Dentoalveolar Ankylosis Impact Efficiency of Orthodontic Treatment

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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 AmericanAssociation of Orthodontists, its constituent societies, and the American Board of Orthodontics · July 2009

Impact Factor: 1.38 · DOI: 10.1016/j.a jodo.2007.04.040 · Source: PubMed

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Lívia Barbosa Loriato

Pontifícia Universidade Católica de Minas …

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Andre Wilson Machado

Universidade Federal da Bahia

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Available from: Andre Wilson MachadoRetrieved on: 17 April 2016

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CASE REPORT

Late diagnosis of dentoalveolar ankylosis:Impact on effectiveness and efficiency of

orthodontic treatmentLı́ via Barbosa Loriato,a André Wilson Machado,a Bernardo Quiroga Souki,b and Tarcı́ sio 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)

Dentoalveolar 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 lo-

cal factor of malocclusion.2-4 Its cause is not well de-

fined, 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 mandib-

ular 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 den-

toalveolar 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 infraocclu-

sion of the ankylosed teeth, inclination of adjacent teeth,

bone defects, and impaction of the succeeding perma-

nent teeth or eruption delay.9 Becker and Karnei-

R’em10-12 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 establishedthrough clinical findings, but radiographs can sometimes

add some information. As suggested by Mullally et al,8

although a clinical diagnosis can be made by infraocclu-

sion, 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 fur-

ther 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 decid-

uous molar in which the diagnosis was not made at the

correct time, resulting in a severe malocclusion. As a re-

sult, when the diagnosis was established, longer and

more complex treatment was necessary. Although thetreatment 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 ortho-

dontic clinic of the School of Dentistry of the Pontifı́cia

Universidade Católica de Minas Gerais in Brazil. His

chief complaints were absence of a mandibular

From the Department of Orthodontics, School of Dentistry, Pontifı́cia Universi-

dade Católica, Belo Horizonte, Minas Gerais, Brazil.a Postgraduate student.b Associate professor.

The authors report no commercial, proprietary, or financial interest in the prod-

ucts or companies described in this article.

Reprint requests to: Lı́via Loriato, Av. Nossa Senhora da Penha, 570/802, Praia

do Canto, Vitória, Espı́rito 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

799

mailto:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]


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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 leftside were in a Class I relationship, whereas the mandib-

ular right first permanent molar was lingually and mesi-

ally inclined. The mandibular right second deciduous

molar was missing.

The panoramic radiograph showed the infraocclu-

sion of the mandibular right second deciduous molar, in-

dicating dentoalveolar ankylosis. The alveolar process

in this region had a severe deficiency in vertical devel-

opment. The permanent successor germ was developing

Fig 1. Pretreatment facial photographs.

Fig 2. Pretreatment intraoral photographs.

800 Loriato et al American Journal of Orthodontics and Dentofacial Orthopedics June 2009


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apically, between the ankylosed deciduous roots. Ceph-

alometrically, 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 de-

signed to begin with uprighting the mandibular right

first permanent molar, followed by extraction of the

mandibular right second deciduous molar and space

management. Phase 2 (corrective approach) objectives

were to obtain the correct alignment, leveling, and den-

tal intercuspation with fixed appliances.

In addition, the patient’s facial characteristics should

be maintained without altering the dentofacial growth

pattern by using different orthodontic mechanics.

Fig 3. Pretreatment models.

Fig 4. Pretreatment panoramic radiograph.

Fig 5. Pretreatment cephalometric tracing.

American Journal of Orthodontics and Dentofacial Orthopedics Loriato et al 801Volume 135, Number 6


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TREATMENT ALTERNATIVES

The major concerns in planning for this patient were

the unfavorable position of the mandibular right first per-

manent 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 extractthe mandibular right second deciduous molar to allow

the eruption of its permanent successor.This goal was accomplished with a lip bumper com-

bined with Class III elastics on the right side and high-

pull headgear to minimize the unwanted mesial forces

on the maxillary arch. It is a simple and effective alter-

native to uprighting the permanent molar, in spite of re-

quiring patient cooperation with the elastics and the

headgear. In case of noncompliance, we would have

had no benefit from these mechanics, and another alter-

native would have been implemented.

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 appli-

ances—eg, segmented mechanics or open-coil springs, as

Fig 6. Progress intraoral photographs.

Fig 7. First progress panoramic radiograph.

Fig 8. Lip bumper maintenance during treatment.

Fig 9. Lingual arch placement.



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wellas other methods that would not require patient coop-

eration during the tooth uprighting. However, considering

the patient’s ageand his mixed dentitionphasewith only 1

first deciduous molar in the right side and not enough an-

chorage teeth, it was not the first choice for interceptive

treatment.

