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Late diagnosis of dentoalveolar ankylosis:


Impact on effectiveness and efficiency of
orthodontic treatment
Article in American journal of orthodontics and dentofacial orthopedics: official publication of the American
Association of Orthodontists, its constituent societies, and the American Board of Orthodontics July 2009
Impact Factor: 1.38 DOI: 10.1016/j.ajodo.2007.04.040 Source: PubMed

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4 authors, including:
Lvia Barbosa Loriato

Andre Wilson Machado

Pontifcia Universidade Catlica de Minas

Universidade Federal da Bahia

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CASE REPORT

Late diagnosis of dentoalveolar ankylosis:


Impact on effectiveness and efficiency of
orthodontic treatment
Lvia Barbosa Loriato,a Andre Wilson Machado,a Bernardo Quiroga Souki,b and Tarcsio Junqueira Pereirab
Belo Horizonte, Minas Gerais, Brazil
Dentoalveolar ankylosis is a local etiologic factor of malocclusion that can have deleterious effects on normal
dental development. Therefore, it is of paramount importance to diagnose the problem as early as possible so
that interception can be performed at the correct time. This case report demonstrates the consequences of
late diagnosis of dentoalveolar ankylosis and discusses its effects on development of the occlusion and
how it can increase orthodontic biomechanical complexity and treatment time. (Am J Orthod Dentofacial
Orthop 2009;135:799-808)

entoalveolar ankylosis is an eruption anomaly


defined as the union of the tooth root to the
alveolar bone, with local elimination of the
periodontal ligament. This condition can result in
replacement root resorption, in which the root is
substituted by bone.1
Dentoalveolar ankylosis has been described as a local factor of malocclusion.2-4 Its cause is not well defined, but it can be associated with dental trauma,5-7
metabolic disturbance,5,7 a genetic tendency, or a local
deficiency in vertical bone growth.5
According to Biederman7 and Moyers,2 ankylosis in
deciduous teeth is about 10 times more likely than in the
permanent dentition, and twice as likely in the mandibular than in maxillary arch. A higher incidence can be
observed in the molar region during the deciduous and
mixed dentition. The incidence of deciduous-tooth dentoalveolar ankylosis was reported to be 1.5% to 9.9%.8
When dental ankylosis occurs early, it is more likely
to have a deleterious impact on the occlusion.7,9 The
most common consequences are progressive infraocclusion of the ankylosed teeth, inclination of adjacent teeth,
bone defects, and impaction of the succeeding perma-

From the Department of Orthodontics, School of Dentistry, Pontifcia Universidade Catolica, Belo Horizonte, Minas Gerais, Brazil.
a
Postgraduate student.
b
Associate professor.
The authors report no commercial, proprietary, or financial interest in the products or companies described in this article.
Reprint requests to: Lvia Loriato, Av. Nossa Senhora da Penha, 570/802, Praia
do Canto, Vitoria, Esprito Santo, Brazil 29055-130; e-mail, lbloriato@yahoo.
com.br.
Submitted, December 2006; revised, March 2007; accepted, April 2007.
0889-5406/$36.00
Copyright 2009 by the American Association of Orthodontists.
doi:10.1016/j.ajodo.2007.04.040

nent teeth or eruption delay.9 Becker and KarneiRem10-12 also added midline shift to the ankylosed
side and extrusion of the antagonist tooth, increasing
the risk of occlusion problems.
Kofod et al6 pointed out that, in a growing child, the
ankylosed tooth does not follow the normal vertical
growth of the alveolar process, and a deficiency occurs,
causing the tooth to be even more impacted.
Diagnosis of dental ankylosis is generally established
through clinical findings, but radiographs can sometimes
add some information. As suggested by Mullally et al,8
although a clinical diagnosis can be made by infraocclusion, percussion, and mobility testing, sometimes lack of
orthodontic movement can confirm the diagnosis.
Since dentoalveolar ankylosis can cause deleterious
effects on occlusal development, early diagnosis and an
effective treatment plan are fundamental to prevent further eruption deviations and more severe malocclusion.
Our aim in this article was to present a patient in the
mixed dentition with dentoalveolar ankylosis of a deciduous molar in which the diagnosis was not made at the
correct time, resulting in a severe malocclusion. As a result, when the diagnosis was established, longer and
more complex treatment was necessary. Although the
treatment was effective, it was not efficient because of
its long duration and biomechanical complexity, caused
by the late diagnosis.
DIAGNOSIS AND ETIOLOGY

A boy, aged 9 years 10 months, of mixed ethnic


background (black and white), was referred to the orthodontic clinic of the School of Dentistry of the Pontifcia
Universidade Catolica de Minas Gerais in Brazil. His
chief complaints were absence of a mandibular
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Fig 1. Pretreatment facial photographs.

