Treatment of Ankylosis of the Mandibular First Molar With

CASE REPORT

Treatment of ankylosis of the mandibular ﬁrst molar with orthodontic traction immediately after surgical luxation

Matheus Melo Pithona and Luiz Antonio^ Alves Bernardesb Jequie, Bahia, and Poc¸os de Caldas, Minas Gerais, Brazil

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

entoalveolar ankylosis is an anomaly of eruption Five treatment approaches have been suggested for that involves anatomic fusion of the alveolar impacted teeth: no treatment, orthodontic treatment, D 1,2 prosthetic buildup, segmental osteotomy, and extrac- bone with the cementum or dentin. The periodontal ligament disappears, and the cementum tion. No treatment might be the option when the and dentin can be resorbed and replaced by bone, infraocclusion is mild and the tooth can be periodically observed. Orthodontic treatment combined with luxa- resulting in fusion.1,3 tion might be an acceptable approach in some cases, Ankylosis can occur during any eruptive period or after 4,5 although there are risk factors including fracture, re- the occlusion is established. If there is dentoalveolar currence of ankylosis, and the need for endodontic ankylosis, vertical growth and development of the treatment. Prosthetic buildup is possible if infraocclu- alveolar bone are affected, diminishing the height and sion is less than 5 mm. Segmental osteotomy is a sur- not allowing vertical movement of the affected tooth, gical procedure in which alveolar bone including the which will remain below the occlusal plane, giving the affected tooth is sectioned and repositioned. Surgical impression of being submerged.2,6 removal might be appropriate for a nonrestorable Ankylosis of a tooth can cause various complications, tooth with severe infraocclusion and tipping of the such as loss of arch length,7 inclination of the adjacent adjacent teeth. This approach, however, often results teeth,8 risk of caries and periodontal disease of the in an exaggerated bony defect. neighboring teeth because of the difficulty of cleaning,9 There have been few case reports regarding treatment food impactation,10 reduction in the vertical height of of submerged permanent molars.13,14 Several articles the teeth next to the infraoccluded tooth with extrusion described the successful orthodontic treatment combined of the antagonist teeth and consequent alteration in the with surgical luxation in 3 adolescent patients with occlusal plane,11 lateral open bite (lateral open occlusal ankylosed permanent posterior teeth.5,12,13 Also, there relationship), tongue habits,9 and deviation of the mid- have been 2 examples in adults.12,13 line to the side of the infraoccluded tooth.11 The aim of this article was to describe a clinical case According to Lim et al,12 of ankylosis of a molar in an adolescent patient, in which surgical luxation followed by traction with a fixed orthodontic appliance was performed. aProfessor orthodontics, Southwest Bahia University UESB, Jequie, Bahia, Brazil. bDiplomate of Brazilian Board of Orthodontics and Dentofacial Orthopedics, Poços de Caldas, Minas Gerais, Brazil. The authors report no commercial, proprietary, or financial interest in the prod- DIAGNOSIS AND ETIOLOGY ucts or companies described in this article. This female patient was 14 years 5 months of age and Reprint requests to: Matheus Melo Pithon, Av Otavio Santos, 395, sala 705, Cen- tro Odontomedico Dr Altamirando da Costa Lima, Vitoria da Conquista, Bahia, sought orthodontic treatment with the chief complaint Brazil, CEP: 45020-750; e-mail, [email protected]. of “crooked teeth.” She was in a good state of general Submitted, September 2009; revised and accepted, October 2009. health. 0889-5406/$36.00 Copyright Ó 2011 by the American Association of Orthodontists. The patient had an Angle Class II subdivision right doi:10.1016/j.ajodo.2009.10.050 molar relationship, with a moderate overbite, a maxillary 396 Pithon and Bernardes 397

Fig 1. Pretreatment photographs.

