Int. J. Oral Surg.

1984: 13: 423--431

(Key words: ankylosis; replantation; replacement resorption; mobility; percussion sound; root resorption)

Tooth ankylosis
Clinical, radiographic and histological assessments

LARS ANDERSSON, LEIF BLOMLOF, SVEN LINDSKOG, BARRY FEIGLIN AND LARS
HAMMARSTROM

Department of Oral Pathology, School of Dentistry, Karolinska Institutet, Clinic of Oral Surgery,
Sodersjukhuset, Clinic of Periodontology, Skanstull, Stockholm, Sweden and Department of
Restorative Dentistry, Melbourne, Australia

ABSTRACT - Ankylosis is a serious condition for the affected teeth as such

teeth form part of the remodelling process of the alveolar bone and are
therefore progressively resorbed. There are, however, very few clinical
studies on tooth ankylosis and the reason for this may be due to the
difficulties that are encountered in the diagnosis of minor areas of
ankylosis. In the present study, the radiographs, percussion sound and
mobility of experimentally extracted and replanted monkey incisors were
compared with a morphometric histological study of ankylosis. Ankylotic
areas were evident radiographically when the ankylosis was located on the
proximal surfaces of the root, but were not evident when the ankylosis
occurred on the lingual and labial surfaces. The percussion sound was dull
and the mobility normal in all non-ankylotic teeth as well as in those teeth
which histologically demonstrated ankylosis on less than 10% of the root
surface. When the ankylosis affected 10-20% of the root surface, 2 out of4
teeth changed their percussion sound from dull to high and these teeth no
longer possessed normal mobility. When more than 20% of the root
surface was affected with ankylosis, the percussion sound was characteris-
tically high in all teeth and no mobility was present.

(Received for publication 20 April 1983, accepted 31 January 1984)

Tooth ankylosis may be defined as a fusion opment of ankylosis of primary molars 10 . A

of cementum or dentin with the alveolar
bone 16 . Primary mandibular molars are the
most commonly affected teeth 13 although
ankylosis is also a common complication of
replanted, permanent teethl-l0.12,16. The
etiology is essentially unknown, but dis-
turbances of local metabolism, excessive
masticatory pressure and genetic distur-
bances have all been implicated in the devel-
familial tendency in the pattern of ankylosis
of primary molars has also been demon-
strated11, The development of ankylosis in
avulsed teeth is associated with injuries sus-
tained by the periodontal membrane during
the extra-alveolar period 4 - 6 ,8.9.
A bony fusion between a tooth and the
alveolar bone may have several serious con-
sequences. It may result in infraocc1usion,
424 ANDERSSON ET AL.
reimpaction and in an incomplete develop-
ment of the alveolar process 7 ,17. The
normal mesial drift of the teeth may also be
prevented as a result of ankylosis 13 • Replan-
ted or transplanted teeth which have
become ankylosed are progressively resor-
bed 5 and this condition has been called
replacement resorption 9 . A transient form
of ankylosis has also been reported 2 ,6, but
in these cases the ankylosis involves only a
limited area of the root surface and the
fusion between the alveolar bone and dental
root is gradually resorbed.
In clinical practice, percussion and mo-
bility tests and radiographic examination
are the methods used for diagnosing the
presence of ankylosis 2 , 7 • ANDREASEN 2 found
that mobility and percussion tests revealed
ankylosis earlier than radiographic exami-
nation in cases of progressive replacement
resorption, but there appears to be no study
that has been performed where the accuracy
of these test methods has been evaluated.
The purpose of the present study was to
compare the results from mobility and per-
cussion tests and radiographic examination
with a morphometrical value of ankylosis.
Material and methods
Teeth
The teeth in this evaluation were accumulated
from a number of separate studies on periodontal
healing of replanted teeth in monkeys; the results
of these studies are currently in preparation for
publication. 60 permanent mandibular and maxil-
lary lateral incisors in 15 monkeys were extracted
under similar conditions with respect to trauma
and time. After extraction, one of the following
treatment procedures was performed: immediate
replantation, air drying, storage in saliva or
storage in milk. 47 teeth were endodontically
treated extra-orally. The teeth were replanted
without splinting after the various treatment pro-
cedures. During the extraction and replantation
of the teeth, the monkeys were anesthetized with
sodium pentobarbital (60 mg/ml, 30 mgjkg body
weight, Meburnal vet.® ACO, Solna, Sweden).
After a period of 8 weeks, the animals were
sacrificed by an overdose of sodium pentobarbital
and decapitated. Immediately following sacrifice,
the percussion sound and mobility of the replan-
ted teeth were recorded on the intact hedds at the
monkeys. 5 teeth, 4 mandibular and I maxillary
incisor, were lost during the experimental period.
Percussion sound
The examination was performed by tapping the
tooth vertically as well as horizontally with the
handle of a probe. High and dull sounds were
recorded 2 • 10 and the adjacent teeth served as
controls.
Mobility
The mobility was tested by moving the tooth in a
labiolingual direction with finger pressure as well
as by means of a periodontometer. The adjacent
teeth served as controls. The periodontometer,
which was a modification of the instrument de-
scribed by MUHLEMAN 14 ,15 was fixed to the
alveolar bone and adjacent teeth. A force of IN
(100 gramforce) was applied on the labial surfaces
of the teeth and horizontal movement in the
labia-lingual direction was measured at the incisal
edge.
Radiographic evaluation
After the percussion and mobility tests, the
frontal part of the mandible and maxilla contain-
ing the replanted teeth and the 2 adjacent teeth
were removed en bloc. The tissue blocks were
immersed in cold 10% neutral buffered formalin
and transported to the laboratory. Within 60 min,
the tissue blocks were radiographed in 3 projec-
tions: orthoradial, mesial excentric 5° to the
orthodradial angle, and distal excentric 5° to the
orthoradial angle. Radiographs (Kodak Ultra
Speed, Kodak, Rochester, USA) were taken at
different exposure times using a Philips Oralix
(Philips, Einhoven, The Netherlands) operated at
65 kY.
The radiographs were evaluated together by 3
observers using magnification glass, variable light
intensity and light-screening. The examination of
the radiographs was performed without knowl-
edge of the results of the histomatrical analyses or
of the percussion and mobility tests. Disappear-
ance of the normal periodontal space with re-
placement by bone in association with an uneven
contour of the root was used as the criterium for
ankylosis. The labial, lingual, mesial and distal
intra-alveolar root surfaces were each divided
into a coronal, middle and apical third.
 DIAGNOSIS OF ANKYLOSIS 425