Fig 2. Pretreatment intraoral photographs.

deciduous molar and inclination of the adjacent teeth


(Figs 1-5).
His medical and dental histories were uneventful.
The facial analysis showed symmetry, a convex profile,
and good balance between the facial thirds, with an
increased lower facial height.
The intraoral examination showed that he was in the
mixed dentition, with the permanent incisors and first
molars already in the arches. In addition, he had
a deep overbite and some diastemas in the anterior

region of the maxillary arch. The molars on the left


side were in a Class I relationship, whereas the mandibular right first permanent molar was lingually and mesially inclined. The mandibular right second deciduous
molar was missing.
The panoramic radiograph showed the infraocclusion of the mandibular right second deciduous molar, indicating dentoalveolar ankylosis. The alveolar process
in this region had a severe deficiency in vertical development. The permanent successor germ was developing

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Fig 3. Pretreatment models.

Fig 4. Pretreatment panoramic radiograph.

apically, between the ankylosed deciduous roots. Cephalometrically, the sagittal and vertical skeletal patterns
were within normal standards, according to the analysis
of Sassouni.13
TREATMENT OBJECTIVES

Phase 1 treatment (interceptive approach) was designed to begin with uprighting the mandibular right
first permanent molar, followed by extraction of the
mandibular right second deciduous molar and space

Fig 5. Pretreatment cephalometric tracing.

management. Phase 2 (corrective approach) objectives


were to obtain the correct alignment, leveling, and dental intercuspation with fixed appliances.
In addition, the patients facial characteristics should
be maintained without altering the dentofacial growth
pattern by using different orthodontic mechanics.

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Fig 6. Progress intraoral photographs.

Fig 8. Lip bumper maintenance during treatment.


Fig 7. First progress panoramic radiograph.
TREATMENT ALTERNATIVES

The major concerns in planning for this patient were


the unfavorable position of the mandibular right first permanent molar and the impaction of the mandibular right
second premolar. Considering this diagnosis, the first
step in interceptive treatment would be to upright the
mandibular right first permanent molar and extract
the mandibular right second deciduous molar to allow
the eruption of its permanent successor.
This goal was accomplished with a lip bumper combined with Class III elastics on the right side and highpull headgear to minimize the unwanted mesial forces
on the maxillary arch. It is a simple and effective alternative to uprighting the permanent molar, in spite of requiring patient cooperation with the elastics and the
headgear. In case of noncompliance, we would have
had no benefit from these mechanics, and another alternative would have been implemented.

Fig 9. Lingual arch placement.

One alternative for removable appliances could be


an active lingual arch. This system would upright the
right permanent molar but could create unwanted side
effects on the mandibular left permanent molar that
would be difficult to control.
Another option would be mechanics with fixed applianceseg, segmented mechanics or open-coil springs, as

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Fig 10. Second premolar eruption.

well as other methods that would not require patient cooperation during the tooth uprighting. However, considering
the patients age and his mixed dentition phase with only 1
first deciduous molar in the right side and not enough anchorage teeth, it was not the first choice for interceptive
treatment.
If none of these alternatives had achieved good results, we could have planned to use mini-implants or
miniscrews for permanent molar uprighting. Although
these have often been used recently, at the time of this
treatment, we had no access to these accessories.
Another problem was eruption deviation of the mandibular right second premolar. Waiting for the spontaneous eruption of this tooth after regaining the space and
extracting its deciduous ankylosed tooth was the conservative alternative. It can be considered that this is the
ideal approach because spontaneous eruption enhances
the possibility of favorable periodontal results. If the expected result was not achieved, surgical exposure and
orthodontic traction with fixed or removable appliances
would be another alternative.
TREATMENT PROGRESS
Phase 1

The therapy began with uprighting the mandibular


right first permanent molar by using a lip bumper combined with Class III elastics on the right side (Fig 6).
High-pull headgear was used to counter the side effects
of the elastics. To optimize this mechanical effect, a maxillary acrylic anterior biteplane was placed to disclude
the posterior teeth and reduce the anterior overbite.