midline deviation to the right, lack of occlusal contact from the muffled sound of the neighboring teeth, and between the mandibular right first molar and the maxil- ankylosis was confirmed. lary right first molar with an open occlusal relationship (open bite) in this region, and a mild arch-length dis- TREATMENT OBJECTIVES crepancy in the mandibular arch (Figs 1 and 2). The treatment objectives were (1) tooth alignment The patient had a straight profile with proportional and leveling, (2) correction of the Class II dental relation- facial thirds and no asymmetries. Radiographically, she ship, (3) occlusal repositioning of the ankylosed mandib- had all of her teeth, with the third molars still forming. ular molar, (4) obtainment of space in the maxillary arch The infraocclusion of the mandibular right first molar to align the teeth, (5) reduction of the vertical overbite, produced a bone defect in this region (Fig 3). and (6) correction of the bone defect in the ankylosed Cephalometrically, the patient had a Class I skeletal molar region. relationship, a trend toward horizontal facial growth, a straight profile (LS-S, 0 mm; LI-S, 0.5 mm), retroclined maxillary incisors and well-positioned mandibular inci- TREATMENT ALTERNATIVES sors (Fig 4). The treatment alternatives were (1) orthodontic A percussion test was performed on the mandibular treatment, and surgical luxation and respositioning of right molar, by using the handle of a clinical mirror for the ankylosed molar; (2) orthodontic treatment to im- this purpose. A sharp sound was produced, different 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.

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Fig 5. Open space for performing traction.

Fig 7. After traction.

fixed orthodontic appliances after surgical luxation. Ini- tially, orthodontic brackets with 0.022 3 0.028-in slots were placed on all teeth. A sequence of 0.014-in, 0.016-in, and 0.018-in steel archwires accomplished the initial alignment and leveling. At this stage, Class II me- chanics were used on the right side to correct the Class II relationship. Then a 0.020-in mandibular archwire was placed with a compressed open-coil spring positioned between the mandibular right second molar and the mandibular right second premolar. To increase the anchorage of the anterior teeth, the teeth were ligated together. After space was opened for the mandibular right first molar (Fig 5), an orthodontic ring was made for this tooth, and a 0.020-in archwire with L-shaped loops was prepared. At this stage, the patient was referred to the maxillofacial surgeon for the luxation (Fig 6). Immediately after the luxation procedure, the patient returned to the orthodontist to begin the traction. Seven days after the archwire was placed, the patient returned, and a positive response to the traction was noted (Fig 7). Fig 6. After luxation, preligature of the arch for immediate 3 fi traction. After this stage, 0.019 0.025-in ideal nishing arches were made to correct the tooth inclination and refine the alignment and leveling. Vertical elastics were used to restoration of the ankylosed tooth; and (3) extraction of achieve improved dental interdigitation. After this, the the ankylosed tooth and placement of orthodontic ap- orthodontic appliances were removed, and a maxillary pliances, followed by an osseointegrated implant in circumferential retainer and a mandibular canine-to- the place of the extracted tooth. canine lingual bonded retainer were placed.

TREATMENT PROGRESS TREATMENT RESULTS After reviewing all of the information, we decided to The orthodontic treatment produced a Class I molar attempt traction of the ankylosed mandibular molar with relationship, reduction of the vertical overbite, tooth

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Fig 8. Posttreatment photographs. alignment and leveling, and traction and repositioning malocclusion and ankylosis of a mandibular first molar. of the ankylosed mandibular molar to the level of the oc- The patient was young and motivated, and the tooth was clusal plane. With traction, the alveolar bone in this re- moderately submerged, so we decided to perform ortho- gion also improved and corrected the alveolar defect. dontic treatment together with surgical luxation. Few The luxated tooth did not fracture, and pulp vitality reports of treating ankylosed molars were found in the was maintained (Figs 8-11). literature.12,17 This will be the fifth report of treating an ankylosed molar, and the fourth in a young patient. The orthodontic treatment was conventional with the DISCUSSION use of fixed edgewise orthodontic appliances. Class II Dentoalveolar ankylosis is generally described as the elastics were used on the right side to take advantage union between dentin cement and the alveolar bone.14 of the absolute anchorage provided by the ankylosed This condition increases the complexity of orthodontic molar, which prevented proclination of the mandibular treatment, making it difficult to resolve the tooth mal- incisors. After achieving distalization of the maxillary position. Several different procedures for treating anky- right posterior teeth, the treatment for the molar ankylosed teeth have been described in the literature.12,15,16 losis was then pursued. The decision of which option to use depends on the Surgical luxation of ankylosed teeth has been used to orthodontic treatment plan, the patient’s motivation allow further orthodontic movement with considerable and age, and the degree of ankylosis. success.18 This technique assumes that, if a tooth is The aim of this article was to report a clinical case of moved enough to disrupt the area of ankylosis but main- orthodontic treatment in a patient with an Angle Class II tains a periapical blood supply, the subsequent

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Fig 9. Posttreatment dental models.

