Ankylosed teeth as abutments for maxillary

protraction: A case report Dr. Kokich

Vincent G. Kokich, D.D.S., M.S.D., Peter A. Shapiro, D.D.S., M.S.D.,

Robert Oswald, D.D.S., M.S.D., Leena Koskinen-Moffett, D.D.S., Odont. D.,
and Sterling K. Clarren, M.D.
Seattle, Wash.

It has been recognized that using the maxillary teeth to deliver extraoral force to the maxilla not only results in
sutural remodeling but also periodontal remodeling and tooth movement. In patients with severe maxillomandibular
malrelationships, the potential for tooth movement often limits the amount and duration of extraoral force and,
consequently, affects the success of treatment. This case report describes a technique to intentionally ankylose
deciduous teeth in a patient with severe maxillary retrusion. The ankylosed teeth were used as abutments to
deliver an anteriorly directed intermittent extraoral force. After 12 months of treatment, the anterior crossbite was
nearly corrected. At that point the ankylosed teeth loosened because of root resorption and the treatment was
terminated. Cephalometric superimposition demonstrated that the occlusal correction was the result of anterior
maxillarl( movement with little mandibular growth and no movement of the ankylosed teeth. The results suggest
that intentionally ankylosed teeth may be used as abutments for extraoral traction in patients with a severe
disturbance in maxillary growth. (AM J ORTHOIJ 88: 303-307, 1985.)

Key wa+ds: Maxillary protraction, Apert’s anomaly, ankylosis, midfacial retrusion, maxillary retrognathism

