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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)
D
entoalveolar ankylosis is an eruption anomaly
defined as the union of the tooth root to the R’em10-12 also added midline shift to the ankylosed
alveolar bone, with local elimination of the side and extrusion of the antagonist tooth, increasing
periodontal ligament. This condition can result in the risk of occlusion problems.
replacement root resorption, in which the root is Kofod et al6 pointed out that, in a growing child, the
substituted by bone.1 ankylosed tooth does not follow the normal vertical
Dentoalveolar ankylosis has been described as a lo- growth of the alveolar process, and a deficiency occurs,
cal factor of malocclusion.2-4 Its cause is not well de- causing the tooth to be even more impacted.
fined, but it can be associated with dental trauma,5-7 Diagnosis of dental ankylosis is generally established
metabolic disturbance,5,7 a genetic tendency, or a local through clinical findings, but radiographs can sometimes
deficiency in vertical bone growth.5 add some information. As suggested by Mullally et al,8
According to Biederman7 and Moyers,2 ankylosis in although a clinical diagnosis can be made by infraocclu-
deciduous teeth is about 10 times more likely than in the sion, percussion, and mobility testing, sometimes lack of
permanent dentition, and twice as likely in the mandib- orthodontic movement can confirm the diagnosis.
ular than in maxillary arch. A higher incidence can be Since dentoalveolar ankylosis can cause deleterious
observed in the molar region during the deciduous and effects on occlusal development, early diagnosis and an
mixed dentition. The incidence of deciduous-tooth den- effective treatment plan are fundamental to prevent fur-
toalveolar ankylosis was reported to be 1.5% to 9.9%.8 ther eruption deviations and more severe malocclusion.
When dental ankylosis occurs early, it is more likely Our aim in this article was to present a patient in the
to have a deleterious impact on the occlusion.7,9 The mixed dentition with dentoalveolar ankylosis of a decid-
most common consequences are progressive infraocclu- uous molar in which the diagnosis was not made at the
sion of the ankylosed teeth, inclination of adjacent teeth, correct time, resulting in a severe malocclusion. As a re-
bone defects, and impaction of the succeeding perma- sult, when the diagnosis was established, longer and
more complex treatment was necessary. Although the
treatment was effective, it was not efficient because of
From the Department of Orthodontics, School of Dentistry, Pontifı́cia Universi- its long duration and biomechanical complexity, caused
dade Católica, Belo Horizonte, Minas Gerais, Brazil.
a
Postgraduate student. by the late diagnosis.
b
Associate professor.
The authors report no commercial, proprietary, or financial interest in the prod-
ucts or companies described in this article. DIAGNOSIS AND ETIOLOGY
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. A boy, aged 9 years 10 months, of mixed ethnic
com.br. background (black and white), was referred to the ortho-
Submitted, December 2006; revised, March 2007; accepted, April 2007. dontic clinic of the School of Dentistry of the Pontifı́cia
0889-5406/$36.00
Copyright Ó 2009 by the American Association of Orthodontists. Universidade Católica de Minas Gerais in Brazil. His
doi:10.1016/j.ajodo.2007.04.040 chief complaints were absence of a mandibular
799
800 Loriato et al American Journal of Orthodontics and Dentofacial Orthopedics
June 2009
deciduous molar and inclination of the adjacent teeth region of the maxillary arch. The molars on the left
(Figs 1-5). side were in a Class I relationship, whereas the mandib-
His medical and dental histories were uneventful. ular right first permanent molar was lingually and mesi-
The facial analysis showed symmetry, a convex profile, ally inclined. The mandibular right second deciduous
and good balance between the facial thirds, with an molar was missing.
increased lower facial height. The panoramic radiograph showed the infraocclu-
The intraoral examination showed that he was in the sion of the mandibular right second deciduous molar, in-
mixed dentition, with the permanent incisors and first dicating dentoalveolar ankylosis. The alveolar process
molars already in the arches. In addition, he had in this region had a severe deficiency in vertical devel-
a deep overbite and some diastemas in the anterior opment. The permanent successor germ was developing
American Journal of Orthodontics and Dentofacial Orthopedics Loriato et al 801
Volume 135, Number 6
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 extract
the mandibular right second deciduous molar to allow
the eruption of its permanent successor.
Fig 9. Lingual arch placement.
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 One alternative for removable appliances could be
on the maxillary arch. It is a simple and effective alter- an active lingual arch. This system would upright the
native to uprighting the permanent molar, in spite of re- right permanent molar but could create unwanted side
quiring patient cooperation with the elastics and the effects on the mandibular left permanent molar that
headgear. In case of noncompliance, we would have would be difficult to control.
had no benefit from these mechanics, and another alter- Another option would be mechanics with fixed appli-
native would have been implemented. ances—eg, segmented mechanics or open-coil springs, as
American Journal of Orthodontics and Dentofacial Orthopedics Loriato et al 803
Volume 135, Number 6
well as other methods that would not require patient coop- After a year of treatment, a more favorable position
eration during the tooth uprighting. However, considering of the mandibular right first permanent molar was veri-
the patient’s age and his mixed dentition phase with only 1 fied, and the patient was referred for extraction of the
first deciduous molar in the right side and not enough an- ankylosed deciduous tooth (Fig 7).
chorage teeth, it was not the first choice for interceptive After the surgery, the lip bumper and elastics were
treatment. maintained until the mandibular right first permanent
If none of these alternatives had achieved good re- molar had reached the correct position. Next, a lingual
sults, we could have planned to use mini-implants or holding arch was placed to preserve the arch perimeter
miniscrews for permanent molar uprighting. Although (Figs 8 and 9). In this way, the mandibular right second
these have often been used recently, at the time of this premolar eruption was observed to be within normal
treatment, we had no access to these accessories. standards (Fig 10).
