CLINICAL REPORT

Biologically oriented preparation technique for surgically

extruded teeth: A clinical report
Marc Llaquet Pujol, DDS,a Andres Pascual La Rocca, DDS, PhD,b Jaume Casaponsa Parerols, DDS,c and
Francesc Abella Sans, DDS, PhDd

The long-term success of ABSTRACT

endodontically treated teeth
Surgical extrusion allows a ferrule to be obtained without the use of orthodontic extrusion or the
requires an adequate root ca- need to remove hard and soft tissues. However, after the healing period, the soft tissue of the
nal treatment and a well- extruded tooth might become thinner, creating an unesthetic gingival margin. Unlike other
sealed coronal restoration.1,2 preparation techniques, the biologically oriented preparation technique provides increased long-
In addition, a successfully term gingival thickness. This article describes the treatment of 3 patients with teeth with no
restored tooth includes cavity ferrule that were surgically extruded and restored with the biologically oriented preparation
wall integrity and the presence technique . (J Prosthet Dent 2020;-:---)
of a 1.5- to 2-mm ferrule,
defined as a “360 degree metal collar of the crown sur- to achieve adequate bone architecture. Furthermore, this
rounding the parallel walls of the dentine extending procedure can result in disharmonious gingival margins
coronal to the shoulder of the preparation.”3-6 In some or interproximal papillae loss, leading to unsatisfactory
clinical situations, these conditions cannot be met, esthetics.12 Rapid orthodontic extrusion is a less-invasive
especially after subgingival carious lesions, endodontic procedure that allows the conservation of hard and soft
cervical perforations, crown-root fractures, and failed tissue.13,14 However, despite rapid orthodontic move-
7
crowns with existing subgingival margins. In such situ- ment and fiberotomy, gingival tissue can unexpectedly
ations, attempts to obtain more ferrule by extending rebound, requiring a subsequent gingivectomy.15,16 It is
preparations subgingivally may lead to an invasion of the also necessary to consider that the patient is required to
biologic width and, consequently, to long-term gingival wear orthodontic appliances, increasing the cost and time
inflammation, pain, and unpredictable loss of hard and of the therapy.
soft tissue.8,9 Surgical extrusion, first developed by Tegsjö et al,17
An adequate ferrule can be obtained while respecting consists of gently luxating the tooth using thin eleva-
the biologic width by using surgical crown lengthening, tors and coronally repositioning the tooth until it is
forced orthodontic extrusion, or surgical extrusion.10-14 restorable.17-25 After the procedure, the extruded surface
Surgical crown lengthening entails removal of hard and of the tooth becomes narrower and smaller, which might
soft tissue to place the alveolar bone crest at least 3 mm eventually reduce both the thickness and width of the
from the margin of the prosthetic crown.10,11 However, soft tissue, creating an asymmetric and unesthetic
this procedure may adversely affect the crown-root ratio, gingival margin.
lead to furcation involvement in molars, and require In 2013, Loi and Di Felice26 proposed vertical tooth
removal of the supporting bone of the neighboring teeth preparation with a biologically oriented preparation

a
Associate Professor, Department of Restorative Dentistry and Endodontics, Universitat Internacional de Catalunya, Sant Cugat del Vallès, Barcelona, Spain.
b
Director, Department of Periodontology, Universitat Internacional de Catalunya, Sant Cugat del Vallès, Barcelona, Spain.
c
Associate Professor, Integrated Clinic for Adults, Universitat Internacional de Catalunya, Sant Cugat del Vallès, Barcelona, Spain.
d
Director, Department of Restorative Dentistry and Endodontics, Universitat Internacional de Catalunya, Sant Cugat del Vallès, Barcelona, Spain.

