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Ankylosed Primary Mola - RS: Results and Treatment Recommendat, Ons From An Eight-Year Longitudinal Study
Ankylosed Primary Mola - RS: Results and Treatment Recommendat, Ons From An Eight-Year Longitudinal Study
PEDIATRICDENTISTRY
Vol. 2, No.1 37
permanent dentition. Typically, there is delayed ex- Purposes of Short-Term and Long-Term Studies
foliation of affected teeth zl with subsequent compli- The purpose of the short-term study was to eluci-
cations such as deflected eruption paths for adiacent date the characteristics of ankylosis of individual
or opposing teeth, z impaction of succedaneous bicus- molars, ~vith respect to age at diagnosis, severity of
pids,%11 localized or generalized loss of needed arch infraocclusion, and distribution of the condition.
length, 21 and tipping of adiacent teeth over the anky- Dentitions in the long-term study were used to
losed primary molar or supraeruption of opposing study the sequelae of ankylosis with respect to over-
teeth. ]~,2~,2z These sequelae may result in malocclu- retention of the primary molar, and the clinical and
sion. radiographic appearance of the succeeding bicuspid
In the past, the treatment of ankylosed primary in comparison with other bicuspids preceded by non-
molars has been largely empirical. Luxation, -° restor- ankylosed primary molars in the same dentitions.
ing the tooth to occlusion ~vith a variety of techniques
and materials, -0~,°’3 and extraction,~,z°, zl have all been Diagnosis of Ankylosis
utilized. While the literature contains many anecdotal The diagnosis was based upon two essential cri-
reports of the relative success of these treatment ap- teria:
proaches, clear documentation of indications, contra- (1.) The entire occlusal surface of the primary
indications and possible sequelae is lacking. In order molar was located at least 1 mmbelow the
to develop more rational bases for treatment, a two- expected occlusal plane as judged from the
part clinical investigation comprising a short-term nearest adjacent non-ankylosed teeth in the
(four-year) study and a long-term (eight-year) study 5same quadrant.
was designed. A group of affected dentitions was fol- (2.) The molar was immobile when subiected man-
lowed longitudinally with periodic examinations, ra- ually to a rocking movement,4 in contrast to
diographs and study models, until complete erup- other (non-exfoliating) primary molars in the
tion of all bicuspids, permanent cuspids, and perma- dentition.
nent second molars. No attempt was made by the The emission of a sharp clear sound on percussion
investigators to dictate treatment of the ankylosed was not an essential criterion because of its subiec-
molars by the attending dentists in order that cur- tivity, a9 Radiographic evidence of bony union was
rently-employed treatment regimes would be used un- ~z
not required because of its variability.
hindered.
Distribution of Primary Molars
The short-term study group comprised 107 denti-
Study Design tions (45 males; 62 females) which at first examina-
tion contained a total of 191 ankylosed molars (Table
Study Population
1). The group included six sibships each containing
A total of 107 healthy Caucasian children of pre- two affected children. Thirty-five dentitions each
dominantly Scandinavian descent, ranging in age from contained a single ankylosed molar and 72 dentitions
three to 12 years and possessing one or more anky- each showed two or more affected molars. The 107
losed primary molars, was studied in the Pediatric ¯ dentitions were studied for four years, during which
Dentistry Clinic of the University of Minnesota time 31 dentitions (29~) showed a recurrence
School of Dentistry. Using periodic clinical and radio- ankylosis involving a further 72 primary molars (Ta-
graphic observations, the history of each ankylosed ble 1 ).
primary molar (test molar), and non-ankylosed pri- Thereafter, the long-term study group contained 46
mary molar in each dentition was followed and ob- dentitions (23 males; 23 females; three sibships each
servations recorded on these teeth and their succeed- with two affected children) totalling 116 ankylosed
ing bicuspids. molars (Table 1).~ These were followed for eight
The majority of children received their dental care years. No additional diagnoses were made during
throughout the study at the clinics of the University the second four years of the study. For this group,
of Minnesota School of Dentistry; the remainder at- the bicuspids preceded by non-ankylosed primary
tended private dentists for regular dental care. In all molars in the same dentitions were pooled as a com-
instances, the ankylosed molar either was ob.served parison group. These teeth were distributed as fol-
periodically, or extracted and appropriate space lows: mandibular first: 9.8; mandibular second: 48 (a
maintenance instituted. No tooth was treated by lux- further three teeth were congenitally absent); maxil-
ation; only ankylosed teeth with congenitally-missing lary first: 86; and maxillary second: 86 (a further two
bicuspids ’were restored’ to occlusion with stainless teeth were congenitally missing). Since many of the
steel crowns. dentitions had contralateral molars affected with
ANKYLOSEDPRIMARYMOLARS
38 MesserandCllne
Table 1. Distribution of ankylosedprimary molarsin i07 affected dentitions
(short- andlong-termstudies)
ankylosis, teeth could not be pair-matched for com- aminedin order to identify distribution characteristics
parisons. Therefore, the findings for each group of for the condition.