Histological evaluation
Following formalin fIxation for 48 h and demin-
eralization in 6% formic acid, the specimens were
embedded in paraffIn and sectioned perpendi-
cular to the long axis of the teeth in step-serial
sections (5 }lm) at levels 70 11m apart. The sections
were stained with hematoxylin and eosin and
examined in a light microscope. For the mor-
phometric evaluation, every third section was
used. Thus, 12-30 sections, 210 /lID apart, were
examined from the cervical level where the root
was completely surrounded by bone to the apex
of the root. The tissue reactions were evaluated as
described by ANDREASEN 1. 3 . A cross formed by 2
lines intersecting at 90° was placed over the
projected cross section of the root and oriented
according to the labia-lingual axis of the tooth.
At the intersections of the 2 lines and the root
surface, corresponding to the mesio-distal and
labia-lingual axis of the tooth, changes in the
periodontium were noted, i.e. 4 measuring points
were used in each section.
Close contact of alveolar bone with cementum
or dentine was registered as ankylosis. The rela-
tive area showing ankylosis was calculated for the
whole intra-alveolar root surface as well as sepa-
rately for the cervical, middle and apical thirds of
each labial, lingual, mesial and distal surface.

Results
Microscopic examination
24 teeth showed varying degrees of anky-
losis, while 31 teeth were free from ankylosis
(Table 1). There were approximately the
same number of registration points demon- 'n'<l'
strating ankylosis in the coronal, middle and .' ...
-.d\'<l'O
tr
~_~I' '[l VI '<l' '0
,.l.t-,.l.,.L
apical parts of the root thus indicating that
II
ankylosis was evenly distributed along the
root surface.
2 types of ankylosis were evident. In the
majority of teeth, ankylosis had been pre-
ceded by resorption of cementum and den-
tine and no cementum was found at the
ankylosis site (Fig. 1). In some teeth, how-
ever, apposition of bone on the cemental
surface had occurred, apparently without .~

previous resorption of the cementum (Fig. .....;

2). This latter type of ankylosis was slightly
more common in the apical part of the
426 ANDERSSON ET AL.

