treatment of ankylosis of the mandibular first molar with … · 2014-04-20 · midline deviation...

CASE REPORT

Treatment of ankylosis of the mandibular firstmolar with orthodontic traction immediately aftersurgical luxation

Matheus Melo Pithona and Luiz Antonio Alves Bernardesb

Jequi�e, Bahia, and Pocos de Caldas, Minas Gerais, Brazil

aProfebDiploPocosThe aucts oReprintro OdBrazilSubm0889-Copyrdoi:10

396

The aim of this article was to report a clinical case of orthodontic treatment in a patient with Class II malocclusionand ankylosis of amaxillary first molar. Surgical luxation was performed, followed immediately by traction with anorthodontic arch with straps. The results obtained were satisfactory, and occlusal equilibriumwas improved. (AmJ Orthod Dentofacial Orthop 2011;140:396-403)

Dentoalveolar ankylosis is an anomaly of eruptionthat involves anatomic fusion of the alveolarbone with the cementum or dentin.1,2 The

periodontal ligament disappears, and the cementumand dentin can be resorbed and replaced by bone,resulting in fusion.1,3

Ankylosis can occur during any eruptive period or afterthe occlusion is established.4,5 If there is dentoalveolarankylosis, vertical growth and development of thealveolar bone are affected, diminishing the height andnot allowing vertical movement of the affected tooth,which will remain below the occlusal plane, giving theimpression of being submerged.2,6

Ankylosis of a tooth can cause various complications,such as loss of arch length,7 inclination of the adjacentteeth,8 risk of caries and periodontal disease of theneighboring teeth because of the difficulty of cleaning,9

food impactation,10 reduction in the vertical height ofthe teeth next to the infraoccluded tooth with extrusionof the antagonist teeth and consequent alteration in theocclusal plane,11 lateral open bite (lateral open occlusalrelationship), tongue habits,9 and deviation of the mid-line to the side of the infraoccluded tooth.11

According to Lim et al,12

ssor orthodontics, Southwest Bahia University UESB, Jequi�e, Bahia, Brazil.mate of Brazilian Board of Orthodontics and Dentofacial Orthopedics,de Caldas, Minas Gerais, Brazil.uthors report no commercial, proprietary, or financial interest in the prod-r companies described in this article.t requests to: Matheus Melo Pithon, Av Ot�avio Santos, 395, sala 705, Cen-ontom�edico Dr Altamirando da Costa Lima, Vit�oria da Conquista, Bahia,, CEP: 45020-750; e-mail, [email protected], September 2009; revised and accepted, October 2009.5406/$36.00ight � 2011 by the American Association of Orthodontists..1016/j.ajodo.2009.10.050

Five treatment approaches have been suggested forimpacted teeth: no treatment, orthodontic treatment,prosthetic buildup, segmental osteotomy, and extrac-tion. No treatment might be the option when theinfraocclusion is mild and the tooth can be periodicallyobserved. Orthodontic treatment combined with luxa-tion might be an acceptable approach in some cases,although there are risk factors including fracture, re-currence of ankylosis, and the need for endodontictreatment. Prosthetic buildup is possible if infraocclu-sion is less than 5 mm. Segmental osteotomy is a sur-gical procedure in which alveolar bone including theaffected tooth is sectioned and repositioned. Surgicalremoval might be appropriate for a nonrestorabletooth with severe infraocclusion and tipping of theadjacent teeth. This approach, however, often resultsin an exaggerated bony defect.

There have been few case reports regarding treatmentof submerged permanent molars.13,14 Several articlesdescribed the successful orthodontic treatment combinedwith surgical luxation in 3 adolescent patients withankylosed permanent posterior teeth.5,12,13 Also, therehave been 2 examples in adults.12,13

The aim of this article was to describe a clinical caseof ankylosis of a molar in an adolescent patient, in whichsurgical luxation followed by traction with a fixed ortho-dontic appliance was performed.