ankylosed molars were compared with those for the
corresponding group of pooled non-ankylosed molars.
Data Collected in Long-TermStudy
Overretention of Ankylosed Primary Molars
Data Collected in Short-Term Study
A molar was deemed overretained if it was still in
Age at Diagnosis of Primary Molar Ankylosis position, and immobile, after the contralateral non-
The age of each child at the time of diagnosis of ankylosed primary molar had exfoliated. An ankylosed
each ankylosed molar was recorded, based on clinical molar which became mobile close to the expected ex-
observations and from existing clinical and radio- foliation time was not considered overretained. In in-
graphic records maintained by the clinic before com- stances of ankylosis of a contralateral pair of molars,
mencement of the study. reference was made to tables of chronology, z4 in con-
iunction with an examination of the eruption se-
Extent of Infraocclusion quence for the particular dentition and the status of
Using study models, the extent of infraocclusion of root development of the succedaneous bicuspids.
each ankylosed molar was classified at diagnosis as Clinical, Radiographic, Occlusal and
one of the following: Periodontal Observations on Bicuspids
Slight: The entire occlusal surface was lo- Whenall bicuspids, permanent cuspids and perma-
cated approximately 1 mmbelow the nent second molars were fully erupted, each bicuspid
expected occlusal plane as iudged was air-dried and examined clinically using a mirror
from the two nearest non-ankylosed and explorer* for the following: coronal and radicular
teeth in the same quadrant. morphology, hypoplasia and hypomineralization, co-
ronal position, and rotation. The periodontal tissues
Moderate: The entire occlusal surface was lo- were examinedclinically and radiographically for evi-
cated with both marginal ridges ap- dence of pocket-formation, lamina dura thickening,
proximately level with, or iust cervi- and alveolar bone loss. Observations were made in-
cal to, the contact area of one or both dependently by both authors, each unaware of
adiacent tooth surfaces. In instances whether the bicuspid was preceded by an ankylosed
of ankylosis of two adiacent primary or non-ankylosed molar. Positive findings were re-
molars, the contact area of the first corded only when there was unanimity between ex-
secondary molar was used for refer- aminers using the following criteria:
ence.
Coronal and radicular morphology:
Severe: The entire occlusal surface was lo- The morphological features of contralateral teeth
cated level with or below the inter- were compared with each other and with those de-
proximal gingival tissue of one or scribed by Wheeler (1974), ~-5 and any marked dif-
both adiacent tooth surfaces. ferences recorded.
Distribution Characteristics of Ankylosis
* No. 5DEexplorer, Hu Friedy Manufacturing Co., Chi-
Sequential study models for each child were ex- cago,Illinois’ 60618.
