teeth: A Literature Review
Martina Cordaro 1,2,3 , Edoardo Staderini 1,2, * , Ferruccio Torsello 1,2 , Nicola Maria Grande 1,3 , Matteo Turchi 1,2
and Massimo Cordaro 1,2

1 IRCCS, Fondazione Policlinico Universitario Agostino Gemelli, 00168 Roma, Italy;

cordaromartina@gmail.com (M.C.); ferruccio.torsello@gmail.com (F.T.); nmgrande@gmail.com (N.M.G.);
matteoturchi90@gmail.com (M.T.); massimo.cordaro@unicatt.it (M.C.)
2 Department of Orthodontics, Università Cattolica del Sacro Cuore, Largo Francesco Vito 1, 00168 Rome, Italy
3 Department of Endodontics, Università Cattolica del Sacro Cuore, Largo Francesco Vito 1, 00168 Rome, Italy
* Correspondence: edoardo.staderini@yahoo.it

Abstract: The need to rehabilitate severely compromised teeth is frequent in daily clinical prac-
tice. Tooth extraction and replacement with dental implant represents a common treatment choice.
However, the survival rate for implants is inferior to teeth, even if severely damaged but properly
treated. In order to reestablish a physiological supracrestal tissue attachment of damaged teeth and
to arrange an efficient ferrule effect, three options can be considered: crown lengthening, orthodontic
extrusion and surgical extrusion. Crown lengthening is considered an invasive technique that causes
the removal of part of the bony support, while both orthodontic and surgical extrusion can avoid this
inconvenience and can be used successfully in the treatment of severely damaged teeth. The aim





 of the present narrative review is to compare advantages, disadvantages, time of therapy required,
Citation: Cordaro, M.; Staderini, E.;
contraindications and complications of both techniques.
Torsello, F.; Grande, N.M.; Turchi, M.;
Cordaro, M. Orthodontic Extrusion Keywords: orthodontic extrusion; surgical extrusion; rapid orthodontic extrusion; forced orthodontic
vs. Surgical Extrusion to Rehabilitate eruption; crown–root fracture; orthodontics
Severely Damaged Teeth: A
Literature Review. Int. J. Environ. Res.
Public Health 2021, 18, 9530. https://
doi.org/10.3390/ijerph18189530 1. Introduction
“Severely damaged teeth” are considered as teeth with severe structural damage due
Academic Editor: Paul B. Tchounwou
to multiple factors: crown–root fractures, extensive carious lesions, cervical root resorption
or other causes that lead to the loss of part of the clinical crown. Such teeth need to be
Received: 31 July 2021
rehabilitated, even considering the high prevalence of subgingival root caries among the
Accepted: 1 September 2021
elderly [1].
Published: 10 September 2021
Nowadays, in the so-called “dental implant era” (Clark and Levin), clinicians often
choose to extract compromised teeth and replace them with dental implants, even if less
Publisher’s Note: MDPI stays neutral
with regard to jurisdictional claims in
invasive options are feasible [2]. Moreover, the lower implants survival rate compared to
published maps and institutional affil-
teeth should be considered even in cases of severely compromised but properly treated
iations.
and maintained teeth [2]. Placing a dental implant is not free from possible intraoperative
and postoperative complications, such as neurological damage and sinus penetration. No
less, extraction is an irreversible action that should be considered as the last resort.
A fixed partial prosthetic denture may represent another alternative to implant place-
ment to replace extracted teeth, but it requires the inevitable mutilation of healthy dental
Copyright: © 2021 by the authors.
tissue of the adjacent abutment teeth. The main limit of this choice is associated with the
Licensee MDPI, Basel, Switzerland.
lower long-term survival rate than both dental implants and post-endodontically restored
This article is an open access article
distributed under the terms and
teeth [3].
conditions of the Creative Commons
For all these reasons, the maintenance and rehabilitation of a compromised tooth still
Attribution (CC BY) license (https:// seems to be the most effective treatment.
creativecommons.org/licenses/by/
4.0/).

Int. J. Environ. Res. Public Health 2021, 18, 9530. https://doi.org/10.3390/ijerph18189530 https://www.mdpi.com/journal/ijerph
Int. J. Environ. Res. Public Health 2021, 18, 9530 2 of 14

Due to prosthetic rehabilitation, it is crucial to create an effective ferrule effect for a