After a year of treatment, a more favorable position


of the mandibular right first permanent molar was verified, and the patient was referred for extraction of the
ankylosed deciduous tooth (Fig 7).
After the surgery, the lip bumper and elastics were
maintained until the mandibular right first permanent
molar had reached the correct position. Next, a lingual
holding arch was placed to preserve the arch perimeter
(Figs 8 and 9). In this way, the mandibular right second
premolar eruption was observed to be within normal
standards (Fig 10).
After 4.5 years, the orthodontic interceptive phase
ended, and the final results were favorable (Figs 11
and 12). The patient maintained his facial and skeletal
characteristics, indicating that the mechanics had no
deleterious impact on the dentofacial growth pattern
and suggesting that the treatment was effective. A transpalatal arch was then placed to maintain the space until
eruption of the permanent dentition.
Phase 2

When the permanent teeth had erupted, except the


third molars, the corrective phase of orthodontic treatment
began. Standard edgewise appliances with .022 x .028-in
slots were bonded and combined with a maxillary biteplane to reduce the anterior overbite. The dental arches
were aligned and leveled, improving intercuspation and
finalizing the treatment. This was uneventful, with routine
archwire sequences (Fig 13). After this phase, the fixed
appliances were removed, and retention began with a removable maxillary circumferential retainer and a removable mandibular spring retainer.

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Fig 11. Intraoral photographs at the end of phase 1.

Fig 12. Cephalometric tracing at the end of phase 1.

Fig 13. Progress intraoral photographs of phase 2.

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Fig 14. Posttreatment facial photographs.

Fig 15. Posttreatment intraoral photographs.


TREATMENT RESULTS

The interceptive approach corrected the malocclusion caused by the mandibular deciduous molar ankylosis. Of course, this initial orthodontic treatment phase
lasted extremely long. However, the effectiveness of
the phase 1 approach was good, since the interceptive
objectives were obtained.
At the end of phase 2, a favorable facial result was
obtained with the maintenance of normal characteristics

and a pleasant smile (Fig 14). Posttreatment records


showed a well-intercuspated occlusion with bilateral
Class I molar and canine relationships and ideal anterior
overjet and overbite (Figs 15 and 16).
The final panoramic radiograph shows good dental
positioning and normal periodontal health, especially
in the area of the former dentoalveolar ankylosis
(Fig 17). Later, the patient was referred for third molar
extraction.

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Fig 16. Posttreatment models.

Fig 17. Posttreatment panoramic radiograph.

Posttreatment cephalometric evaluation according


to Sassounis analysis13 showed maintenance of the
skeletal characteristics (Fig 18); the patients skeletal
pattern was not altered by the mechanics, except for
expected growth changes (Fig 19).
DISCUSSION

In this patient, late diagnosis of mandibular deciduous molar ankylosis led to several alterations, mainly

Fig 18. Posttreatment cephalometric tracing.

tooth infraocclusion, lack of growth of the alveolar


process in this area, and the deviated eruption of the
mandibular right first permanent molar, thus establishing a severe malocclusion in the initial mixed dentition.
The mesial tipping of the first permanent molar and
the distal inclination of the first deciduous molar adjacent
to the ankylosed tooth can be explained, according to
Becker and Karnei-Rem,10 by a local change of the

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Fig 19. Cephalometric superimposition.