PEDIATRICDENTISTRY
Vol. 2, No.I 39
Table 2. Extent of infraocclusion of 263 ankylosedprimary molarsat initial
diagnosis(short-term study)
ANKYLOSEDPRIMARYMOLARS
40 MesserandCline
Table 3. Three clinical patterns of primary molar ankylosis in 107 dentitions
diagnosed over four-year observation period (short-term study)
Total
Ankylosis Pattern Arch Distribution (no. dentitions) dentitions (%)
III Multiple Molars Mand 3 teeth — 1 pair plus 1 single (8) 24 (22%)
and 4 teeth — 1 pair plus 2 singles (5)
Max 5 teeth —2 pairs plus 1 single (9)
6 teeth —3 pairs (1)
7 teeth —3 pairs plus 1 single (1)
PEDIATRIC DENTISTRY
Vol. 2, No. 1 41
affected in 35 dentitions (3370). Pattern III com- Occlusal Observation on Bicuspids
prised multiple ankylosed molars ranging from three The occlusal observations for test bicuspids are
to seven affected teeth (24 dentitions, or 2270). This shown in Table 5. Amongmandibular first bicuspids,
pattern was viewed as a combination of one, two, or four test teeth (670) and three unaffected bicuspids
three molar pairs (as Pattern I), plus one or more (1170) were in infraocclusion; the difference was not
single occurrences in any quadrant. statistically significant. Inadequate mesiodistal space
was present for 35 test mandibular first bicuspids
Results of Long-TermStudy (55g) and for 15 unaffected mandibular first bicus-
pids (54g). This difference was not statistically sig-
Overretention of Ankylosed Primary Molars nificant. A total of 58 (90.6%) test mandibular first
The treatment histories are summarized in Table 4. bicuspids showed coronal rotation (slight: 41 teeth,
Most mandibular first molars exfoliated on schedule, moderate: 17 teeth, severe: none); among unaffected
and none left residual root fragments. Mandibular bicuspids, only three (11~;) were rotated. Statistically,
second molars were less prone to exfoliation; residual test mandibular first bicuspids were significantly
root fragments were shown by two molars that ex- more frequently rotated than unaffected mandibular
foliated and by four molars that were extracted ahead first bicuspids (Z=7.4672; p<0.01).
of exfoliation. None of the 11 maxillary molars that Among test mandibular second bicuspids, four
were extracted early left root fragments. Five mandib- teeth (llg) were in infraocclusion. This distribution
ular second molars without permanent successors did not differ significantly from that of unaffected
were restored with stainless steel crowns. During the mandibular second bicuspids (four teeth or 8g were
observation period, these teeth became severely infra- in infraocclusion). Eleven test mandibular second bi-
occluded and radiographically showed extensive re- cuspids (30g) and four unaffected bicuspids (8~;)
placement of the periodontal ligament with mineral- showed inadequate mesiodistal space. This difference
ized tissue. Periodic replacement of the crowns was ~vas statistically significant (Z=2.6327, p<0.01). The
required to maintain occlusion. Eventually, orthodon- distribution of rotated mandibular second bicuspids
tic treatment was instituted for one child and the in the test group (21 rotated or 58g) did not differ
tooth was extracted surgically. significantly from that of the unaffected group (29
rotated or 60~o).
Clinical and Radiographic Appearance None of the eleven test maxillary bicuspids were
of Bicuspids infraoccluded; one showed mesiodistal space inade-
Table 5 summarizes the clinical and radiographic quacy and four teeth were rotated. These sample sizes
appearance of the test bicuspids. were deemed too small for statistical comparison with
Amongtest mandibular bicuspids, hypoplasia and/ unaffected maxillary bicuspids.
or hypomineralization defects were seen in 25 of the Periodontal Observations on Bicuspids
64 (39~) first bicuspids and in eight of the 36 (22g)
second bicuspids. In all instances, similar multiple The periodontal observations on the test bicuspids
enamel surface defects were seen in other bicuspids in are shown in Table 5. Amongthe 64 test mandibular
the same dentition, and in no instance could the de- first bicuspids, none of those preceded by first pri-
fects be clearly attributed to ankylosis of the pre- mary molars exfoliating on schedule showed any un-
ceding primary molar or to the treatment procedure usual findings. Of the 11 in the extraction group, the
(observation until exfoliation, or extraction) that had t~vo bicuspids preceded by overretained mandibular
been followed. Very mild fluorosis was seen in 40g first molars both showed periodontal pocketing (3-4
of the 46 dentitions studied. mm), thickening of the lamina dura and inadequate
On radiographic examination, four test bicuspids vertical alveolar bone height. The latter two observa-
showed "V"-shaped notching of the root outline, lo- tions were also recorded for one mandibular first bi-
cated in the middle one-third. In three instances, the cuspid preceded by a primary molar which was ex-
preceding primary molar had been overretained and tracted early. Nbne of the unaffected mandibular first
ex-tracted. Of bicuspids preceded by non-ankylosed bicuspids showed these periodontal findings.