desirable biomechanical behavior of the tooth [4]. The presence of 1.5–2 mm of sound
supragingival dental tissue significantly increases tooth fracture resistance [4,5].
Even an adequate distance between crown margin and alveolar crest must be ensured
to respect the supracrestal tissue attachment [4,6]. Supracrestal tissue attachment, com-
monly known as biological width, is defined as “the dimension of tissues placed coronally
to the crest of the alveolar bone” [6,7]. Preserving it is a fundamental requirement for the
health of periodontal tissues; any violation of its integrity can lead to gingival inflammation
and consequent loss of clinical attachment and bone resorption [6].
Biological width is stated to be 2.04 mm, which represents the sum of epithelial and
connective tissue average measurements with a significant intra- and inter-individual
variability [6–8]. Therefore, the clinician should measure the individual dimension of
biological width by performing a bone sounding, or ensure at least a distance of 3–4 mm
between the alveolar crest and the crown margin [4,9,10].
In the case of a severely damaged tooth without sufficient supra-alveolar structure to
achieve an effective ferrule effect and to ensure the preservation of the supracrestal tissue
attachment, the clinician should assess as treatment options:
• Surgical crown lengthening;
• Orthodontic extrusion;
• Surgical extrusion [11].
Surgical crown lengthening, when performed for restorative purposes, requires the
execution of an apically repositioned flap with bone resection [12]. As a general rule, it is
necessary to remove an amount of bone in order to expose at least 4 mm of healthy dental
tissue. The exposed healthy dental tissue will be then covered by gingival proliferation
during healing from 2 to 3 mm [12].
The surgical technique requires the execution of an internal bevel incision whose
distance from the gingival margin depends on the pocket depth and on the keratinized
gingiva width. Two relief incisions can be added [12]. A full-thickness flap is performed to
expose the bone; by using fissure burs and/or bone chisels, bone recontouring is carried
out on the compromised tooth and extended to the adjacent teeth to harmonize the gingival
morphology. Finally, the flap is repositioned at the level of the bone crest and sutured [12].
Bone removal can cause a significant worsening of the crown/root ratio, exposure of the
furcation and severe weakening of the periodontal ligament of the tooth to be exposed and
of the adjacent teeth [1,4,13]. Therefore, this technique is contraindicated in the exposure of
subgingival lesions of a single tooth, especially in aesthetic areas [12].
More conservative techniques, such as orthodontic extrusion and surgical extrusion,
should be preferred to restore severely compromised teeth.
The aim of this review is to compare advantages, disadvantages, time of therapy
required, contraindications and complications for both techniques.

2. Materials and Methods

In order to analyze both orthodontic extrusion and surgical extrusion, a literature
search was performed using PubMed database. The keywords used were “orthodontic
extrusion”, “forced orthodontic extrusion”, “forced orthodontic eruption” and “surgical
extrusion”; no filter was applied regarding patients’ age, sex and country. Original articles
and reviews in the English language describing one or both techniques were selected based
on title and abstract. The reference list of the included articles was analyzed and added to
the screening phase. No restrictions were placed on the publication status of the articles
or year.

3. Results
A total of 57 articles on surgical extrusion, 52 articles on orthodontic extrusion,
4 articles on ferrule effect, 9 articles on biological width and 16 articles on surgical crown
lengthening were selected. These were divided into groups (e.g., orthodontic extrusion
Int. J. Environ. Res. Public Health 2021, 18, 9530 3 of 14

group, surgical extrusion group, etc.) and completely read. After full-text screening,
12 articles were eligible for the qualitative summary of the results.

4. Discussion
Based on the literature review, orthodontic extrusion and surgical extrusion will be
discussed by analyzing the advantages, disadvantages, indications, contraindications and
complications of each technique. The results are summarized in Table 1. A combined
therapy, that merges the advantages of both techniques, is proposed as a future therapy to
rehabilitate severely damaged teeth.

Table 1. Indications, contraindications, advantages and disadvantages of both orthodontic extrusion and surgical extrusion.

Orthodontic Extrusion Surgical Extrusion

Rehabilitation of teeth with subgingival lesions or
that are severely damaged;
Teeth that cannot be restored with conventional
Treatment of restorations that violate the
techniques with root anatomy compatible with
biological width;
atraumatic extraction (single-rooted teeth).
Indication Correction of angular defects and pink aesthetic;
Teeth with endodontic clinical scenarios difficult to
Regeneration of the alveolar ridge (for implant
treat through classic procedures that need to
purposes);
be extruded.
Orthodontic extraction;
Treatment of impacted teeth (canines).
Ankylosis or hypercementosis;
Vertical root fracture;
Teeth with root anatomy not compatible with
Close proximity to the roots of adjacent teeth;Severe
atraumatic extraction (e.g. multi-rooted teeth with
Contraindications internal or external root resorption;
divergent roots).
Untreated periodontitis or periapical disease;
Medical contraindications to any surgical therapy.
Short roots and exposition of furcation in
multirooted teeth.
Rapidity: in just one time it is possible to obtain the
extrusion of the desired amount and the correction
of endodontic problems, with the possibility to
Minimally invasive treatment: no loss of bone or inspect and treat otherwise inaccessible areas
periodontal tissue. without damaging the contiguous elements.
Advantages Simple and predictable technique. Compared to surgical crown lengthening, less bone
Better crown/root ratio than surgical crown loss and better maintenance of the interproximal
lengthening. papilla.
Compared to orthodontic extrusion: less coronal
migration of support tissues and much shorter time
of therapy required.
Long time of treatment required;
Risk of ankylosis and root resorption due to
Worsening oral hygiene and aesthetic problems;
Disadvantages periodontal ligament trauma;
High patient compliance required if fiberotomy is
Absence of a universal protocol.
performed weekly.

