INTRUSION VIA HYPEROCCLUSION against cantilevered bridge. Andrews Intrusion Phenomenon. Part #1

4 Rating(s).


Posted on By Anton Andrews In Occlusion

Bets have been raised with this case.
30 y.o. healthy man, #19 replaced with 8x11 implant with 5.7 mm platform.
In spite the challenges I give good prognosis- its only 1.4 mm to intrude the premolar and much less for the molar.
I might consider to add a TAD on the buccal as well.
Comments, discussion?

Reverse Restorative rehabilitation - RRR
1.4 mm to intrude the premolar

angled access hole feature


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19 Comments

Intriguing concept. Even if it can be done... how long will it take?, how will the patient tolerate it? and what are the unforeseen sequela?.The challenges I contemplate with utilizing hyperocclusion to intrude the opposing dentition is patient discomfort, potential for eliciting TMD, grinding (forces would not be totally vertical but also horizontal), potential fractures, and of course unpredictable length of time etc.. It seems to me that judicious selective grinding of the upper premolar and molar would create a predictable and ideal occlusal plane in a very short period of time. Especially since that was already done on the adjacent 1st premolar and that 12 & 14 need to be restored anyway. I just don't see the advantage of this approach for this case.


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Hi Henry, thank you for the comment.
All your questions make perfect sense since they are based on current official basic concepts of Dentistry.
So to begin our discussion, please tell us what is the
MAIN CAUSE for teeth to erupt after loss of antagonists according to the current official basic concepts of Dentistry?
BTW as we all know, this force is strong enough to super-erupt lower teeth as well, so please do not provide that "gravity theory".
In the mean time, to prepare for the following discussion (TMJ) I post couple more images to complete the case presentation.

front view
left side


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I actually did not base my response on "current official basic concepts of Dentistry". I'm sure I don't know all of them. Rather, I simply based it on patient management considerations. The questions I would ask myself under similar circumstances; 1) how long will intrusion take utilizing hyperocclussion? 2) How comfortable and functional would this patient be during that time while having just one tooth in occlusion? 3) what are the possible complications and are they worth it? and finally 4) is there a simpler solution to this very minor clinical challenge?
We all know that intrusion utilizing controlled, unidirectional forces through orthodontics, appliances or magnets is a documented biological fact requiring a significant amount of clinical time. While I admire the creativity in the suggested approach of utilizing hyperocclusion instead, I'm simply asking if we know what the sequela of uncontrolled, multi-directional forces of this technique would be and are they worth it while other more efficient solutions, with a lower risk profile, exist?


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I wonder if anyone on this forum is able to tell us what is the
MAIN CAUSE for teeth to erupt after loss of antagonists according to the current official basic concepts of Dentistry?


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Anton; First, I admire your desire to move implant dentistry in a forward direction. What you are presenting here is anecdotal. When you do things a few times, it is perfectly acceptable to tell your closest dental friends that you 'are on to something." It is another thing to pronounce a break through in the science of implant or orthodontic dentistry. Henry is correct in asking you how long the intrusion should take and what are the possible negative outcomes here and are they worth it? If you have ground breaking dentistry to announce, we are all for it. In 1992, I intentionally placed acid on the pulp (and surrounding tooth structure) to cover a pin head exposure when removing the last bit of caries. This could not be talked about until I saw Bill Dickerson at a meeting and we chatting about our 'advancement.' We still could not publically discuss bonding over the pulp until Bill Strupp, the very well respected prosthodontist, published his findings shortly thereafter and the profession accepted his protocol. I know about being first but I don't know about being right. You have to have more than a few cases and you should not be defensive about your work. It will stand on its own, for better or worse Regards, Gerald


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Gerald,
I expected your comment here for some reasons:)
But you never answered the question.
Yes I admit that my finding was made by chance as most of discoveries including the one you've mentioned.
This forum provides great opportunity to discuss many topics including this one . So I am taking advantage to discuss with colleagues fresh ideas and treatment modalities before writing a paper.
Asking questions I try to establish what is known by now , including a cause, treatment options etc.
I hope that my colleagues who position themselves as "experts", "specialists", "professors" etc could contribute to the discussion.


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Hi Anton; It is a GOOD thing that you can anticipate my comments. While I do not disagree with anything you say, You are often to pronounce 'observations' as facts. For observations to move to the next level, you and others will have to predictably duplicate your findings. This hasn't been done. Therefore, you are hypothesizing that you can do what you say you do. I don't know whether time will validate your conclusions or not...After doing clinical dentistry for almost 4 decades, I take everything with a grain of salt. Regards, gerald


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I agree Gerald,
for now there are only observations.
But it will be easy to reproduce due to simplified treatment protocol compared to currently available : braces with or without TADS, RCTs with P&C and crowns etc.
I have no doubt that more clinical data needs to be received in order to make INTRUSION VIA HYPEROCCLUSION treatment modality available to a dental practitioner .