molars, none showed "V" root notching. The distri- Amongthe 16 test mandibular second bicuspids in
bution of apical root flexion did not differ signifi- the exfoliation group, one bicuspid .showed pocket
cantly between bicuspids preceded by ankylosed or formation (3-4 mm)and this tooth, plus a second bi-
non-ankylosed primary molars. cuspid in the same group, showed inadequate vertical
alveolar bone height. Reduced alveolar bone height
was ~Iso shown by a further three bicuspids in the
ANKYLOSEDPRIMARYMOLARS
42 MesserandCline
Table 4. Treatmenthistory for 116 ankylosedmolarsin 46 affected dentitions
(long-termstudy)
Exfoliated on
schedule 53 (83) 16 (39) 0 0 69
Extracted before
exfoliation time 9 (14) 15 (37) 7 (100) 4 (100) 35
Overretained and
extracted 2 (3) 5 (12) 0 0 7
Occlusion restored
with steel crown* 0 5 (12) 0 0 5
Total 64 41 7 4 116
Crown
hypoplasia 2 1 0 1 0 0 4
hypomineralization 17 5 5 2 0 0 29
Root
"v" notching 1 1 0 2 0 0 4
apical flexion 8 2 1 2 1 0 14
Occlusion
infraocclusion 2 2 2 2 0 0 8
m-d space inadequate 30 5 4 7 1 0 47
rotation 47 11 13 8 3 1 83
Periodontal
pocket formation 0 2 1 1 1 0 5
lamina dura thickened 0 3 0 0 1 0 4
alveolar boneloss 0 3 2 4 1 0 10
* Only 111 of the 116 teeth are shownsince five mandibular secondbicuspids
were congenitally absent.
t Preceding primary molar exfoliated on schedule.
11 Precedingprimary molar extracted either before exfoliation time or following
overretention.
PEDIATRICDENTISTRY
Vol.2, No.! 43
late extraction group. None of the unaffected man- subsequent to ankylosis of the mandibular second
dibular second bicuspids showed similar periodontal molar in the same dentition, but there was a high in-
findings. Of the eleven test maxillary bicuspids, peri- cidence of ankylosis of the latter tooth subsequent to
odontal pathology was seen for one maxillary first involvement of the former. Owent has observed that
bicuspid. The periodontal pocket depth was 3-4 mm. ankylosis of maxillary molars usually occurs coinci-
None of the unaffected maxillary bicuspids showed dent with involvement of opposing mandibular mo-
periodontal pocket formation, lamina dura thickening lars, and this is supported by the present observations
or alveolar bone discrepancy. where 30 of the 37 ankylosed maxillary molars were
present in dentitions which also showed mandibular
Discussion involvement. However, it is not an invariable finding
as there were seven instances of affected maxillary
Characteristics of AnkylosedMolars molars where no mandibular molar was involved
As shown previously,12,1~ the mandibular first pri- either initially, or on longitudinal study.
mary molar was the tooth most frequently affected by The present study indicates that individual molars
ankylosis in the present study. Since this tooth usually tend to show a somewhat typical pattern of severity.
shows only slight and rarely moderate infraocclusion, In comparison with mandibular molars, maxillary mo-
and typically exfoliates on schedule, the diagnosis of lars tend to show severe, early involvement and the
ankylosis may be missed. Consequently, it is not sur- relative severity maybe partially reflecting a spurt of
prising that the mandibular second molar, which is alveolar bone growth coincident with the eruption of
usually in more severe infraocclusion, has been con- the maxillary first permanent molars. The relative
sidered to be the tooth most frequently affected by slightness of the typical infraocclusion of the affected
ankylosis.4,13,14 In the present study, maxillary molars mandibular first primary molar may reflect, in part,
were affected less frequently than mandibular molars, a lessened increment in vertical alveolar bone growth
and the maxillary second molar least of all, confirm- occurring in the cuspid-first molar region prior to the
ing the observations of many other surveys on this exfoliation time of the first primary molar.
4,1"~-1
aspect 5of ankylosis. The decided tendencies seen toward multiple oc-
The present study appears to be one of very few currences, contralaterally affected teeth, and lack of
~5,~6
examining the time of diagnosis .of ankylosis. predilection for the side of the arch first affected,
Since a criterion for inclusion of the dentition in the confirm previous studies.4,14, ~9 In the present study,
study was the presence of at least one tooth already only 35 of the 107 dentitions (33~g) in the four-year
ankylosed, the actual onset of the condition for these study showed ankylosis limited to a single molar, and
teeth cannot be determined. Also, the diagnostic cri- the remaining 72 dentitions (67~o) each contained two
teria are applicable only after the tooth has begun or more ankylosed molars totaling 228 affected teeth.