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technique (BOPT) for periodontally healthy teeth. These
authors claimed that this method increases gingival
thickness, potentially benefiting the stability of the gingival
tissue, which has been confirmed by a randomized clinical
trial.27 However, studies on the ideal prosthetic prepara-
tion for surgically extruded teeth are lacking. The purpose
of this article was to present 3 clinical reports combining
surgical extrusion with the BOPT.
CLINICAL REPORT
Patient 1
A 47-year-old woman came to the Department of End-
odontics (Universitat Internacional de Catalunya, Barce-
lona, Spain) complaining of tenderness to percussion of
her maxillary left second premolar. Her medical history
was noncontributory. Clinical and radiographic examina-
tion revealed a carious lesion extending beyond the
gingival margin in the mesial, distal, and palatal aspects
(Fig. 1A). The tooth did not respond to cold testing (Endo-
Frost; Roeko). After removing the caries, less than 2 mm
was observed between the sound tooth margin and the
bone crest, which was considered insufficient for a suc-
cessful restoration. Therefore, the following treatment
options were proposed: surgical crown lengthening, or-
thodontic extrusion, surgical extrusion, or extraction.
To avoid removing 3 to 4 mm of bone crest, the tooth
was extruded surgically by following the technique
described by Kahnberg et al.19 Under local anesthesia,
the tooth was luxated with thin elevators (Luxator L2S;
Directa) that were placed no more than 1 mm within the
gingival margin to avoid damaging the periodontal liga-
ment. The tooth was dislocated from its socket using thin
forceps and extruded to a coronal position to expose
sufficient supracrestal tooth structure. The tooth was
then splinted for 4 weeks with a semirigid orthodontic
retainer attached to the adjacent teeth with composite
resin (Fig. 1B, 1C) and subsequently endodontically
treated. After the surgery, the patient was prescribed
analgesics and antibiotics for 1 week and instructed to
rinse daily with 0.12% chlorhexidine and to follow a soft
diet for 2 weeks.
Patient 2
A 35-year-old woman with a noncontributory medical
history was referred to the endodontics department
(Universitat Internacional de Catalunya, Barcelona,
Spain) complaining of recurrent displacement of a metal-
ceramic crown with a cast post in her mandibular left
second premolar. Clinical and radiographic examination
revealed a subgingival carious lesion, an existing end-
odontic treatment, and no signs of a periapical lesion
(Fig. 2A, 2B). The carious lesion was removed, leaving the
tooth with an insufficient remaining ferrule. Therefore,
the patient was presented with the same treatment
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options as for patient 1, and she opted for endodontic
retreatment, post placement, and surgical extrusion to
prevent an extensive osseous resection (Fig. 2C-F). The
same surgical protocol was performed, but the post-
surgical fixation was for 5 weeks because of slight
mobility of the tooth.
Patient 3
A 45-year-old woman with a noncontributory medical
history came to the emergency department (Universitat
Internacional de Catalunya, Barcelona, Spain) with a
horizontal crown fracture of her maxillary left canine,
which had been endodontically treated and restored with
a crown. The fracture extended subgingivally, leaving
insufficient ferrule for crown restoration (Fig. 3A, 3B).
Among the treatment options presented to patients 1
and 2, crown lengthening and orthodontic extrusion
were contraindicated for esthetic reasons; therefore,
surgical extrusion was performed after endodontic re-
treatment and post placement (Fig. 3C-E).
A glass fiber post (Exacto; Angelus) was placed in
all 3 teeth with composite resin foundation restorations
(SDR; Dentsply Sirona) (Figs. 1D, 2G). The tissue was
left to heal for 2 months (Figs. 1D, 2G), after which
the teeth were prepared for zirconia crowns by
following the BOPT.26 First, the supragingival part was
prepared using a diamond flameeshaped rotary in-
strument (FG863G/012C; Sweden & Martina), and the
subgingival part was prepared as follows: the rotary
instrument (FG863G/012C; Sweden & Martina) was
tilted at an oblique angle to prepare the tooth and the
internal aspect of the sulcus simultaneously, leaving a
vertical surface and eliminating the cement-enamel
junction (Figs. 1E, 2H, 3F). The surface was then
refined with a 20-mm-grit diamond rotary instrument
(FG862FC/012C; Sweden & Martina), and an interim
acrylic resin (C&B V Dentine; Major Prodotti Dentari)
crown was fabricated with the technique described by
Loi and Di Felice 26 and left for 3 months. After this
period, impressions were made for the definitive zir-
conia crown (Figs. 1F, 2I, 3G, 3H).
After 2 years, the probing depth was less than or
equal to 4 mm around all 3 teeth, and no recession or
mobility was present. The radiographic examination
revealed no marginal bone loss or root resorption and a
periodontal ligament with normal morphology (Figs. 1G,
1H, 2J-L, 3I, 3J).
DISCUSSION
Surgical extrusion is a straightforward, 1-step procedure
used to restore teeth with extensive tooth loss and cer-
vical margins near the bone crest, preserving periodontal
tissue in a significantly reduced treatment time and at a
Llaquet Pujol et al
- 2020 3

Figure 1. Surgical extrusion of maxillary left second premolar. A, Initial radiograph of nonrestorable tooth. B, C, Semirigid stabilization. D, E, Endodontic
treatment and tooth preparation using biologically oriented preparation technique. F, Tooth at 3 months. G, H, Clinical and radiographic views at 2
years showing normal gingival architecture, no marginal bone loss, or periapical pathology.