Fig. I. Replanted maxillary lateral incisor. (A) Histological section from the cervical third of the root.
Ankylosis is present on the distal and lingual root surfaces. Bar=400 )lm. (B) Histological section from
the middle third of the root. Ankylosis is present on the lingual root surface. Bar=400 11m. (C) Detail of
ankylotic area in Fig. IA. Note osteoclastic resorption (arrows). Bar= 100 tl1n. (D) Radiograph of the
same incisor. Arrows at A and B indicate the levels at which the sections in Fig. lA, B were taken. In
these areas, a normal periodontal space is seen 011 the radiograph. (E) Detail of ankylotic area in Fig.
lB. Bar=lOO Jim.
 DIAGNOSIS OF ANKYLOSIS 427

Fig. 2. Replanted maxillary lateral incisor. (A) Histological section showing apposition of bone on the
cemental surface without previous resorption of the cementum. Bar=400 J.lm. (B) Radiograph of the
same incisor. On the distal root surface, the periodontal space cannot be followed completely. Arrow
indicates the level at which the section in Fig. 2 was taken.

roots. 2 types of bony connection to the duced an uneven radiographic contour of

surrounding alveolar bone could be distin-
guished. The ankylotic areas consisted
either of thin bony trabeculae (Fig. 1) or of
wide bony areas (Figs. 1,3). In the majority
of teeth, both types of connection between
the site of ankylosis and alveolar bone were
seen (Fig. 1), but there were some teeth
where only one type was found.
Radiographic evaluation in relation to micro-
scopic examination
13 teeth showed radiographic signs of anky-
losis. In 10 of these teeth, more than 10% of
the root surface was ankylotic (Table 1). 3
teeth with radiographic signs of ankylosis
proved to have a histologically normal
periodontal membrane, although shallow
resorption cavities were present which pro-
the root.
11 teeth proved to be ankylotic although
ankylosis was not seen on the radiographs
(Table 2, Figs. 1,4). In 1 tooth, even though
79% of the root surface was ankylotic, the
ankylosis had nevertheless escaped radi-
ographic detection (Fig. 4). In this tooth,
there was a thin layer of bone on the root
surface which was connected with the sur-
rounding alveolar bone by a few thin trabe-
culae. This trabecular area apparently simu-
lated a periodontal membrane in the
radiograph.
Percussion and mobility tests in relation 10
microscopic examination
All control teeth neighbouring the experi-
mental teeth had a dull percussion sound
428 ANDERSSON ET AL.

Fig. 3. Replanted maxillary lateral incisor. (A) Histological section. Almost the entire root surface is
ankylotic. Bar =400 11m. (B) Radiograph of the same tooth. No trace of the periodontal space can be
seen on the radiograph at the level where the section was taken (arrow).

Fig. 4. Replanted maxillary incisor. (A) Histological section. Almost the entire root surface is ankylotic.
Note the thin layer of bone on the root surface which is connected with the surrounding alveolar bone
by a few thin trabeculae. Bar=400 JIm. (B) Radiograph of the same tooth as in Fig. 4A. A radio/uscent
zone is seen close to the root surface simulating a periodontal space which made a correct radiographic
diagnosis of ankylosis impossible. Arrow indicates the level of histological section. (C) Detail of
ankylotic periodontal area in Fig. 4A.
 DIAGNOSIS OF ANKYLOSIS 429

Table 2. Histometric values of ankylosis subdivided on surfaces of 21 maxillary and mandibular lateral
incisors with ankylosis

Mesial surface Labial and lingual surface Distal surface

cervical middle apical cervical middle apical cervical middle apical

tooth third third third third third third third third third

12 1/5
12 3/6
12 6/8
32 4/8
22 3/8 1/10 2/5
42 7/8 4(8 1/16
22 7/18 6/18 13/9 I 2/9
32 4/12 6/6 2/6
32 4/4 2/4 1/8 2/8 1 2/ 4 I
42 4/7 1/7 11/14 4/14
22 18/18 9/18 2/18 2/9
22 5/11 12/22 8/22 3/22 8/11 6/11
22 1/8 []Z[] 7/16 8/16 7/16 7/8 5/8
42
22
3/5 GZD 5/5
5/8
4/10
8/16
3/10
5/16
6/10
15/16
1/5
4/8 1/8
3/5
[1Z[]
22 [474] 4/4 7/8 4/4 4/4 3/4
42 4/7 3/7 6/7 1/14 6/14 12/14 15/7 I 7/7 7/7
12 17/7 I 5/7 4/7 11/14 12/14 9/14 3/7 2/7 3/7
12 4/8 8/8 MJ 8/16 15/16 13/16 8/8 8/8 QKJ
12 5/6 3/6 2/6 12/12 10/12 12/12 6/6 6/6 1/6
22 7/7 3/7 2/7 14/14 9/14 13/14 6/7 7/7 16/7 I
Each quotient indicates the number of sections with ankylosis in the registration points divided by the
total number of registration points in the actual third of that surface. Framed quotients indicate that
diagnosis of ankylosis was possible on the radiographs.