to manifest the condition clinically, and presumably The teeth were distributed in three distinct clinical
the cellular changes occur considerably in advance of patterns which serve to indicate where a contralateral
the clinical picture. Nevertheless, the approx.imations occurrence of the condition is likely to occur, and
made in the present study serve to show that the provide a basis for treatment recommendations, as
four different primary molars are prone to ankylose described below. Contralateral occurrences are more
at various times and that these are usually quite typi- likely in the mandibular arch than in the maxillary,
cal for each molar. and single occurrences are more likely to occur in
Maxillary primary molars tended to ankylose early, the maxillary than in the mandibular arch.
either before the eruption of the maxillary first per-
manent molar (as was shown by most of the second Characteristics of Succeflaneous Bicuspids
primary molars studied) or at approximately the The present study indicates that the presence of a
same time as the maxillary first permanent molar preceding ankylosed primary molar is not likely to
erupted (as seen for most of the maxillary first pri- affect coronal morphologyor to initiate coronal hypo-
mary molars studied). Mandibular primary molars plasia and/or hypomineralization of the succeeding
tended to ankylose later than maxillary molars, the bicuspid. This lends support to the opinion of Kollar
mean age of diagnosis for mandibular first molars be- (1972) 3° that the morphological template of the
ing 7.1 years and 8.0 years for mandibular second crown is established very early in embryological de-
molars. The majority of the mandibular first molars velopment and is not readily altered. For the maiority
became ankylosed soon after the eruption of the first of the ankylosed teeth studied in the present report,
permanent molar in the same quadrant, but this was the crowns of the succedaneous bicuspids were al-
unusual among mandibular second molars. Ankylosis ready fully formed at the time described as the first
of mandibular first molars did not appear to occur clinical diagnosis of the condition. Presumably the
ANKYLOSEDPRIMARYMOLARS
44 MesserandCl|ne
cellular changes involved in the process of ankylosis Prognosis and Treatment Recommendations
had no effect on the coronal tissues of the forming The present investigation did not seek to evaluate
succedaneous tooth. The lack of an increased preva- comparatively the efficacy of several treatment re-
lence of enamel surface defects in the succeeding gimens for ankylosed molars. Instead, the study sought
bicuspids is in contrast to the findings of Rule, to observe the consequences of the three treatment
Zacherl and Pfefferle (1972). 31 In a sample of 262 approaches (observation; extraction; restoration to oc-
bicuspids succeeding ankylosed primary molars, these clusion) utilized by the attending dentists. The lit-
workers described a statistically significant increase erature reveals widely divergent opinions on the treat-
in the number of enamel surface defects over those ment of ankylosed primary molars. Hovell (1966)z~
seen in control bicuspids and speculated on a corre- stated that most cases require no treatment other than
lation between ankylosis and the coronal abnormali- observation, while others recommendsurgical extrac-
ties. The present study examined a larger sample of tion as the usual treatment on the basis that ankylosed
children with ankylosed teeth, and also identified teeth neither exfoliate nor allow the eruption of the
that 40~ of the dentitions demonstrated very mild succeeding permanent teeth.9, z4-3~ 11 Andlaw (1974)
fluorosis. This could have masked additional enamel has developed a more conservative series of treatment
defects of a non-fluorotic origin. recommendations based upon the extent of infraoc-
No clear association was found in the present study clusion of the affected tooth. The present study adds
between apical flexion of the roots of succeeding bi- to those recommendations by taking into considera-
cuspids and "V"-shaped notches in the root periphe- tion also the three clinical patterns of ankylosis de-
ries, and ankylosis of the preceding molars. Notching scribed and the recognized ankylosis characteristics
of the root outline on a radiograph is an equivocal for each type of primary molar.
finding since the appearance of the root outline is The findings of the present study suggest that the
largely dependent upon the radiographic technique maiority of ankylosed mandibular first primary molars
employed. These observations support the conclusion can be expected to become involved after the erup-
of Steigman, Koyoumdiisky-Kaye and Matrai (1974), tion of the mandibular first permanent molar, and
that ankylosed teeth usually have no causative influ- that the condition is likely to becomebilateral. Anky-
2ence on the rate of development of their successorsP losis of other primary molars in the dentition is likely,
Examination of the occlusion of the succedaneous especially of the mandibular second primary molars.