4.1. Orthodontic Extrusion

Orthodontic extrusion, also known as forced orthodontic extrusion or forced orthodon-
tic eruption, is defined as tooth movement caused by coronally directed orthodontic forces.
It is performed to change tooth position or induce therapeutic changes on the surrounding
alveolar bone and soft tissue [14].
It is indicated:
• In the treatment of traumatized or impacted teeth (canines) [14–18];
• To expose dental structure to facilitate tooth restoration in the case of a subgingival
or infraosseous lesion or to confer an adequate ferrule effect, especially in aesthetic
areas [14,15,19];
• To correct a biological width violation [15];
Int. J. Environ. Res. Public Health 2021, 18, x FOR PEER REVIEW 4 of 14

• To expose dental structure to facilitate tooth restoration in the case of a subgingival

or
Int. J. Environ. Res. Public Health 2021, 18, 9530infraosseous lesion or to confer an adequate ferrule effect, especially in aesthetic
4 of 14
areas [14,15,19];
• To correct a biological width violation [15];
• To reduce angular bone defects [14,15,20–22];
• To reduce angular bone defects [14,15,20–22];
• To correct an inadequate gingival zenith level and to modify the gingival architecture
• To correct an inadequate gingival zenith level and to modify the gingival architec-
[14,23,24];
ture [14,23,24];
• For peri-implant purposes, to increase the volume of the alveolar ridge and the ke-
• For peri-implant purposes, to increase the volume of the alveolar ridge and the
ratinized gingiva
keratinized [15,23,25];
gingiva [15,23,25];
•• To perform orthodontic extraction, when
To perform orthodontic extraction, when surgical
surgical extraction
extraction isiscontraindicated
contraindicated[15].
[15].
It is contraindicated
It is contraindicated in in case
case ofof ankylosis
ankylosis or or hypercementosis
hypercementosis (since (since the
the extra
extra load
load
would cause
would cause the
the intrusion
intrusion of of the
the anchoring
anchoring teeth),
teeth), vertical
vertical root
root fracture,
fracture, proximity
proximity to to the
the
roots of contiguous teeth, severe internal or external root resorption,
roots of contiguous teeth, severe internal or external root resorption, short root length, short root length,
untreated periodontitis or
untreated periodontitis or periapical
periapical disease
disease andand when
when it it would
would cause
cause the
the exposure
exposure of of the
the
furcation in multi-rooted teeth
furcation in multi-rooted teeth [14,15,26]. [14,15,26].
In
In 1973,
1973, Heithersay
Heithersay firstfirst described
described the the use
use of
of orthodontic
orthodontic extrusion
extrusion to to move
move coronally
coronally
the
the remaining
remaining root root ofof fractured
fractured teethteeth [14,27].
[14,27].
Orthodontic
Orthodontic extrusion (Figures11and
extrusion (Figures and2)2)exerts
exerts only
only tension
tension on onthethe surrounding
surrounding tis-
tissues,
sues, and this kind of orthodontic force stimulates marginal bone
and this kind of orthodontic force stimulates marginal bone apposition through increasing apposition through in-
creasing osteoblastic activity. Therefore, orthodontic extrusion can
osteoblastic activity. Therefore, orthodontic extrusion can be used to correct intraosseous be used to correct in-
traosseous defects
defects [14,28]. [14,28].itSimilarly,
Similarly, is possible it to
is possible
modify softto modify soft tissue morphology
tissue morphology with
with an increase
an increase
in the amount in the amount of gingiva,
of keratinized keratinized gingiva,atidentifiable
identifiable first as a “redat first
patch”as [15,27].
a “red patch”
Based
[15,27].
on this Based
concept,on inthis2018
concept,
“Guided in 2018 “Guided regeneration”
orthodontic orthodontic regeneration"
was proposed wasbyproposed
Paolone
by Paolone
et al., et al.,the
to ensure to reconstitution
ensure the reconstitution of dental
of dental support support
tissues tissues
by using by using
extrusive extrusive
orthodontic
orthodontic
movementsmovements
[23]. [23].

Orthodonticextrusion
Figure 1. Orthodontic extrusionofoftooth
tooth1.5
1.5with
with insufficient
insufficient ferrule
ferrule effect.
effect. Preoperative
Preoperative clinical
clinical oc-
clusal and vestibular views and radiograph (a–c): tooth with deep caries. Endodontic
occlusal and vestibular views and radiograph (a–c): tooth with deep caries. Endodontic treatment and
post-endodontic restoration
post-endodontic restoration with
with post
post was
was performed:
performed: occlusal
occlusal and
and buccal
buccal views
views and
and post-operative
post-operative
radiograph (d–f).
radiograph (d–f).