and normal mobility. Periodontometer mea-
surements of these teeth revealed a horizon-
tal mobility greater than 0.15 mm. 38 of the
replanted teeth had a dull percussion sound
and normal or slightly increased mobility
(Table I). Their horizontal mobility was
greater than 0.15 mm. 31 of these teeth were
free from ankylosis on histological analysis,
while 7 proved histologically to be ankylo-
tic. The ankylotic areas in the latter 7 teeth
covered less than 20% of the intra-alveolar
root surface and were found to be connected
with one or very few trabeculae to the
alveolar bone in one limited area (Fig. 5). 2
other teeth which also had less than 20% of
their root surface involved by ankylosis had
a decreased mobility and a high percussion
sound. The latter teeth were connected to
the bone with numerous trabeculae located
on various surfaces of the root (Fig. 6). The
remaining 15 teeth lacked mobility using the
finger pressure method, had a high per-
cussion sound and periodontometer values
of horizontal mobility were 0-0.07 mm. All
these teeth proved to be ankylosed histologi-
cally and the ankylosis covered more than
20% of the intra-alveolar root surface.
Discussion
A high percussion sound and a decreased
mobility were more sensitive and accurate
430 ANDERSSON ET AL.

Fig. 5. Histological section of replanted lateral incisor which had a normal percussion sound and a
nomlal mobility. (A) Limited ankylosis is seen. Bar= 300 J1m. (B) Detail of the ankylotic area. Note
osteoclastic resorption (arrow) Bar= 100 J1m.
Fig. 6. Histological section of lateral incisor which had a high percussion sound and reduced mobility.
Ankylosis is present at numerous small locations (arrows). Bar=400 11m.

signs of ankylosis than was radiographi-
cally-observable changes of the width ofthe
periodontal membrane. The radiographic
diagnosis of ankylosis was totally dependent
upon the location of the ankylosis. Labial
and lingual ankylosis could not be detected
by means of radiographic examination and
only 11 out of 31 ankylotic areas on the
proximal surfaces were revealed in the
radiographs. The presence of overlapping
structures may be one explanation for this
finding and also as demonstrated in the
present study, bone marrow spaces may
erroneously be interpreted as being the
periodontal membrane. Furthermore, an
uneven root surface combined with overlap-
ping bone trabeculae may lead to a false
positive diagnosis of ankylosis. The single
rooted maxillary and mandibular incisors
used in this study provide for the least
possibility of error in the radiographic exa-
mination of the periodontal membrane
space. Radiographic examination may be
even less useful for the diagnosis of anky-
losis of multi-rooted teeth.
A correct diagnosis of ankylosis was pos-
sible by means of the mobility and per-
cussion tests when 20% or more of the
incisor root surface was involved. 2 teeth
with ankylosis occupying less than·20% of
the root surface escaped detection by means
of percussion and mobility tests. The bone
trabeculae responsible for the ankylosis in
these teeth were very thin and undergoing
osteoclastic bone resorption. This ankylosis
may be of the transient type which has
previously been described by ANDREASEN 2 •6
and the lack of a correct diagnosis may thus
be of little clinical importance. It should also
be noted that all non-ankylotic teeth had a
normal dull percussion sound and a norma]
mobility.
The present study has thus shown that the
most reliable methods for diagnosing anky-
losis were percussion and mobility tests.
When less than 20% of a root surface was
 DIAGNOSIS OF ANKYLOSIS
ankylotic, a correct diagnosis seemed to be
impossible with clinical methods.
Acknowledgements - This investigation was sup-
ported by Grant no. X06001-03B from the Swe-
dish Medical Research Council and Folksam
Forskningsfond.
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Address:
L. Andersson
Department of Oral Pathology
School of Dentistry
Karolinska Institutet
Box 4064
S-141 04 Huddinge
Sweden