0 rthodontists traditionally have used the

maxillary teeth as handles to deliver extraoral force to
the maxilla. Studies of posteriorly directed extraoral
forces in human patients’.’ and monkeys3-5 and ante-
riorly directed forces in monkeyP3’ and human pa-
tients8sghave shown that bony remodeling occurs both
in the periodontal ligament and at the circummaxil-
lary sutures. This remodeling activity results in tooth
movement and repositioning of the maxilla. In many
patients the tooth movement is acceptable and often
desirable to correct a malocclusion. However, in some
severe maxillomandibular malrelationships , a substan-
tial amount of skeletal movement is required, which
can compromise the periodontal support of the teeth.
In these patients it would be advantageous to have an
immovable object in the bone to transmit the extraoral
force directly to the sutural ligaments and produce only
skeletal remodeling. We have previously used inten-
tionally ankylosed teeth to expand the intermaxillary
suture in monkeys.” In this article we will describe
the use of intentionally ankylosed teeth as abutments
for maxillary protraction in a patient with Apert
syndrome.
From the Departments of Orthodontics and Endodontics, School of Dentistry,
University of Washington, and Children’s Orthopedic Hospital, Seattle.
CASE REPORT
DIAGNOSTIC FINDINGS
The parents of this 5year 7-month old boy wished to
correct his craniofacial deformity. The child had Apert syn-
drome with premature synostosisof both coronal suturesand
concomitant cranial base anomalies that included shortening
of the anterior cranial fossa(Fig. 1). As a result, the midfacial
structures (maxilla and zygoma) were underdeveloped an-
teroposteriorly and vertically. The child was in the deciduous
de&ion stage and had a severeAngle ClassIII malocclusion.
The entire maxillary dentition was in lingual crossbite with
the mandibular dental arch (Fig. 2, a). A panoramic radio-
graph showed the effects of reduced maxillary growth on
dental development with crowding and superimpositionof the
posterior tooth buds within the alveolus. The cephalometric
analysisrevealeda normally positioned mandible but retrusion
of the maxilla relative to the rest of the craniofacial structures
(Fig. 2, c).
TREATMENT ALTERNATIVES
Several treatment alternatives were considered for this
patient. One alternative was surgicalrepositioning of the max-
illa. If the surgical segment extended far enough superiorly,
this alternative would improve not only the malocclusion, but
also the midfacial retrusion. However, we were concerned
about the likelihood of additional surgery at a later age. Pre-
vious reports involving human patients” and monkeys,‘* have
shown either reduction or cessationof maxillary growth after
surgical midfacial advancement.
A second treatment alternative that was considered in-
303
304 Kokich et al.
Fig. 1. Pretreatment (a) and posttreatment (b) facial photographs of a patient with Apert anomaly.
During the 12 months of maxillary protraction, the relative prominence of the midface has been im-
proved. The custom-made face mask was worn for approximately 10 hours each day.
volved extraoral traction to protract the maxilla. With this
plan the deciduous teeth would be used to transmit the force
to the maxilla with concomitant bony remodeling at the cir-
cummaxillary suturesand tuberosity. Our major concern with
this plan was that the anterior crossbite was severe and the
deciduous dentition might not withstand such an excessive
amount of anterior tooth movement without exfoliation. Re-
cently, we completed an experiment in nonhuman primates
in which we intentionally ankylosed permanent maxillary lat-
eral incisors and used them as abutments to expand the in-
termaxillary suture.” The ankylosedteeth facilitated a purely
skeletal responseto force application. With this background
information, we decided to apply the same principles to our
patient with severemaxillary hypoplasia.
TREATMENT PLAN
Our plan involved intentional tooth ankylosis and the
application of anteriorly directed extraoral force to the an-
kylosed teeth to protract the maxilla. Since the patient had
only deciduous teeth, we decided to ankylose the maxillary
canines. The right and left deciduous maxillary canines were
extracted (Fig. 3, a). Accesspreparations were made in the
lingual surfaces of the crowns and the pulps were removed
with an endodontic broach. The root canalswere cleaned with
endodontic reamers and a zinc oxide, and eugenol paste was
injectedinto the canalswith a syringe. The accesspreparations
were filled with composite acrylic. To allow for attachment
of the protraction force, a 2-mm wide hole was made through
the crown of the teeth in a labiolingual direction and a piece
of 0.040 inch-wire was shapedinto a hook and passedthrough
the hole (Fig. 3, b). The wires were securedin position with
composite acrylic (Fig. 3, c).
The root surfaces were curetted to remove any remaining
periodontal fibers. To insurethat the teeth could be completely
Am. .I. Orrhod.
Oclohr~r 19x5
b
reimplanted into the sockets, 1% mm of the root apiceswere
removed. After careful reimplantation, they were ligated to
the adjacent deciduous teeth with 0.008 inch-ligature wire
and stabilized with compositeacrylic (Fig. 4). The teeth were
intentionally kept out of their sockets for 45 minutes.
The deciduous canines were evaluated 8 weeks postop-
eratively to determine if they had ankylosed. The teeth were
immobile and emitted a dull sound with percussion. This
indicated ankylosis and anterior maxillary protraction was
initiated. A metal framework was adapted and modified to fit
the patient’s face with customacrylic supportson the forehead
and chin (Fig. 1, b). Elasticswere usedto deliver a l&ounce
force to the ankylosed canines in an anterior direction.
RESULTS
The patient wore the protraction appliance approx-
imately 10 hours each day for 12 months. During the
treatment interval, the deciduous teeth remained im-
mobile. Study models and a lateral cephalometric head
film were taken after 12 months of treatment to evaluate
the patient’s progress. The superimposition of pretreat-
ment and posttreatment cephalograms (Fig. 2, d)
showed that the maxilla had been anteriorly protracted
approximately 4 mm. During that time the deciduous
canines remained stationary within the maxillary al-
veolus. A comparison of the study models (Fig. 2, u
and b) showed that although the anterior crossbite still
remained, the posterior occlusion had been improved.
At 12 months the maxillary right deciduous canine be-
came mobile. A periapical radiograph revealed that the
root had been resorbed. At that point the treatment was
suspended.
vobime 88 Ankylosed teeth and maxillary protraction 305
Number 4

Fig. 2. Pretreatment and posttreatment study models (a and b) and cephalometric tracings (c and d).
Prior to treatment, the patient had a severe Class III malocclusion with a complete anterior crossbite
and maxillary retrusion. After 12 months of maxillary protraction, the anterior crossbite was nearly
corrected. The cephalometric superimpositions show approximately 4 mm of maxillary movement in
an anterior directian. The mandible showed little change.