Hard tissue increment is advantageous if orthodontic extrusion is carried out to correct

infraosseous defects or for pre-implant purposes, since the increased keratinized tissue
can improve the aesthetic result of the final prosthetic restoration [27]. On the other hand,
it may show an undesirable effect if extrusion is performed to expose the subgingival
structure of a tooth to be restored. This would require a periodontal surgery to expose
subgingival lesions or healthy dental tissue needed for restorative purposes.
To prevent gingival coronal migration, the use of circumferential fiberotomy, namely
the 360◦ incision of the supracrestal gingival fibers, has been proposed [15,27]. It is usually
performed with a sharp scalpel blade inserted in the sulcus and used circumferentially to
sever the fibers. A small injection of anesthetic is required.
Especially when combined with root planning, the fiberotomy was more effective in
preventing coronal soft tissue migration than orthodontic extrusion alone [29,30]. Root
planning takes away the supracrestal gingival fibers remaining on the tooth surface and
previously cut by the fiberotomy. The recovery of the previous attachment level hinged on
Int. J. Environ. Res. Public Health 2021, 18, 9530 5 of 14

Int. J. Environ. Res. Public Health 2021,the

18,reinsertion
x FOR PEER REVIEW
of the supracrestal 5 of 14
gingival fibers; the fiberotomy prevents their reinsertion,
thus obtaining the optimal crown length to be restored [30].

Figure2.2.Orthodontic
Figure Orthodonticextrusion
extrusionof
of1.5
1.5with
withinsufficient
insufficientferrule
ferruleeffect.
effect.Orthodontic
Orthodontictherapy
therapytotoextrude
extrude
tooth 1.5 (a). Tooth preparation after orthodontic extrusion: buccal and vestibular views (b,c).
tooth 1.5 (a). Tooth preparation after orthodontic extrusion: buccal and vestibular views (b,c). Pros-
thetic rehabilitation: post-operative radiograph and buccal and occlusal views (d–f).
Prosthetic rehabilitation: post-operative radiograph and buccal and occlusal views (d–f).

Hard tissue
However, increment
there is a broad is advantageous
disagreementifinorthodontic
the literature extrusion
about the is carried
correct out
timingto cor-
to
rect infraosseous defects or for pre-implant purposes, since
perform this technique. Some authors recommend a weekly fiberotomy [15,31,32]. Others the increased keratinized tis-
sue canto
suggest improve
performthe aesthetic only
fiberotomy resultonce,
of the finalthe
when prosthetic
orthodontic restoration
movement [27].isOn the other
completed,
hand, it may show an undesirable effect if extrusion is performed
just before the surrounding tissue remodeling occurs, or immediately before extrusion, so to expose the subgingi-
val structure
that the tooth of cana tooth
extrude to without
be restored. This would
dragging require
the gingiva a periodontal
with it [15,33,34]. surgery to expose
subgingival
Regarding lesions or healthy
the timing dental tissue
of fiberotomy, manyneeded for restorative
clinicians consider purposes.
this technique unpre-
To prevent
dictable, gingival
as a corrective coronal migration,
periodontal surgery atthe theuseendofofcircumferential
the treatment may fiberotomy, namely
be still required
the
to 360° incision
correct of the
tissue level supracrestal
discrepancy gingival
between thefibers,
toothhas been proposed
extruded and adjacent[15,27]. It is[15].
teeth usually
performed with a sharp scalpel blade inserted in the sulcus and
Orthodontic extrusion can be obtained using different orthodontic strategies: fixed appli- used circumferentially to
sever removable
ances, the fibers. A small injection
appliances of anesthetic
and temporary is required.
anchorage devices such as mini-screws [11,35].
Even Especially
the use of neodymium–iron–boron
when combined with root magnets
planning, hasthebeen proposedwas
fiberotomy [36].more
Different treat-
effective in
ment choice coronal
preventing variablessoft must be considered,
tissue migration than such orthodontic
as patient preference,
extrusionoral alonehygiene,
[29,30].avail-
Root
ability
planningof an appropriate
takes away theorthodontic
supracrestal anchorage
gingivaland amount
fibers of dental
remaining crown
on the available
tooth surface[11].and
In the case
previously cut illustrated
by the fiberotomy.in FiguresThe 1 and 2, a severely
recovery of the damaged upper second
previous attachment premolar
level hinged
was restored.
on the The tooth
reinsertion of thepresented
supracrestala longgingival
root (Figure 1c),the
fibers; which was considered
fiberotomy preventsa favorable
their rein-
condition for tooth extrusion. The root canal treatment
sertion, thus obtaining the optimal crown length to be restored [30]. and a provisional restoration with
carbon-fiber
However, post wasisperformed
there (Figure 1d).inThe
a broad disagreement thecrown height
literature aboutwasthereduced to allow
correct timing to
the extrusion
perform of the toothSome
this technique. without interference
authors recommend withathe opposing
weekly arch and
fiberotomy to avoidOthers
[15,31,32]. tooth
fractures
suggest to which are frequent
perform fiberotomy in the
onlyendodontically
once, when the treated teeth. movement is completed,
orthodontic
Three braces were bonded on teeth 1.6, 1.5
just before the surrounding tissue remodeling occurs, or immediately and 1.4, taking care to position the bracket
before extrusion, so
on tooth 1.5 approximately 3 mm more apically than
that the tooth can extrude without dragging the gingiva with it [15,33,34]. the neighboring teeth.
Intrasulcular
Regarding the fiberotomy was performed
timing of fiberotomy, many with a 15c surgical
clinicians consider blade 360◦ around
this technique the
unpre-
second premolar. Scaling and root planning of this tooth was
dictable, as a corrective periodontal surgery at the end of the treatment may be still re- also carried out to contrast
the tendency
quired of fibers
to correct tissueto level
re-attach to the tooth.
discrepancy between the tooth extruded and adjacent teeth
[15]. A sectional 0.014 NiTi wire was tied to the three brackets, thus developing an extrusive
force Orthodontic
on tooth 1.5 and counteraction forces
extrusion can be obtained using on teethdifferent
1.4 and 1.6. A stainless-steel
orthodontic strategies: round
fixed
0.020 wire was bonded on the palatal surfaces of teeth 1.4
appliances, removable appliances and temporary anchorage devices such as mini-screws and 1.6 so as to splint them to
create an anchorage unit.
[11,35]. Even the use of neodymium–iron–boron magnets has been proposed [36]. Differ-
After the successful extrusion, the tooth was prepared with a knife edge finishing line
ent treatment choice variables must be considered, such as patient preference, oral hy-
(Figure 2c) for a provisional resin crown and finally restored with a monolithic zirconia
giene, availability of an appropriate orthodontic anchorage and amount of dental crown
crown (Figure 2d–f).
available [11].
In the case illustrated in Figures 1 and 2, a severely damaged upper second premolar
was restored. The tooth presented a long root (Figure 1c), which was considered a favor-
able condition for tooth extrusion. The root canal treatment and a provisional restoration
with carbon-fiber post was performed (Figure 1d). The crown height was reduced to allow
the extrusion of the tooth without interference with the opposing arch and to avoid tooth
fractures which are frequent in the endodontically treated teeth.
Int. J. Environ. Res. Public Health 2021, 18, 9530 6 of 14