Another problem was eruption deviation of the man- After 4.5 years, the orthodontic interceptive phase
dibular right second premolar. Waiting for the spontane- ended, and the final results were favorable (Figs 11
ous eruption of this tooth after regaining the space and and 12). The patient maintained his facial and skeletal
extracting its deciduous ankylosed tooth was the conser- characteristics, indicating that the mechanics had no
vative alternative. It can be considered that this is the deleterious impact on the dentofacial growth pattern
ideal approach because spontaneous eruption enhances and suggesting that the treatment was effective. A trans-
the possibility of favorable periodontal results. If the ex- palatal arch was then placed to maintain the space until
pected result was not achieved, surgical exposure and eruption of the permanent dentition.
orthodontic traction with fixed or removable appliances
would be another alternative. Phase 2
When the permanent teeth had erupted, except the
TREATMENT PROGRESS third molars, the corrective phase of orthodontic treatment
began. Standard edgewise appliances with .022 x .028-in
Phase 1 slots were bonded and combined with a maxillary bite-
The therapy began with uprighting the mandibular plane to reduce the anterior overbite. The dental arches
right first permanent molar by using a lip bumper com- were aligned and leveled, improving intercuspation and
bined with Class III elastics on the right side (Fig 6). finalizing the treatment. This was uneventful, with routine
High-pull headgear was used to counter the side effects archwire sequences (Fig 13). After this phase, the fixed
of the elastics. To optimize this mechanical effect, a max- appliances were removed, and retention began with a re-
illary acrylic anterior biteplane was placed to disclude movable maxillary circumferential retainer and a remov-
the posterior teeth and reduce the anterior overbite. able mandibular spring retainer.
804 Loriato et al American Journal of Orthodontics and Dentofacial Orthopedics
June 2009
ankylosed tooth is submucosal with considerable defi- 6. Kofod T, Würtz V, Melsen B. Treatment of an ankylosed central
ciency in the alveolar process, the restoration would incisor by single tooth dento-osseous osteotomy and a simple dis-
traction device. Am J Orthod Dentofacial Orthop 2005;127:72-80.
have no benefit for the already established sequelae.
7. Biederman W. Etiology and treatment of tooth ankylosis. Am J
This treatment success was partially due to the Orthod 1962;48:670-84.
patient’s dentofacial growth pattern (Class I). 8. Mullally BH, Blakely D, Burden DJ. Ankylosis: an orthodontic
Late diagnosis of dentoalveolar ankylosis of a decid- problem with a restorative solution. Br Dent J 1995;179:426-9.
uous tooth can have a fundamental impact on the effec- 9. Kurol J. Early treatment of tooth-eruption disturbances. Am J
tiveness and efficiency of orthodontic treatment. An Orthod Dentofacial Orthop 2002;121:588-91.
10. Becker A, Karnei-R’em RM. The effects of infraocclusion: part 1.
effective treatment is defined as one with satisfactory re-
Tilting of the adjacent teeth and local space loss. Am J Orthod
sults. On the other hand, the term efficiency is applied to Dentofacial Orthop 1992;102:256-64.
effective treatments that were concluded in the mini- 11. Becker A, Karnei-R’em RM. The effects of infraocclusion: part
mum amount of time.21 2. The type of movement of the adjacent teeth and their verti-
According to these guidelines, this treatment was ef- cal development. Am J Orthod Dentofacial Orthop 1992;102:
fective, having achieved excellent dental, skeletal, and 302-9.
12. Becker A, Karnei-R’em RM. The effects of infraocclusion: part 3.
facial results, both esthetically and functionally. How-
Dental arch length and the midline. Am J Orthod Dentofacial
ever, it was not efficient. The amount of time to complete Orthop 1992;102:427-33.
phase 1 therapy was too long—more than 4 years— 13. Sassouni V. Orthodontics in dental practice. St Louis: C.V.
because of the late diagnosis and the interceptive treat- Mosby; 1971.
ment. 14. Proffit WR. Philosophy of early treatment: questions and answers.
Proceedings of AAO: When to treat – making decisions: a sympo-
sium on early treatment [CD-ROM]; 2005 Jan 21-23; Las Vegas,
CONCLUSIONS
Nev.
This clinical case illustrates the importance of mon- 15. Ackerman JL, Proffit WR. Preventive and interceptive orthodon-
itoring the development of dental occlusion, from tics: a strong theory proves weak in practice. Angle Orthod 1980;
deciduous dentition on, because of the risk that a late 50:75-87.
16. Starnes LO. Comprehensive phase I treatment in the middle
diagnosis can impact the efficiency of the orthodontic
mixed dentition. J Clin Orthod 1998;32:98-110.
therapy, even when it does not alter its effectiveness. 17. Freeman JD. Preventive and interceptive orthodontics: a critical
review and the results of a clinical study. J Prev Dent 1977;4:
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