DISCUSSION gins with no tooth movement. We have now success-

Two different methods to achieve a rigid handle on
the maxilla havIe been tested experimentally in non-
human primates-interosseous implants and anky-
losed teeth. In our laboratory we have successfully im-
planted bioglass-coated aluminum oxide implants in mon-
keyP4 and dogs.15 We have delivered up to 32 ounces
of force to these implants and have produced substantial
sutural remodeling with no movement of the implants.‘6
Brtiemark” has achieved long-term success in human
patients with osseointegrated implants that have been
used as abutments for fixed bridges. These implants can
apparently remain in the bone indefinitely. However, in
many orthodontic patients, implants would be needed
only temporarily during treatment and might need to
be removed surgically after the skeletal movement was
completed.
In our labor,atory we have also intentionally anky-
iosed teeth and have used these teeth as abutments to
mediate tension across the intermaxillary and interpre-
maxillary sutures in monkeys.” In all situations the
teeth predictably ankylosed. Furthermore, the anky-
losed teeth were stable supports for the transpalatal
force, resulting in bony remodeling at the sutural mar-
fully used this method in a patient with severe maxillary
hypoplasia. During his treatment the intentionally an-
kylosed maxillary deciduous canines were stable sup-
ports for an anteriorly directed force to the maxilla;
Which tooth to ankylose depends upon the patient’s
age and the type and severity of the malocclusion. In
the present patient we chose the deciduous canines for
three reasons. First, they are single-rooted teeth which
simplifies the endodontic procedure as well as the ex-
traction and reimplantation of the teeth. Second, the
maxillary deciduous canines may be retained longer
than the other maxillary deciduous teeth since the per-
manent canines are often the last teeth to erupt. Third,
the deciduous canines are well-positioned to deliver an
anteriorly directed force with minimal tipping of the
occlusal plane. Although we have not yet encountered
a situation that would require ankylosing a permanent
tooth, we see no contraindications other than the even-
tual loss of that tooth by root resorption or extraction.
The present study made use of certain facts that are
known to be associated with ankylosis-mechanical
trauma to the periodontal ligament and prolonged des-
siccation of the root. Destruction of the periodontal
306 Kokich et al. Am. J. Orihod.
Ocroher 19x5

Fig. 3. Photographs of the maxillary lefl deciduous canine. After extraction (a) and root canal therapy,
a hole was drilled through the crown of the tooth. A wire was passed through the hole and shaped
into a hook (b) to connect the elastic force to the face mask. The wire was secured with composite
acrylic (c).

Fig. 4. Pretreatment (a) and posttreatment (b) intraoral photographs. During the 12 months of treatment,
the maxillary permanent central incisors erupted. The deciduous canines remained immobile in the
bone for 12 months.