DIAGNOSIS AND ETIOLOGY

This female patient was 14 years 5 months of age andsought orthodontic treatment with the chief complaintof “crooked teeth.” She was in a good state of generalhealth.

The patient had an Angle Class II subdivision rightmolar relationship, with a moderate overbite, a maxillary

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Fig 1. Pretreatment photographs.

Pithon and Bernardes 397

midline deviation to the right, lack of occlusal contactbetween the mandibular right first molar and the maxil-lary right first molar with an open occlusal relationship(open bite) in this region, and a mild arch-length dis-crepancy in the mandibular arch (Figs 1 and 2).

The patient had a straight profile with proportionalfacial thirds and no asymmetries. Radiographically, shehad all of her teeth, with the third molars still forming.The infraocclusion of the mandibular right first molarproduced a bone defect in this region (Fig 3).

Cephalometrically, the patient had a Class I skeletalrelationship, a trend toward horizontal facial growth,a straight profile (LS-S, 0 mm; LI-S, 0.5 mm), retroclinedmaxillary incisors and well-positioned mandibular inci-sors (Fig 4).

A percussion test was performed on the mandibularright molar, by using the handle of a clinical mirror forthis purpose. A sharp sound was produced, different

American Journal of Orthodontics and Dentofacial Orthoped

from the muffled sound of the neighboring teeth, andankylosis was confirmed.

TREATMENT OBJECTIVES

The treatment objectives were (1) tooth alignmentand leveling, (2) correction of the Class II dental relation-ship, (3) occlusal repositioning of the ankylosed mandib-ular molar, (4) obtainment of space in the maxillary archto align the teeth, (5) reduction of the vertical overbite,and (6) correction of the bone defect in the ankylosedmolar region.

TREATMENT ALTERNATIVES

The treatment alternatives were (1) orthodontictreatment, and surgical luxation and respositioning ofthe ankylosed molar; (2) orthodontic treatment to im-prove the relationship of the other teeth, followed by

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Fig 2. Pretreatment dental models.

Fig 3. Pretreatment radiographs. Fig 4. Pretreatment cephalometric tracing.

398 Pithon and Bernardes

September 2011 � Vol 140 � Issue 3 American Journal of Orthodontics and Dentofacial Orthopedics

Fig 5. Open space for performing traction.

Fig 6. After luxation, preligature of the arch for immediatetraction.

Fig 7. After traction.


restoration of the ankylosed tooth; and (3) extraction ofthe ankylosed tooth and placement of orthodontic ap-pliances, followed by an osseointegrated implant inthe place of the extracted tooth.

TREATMENT PROGRESS

After reviewing all of the information, we decided toattempt traction of the ankylosed mandibular molar with


fixed orthodontic appliances after surgical luxation. Ini-tially, orthodontic brackets with 0.022 3 0.028-in slotswere placed on all teeth. A sequence of 0.014-in,0.016-in, and 0.018-in steel archwires accomplished theinitial alignment and leveling. At this stage, Class II me-chanics were used on the right side to correct the ClassII relationship. Then a 0.020-in mandibular archwirewas placedwith a compressed open-coil spring positionedbetween the mandibular right secondmolar and theman-dibular right second premolar. To increase the anchorageof the anterior teeth, the teeth were ligated together.

After space was opened for the mandibular right firstmolar (Fig 5), an orthodontic ring was made for thistooth, and a 0.020-in archwire with L-shaped loopswas prepared. At this stage, the patient was referred tothe maxillofacial surgeon for the luxation (Fig 6).

Immediately after the luxation procedure, the patientreturned to the orthodontist to begin the traction. Sevendays after the archwire was placed, the patient returned,and a positive response to the traction was noted (Fig 7).After this stage, 0.019 3 0.025-in ideal finishing archeswere made to correct the tooth inclination and refine thealignment and leveling. Vertical elastics were used toachieve improved dental interdigitation. After this, theorthodontic appliances were removed, and a maxillarycircumferential retainer and a mandibular canine-to-canine lingual bonded retainer were placed.