4.1.1. Advantages
Orthodontic extrusion is a safe, minimally invasive and highly predictable treatment,
rarely associated with complications [14,15,34,37,38].
It shows several advantages if compared to surgical crown lengthening. First, tooth
structure and periodontal support maintenance is crucial: as previously mentioned, in
surgical crown lengthening it is required to extend bone resection on the adjacent teeth
to harmonize the gingival morphology. This causes bone loss and a possible damage of
the periodontal support as well as a worsening of the crown/root ratio of these teeth [15].
Conversely, orthodontic extrusion can just cause tooth displacement or even increase
the volume of dental support tissues, which is particularly advantageous for implant
purposes [23].
The combination of orthodontic extrusion and fiberotomy can be particularly advan-
tageous in highly aesthetically demanding areas, where surgical crown lengthening on a
single tooth could lead to an unsatisfactory aesthetic result [14,30].
Finally, a relatively simple tooth movement is required to perform orthodontic ex-
trusion: it is considered the easiest among the orthodontic movements as it simulates the
physiological dental eruption [15,39].

4.1.2. Disadvantages
The main disadvantage of orthodontic extrusion is treatment time, with an average of
4 to 6 weeks [15]. In addition, from 4 weeks up to 6 months of retention may be required,
depending on the treatment goal [15]. For this reason, clinicians and patients may not
choose orthodontic extrusion as the first treatment option [15].
Furthermore, if fiberotomy is performed weekly, a high patient compliance is re-
quested with the possible need of periodontal surgery at the end of the treatment [15].
As all orthodontic devices, it can cause oral hygiene worsening and aesthetic prob-
lems [15].

4.1.3. Complications
Orthodontic movements, especially if performed on traumatized teeth or through the
application of heavy forces, can cause root resorption [14]. However, it can be considered a
rare event when performing extrusive movement [14,27,34].
If heavy forces are applied, the risk of causing intrusion of the anchoring teeth and
ankylosis of the tooth to be extruded increases, due to the trauma exerted on the periodontal
ligament [15,27,40,41].
Relapse, namely the intrusive dislocation of the extruded tooth, represents an undesir-
able event much more frequent than the previous ones.
Fiberotomy, regardless of whether it is performed before or after orthodontic move-
ment, and a retention period of at least 3–4 weeks, help to reduce this undesirable ef-
fect [14,27,30,34,42–44].

4.2. Surgical Extrusion

Surgical extrusion (Figures 3–5), also known as intra-alveolar transplantation, is the
procedure whereby the remaining structure of a tooth is intentionally replaced to a more
coronal/supragingival position in the same tooth’s original socket [45–47].
 4.2.Surgical
4.2. SurgicalExtrusion
Extrusion
Surgicalextrusion
Surgical
Int. J. Environ. Res. Public Health 2021, 18, 9530
extrusion(Figures
(Figures3–5),
3–5),also
alsoknown
knownas asintra-alveolar
intra-alveolartransplantation,
transplantation,isis7the
the
of 14
procedure whereby the remaining structure of a tooth is intentionally replaced to
procedure whereby the remaining structure of a tooth is intentionally replaced to a more a more
coronal/supragingivalposition
coronal/supragingival positionininthe
thesame
sametooth’s
tooth’soriginal
originalsocket
socket[45–47].
[45–47].