Fig 10. Posttreatment radiographs. Fig 11. Posttreatment cephalometric tracing. inﬂammatory reaction could result in formation of a new Biederman19 advocated surgical luxation of an anky- ﬁbrous ligament in the area of ankylosis.18 Based on losed permanent tooth, and, if no change were apparent these assumptions, an attempt was made to luxate the after 6 months, a second procedure should be per- molar (Fig 12). formed. Moreover, he suggested extracting the tooth if

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Fig 12. Superimposed cephalometric tracings. the second luxation were unsuccessful. In our patient, it with immediate orthodontic traction is a possibility was not necessary to perform a second luxation, since and might be the most opportune therapy in the treat- the tooth responded well to the ﬁrst surgery. The ortho- ment of some ankylosed mandibular molars. dontic force was applied immediately after luxation. Turley et al20 suggested immediate application of an or- REFERENCES thodontic force after luxation so that the tooth will not 1. Sapir S, Kalter A, Sapir MR. Decoronation of an ankylosed perma- ankylose again. This might be the reason that it was not nent incisor: alveolar ridge preservation and rehabilitation by an im- necessary to perform the second luxation. plant supported porcelain crown. Dent Traumatol 2009;25:346-9. Before we began the treatment, the patient and her 2. Kurol J. Impacted and ankylosed teeth: why, when, and how to in- tervene. Am J Orthod Dentofacial Orthop 2006;129(Supp):S86-90. guardian were informed that our treatment would be an 3. Filippi A, Pohl Y, von Arx T. Treatment of replacement resorption attempt. Depending on the response, the therapy might by intentional replantation, resection of the ankylosed sites, and be changed to extraction of the tooth if it fractured during Emdogain—results of a 6-year survey. Dent Traumatol 2006;22: luxation, or to restoration to reestablish occlusal contact. 307-11. Ankylosis of a tooth in a young patient eventually 4. Mullally BH, Blakely D, Burden DJ. Ankylosis: an orthodontic problem with a restorative solution. Br Dent J 1995;179:426-9. leads to infraocclusion and a defect in the alveolar pro- 5. Geiger AM, Bronsky MJ. Orthodontic management of ankylosed cess because of arrested development of the alveolar permanent posterior teeth: a clinical report of three cases. Am J Or- ridge.21 This condition was seen in the patient and cor- thod Dentofacial Orthop 1994;106:543-8. rected with traction of the tooth. 6. Isaacson RJ, Strauss RA, Bridges-Poquis A, Peluso AR, Lindauer SJ. At the conclusion of treatment, there was better oc- Moving an ankylosed central incisor using orthodontics, surgery and distraction osteogenesis. Angle Orthod 2001;71:411-8. clusal contact with the addition of the ankylosed tooth 7. Adams TW, Mabee ME, Browman JR. Early onset of primary molar in function. An important fact noted at the end was ankylosis: report of a case. ASDC J Dent Child 1981;48:447-9. root resorption of the distal root of the molar. Possibly 8. Douglass J, Tinanoff N. The etiology, prevalence, and sequelae of in- it was the distal root that was ankylosed. The patient is fraocclusion of primary molars. ASDC J Dent Child 1991;58:481-3. now in orthodontic retention and is being evaluated pe- 9. Pithon MM, Bernardes LAA. Treatment of dentoalveolar ankylosis in permanent teeth: report of a clinical case. J Bras Ortodon Ortop riodically. An important and positive fact was that pulp Facial 2004;9:440-5. vitality was maintained. 10. Becker A, Karnei-R’em RM, Steigman S. The effects of infraocclusion: part 3. Dental arch length and the midline. Am J Orthod Den- CONCLUSIONS tofacial Orthop 1992;102:427-33. 11. Becker A, Karnei-R’em RM. The effects of infraocclusion: part 2. From the treatment provided in this clinical case, it The type of movement of the adjacent teeth and their vertical de- can be concluded that surgical luxation associated velopment. Am J Orthod Dentofacial Orthop 1992;102:302-9.

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