Relocation of Infrapositioned Ankylosed Teeth: Description ... · Relocation of Infrapositioned Ankylosed Teeth: Description of Orthodontic Bone Stretching and Case Series Philippe

DENTOALVEOLAR SURGERY

Relocation of InfrapositionedAnkylosed Teeth: Description of

Orthodontic Bone Stretching and CaseSeries

Philippe Bousquet, DDS, PhD,* Christ!ele Artz, DDS, MSc,yMatthieu Renaud, DDS, MSc,z and Pierre Canal, DDS, PhDx

Different treatments have been proposed to manage the consequences of ankylosed teeth. This clinicalreport, which includes several different clinical conditions, describes an orthodontic bone-stretching pro-cedure that can be used to relocate ankylosed teeth. The orthodontic bone-stretching technique involvesonly partial osteotomies, without the mobilization or repositioning of the alveolar segment, combinedwith orthodontic forces. The applied force facilitates tooth movement to the occlusal plane and canmodify the axis of the ankylosed tooth. This relocation is possible because of a bone-stretching phenom-enon in the surgical area. In all of the cases, relocation of the ankylosed teeth was successfully performedand the gingival margins were corrected to improve the esthetic results.! 2016 American Association of Oral and Maxillofacial SurgeonsJ Oral Maxillofac Surg -:1.e1-1.e12, 2016

Severe injuries of the periodontal ligament, frequentlythe permanent maxillary incisors in children, may leadto the ankylosis phenomenon, resulting in fusion be-tween the mineralized root surface and the alveolarbone.1,2 Such ankylosis disturbs dentoalveolardevelopment during growth. In fact, an ankylosedtooth in a growing child does not erupt, resulting ina vertical insufficiency of osseous growth, which canlead to infraclusion, an unesthetic smile, andocclusal disharmony. Therefore, a patient with anankylosed tooth might require treatment forinfraclusion and alveolar bone deficiency.Ankylosis is clinically diagnosed by acute sound per-

cussion (tooth resounding like crystal) and lack ofmobility in comparison with dull sound percussionand physiological mobility of the adjacent unaffectedteeth (the periodontal ligament absorbs sound andallows mobility). A Periotest device (Siemens AG,

Bensheim, Germany) is an instrument for the quantifi-cation of tooth mobility and can be used to confirmankylosis. An electronic tapping head percusses theteeth. Ankylosed teeth have a shorter contact time,resulting in lower Periotest values than those for intactor mobile teeth.3 Ankylosis also can be discovered orconfirmed during orthodontic treatment by toothimmobility under an applied orthodontic force. More-over, ankylosis can be confirmed by radiographic eval-uation, showing a lack of ligament space.

Several alternatives exist to treat the consequencesof ankylosed teeth. The first solution is extraction ofthe ankylosed tooth. Rehabilitation can be conductedwith a bridge, but periodontal surgery (gingival graft)might be necessary to improve the mucosal volumeof the ridge.4 Treatment using a dental implant alsocan be used after extraction. However, bone regenera-tion with grafting may be necessary for vertical and

Received from Universit"e de Montpellier, Montpellier, France.

*Professor, Department of Periodontology, School of Dentistry;

Laboratoire Biologie Sant"e et Nanoscience EA42503.

yProfessor, Department of Orthodontics.

zDoctor, Laboratoire Biologie, Sant"e et Nanoscience EA42503.

xProfessor, Department of Orthodontics.