Figure3.
Figure
Figure 3.3.Surgical
Surgical extrusion
Surgical extrusion of
extrusion of tooth
of tooth 1.2
tooth 1.2 with
1.2 with insufficient
with insufficient ferrule
insufficient ferrule effect
ferruleeffect (a,b).
effect(a,b). Tooth
(a,b).Tooth was
Toothwas extracted
wasextracted
extracted
with
with an
an atraumatic
atraumatic method
method (c)
(c) and
and then
then reimplanted
reimplanted and
and splinted,
splinted, waiting
waiting for
for healing
healing
with an atraumatic method (c) and then reimplanted and splinted, waiting for healing (d–f). (d–f).
(d–f).

Figure4.4.Surgical
Figure
Figure Surgicalextrusion
extrusionof
extrusion of1.2
of 1.2tooth
1.2 toothwith
tooth withinsufficient
with insufficientferrule
insufficient ferrule effect.
ferruleeffect. Prosthetic
effect.Prosthetic rehabilitation.
Prostheticrehabilitation.
rehabilitation.

Figure5.
Figure
Figure 5.5.Surgical
Surgicalextrusion
Surgical extrusionof
extrusion of1.2
of 1.2tooth
1.2 toothwith
tooth with insufficient
withinsufficient ferrule
insufficientferrule effect.
ferruleeffect. Preoperative
effect.Preoperative radiograph
Preoperativeradiograph
radiograph (a).
(a).
(a).
Primaryendodontic
Primary endodontictreatment
treatment(b).
(b).Reimplantation
Reimplantationafter
afterretrograde
retrogradeendodontic
endodontictreatment
treatmentand
andsplint
splint
Primary endodontic treatment (b). Reimplantation after retrograde endodontic treatment
(c).Tooth
(c). Toothpreparation
preparationand
andprosthetic
prostheticrehabilitation
rehabilitationafter
afterhealing
healingprocess
process(d,e).
(d,e).
and splint (c). Tooth preparation and prosthetic rehabilitation after healing process (d,e).

Thistechnique
This
This techniqueisis
technique advocated
isadvocated
advocated asas
as anan
an alternative
alternative toextraction,
to
alternative extraction, orthodontic
orthodontic
to extraction, extrusion
extrusion
orthodontic and
and
extrusion
surgical
surgical crown
crown lengthening
lengthening for
for the
the rehabilitation
rehabilitation of
of severely
severely compromised
compromised
and surgical crown lengthening for the rehabilitation of severely compromised teeth. It teeth.
teeth. It
It allows
allows
therelocation
the relocation
allows ofaasubgingival
of
the relocationsubgingival lesionor
lesion
of a subgingival orthe
themargin
margin
lesion or the ofamargin
of atooth
toothmore
more coronally
coronally
of a tooth more incoronally
in orderto
order to
restore
restore
in it,
orderit, conferring
to conferring
restore aa sufficient
sufficient
it, conferring ferrule and
ferrule
a sufficient and respecting
respecting
ferrule the biological
the
and respectingbiological width space
width
the biological space
width
[11,45,46,48].
[11,45,46,48].
space [11,45,46,48].
Surgical extrusion can be performed with or without the complete tooth removal from
the alveolus: the tooth can just be moved coronally or it can be extracted from its alveolus
and re-implanted more coronally.
Since there are no significant differences in success rate between surgical extrusion
without tooth extraction and surgical extrusion associated with extraoral manipulation and
intentional replantation, tooth extraction is convenient in the majority of cases. Indeed, this
Int. J. Environ. Res. Public Health 2021, 18, 9530 8 of 14