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Anton, I’m not sure what kind of discussion you are trying to elicit. You show a case with mostly graphic screen captures and no clinical restorative treatment. You suggest that you want to intrude an opposing premolar (1.4mm) and molar strictly through hyper-occlusion. Yet you offer no hyposthesis for why you want to do this. You’re obviously dubious yourself, even if you say the prognosis is good, because you admit that it may be necessary to utilize the much more standard TAD approach. You then ask for comments and discussion. However, when I comment that 1) it might be easier to achieve an appropriate occlusal plane through more conventional means, such as selective grinding, and 2) ask you how long you envision this treatment to take?, and 3) how comfortable will the patient be during this treatment?... Instead of answering any of the questions paused, which is the minimum basis of healthy discussions, your response is asking if anyone can tell you what is the MAIN CAUSE of tooth eruption? Which BTW, to my understanding, is multifactorial (theories…regulated by the dental follicle proper, regulated by gene expression, regulated my muscular equilibrium, regulated by tooth socket distortions caused by functional jaw deformations, hydrostatic pressure etc… to name but a few), and has no official single cause consensus in the profession.
You are clearly a knowledgeable and talented clinician. Therefore, if you have a hypothesis you’re exploring as to why hyper-occlusion may be a superior method to intrude teeth, and if you have a case or series of cases to show, please tell us and show us and then we can have a discussion and we can all learn from it. Otherwise, it sounds more like a game and not a professional and respectful discussion.


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Henry,
when we try to treat any condition it is make sense to establish the cause.
To the list of theories you’ve provided I could also add another ridiculous one stating that teeth super-eruption caused by cement deposition/thickening on the root surface.
Unfortunately they all do not explain the origin of the erupting force, neither it’s mechanism. That is why there is no official single cause consensus in the profession.
It reminds me the history of H.Pilory discovery . I still remember well, back in 1980s I was studying internal medicine and there were 15+ official theories listed in a textbook “explaining” etiology of a stomach ulcer. None of them were correct as we all know.
http://en.wikipedia.org/wiki/Helicobacter_pylori#History
To answer your questions,
I've done few INTRUSION VIA HYPEROCCLUSION cases and one was quite extreme. I intruded an entire upper quadrant against a single lower implant.
In all cases patients didn't report any discomfort and amazingly there were no loss of bone neither around implant, nor intruded teeth.
Treatment time depends on few factors and takes 4-6 months to complete.

Upper left quadrant before inttrusion
Same quadrant after 6 months of intrusion. #19 is an implant


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Dear Anton. I have been thinking about your theory. Unfortunately I think is not a breakthrough. I might be wrong but I totally agree with Dr. Henry Salama. There are proven methods for orthodontic intrusion and we have used TADS succesfully as well as had our OMFS do segmental osteotomies for the same purpose many times. In my humble opinion this is like trying to "invent" the formula for Coca-cola. I am in favor of advances in dentistry. However I honestly do not think this approach works with all due respect. Miguel


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Miguel,
I respect your opinion but Inrtusion via Hyperocclusion is a breakthrough in dentistry and Orthodontics.
It had been known before but wasn't widely usable in adults cases due to attempts using teeth against teeth for intrusion.
I developed and introduced easily reproducible protocol to intrude against implants using final cad-cam restorations , not temps.
Compared to braces, TADs and especially segmental surgeries it has much less ,if any morbidity, easy to implement, shorter chair tx time .and it's less expensive for patients.


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Hi Anton, another concern of mine will be occlusal trauma. Perhaps is me not knowing enough about your proposed treatment modality. But I have not seen many papers in serious refereed journals on this technique. I have done many TADS instrusions plus quite a few segmental surgeries with our OMFS. Both are economical accesible (at least in our upper & upper mid class patients in Venezuela) and safe procedure (not to much morbidity). Therefor until furhter scientific data is avaidable. For me your proposal is not usable in my patients. Regards, Miguel


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Miguel,
it's not usable for you because it would be done by a restorative dentist.
BTW your work is fantastic! The only problem, you need to have a genius like Dr. Ravelo around to streamline these type of treatments .
Regarding occlusal trauma, have you seen NTI Night Guards?
They only touch one or two teeth and prevent occlusal trauma through the overload of pressure receptors which relaxes the muscles. Intrusion via Hyperocclusion works the same way.
Great discussion, amigo Miguel!

NTI night guard


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It seems from the xray that the premolar needs endodontic treatment
Followed by a crown,the first molar needs a crown too.I wonder what would the patient benefit from the intrusion plan?


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George, thank you for the comment,
Yes, it looks like a cavity on the distal of the premolar.
First of all the tooth is vital and symptom-free , and it's not 100% RCT is needed.
Secondly , even if RCT is done, the tooth still a)can be intruded and b) a new crown on #13 can be made to fit the lower teeth occlusally but it won't make any difference because the contours on the lower restorations are FINAL.

lower bridge delivered, caries on #13 filled with composite.


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My question Anton is not whether intrusion could be done but rather it's benefit if occlusion can be adjusted easily with conventional means.


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Anton, what implant system are you using? Some implants probably would not hold up.


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Peter, for this case I used 8x11 implant with 5.7 mm zimmer platform, with 3mm internal hex.
I had 7 cases restored with this type of cantilever, no failures so far , not even screw-loosening.
What makes you believe in failure?


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