TREATMENT RESULTS

The orthodontic treatment produced a Class I molarrelationship, reduction of the vertical overbite, tooth


Fig 8. Posttreatment photographs.


alignment and leveling, and traction and repositioningof the ankylosed mandibular molar to the level of the oc-clusal plane. With traction, the alveolar bone in this re-gion also improved and corrected the alveolar defect.The luxated tooth did not fracture, and pulp vitalitywas maintained (Figs 8-11).

DISCUSSION

Dentoalveolar ankylosis is generally described as theunion between dentin cement and the alveolar bone.14

This condition increases the complexity of orthodontictreatment, making it difficult to resolve the tooth mal-position. Several different procedures for treating anky-losed teeth have been described in the literature.12,15,16

The decision of which option to use depends on theorthodontic treatment plan, the patient’s motivationand age, and the degree of ankylosis.

The aim of this article was to report a clinical case oforthodontic treatment in a patient with an Angle Class II

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malocclusion and ankylosis of a mandibular first molar.The patient was young andmotivated, and the tooth wasmoderately submerged, so we decided to perform ortho-dontic treatment together with surgical luxation. Fewreports of treating ankylosed molars were found in theliterature.12,17 This will be the fifth report of treatingan ankylosed molar, and the fourth in a young patient.

The orthodontic treatment was conventional with theuse of fixed edgewise orthodontic appliances. Class IIelastics were used on the right side to take advantageof the absolute anchorage provided by the ankylosedmolar, which prevented proclination of the mandibularincisors. After achieving distalization of the maxillaryright posterior teeth, the treatment for the molar anky-losis was then pursued.

Surgical luxation of ankylosed teeth has been used toallow further orthodontic movement with considerablesuccess.18 This technique assumes that, if a tooth ismoved enough to disrupt the area of ankylosis but main-tains a periapical blood supply, the subsequent

Journal of Orthodontics and Dentofacial Orthopedics

Fig 9. Posttreatment dental models.

Fig 10. Posttreatment radiographs. Fig 11. Posttreatment cephalometric tracing.


inflammatory reaction could result in formation of a newfibrous ligament in the area of ankylosis.18 Based onthese assumptions, an attempt was made to luxate themolar (Fig 12).


Biederman19 advocated surgical luxation of an anky-losed permanent tooth, and, if no change were apparentafter 6 months, a second procedure should be per-formed. Moreover, he suggested extracting the tooth if


Fig 12. Superimposed cephalometric tracings.


the second luxation were unsuccessful. In our patient, itwas not necessary to perform a second luxation, sincethe tooth responded well to the first surgery. The ortho-dontic force was applied immediately after luxation.Turley et al20 suggested immediate application of an or-thodontic force after luxation so that the tooth will notankylose again. This might be the reason that it was notnecessary to perform the second luxation.

Before we began the treatment, the patient and herguardian were informed that our treatment would be anattempt. Depending on the response, the therapy mightbe changed to extraction of the tooth if it fractured duringluxation, or to restoration to reestablish occlusal contact.

Ankylosis of a tooth in a young patient eventuallyleads to infraocclusion and a defect in the alveolar pro-cess because of arrested development of the alveolarridge.21 This condition was seen in the patient and cor-rected with traction of the tooth.

At the conclusion of treatment, there was better oc-clusal contact with the addition of the ankylosed toothin function. An important fact noted at the end wasroot resorption of the distal root of the molar. Possiblyit was the distal root that was ankylosed. The patient isnow in orthodontic retention and is being evaluated pe-riodically. An important and positive fact was that pulpvitality was maintained.

CONCLUSIONS

From the treatment provided in this clinical case, itcan be concluded that surgical luxation associated

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with immediate orthodontic traction is a possibilityand might be the most opportune therapy in the treat-ment of some ankylosed mandibular molars.