transseptal fibers, which are reoriented diagonally downward in the direction to the infraoccluded ankylosed tooth.
There is no consensus in the literature about the
ideal time to start orthodontic treatment. According to
Proffit,14 the gold standard for the right time to begin
orthodontic treatment is the final phase of the mixed
dentition, with early treatment started before this and
late treatment after this. Some situations require early
treatment; one of them is dentoalveolar ankylosis.
In this way, the appropriate treatment after dentoalveolar ankylosis diagnosis should mitigate the
consequences and damages caused by this alteration.
Kurol9 stated that it is easier to implement early treatment, because of the shorter treatment duration and
lower cost.
The orthodontic interceptive approach (phase 1) is
important in the process. According to Ackerman and
Proffit,15 interceptive procedures are intended to eliminate interferences with the normal development of the
occlusion.
According to Starnes,16 phase 1 should ideally begin
between the ages of 6 and 8 years. Between 7 and 9 years
of age, according to Freeman,17 interception of any condition that can influence the growth pattern, tooth development, and eruption should be accomplished.
In this context, Kurol9 pointed out that deviated
eruption requires early diagnosis to intervene at the
ideal moment and intercept the problem. It should
have been done in our patient if the diagnosis was established immediately after the clinical findings.
Another advantage of 2-phase treatment started in
the mixed dentition is that, generally, the patient tends
to be more cooperative. This characteristic was essential
to the success of our case. The relatively complex mechanics and the long treatment time required the
patients efforts and compliance with the therapy.

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807

Because of the late start, the interceptive approach


was begun immediately after the diagnosis of this patient. The correction of the inclination and positioning
of the mandibular right first permanent molar was established as a priority. A lip bumper was used with Class III
elastics to upright the mandibular right first permanent
molar, along with a maxillary biteplane to open the
posterior bite.
Celsus observed in 25 B.C. that overretention of
deciduous teeth could cause displacement of developing
permanent teeth.18 This calls for extraction of the deciduous tooth to allow the permanent successor to erupt
into a more favorable position in the arch.
In this patient, the ankylosed deciduous molar was
extracted after the first permanent molar was uprighted,
thus reducing the risk of damaging hard structures (teeth
and bones) and adjacent soft tissues. The decision to
wait until the right moment to extract the ankylosed
tooth was made because of the possibility of the inclined
adjacent teeth interfering with the surgical intervention.9
Radiographic follow-up showed that the spontaneous eruption of the mandibular right second premolar
happened under normal conditions (Fig 10). Messer
and Cline19 had also verified that an ankylosed deciduous tooth does not affect the successors development or
crown morphology. However, contrary to the outcome
in our patient, those authors described the possibility
of intrabony dental rotation, leading to a lack of space.
Messer and Cline19 also found greater susceptibility to
periodontal breakdown, with lack of alveolar bone
height and formation of periodontal pockets, especially
when the ankylosed tooth was retained for a long time or
when extraction was needed. However, periodontal
breakdown did not occur in our patient.
Becker and Shochat20 showed that extraction of an
ankylosed tooth allows for recovery of the eruption process of the developing permanent successor and the development of normal root length. In some situations,
however, altered morphology occurs. In our patient,
no morphologic changes in the second premolar were
found.
After permanent molar correction, the dental position and the mandibular arch perimeter were maintained
with a lingual arch, allowing the other permanent teeth
to erupt and the permanent dentition to be established. If
the mandibular right second premolar had not erupted
spontaneously, surgery followed by orthodontic traction
could have been planned.
Another option for dealing with an ankylosed tooth
would be restoration to create contact with adjacent
teeth.7,19 However, as described by Biederman7 and
Mullally et al,8 this relatively conservative and simple
method is not feasible for all patients. When the

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ankylosed tooth is submucosal with considerable deficiency in the alveolar process, the restoration would
have no benefit for the already established sequelae.
This treatment success was partially due to the
patients dentofacial growth pattern (Class I).
Late diagnosis of dentoalveolar ankylosis of a deciduous tooth can have a fundamental impact on the effectiveness and efficiency of orthodontic treatment. An
effective treatment is defined as one with satisfactory results. On the other hand, the term efficiency is applied to
effective treatments that were concluded in the minimum amount of time.21
According to these guidelines, this treatment was effective, having achieved excellent dental, skeletal, and
facial results, both esthetically and functionally. However, it was not efficient. The amount of time to complete
phase 1 therapy was too longmore than 4 years
because of the late diagnosis and the interceptive treatment.
CONCLUSIONS

This clinical case illustrates the importance of monitoring the development of dental occlusion, from
deciduous dentition on, because of the risk that a late
diagnosis can impact the efficiency of the orthodontic
therapy, even when it does not alter its effectiveness.
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