allows the clinician to visually inspect the root surface and the anatomical structures of the
apical area, with a single apical foramen or multiple portals of exit. This procedure should
be performed under magnification with loupes; or better, with an operative microscope.
In many cases, it is necessary to endodontically treat the tooth with an apicectomy, a
retrograde preparation and cleaning of the root canal and the sealing of the preparation.
The root resection is made using high-speed burs and it is performed following the same
indications used in apical surgery (resection of 3 mm of apical root length); the resection
can be shorter when a pathological root resorption is present or when the overall length
of the root is not compatible with such resection length. The retrograde preparation can
be performed using ultrasonic surgical retrotips or small high-speed rotary burs used in
a delicate way, respecting the axis of the root canal; the retrograde sealing is performed
using putty such as bioceramic materials condensed using the same instruments used in
apical surgical procedures [45,49–51].
The extraoral inspection of the root surface enables the identification of anatomical
variations, secondary canals and cracks spread along all surfaces of the root [45]. Indeed, it
has been shown that in approximately 30% of teeth with crown–root fractures, replantation
was not possible due to severe cracks or fractures already present on the root surface [52].
By intentionally replanting the tooth to extrude, it is possible to manage complex
endodontic cases that are difficult to treat with conventional orthograde or retrograde
techniques, such as natural or iatrogenic root canal obstruction and proximity to important
anatomical structures, or in cases where root damage is not easily accessible or repairable
intraorally, such as cervical root resorption [45,53].
These indications were described by Grossmann in 1996 for intentional replanta-
tion. Even if intentional replantation differs from surgical extrusion because the tooth is
repositioned at the same level where it was originally, indications for the latter are the
same [45,54,55].
Both intentional replantation and surgical extrusion are indicated in permanent teeth
with an ideal root anatomy to perform an atraumatic extraction [45]. This condition is
often satisfied in single-rooted teeth. In multi-rooted teeth with unfavorable anatomy, the
attempted extraction can result in severe damage of the root surface or tooth fracture [45].
Therefore, in this type of tooth, surgical extrusion and intentional replantation are con-
traindicated [45]. A preoperative CBCT may be indicated, especially in multi-rooted teeth,
to assess the suitable root morphology [45,56–58].
Despite the severe advantages mentioned above, surgical extrusion and intentional
replantation are often considered by many clinicians as a last-resort procedure [45]. This
is supposedly due to the common concern to inevitably cause damage to the periodon-
tal ligament during extraction and the consequent risk to develop ankylosis and root
resorption [45].
The clinical procedures of both surgical extrusion and intentional replantation start
with local anesthesia and incision of the supracrestal fibers of gingival attachment. In
various studies, a systemic antibiotic prophylaxis is suggested [59–65]. In order to limit any
potential root surface damage, luxation should be avoided or performed with particular
care, and only rotatory movements should be preferred. After tooth extraction, it should
be visually inspected, preferably under magnification, to check for root fractures or severe
cracks that would compromise treatment success (Figure 3c). During extraoral manipula-
tion, the tooth should be firmly held, to avoid periodontal ligament damage, and it should
be irrigated with sterile saline solution [50]. If required, apicectomy and retrograde sealing
can be performed as previously described [66]. The extraoral handling time should not
exceed 15 min; if more time is needed, the survival rate could be lowered [45,51,67]. Once
the seal has been performed and the blood clot removed, it is possible to replant the tooth
in its socket to the level that is clinically convenient [45]. It is possible to rotate by 90◦ or
180◦ the root before reinserting it to facilitate the exposure of the lesion or improve the
ferrule [68]. After the reimplantation, it is suggested to verify the level of repositioning
and carefully check the occlusal contacts to adapt them in case of precontact; at the same
Int. J. Environ. Res. Public Health 2021, 18, 9530 9 of 14

time, the overall position of the tooth should be evaluated with a radiograph. Once the
tooth is replanted, it should be splinted using a semirigid orthodontic splint bonded to
the adjacent teeth; this kind of splint permits post-op minimal adjustments of the position
and it is recommended when compared with rigid splints [45,69,70]. The time of splinting
retention depends on tooth post-operatory stability, though it usually ranges between 1
and 3 weeks [71,72].
Success criteria include periodontal healing without signs of progressive root resorp-
tion or ankylosis, the absence of significant marginal bone loss and the absence of tooth
mobility beyond physiological limits [45,46].
Variables influencing the outcome are represented by an atraumatic extraction method,
which provides the least possible damage to the cementoblast layer on the root surface, and
by a rapid extra-alveolar handling, lasting less than 15 minutes, without using chemicals po-
tentially harmful to periodontal ligament cells’ survival, such as sodium hypochlorite [73].

4.2.1. Advantages
A short time to extrude the tooth is beneficial; in a single session, the desired amount
of extrusion can be obtained.
It is possible to endodontically treat the tooth simultaneously with extrusion; api-
coectomy and retrograde filling can be performed outside the alveolus, visually checking
the seal.
Furthermore, the achievement of aesthetic results and the low incidence of failure
documented so far in the literature should encourage its use [46–48,74–81].
Finally, surgical extrusion compared to surgical crown lengthening allows a better
maintenance of the interproximal papilla and less marginal bone loss [81].

4.2.2. Disadvantages
As mentioned above, both surgical extrusion and intentional replantation are not
indicated for teeth with root morphology non-compatible with atraumatic extrusion. More-
over, the risk of causing root resorption or ankylosis due to a non-cautious handling of the
periodontal ligament, as well as the wide discrepancy in success rate of the results reported
by various studies and the absence of a universally established protocol, do not encourage
clinicians to choose this therapeutic option [45].

4.2.3. Complications
The most frequent complication associated with this technique is non-progressive root
resorption, which can affect up to 30% of cases [11,71].
Other complications are tooth fracture during extraction, progressive root resorption,
marginal bone loss and persistent mobility that can lead to tooth loss [11,71].

4.3. Combined Therapy

As previously described, intentional replantation can be pursued if traditional or-
thograde and/or retrograde endodontic techniques have failed or are considered unfeasi-
ble [45,82].
One of the factors that most influences the success of this procedure is the preservation
of periodontal ligament of extracted tooth. Preventing chemical and mechanical damage
through a rapid and careful extraoral tooth manipulation and the execution of extraction
as atraumatically as possible can improve the prognosis [45,83].
Extraction movements, therefore, are closely related to the success of intentional re-
plantation and to the development of complications, such as ankylosis and root resorption,
associated with this technique [45,53,82,83].
For this reason, various atraumatic extraction methods have been proposed for both
intentional replantation and surgical extrusion, such as vertical extraction procedures [84].
The most recommended extraction method is still holding the tooth with forceps beyond
the CEJ, using preferably rotary movements [45,83].
Int. J. Environ. Res. Public Health 2021, 18, 9530 10 of 14