Address correspondence and reprint requests to Dr Bousquet: 40

rue des Dunes, 34500 Beziers, France; e-mail: dr.philippebousquet@

free.fr

Received March 17 2015

Accepted June 2 2016

! 2016 American Association of Oral and Maxillofacial Surgeons

0278-2391/16/30245-2

http://dx.doi.org/10.1016/j.joms.2016.06.002

1.e1

lateral bone augmentation before implant place-ment.5,6 This surgical treatment represents the bestmanagement for ankylosed teeth with severe rootresorption, root fracture, or infection, usually leadingto a poor prognosis.A second treatment option involves the conserva-

tion of ankylosed teeth on the arch. However, reloca-tion to a correct position needs a surgical optionbecause orthodontic treatment alone cannot correctthe position of the ankylosed tooth. Surgical luxation,7

segmental osteotomy with distraction,8-10 andsegmental osteotomy with repositioning11 arepossible alternative treatments. However, de Souzaet al12 reported the lack of a high level of evidencefor treatment options and the management of anky-losed anterior teeth.Recently, a new orthodontic technique using bony

block movement was presented for the treatment ofankylosed teeth with promising results.13 The aim ofthis clinical report is to describe an alternative surgicaltechnique of orthodontic bone stretching (OBS) forthe management of ankylosed teeth in different clin-ical situations.The described cases were treated at Montpellier

University Hospital. The procedure was approved bythe local ethical committee (South of France Commit-tee, Nice, France), and all of the participants providedwritten informed consent.

Presurgical Preparation

First, orthodontic treatment was conducted for dys-morphosis correction, excluding ankylosed teeth. Sec-ond, a specific orthodontic preparationwas performedbefore the surgical treatment (anchorage control, gen-eration of an open space around the ankylosed tooth,and alignment of the anterior gingival margins).Before surgery, dental computed tomography must

be performed to evaluate the position of the roots in3 dimensions for surgical planning. The distance ofthe ankylosed tooth from the adjacent teeth, the axisof the ankylosed tooth, and the bone volume are impor-tant factors for positioning the corticotomy. Bone den-sity and cortical thickness also are evaluated to securethe osteotomy, which extends through the corticalbone, penetrating into the cancellous bone. Before sur-gery, an orthodontic attachment is bonded to the labialor palatal crown surface of the ankylosed tooth.

Surgical Procedure

With the patient under local anesthesia, a buccalsulcular incision and 1 or 2 vertical releasing incisionsare made on the distal side of the teeth adjacent to theankylosed tooth. A full-thickness mucoperiosteal flapis reflected to expose the alveolar bone.

The surgical procedure is performed using a SatelecPiezotome 2 with BS1 or BS5 slim tips (Acteon Group,Merignac, France). One buccal vertical interdentalosteotomy cut is performed on either side of the anky-losed tooth in the same axis of the root maintaining asafe distance from the adjacent teeth. Next, the 2vertical cuts are connected through a third cut thatis positioned in a subapical manner to the root apexof the ankylosed tooth.

The osteotomy involves the buccal cortex andcancellous bone preserving the palatal cortex intact.Therefore, no mobility of the sectioned dento-osseous complex is observed (Fig 1). For occlusalmovement, ultrasonic cuts are generated on thebuccal side. In contrast, for palatal movement, thecuts are generated on the palatal side. The mucoper-iosteal flap is repositioned and sutured (Vicryl No.4-0 and 5-0; Ethicon, Issy-Les-Moulineaux, France).

Immediately after the surgical procedure, heavyorthodontic traction on the ankylosed tooth is per-formed. It is important to know the precise directionof the movement executed on the dento-osseous com-plex, which must be in the same axis of the corticoto-mies. The force must not exceed the anchorage valueof the adjacent teeth.

The patient is prescribed amoxicillin (1 g 2 times aday for 6 days), prednisolone (60 mg for 3 days), acet-aminophen (1 g 3 times a day for 3 days), and a 0.12%chlorhexidine solution (rinsing twice a daily starting24 hours after surgery for 10 days). The sutures areremoved after 10 days. Continuous force must beapplied to the ankylosed tooth, and the patientundergoes traction reactivation every 2 weeks untiltooth repositioning is achieved. Movement of thedento-osseous complex is observed after 1 to 4 weeks.When the ankylosed tooth reaches the occlusal plane,an arch wire retainer is inserted for a period of6 months to monitor the evolution. After removal ofthe appliance, a wire is bonded to the incisors andcanines, including the ankylosed teeth.