REFERENCES

1. Sapir S, Kalter A, Sapir MR. Decoronation of an ankylosed perma-nent incisor: alveolar ridge preservation and rehabilitation by an im-plant supported porcelain crown. Dent Traumatol 2009;25:346-9.

2. Kurol J. Impacted and ankylosed teeth: why, when, and how to in-tervene. Am J Orthod Dentofacial Orthop 2006;129(Supp):S86-90.

3. Filippi A, Pohl Y, von Arx T. Treatment of replacement resorptionby intentional replantation, resection of the ankylosed sites, andEmdogain—results of a 6-year survey. Dent Traumatol 2006;22:307-11.

4. Mullally BH, Blakely D, Burden DJ. Ankylosis: an orthodonticproblem with a restorative solution. Br Dent J 1995;179:426-9.

5. Geiger AM, Bronsky MJ. Orthodontic management of ankylosedpermanent posterior teeth: a clinical report of three cases. Am J Or-thod Dentofacial Orthop 1994;106:543-8.

6. Isaacson RJ, Strauss RA, Bridges-Poquis A, Peluso AR, Lindauer SJ.Moving an ankylosed central incisor using orthodontics, surgeryand distraction osteogenesis. Angle Orthod 2001;71:411-8.

7. Adams TW, Mabee ME, Browman JR. Early onset of primary molarankylosis: report of a case. ASDC J Dent Child 1981;48:447-9.

8. Douglass J, Tinanoff N. The etiology, prevalence, and sequelae of in-fraocclusion of primary molars. ASDC J Dent Child 1991;58:481-3.

9. Pithon MM, Bernardes LAA. Treatment of dentoalveolar ankylosisin permanent teeth: report of a clinical case. J Bras Ortodon OrtopFacial 2004;9:440-5.

10. Becker A, Karnei-R’em RM, Steigman S. The effects of infraocclu-sion: part 3. Dental arch length and the midline. Am J Orthod Den-tofacial Orthop 1992;102:427-33.

11. Becker A, Karnei-R’em RM. The effects of infraocclusion: part 2.The type of movement of the adjacent teeth and their vertical de-velopment. Am J Orthod Dentofacial Orthop 1992;102:302-9.

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12. Lim WH, Kim HJ, Chun YS. Treatment of ankylosed mandibularfirst permanent molar. Am J Orthod Dentofacial Orthop 2008;133:95-101.

13. Chaushu S, Becker A, Chaushu G. Orthosurgical treatment with lin-gual orthodontics of an infraoccluded maxillary first molar in anadult. Am J Orthod Dentofacial Orthop 2004;125:379-87.

14. Takahashi T, Takagi T, Moriyama K. Orthodontic treatment ofa traumatically intruded tooth with ankylosis by traction aftersurgical luxation. Am J Orthod Dentofacial Orthop 2005;127:233-41.

15. Huck L, Korbmacher H, Niemeyer K, Kahl-Nieke B. Distraction os-teogenesis of ankylosed front teeth with subsequent orthodonticfine adjustment. J Orofac Orthop 2006;67:297-307.


16. Kofod T, Wurtz V, Melsen B. Treatment of an ankylosed central in-cisor by single tooth dento-osseous osteotomy and a simple dis-traction device. Am J Orthod Dentofacial Orthop 2005;127:72-80.

17. Paleczny G. Treatment of the ankylosed mandibular permanentfirst molar: a case study. J Can Dent Assoc 1991;57:717-9.

18. Delmar DA. Ankylosis of teeth in the developing dentition. Quin-tessence Int 1986;17:303-8.

19. Biederman W. Etiology and treatment of tooth ankylosis. Am J Or-thod 1962;48:670-84.

20. Turley PK, Crawford LB, Carrington KW. Traumatically intrudedteeth. Angle Orthod 1987;57:234-44.

21. Steiner DR, West JD. Orthodontic-endodontic treatment planningof traumatized teeth. Semin Orthod 1997;3:39-44.


treatment of ankylosis of the mandibular first molar with … · 2014-04-20 · midline deviation...

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