ligament is necessary for ankylosis.” To achieve this
with a replantation technique, the periodontal ligament
can be removed or allowed to dry for a certain length
of time. L&z and Waerhaug19 and Sherman” demon-
strated in animal experiments that the periodontal lig-
ament is reestablished after replantation if its vitality is
maintained; in contrast, teeth that are replanted with no
periodontal ligament are ankylosed in 30 days. Exper-
imentation with human and primate teeth by Slider and
associates*’ showed that the number of viable cells in
the periodontal ligament declines rapidly with increased
drying time. Cvek, Granath, and Hollendel-2’ found that
teeth replanted after 40 minutes seem to have a high
tendency for ankylosis. Therefore, in our patient we
removed the periodontal ligament and kept the teeth
out of the sockets for 45 minutes before replantation.
In our experiments we have chosen a predictable
method to ankylose teeth, that is, extraction and re-
plantation. Others have noted that thermal injury will
produce ankylosis of teeth.” Parker, Frishe, and Grant23
found that injuring the tooth roots of dogs with a dental
bur followed by rigid splinting of the teeth results in
ankylosis. Rubin and Biederman*“ repeated this pro-
cedure in monkeys but failed to produce ankylosis. The
latter researchers also tested chemical irritation (phe-
nol), traumatic occlusion. and luxation as possible ways
to ankylose teeth. They concluded that luxation is the
only predictable method of intentionally ankylosing
teeth in monkeys.
The present article describes a successful method
to establish an immovable handle in the maxilla and
deliver an extraoral force to the circummaxillary su-
tures. This technique is especially appropriate for pa-
tients with maxillary hypoplasia resulting from a dis-
turbance in maxillary growth. Patients with any of the
complex brachycephalic disorders (Crouzon, Apert,
and Pfeiffer syndromes) usually have severely retruded
midfaces and could benefit from this approach. Some-
times these patients require surgery at an early age. In
such patients ankylosed teeth might be beneficial post-
operatively to provide an abutment for anteriorly di-
rected support during healing and subsequent facial
growth. In other less severe maxillary growth distur-
bances, such as cleft lip and palate anomalies, the an-
Volume88
Number 4
kylosis and anterior protraction technique could provide
an excellent way to produce skeletal movement without
unwanted tooth Imovement. We continue to investigate
the application of this technique in these types of max-
illofacial anomalies.
REFERENCES
1. Wieslander L: The effects of orthodontic treatment on the con-
current development of the craniofacial complex. AM J ORTHOD
49: 15-27, 1963.
2. Bade11ML: An evaluation of extraoral combined high-pull trac-
tion and cervical traction to the maxilla. AM J ORTHOD69: 431-
446, 1976.
3. Sproule WR: Dentofacial changes produced by extraoral cervical
traction to the maxilla of the Macucu mularru. Master’s thesis,
University of Washington, 1968.
4. Frederick DL: Dentofacial changes produced by extraoral high-
pull traction to the maxilla of Macaca mufatta. Master’s thesis,
University of Washington, 1969.
5. Elder JR, Tue-nge RH: Cephalometric and histologic changes
produced by extraoral high-pull traction to the maxilla of Macaw
mulutta. AM J ORTHOD66: 599-617, 1974.
6. Kambara T: Dentofacial changes produced by extraoral forward
force in the Macuca irus. AM J ORTHOD71: 249-277, 1977.
1. Jackson GW, Kokich VG, Shapiro PA: Experimental and post-
experimental response to anteriorly directed extraoral force in
young Macaca nemestrina. AM J ORTHOD76: 318-333, 1979.
8. Subtelny JD: Oral respiration: Facial maldevelopment and cor-
rective dentofacial orthopedics. Angle Orthod 50: 147-164,
1980.
9. Rygh P, Tindlund R: Orthopedic expansion and protraction of
the maxilla in cleft palate patients-a new treatment rationale.
Cleft Palate J 19: 105-l 12, 1982.
10. Guyman G, Kokich V, Oswald R: Ankylosed teeth as abutments
for palatal expansion in the rhesus monkey. AM J ORTHOD77:
486-499, 1980.
11. Freihofer H: The timing of facial osteotomies in children and
adolescents. Clin Plast Surg 9: 445-456, 1982.
12. Shapiro PA, Kokich VG, Hohl TH, Loe C: The effects of early
Ankylosed teeth and maxillary protraction 307
LeForte I osteotomies on craniofacial growth in juvenile Macaca
nemestrina. AM J ORTHOD79: 492-499, 1981.
13. Smith J: Bone dynamics associated with the controlled loading
of bioglass-coated aluminum oxide endosteal implants. AM J
ORTHOD76: 618-636, 1976.
14. May BF, Shapiro PA: A method of obtaining an epithelial at-
tachment on an endosseous implant. J Prosthet Dent 45: 550.
557, 1981.
1.5. Klein DJ, Shapiro PA: Soft tissue reaction to an autologous root
implant. J Prosthet Dent 52: 82-87, 1984.
16. Turley PK, Shapiro PA, Moffett BC: The loading of bioglass-
coated aluminum oxide implants to produce sutural expansion
of the maxillary complex in the pigtail monkey. Arch Oral Biol
25: 459-469, 1980.
17. Adell R, Lekholm U, Rockier B, Bdnemark PI: A 15-year study
of osseointegrated implants in treatment of the edentulous jaw.
Int J Oral Surg 6: 387-416, 1981.
18. Atrizadeh F, Kennedy J, Zander H: Ankylosis of teeth following
thermal injury. J Periodont Res 6: 159-167, 1971.
19. Lee H, Waerhaug J: Experimental replantation of teeth in dogs
and monkeys. Arch Oral Biol 3: 176-184, 1961.
20. Sherman P Jr: Intentional replantation of teeth in dogs and mon-
keys. J Dent Res 47: 1066-1071, 1968.
21. Seder PO, Otteskog P, Andreasen JO, Modeer T: Effect of drying
on viability of periodontal membrane. Stand J Dent Res 85: 164-
168, 1977.
22. Cvek M, Granath LE, Hollender L: Treatment of nonvital per-
manent incisors with calcium hydroxide. III. Variation of oc-
currence of ankylosis of replanted teeth with duration of extra-
alveolar period and storage environment. Odontol Revy 25: 43-
56, 1974.
23. Parker WS, Frishe HE, Grant TS: The experimental production
of dental ankylosis. Angle Orthod 34: 103-107, 1964.
24. Rubin PL, Biederman W: An attempt to produce tooth ankylosis.
J Dent Res 40: 744, 1962.
Reprint requests to:
Dr. Vincent G. Kokich
Department of Orthodontics
University of Washington School of Dentistry
Seattle, WA 98195