It is important to consider that most teeth requiring intentional replantation have

a weakened dentinal structure due to previous root canal treatments or retreatments,
extensive restorations and root canal posts [82,83]. Therefore, a firm grasp during tooth
extraction can lead to their fracture [83].
To overcome this problem, in 2010, a new protocol called “Atraumatic Safe Extraction”
(ASE) was introduced by Choi et al., whereby a preoperative orthodontic extrusion for
2–3 weeks is performed before surgery to increase the mobility and volume of the peri-
odontal ligament of the tooth to be intentionally replanted [1,82,83]. The preoperative
orthodontic mobilization makes extraction easier, thus reducing the risk of complications
such as root resorption and ankylosis [82,83].
The same authors, in 2014, in a comparative retrospective study between intentional re-
plantation with and without ASE technique, found that preoperative orthodontic extrusion
reduces the risk of root resorption and tooth fracture during extraction, thus statistically
significantly increasing the survival rate of the intentionally replanted teeth [83]. Other
variables, such as age, sex, tooth type and position, do not seem to influence its survival [83].
Preoperative orthodontic extrusion can be useful, especially if intentional replantation
is planned on teeth with complex root anatomy, a condition associated with a higher risk of
fracture during extraction, or if the tooth to be replanted has received repeated non-surgical
root canal treatments that have weakened roots or in the case of a tooth with a small
residual coronal structure [82,83].
A similar approach, termed “ortho-transplantation”, was previously proposed by
Hayashi to prevent postoperative root resorption in tooth autotransplantation [85]. The
author suggested that performing a preoperative orthodontic extrusion would increase
the volume of the periodontal ligament of the donor tooth, preventing root resorption
after transplantation [83,85]. In the ASE protocol, the same concept was adapted as that of
intentional replantation to prevent root resorption [1,83]. Similarly, the same methodology
should be applied to surgical extrusion techniques as well; its use has been described only
in a retrospective study by Choi et al. in 2019 [1]. In this method, orthodontic forces of
about 50 g are applied using a system of orthodontic brackets or orthodontic brackets and
buttons and a Ni-Ti arch 0.014 [1,82,83]. In the posterior teeth, a 0.016 × 0.022 arch can be
bent as a L to achieve extrusion [83].
Once tooth appears 1–2 mm extruded and its mobility increases, the extraction is
carried out using Physics forceps, extractive forceps developed by Misch and Perez in order
to minimize damage to the root surface during extraction. It is possible to proceed further
with the classic intentional replanting protocol [1,82,83]. The extracted tooth is kept under
constant hydration with cold physiologic saline, visually inspected and then reimplanted
more coronally, as much as needed to expose the subgingival lesion, though considering
the crown/root ratio.

5. Conclusions
Both surgical and orthodontic extrusion can be used successfully in the treatment of
severely compromised teeth.
It is advisable to perform surgical extrusion if there is the necessity to solve endodontic
problems that cannot be treated with conventional orthograde endodontic techniques, or
as an alternative to the extraction of teeth that cannot be alternatively restored.
It is preferable to choose orthodontic extrusion if a highly predictable treatment is
requested, if an orthodontic device is already present and if it is necessary to preserve tooth
vitality or treat teeth non-compatible with an atraumatic extraction.
A future perspective to pursue is a combined technique, able to merge the advantages
of each technique.
By performing a preliminary orthodontic mobilization, a procedure that increases the
volume of the periodontal ligament, it is possible to make the extraction much less traumatic
while performing surgical extrusion. This approach drastically decreases tooth fracture
risk, which is the most frequent cause of failure related to surgical extrusion. Compared to
Int. J. Environ. Res. Public Health 2021, 18, 9530 11 of 14

orthodontic extrusion, the time and patient compliance required are considerably reduced:
on average, only 2–3 weeks of orthodontic mobilization are sufficient to proceed with
surgical extrusion. Therefore, there is no need to perform fiberotomy, which may cause
considerable discomfort, especially if it is performed weekly.
Further studies on orthodontic extrusion preliminary to a surgical extrusion are needed.

Author Contributions: Conceptualization, M.C. (Massimo Cordaro), and E.S.; methodology, M.C.
(Massimo Cordaro), M.C. (Martina Cordaro) and E.S.; software, M.T.; validation, M.C. (Massimo
Cordaro), E.S. and M.T.; formal analysis, E.S.; investigation, M.C. (Martina Cordaro) and E.S.;
resources, M.C. (Massimo Cordaro) and M.C. (Martina Cordaro); data curation, M.C. (Martina
Cordaro), F.T. and N.M.G.; writing—original draft preparation, M.C. (Martina Cordaro); writing—
review and editing, M.T., E.S., F.T. and N.M.G.; supervision, M.C. (Massimo Cordaro); funding
acquisition, M.C. (Massimo Cordaro). All authors have read and agreed to the published version of
the manuscript.
Funding: This research received no external funding.
Institutional Review Board Statement: Not applicable.
Informed Consent Statement: Not applicable.
Conflicts of Interest: The authors declare no conflict of interest.

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