FIGURE 1. Schema showing partial buccal cuts: frontal view andlateral view. The corticotomies run deep, but the palatal corticalbone is preserved.

Bousquet et al. Ankylosed Teeth and Orthodontic Bone Stretching.J Oral Maxillofac Surg 2016.

1.e2 ANKYLOSED TEETH AND ORTHODONTIC BONE STRETCHING

CASE 1

A healthy 15-year-old boy was referred for ankylosedupper left central incisor repositioning. He had intru-sion of the tooth at the age of 12 years followed byimmediate repositioning and splinting for a few weeksand subsequent endodontic treatment. At age 14 years,the tooth was diagnosed as ankylosed to the maxilladuring subsequent orthodontic treatment.

Plaque control was not ideal, but there was no peri-odontal disease, except for gingivitis located in themaxilla (Fig 2). After clinical diagnosis, cone-beamcomputed tomography (CBCT) radiographsconfirmed the ankylosis (Fig 3).

After orthodontic preparation, with exclusion of theankylosed tooth (Fig 4), a dysmorphosis correction ledto the infraclusion of the ankylosed central incisor. Arate of 3 mm with an index of infraposition of 2(moderate) according to the Malmgren and Malmgrenclassification14 was diagnosed. The treatment planincluded ankylosed tooth repositioning with OBS afterorthodontic preparation (anchorage and generation ofan open space to facilitate tooth repositioning withoutobstruction). CBCT was used to diagnose the anky-losis, resorption area, and apical fenestration underthe nasal spine, as well as to determine the ideal spaceto relocate the ankylosed tooth. The tooth axis indi-cated vertical and low palatal traction.

Before surgery, orthodontic brackets were bondedonto the labial and palatal crown surfaces to facilitateimmediate tooth traction. OBS was performed asdescribed previously: One vertical osteotomy oneach side of the roots was performed, and a horizontalosteotomywasmade apically connecting the 2 vertical

FIGURE 2. Intraoral photograph before orthodontic treatment incase 1.


FIGURE 3. Cone-beam computed tomography of left central incisor in case 1. Ankylosis was confirmed. A, anterior; P, posterior.

Bousquet et al. Ankylosed Teeth and Orthodontic Bone Stretching. J Oral Maxillofac Surg 2016.

BOUSQUET ET AL 1.e3

osteotomies (Fig 5). The depth of the corticotomieswas increased to decrease the strength of the blockand to facilitate movement. Immediately after surgery,orthodontic traction was introduced with a correct

axis. Palatal and vestibular strengths were used alter-nately or in combination (Fig 6). No complicationswere encountered during or after surgery or duringthe orthodontic traction period. After 2 months ofreactivation, the ankylosed tooth was correctly reposi-tioned and orthodontic retention was performed(Figs 7A, B). Importantly, vertical bone augmentationwas achieved with simultaneous soft tissue augmenta-tion with optimal gingival margin alignment. Plaquecontrol was improved to produce healthy periodontaltissues (Fig 7C).

CASE 2

A 17-year-old boy was treated for an anterior openbite with atypical swallowing and a mouth-breathinghabit. When orthodontic treatment began, the rightmaxillary incisors were immobile despite the applica-tion of orthodontic forces, leading to maxillary arcadeintrusion (Fig 8). The dental history included traumato the right maxillary incisors from a bicycle fall atthe age of 14 years. CBCT imaging showed root resorp-tion and lack of the periodontal ligament to the rightmaxillary incisors, confirming ankylosis of the teeth(Fig 9). The diagnosis was ankylosis of the right maxil-lary incisors with apical and internal resorption of thecentral incisor. The results of vitality tests were posi-tive. After an endodontic consultation, it was decidedto monitor the evolution of the resorption and to relo-cate the teeth.

In a first step, the treatment objectives includedcorrection of the posterior crossbite, Class II malocclu-sion, and tongue thrust, as well as obtaining a normalincisor relationship. A leveling process and an align-ment phase were completed, with exclusion of the 2ankylosed teeth (Fig 10). The index of infrapositionwas 4 (extreme). The second step included reposition-ing of the ankylosed incisors with OBS.