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Figure 2. A, B, Lateral view and radiograph of unrestorable mandibular left second premolar. C, Endodontic retreatment, post placement, and
foundation restoration. D, E, F, Coronal repositioning of tooth during surgical extrusion and semirigid splinting. G, Tooth at 2 weeks. H, Tooth
preparation, 2 months after reestablishment of biologic width. I, Tooth at 3 months. J, K, L, Clinical and radiographic views after 2 years showing
esthetic marginal contour without recession or periapical lesion.

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Figure 3. A, B, Clinical and radiographic views of unrestorable tooth. C, Endodontic retreatment and post placement. D, E, Surgical extrusion and tooth splinting.
F, Preparation with biologically oriented preparation technique for zirconia crowns of maxillary left lateral incisor and canine. G, H, Occlusal and lateral view at
3 months. I, J, Clinical and radiographic views showing stable cervical soft tissues around canine and normal contour of periodontal ligament after 2 years.

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6 Volume
lower cost when compared with orthodontic treat-
ment.20,21 In the 2-year follow-up of the patients in this
clinical report, none of the 3 teeth presented pathologic
probing depth, marginal bone loss, or periapical pathol-
ogy. In a study with a 10-year follow-up, Kahnberg22
reported no progressive root resorption or physiologic
pocket depths. Elkhadem et al23 concluded from a sys-
tematic review that in spite of the limited and low evi-
dence level, surgical extrusion may be considered a suc-
cessful treatment for managing extensively carious teeth,
findings also supported by other authors.24,25 The 3 pa-
tients in the present report were informed of possible
risks and complications, including tooth fracture or cracks
as a result of the force applied with the forceps. Con-
traindications to surgical extrusion include curved and/or
short roots and teeth with previous attachment loss and/
or with poor endodontic prognosis.23
Once the tooth is positioned coronally, the supracrestal
structure becomes narrower in relation to the alveolus and
the adjacent teeth. Accordingly, the gingival contour may
become thinner and lack symmetry with the adjacent
teeth. In addition, an overcontoured restoration is required
to fill the interdental gingival space.24 To address this
problem, the teeth were prepared with the BOPT because
this procedure increases the volume of the coronal soft
tissue by remodeling the cervical area of the interim
crown.26 The interaction between the preparation, the
interim restoration, and the gingiva provides long-term
stability to the soft tissues.26 Paniz et al27 reported
similar results with a 12-month randomized clinical trial in
which less gingival recession was observed in the feather
edge as compared with chamfer finishing lines. This
improved periodontal outcome has special relevance for
anterior teeth in which subgingival margin placement,
usually recommended in this area, has been associated
with increased gingival recession and inflammation.8,9,25
Esthetic gingival contours with no recession after 2 years
were observed in all 3 teeth in the present report.
SUMMARY
Surgical extrusion is a therapeutic option with a high
success rate. Unlike crown lengthening and orthodontic
extrusion, this procedure allows for the successful resto-
ration of single-rooted teeth with no ferrule without the
need to remove hard and soft tissue or to use orthodontic
appliances. Moreover, using the BOPT could lead to
improved gingival architecture and provide greater long-
term soft-tissue stability with the extruded teeth.
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Corresponding author:
Dr Marc Llaquet Pujol,
Dentistry Faculty
Universitat Internacional de Catalunya
C/Josep Trueta s/n
Sant Cugat del Vallès 08195
Barcelona
SPAIN
Email: mllaquet@uic.es
Acknowledgments
The authors thank R Serrat and S Fairhurst for their clinical contribution.
Copyright © 2020 by the Editorial Council for The Journal of Prosthetic Dentistry.
https://doi.org/10.1016/j.prosdent.2020.05.005
Llaquet Pujol et al