If none of these alternatives had achieved good re-

sults, we could have planned to use mini-implants or

miniscrews for permanent molar uprighting. Althoughthese 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 man-

dibular right second premolar. Waiting for the spontane-

ous eruption of this tooth after regaining the space and

extracting its deciduous ankylosed tooth was the conser-

vative alternative. It can be considered that this is the

ideal approach because spontaneous eruption enhances

the possibility of favorable periodontal results. If the ex-

pected 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 com-

bined 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 thismechanical effect,a max-

illary 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 veri-

fied, 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 secondpremolar 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 trans-

palatal arch was then placed to maintain the space until

eruption of the permanent dentition.

Phase 2When the permanent teeth had erupted, except the

thirdmolars, the corrective phaseof orthodontic treatmentbegan. Standard edgewise appliances with .022 x .028-in

slots were bonded and combined with a maxillary bite-

plane to reduce the anterior overbite. The dental arches

were aligned and leveled, improving intercuspation and

finalizing thetreatment. Thiswas uneventful, withroutine

archwire sequences (Fig 13). After this phase, the fixed

appliances were removed, and retention began with a re-

movable maxillary circumferential retainer and a remov-

able mandibular spring retainer.

Fig 10. Second premolar eruption.



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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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TREATMENT RESULTS

The interceptive approach corrected the malocclu-

sion caused by the mandibular deciduous molar ankylo-

sis. 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.

Fig 14. Posttreatment facial photographs.

Fig 15. Posttreatment intraoral photographs.



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Posttreatment cephalometric evaluation according

to Sassouni’s analysis13 showed maintenance of the

skeletal characteristics (Fig 18); the patient’s skeletal

pattern was not altered by the mechanics, except for

expected growth changes (Fig 19).

DISCUSSION

In this patient, late diagnosis of mandibular decidu-

ous molar ankylosis led to several alterations, mainly

tooth infraocclusion, lack of growth of the alveolar

process in this area, and the deviated eruption of the

mandibular right first permanent molar, thus establish-

ing 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-R’em,10 by a local change of the

Fig 16. Posttreatment models.

Fig 17. Posttreatment panoramic radiograph.

Fig 18. Posttreatment cephalometric tracing.



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transseptal fibers, which are reoriented diagonally down-

ward in thedirection to theinfraoccluded ankylosedtooth.

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 den-

toalveolar ankylosis diagnosis should mitigate the

consequences and damages caused by this alteration.

Kurol9 stated that it is easier to implement early treat-ment, 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 elimi-

nate 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 con-

dition that can influence the growth pattern, tooth devel-

opment, and eruption should be accomplished.In this context, Kurol9 pointed out that deviated

eruption requires early diagnosis to intervene at theideal moment and intercept the problem. It should

have been done in our patient if the diagnosis was estab-

lished 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 me-

chanics and the long treatment time required the

patient’s efforts and compliance with the therapy.

Because of the late start, the interceptive approach

was begun immediately after the diagnosis of this pa-

tient. The correction of the inclination and positioning

of the mandibular right first permanent molar was estab-

lished as a priority. A lip bumper was used with Class IIIelastics 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 decid-

uous 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 spontane-

ous eruption of the mandibular right second premolar

happened under normal conditions (Fig 10). Messer

and Cline19 had also verified that an ankylosed decidu-

ous tooth does not affect the successor’s 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 boneheight 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 pro-

cess of the developing permanent successor and the de-

velopment 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 posi-tion 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 ad jacent

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

Fig 19. Cephalometric superimposition.



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ankylosed tooth is submucosal with considerable defi-

ciency in the alveolar process, the restoration would

have no benefit for the already established sequelae.

This treatment success was partially due to the

patient’s dentofacial growth pattern (Class I).Late diagnosis of dentoalveolar ankylosis of a decid-

uous tooth can have a fundamental impact on the effec-

tiveness and efficiency of orthodontic treatment. An

effective treatment is defined as onewith satisfactory re-

sults. On the other hand, the term efficiency is applied to

effective treatments that were concluded in the mini-

mum amount of time.21

According to these guidelines, this treatment was ef-

fective, having achieved excellent dental, skeletal, and

facial results, both esthetically and functionally. How-

ever, it was notefficient. The amount of time to complete

phase 1 therapy was too long—more than 4 years—

because of the late diagnosis and the interceptive treat-

ment.

CONCLUSIONS

This clinical case illustrates the importance of mon-

itoring 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.

REFERENCES

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São Paulo, Brazil: Dental Press Editora; 2002.

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Medical Publishers; 1988.

3. Proffit WR, Fields HW. Contemporary orthodontics. St Louis:

C.V. Mosby; 1999.

4. Graber TM, Vanarsdall RL. Orthodontics: current principles and

techniques. St Louis: C.V. Mosby; 2000.

5. Mancini G, Francini E, Vichi M, Tollaro I, Romagnoli P. Primary

tooth ankylosis: report of case with histological analysis. ASDC J

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