Immediately before surgery, a stainless steel archwire was placed on the maxilla and on the mandible.Moreover, a nickel-titanium arch wire (round, 0.016! 0.016 inch) was placed on both of the maxillaryankylosed teeth and was superimposed on the mainarch. This arch wire applied a continuous orthodonticforce to the ankylosed teeth. With the patient underlocal anesthesia, the mucoperiosteal flap wasreflected, and the same surgical procedure (OBS)was conducted. The mucoperiosteal flap was reposi-tioned and sutured (Fig 11). The appliance was acti-vated immediately and every 2 weeks. When theankylosed teeth reached the occlusal plane andwhen the orthodontic treatment was concluded, afinal 0.021 ! 0.025–inch stainless steel arch wirewas inserted and retained for a period of 6 months(Fig 12).

The total treatment time to relocate the teeth to theocclusal plane was 4 months, followed by 6 months of

FIGURE 4. Orthodontic preparation in case 1, excluding theankylosed tooth, led to the correction of dysmorphosis. Theankylosed tooth appeared in infraposition.


FIGURE5. Surgical treatment in case 1: vertical and apical partialosteotomies.



retention. After removal of the appliance, the anteriormaxillary teeth were stabilized with a lingual bondedretainer. The maxillary anterior gingival marginswere improved, and alignment and leveling werecompleted in both arches. A normal overjet and over-

bite improved the midline coincidence, and Class Imolar and canine relationships were obtained. Thepost-treatment panoramic radiograph showed thatthe roots of the teeth were relatively parallel with sta-ble root resorption, except for the upper right canine,

FIGURE 6. Continuous force applied to ankylosed tooth in case 1. A, Arch wire on palatal side. B, Elastic wire on buccal side.


FIGURE7. Intraoral photographs after removal of appliance in case 1.A, Frontal view 6months after surgery. B, Occlusal view 6months aftersurgery. C, Frontal view of maxillary incisors 18 months after surgery.


BOUSQUET ET AL 1.e5

which presentedmoderate external apical root resorp-tion. The superimposition of the pretreatment andpost-treatment lateral cephalometric tracings showedan overall vertical increase of the alveolar segment,and point A could not be considered because it wassupported by the corticotomy (Fig 13). In addition,the right maxillary incisors were retroclined andextruded because of the alveolar segment movement.

At the 24-month post-treatment visit, the treatmentresult was stable with some gingival recession(<0.5 mm) on the right central incisor. The peri-odontal status did not show pathology, but the lackof plaque control aggravated the existing enameldefects. Cosmetic treatment of the anterior maxillaryteeth was performed (Fig 14). A 2 years’ follow-up,CBCT comparison showed interdental alveolar bonemovement to the occlusal plane and stable rootmorphology with internal resorption (Fig 15).

CASE 3

A 12-year-old girl presented with immobility of themaxillary central incisors despite active orthodontictreatment (Fig 16A). The OBS procedure was per-formed after flap elevation (Fig 16B). In this case,the intended movement was in the labial and distaldirection. The bone cuts separating the 2 teethwere thin for the interdental corticotomy (BS1 andRD2 tips; Acteon Group), and the bone cuts werebroader for the distal and apical corticotomies toimprove movement (SL1 tip; Acteon Group). Immedi-ately after surgery, a spring was placed between thecentral incisors. After 1 month of application oforthodontic forces, the space between the 2 incisors

FIGURE 8. Intrusion of anterior section and right side in case 2.Ankylosis was confirmed.


FIGURE 9. Cone-beam computed tomography in case 2 showing apical resorption of right incisors, as well as internal resorption of right cen-tral incisor.



was increased and the incisors were correctly reposi-tioned (Figs 16C, D).Despite the teaching of oral hygiene technique, pla-

que control remained very poor, with the consequent

occurrence of gingivitis. A temporary esthetic treat-ment of the crowns was performed with compositerestoration. The gingival defect was corrected withpapilla regeneration (Fig 17). Comparison of the

FIGURE 10. Treatment result before surgery in case 2. A, Frontal view: infraclusion of right incisors (index of 4). B, Occlusal view.


FIGURE 11. Surgical treatment in case 2. A, Corticotomy using Satelec Piezotome 2 with BS1. B, Two vertical cuts connected by third sub-apical cut. C, Suture of flap.


BOUSQUET ET AL 1.e7

panoramic images showed interdental alveolar bonestretching and movement of the teeth (Fig 18).

Discussion

Extraction of ankylosed teeth does not compensatefor the alveolar hypo-development resulting from lackof growth and can lead to a complex bony ridge defect.For esthetic rehabilitation, vertical bone augmentation

by tissue regeneration or bone grafting is often neces-sary. These techniques have not shown reproducibleor optimal results. Given the low number of patienttreatments reported in the literature, the use of suchvertical bone augmentation is limited.15 Conservingthe tooth on the arch and moving it to the occlusalplane could be a better treatment option.

For the relocation of ankylosed teeth, a segmentalosteotomy is performed, as shown in case reports.12

The immediate mobilization and repositioning of thealveolar segment,16 associated with or without bonegrafts,17 comprise a different technique with goodresults. For this procedure, maintenance of the soft tis-sue attachment to the bone is an important limitingfactor for vascularization and immediate movementof the dento-osseous complex.17 To enable a gradualand slower soft tissue stretching, an osteotomy associ-ated with a distraction device has been proposed totreat ankylosed teeth.18 Although adequate resultshave been reported, these techniques use a specificdevice that is sometimes complex and constraining.Furthermore, distractors have a unidirectional impactwith heavy strengths (distraction rate of 0.5 to1 mm/d); these techniques poorly predict movementin the sagittal direction and can lead to incorrectdistraction vectors.19,20

In OBS the osteotomy is limited to the buccal side ofthe alveolar bone. Vascularization is ensured by thepresence of the palatal bone and the attached soft tis-sues. The surgical area is completely immovablebecause the osteotomy is not complete. This less trau-matic technique facilitates the movement of ankylosedteeth toward the occlusal plane, reflecting several phe-nomena. The cortical section decreases the resistanceof the dental bone block. Before surgery, the orthodon-tic force does not move the ankylosed teeth and canlead to the intrusion of adjacent teeth. The anchorageof the arch is too low, and the resistance of the anky-losed tooth is too high. The partial buccal osteotomiesfacilitate the effect of orthodontic forces on the palatalcortical bone. In accordance with the Frost principleof the healing response,21 the relocation of the anky-losed tooth without ligament movement is permittedby bone movement. The OBS technique appears tobe a bone-stretching phenomenon using ankylosedteeth as anchorage points.

This result is different from bone distraction.Indeed, in OBS it is important not to wait for the for-mation of bone callus in the area of the partial os-teotomies. The applied forces are immediate andcontinuous, preventing healing in the area of thebone cuts and stretching the residual palatal bone.The use of a system to stabilize the block is notnecessary, and the attached orthodontic deviceonly induces and directs the movement into thedesired axis.

FIGURE 12. Intraoral photograph in case 2: frontal view. Theankylosed teeth were moved to the occlusal plane.


FIGURE 13. Superimposition of initial and final cephalometrictracings in case 2.



Animal studies showed that a corticotomy increasedthe turnover of alveolar bone. Sebaoun et al22 reportedthat catabolic and anabolic activities were 3 timesgreater in the area adjacent to the cut. The osteoclastcount and quantity of bone apposition were higherin this area. Bone fill increased using the Piezotome

compared with conventional instrumentation (bur orsaw blade), leading to considerably higher bone activ-ity and mineral density.22 This phenomenon is biolog-ical, but the clinical effect was not demonstrated andclinical studies are needed to confirm differences. Anincrease in the expression of the genes involved in

FIGURE 14. A, B, Intraoral photographs at 24 months after treatment in case 2: frontal view (A) and occlusal view (B). C, Photograph afteresthetic treatment of enamel defects.


FIGURE 15. Cone beam radiographs after surgery and at 2 years after treatment in case 2. The interdental alveolar bone around the rightincisors was moved using the orthodontic bone-stretching technique.


BOUSQUET ET AL 1.e9

bone healing also was reported.23 This modification ofactivity is important for rapid orthodontic movements.Wilcko et al24 used these techniques and proposedthat during the healing process, rapid toothmovementresults from bone remodeling and pressure on theperiodontal ligament and its hyalinization, facilitatingtooth movement in bone.For the relocation of ankylosed teeth by the OBS

technique, with the lack of the periodontal ligament,only the biological bone phenomena associated withultrasonic corticotomy may be present near partial

osteotomies and can accelerate the bone-stretchingmovement in the area of the cuts, near the preservedcortical bone. The result of this strict bone move-ment is repositioning of the tooth in the archthrough orthodontic traction. In the block of 2 anky-losed teeth (case 2), the right interincisor crestallevel moves with the block, and this phenomenonwas confirmed after comparison of the CBCT radio-graphs. The slow bone movement (approximately2 mm per month) allows for the adaptation of thesoft tissue.

FIGURE 16. Case 3. A, Lack of movement of central incisors. B, Adaptation of cuts to desired movement. C, Displacement resulting from15 days of spring forces. D, After 1 month of spring forces, the patient presented with poor plaque control.


FIGURE 17. Intraoral photographs after relocation of maxillary central incisors, as well as temporary esthetic treatment for crown reconstruc-tion, in case 3. A, Frontal view. B, Occlusal view.



FIGURE 18. Panoramic radiographs in case 3. A, Before surgery. B, Two months after teeth relocation by orthodontic bone-stretching tech-nique.


BOUSQUET ET AL 1.e11

Orthodontic preparation is essential and is associ-ated with the adequate management of the tissuearound the ankylosed tooth. On the basis of our expe-rience, we think that more than 2 mm between theroots of adjacent teeth should be sufficient to allowfor thin partial osteotomies, while leaving enoughbone on each side to prevent vascularization of theseptum. The use of an ultrasonic saw with a slim pro-file is preferred for precise surgery.As the maxilla grows in the vertical direction, the

ankylosed tooth and alveolar segment remain in infra-clusion in most cases because there is no additionalalveolar growth at the ankylosed tooth site. After or-thodontic treatment of an ankylosed tooth, the func-tional and esthetic results may not remain stableover time if the jaw continues to grow. The continuousgrowth of a patient must be considered when plan-ning the treatment. The degree of such infraclusion de-pends on individual growth, age, and gender.25 Slightovertreatment could be a solution to compensate forthis phenomenon.The OBS technique is a viable procedure for the

treatment of ankylosed teeth. This surgical procedureseems to facilitate tooth positioning in 3 dimensions.Gingival margins can be corrected as necessary forimproving esthetic results. Clinical trials are necessaryto support clinical practice and to compare OBS, os-teotomy, and distraction.

Acknowledgment

The authors thank Dr L. Delsol, Department of Orthodontics,School of Dentistry, Montpellier University, for performing ortho-dontic treatment in case 1.

References

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5. Darby I, Chen ST, Buser D: Ridge preservation techniques forimplant therapy. Int J Oral Maxillofac Implants 24:260, 2009

6. Jensen SS, TerheydenH: Bone augmentation procedures in local-ized defects in the alveolar ridge: Clinical results with differentbone grafts and bone-substitute materials. Int J Oral MaxillofacImplants 24:218, 2009

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Relocation of Infrapositioned Ankylosed Teeth: Description ... · Relocation of Infrapositioned Ankylosed Teeth: Description of Orthodontic Bone Stretching and Case Series Philippe