bicuspids suggests that those preceded by an anky- The first primary molar is likely to demonstrate only
losed primary molar are more likely to demonstrate slight, progressing but occasionally to moderate, infra-
inadequate mesiodistal space and to show coronal ro- occlusion and can be expected to loosen and exfoliate
tation. Although these differences were demonstrated on schedule. This expectation confirms the observa-
to be significant statistically, it cannot be concluded tions of Steigmanet al. 1~ on the ankylosis characteris-
to be more than a trend since the entire occlusion of tics of the .mandibular first primary molar. For these
the affected dentitions was not evaluated. In addition, teeth, it is assumed that during the normal process of
the bicuspids used for comparison were located in exfoliation, the ankylosing tissue is resorbed, allowing
the same dentitions which showed ankylosed teeth, the tooth to becomemobile and exfoliate. ]° Rarely is
thereby introducing a bias into the statistical treat- extraction or exfoliation of this tooth followed by
ment of the data. residual root fragments. Therefore, the clinician is
Bicuspids succeeding ankylosed primary molars ap- recommended to monitor dentitions with ankylosed
pear more likely to exhibit periodontal pathology mandibular first molars by employing study models
(and particularly if the molar was overretained or and space measurements, and to extract these teeth
required extraction) than bicuspids succeeding non- only if they are severely infraoccluded and space loss
ankylosed molars. The lack of vertical alveolar bone is imminent. If supraeruption of opposing teeth ap-
height coupled with periodontal pocket formation is pears imminent, restoration of the occlusal surface to
thought to be due to a failure of alveolar bone devel- full vertical dimension could be considered.
opment which normally occurs with exfoliation of the The ankylosed mandibular second primary molar
primary tooth and eruption of the permanent tooth. is likely to be affected bilaterally, and onset is likely
An ankylosed primary molar is retained at its vertical to occur later than that of the mandibular first pri-
position by the ankylosin~ tissue while adjacent teeth mary molar. With time, mandibular second molars
continue to moveocclusally with appositional alveolar tend to become progressively more severely infraoc-
bone growth. The impedance of primary tooth move- cluded than mandibular first molars. Mesial tipping
ment serves to restrict vertical alveolar bone deposi- of the adiacent first permanent molar over the occlu-
tion, hence there may be a reduced amount of bone sal surface of the affected tooth may occur, resulting
surrounding the bicuspid. in loss of arch length. Failure to monitor these teeth
PEDIATRICDENTISTRY
Vol. 2, No.1 45
can result in overretention of the molar and a local- severe infraocclusion, with an onset which may pre-
ized lack of vertical alveolar bone. Ankylosed mandib- cede the eruption of the adjacent first permanent
ular second molars should be kept under close obser- molar. Maxillary first primary molars also tend to in-
vation with study mo~tels and arch length measure- creasingly severe infraocclusion and the onset may
ments. Extraction should be performed if the tooth occur close to the time of eruption of the first perma-
becomes moderately infraoccluded and/or mesial tip- nent molar. Additional ankylosed molars in the man-
ping of the mandibular first permanent molar is im- dibular arch are likely to follow. The obvious severity
minent, or if the molar fails to exfoliate on schedule for of the ankylosis of the maxillary primary molars in the
that dentition. A passive lower lingual arch is a useful present long-term study clearly indicated the need for
space maintainer in the former situation. Following early extraction. It is likely that failure to extract
either extraction or exfoliation of the mandibular sec- these teeth would have resulted in tipping of adja-
ond molar, the area should be examined closely for cent non-ankylosed teeth and consequent loss of arch
root fragments as these may occur following the typi- length and inadequate vertical alveolar bone growth
cally uneven resorption of the mesial and distal roots. leading to compromised periodontal support for the
Restoration of singly affected mandibular molars succeeding bicuspids. Regardless of the severity of
showing only slight infraocclusion with built-up res- the infraocclusion, it is recommendedthat ankylosed
torations or stainless steel crowns appears to be a and immobile maxillary molars be extracted as early
useful interim treatment during the mixed dentition as appears feasible. Since such extractions frequently
period. There must be a permanent successor present require a surgical removal of the tooth on a child
and both the vertical and mesiodistal dimensions of aged seven years or under, appropriate consideration
the crown of the ankylosed tooth need to be main- should be given to the behavior management of the
tained adequately. Active vertical alveolar bone child. In our experience, a distal shoe space main-
growth related to the adjacent unaffected teeth is tainer is a useful appliance in the situation where an
likely to necessitate the periodic replacement of the ankylosed maxillary second primary molar requires
restoration. If however, the primary molar is in mod- extraction prior to the eruption of the adjacent first
erate or severe infraocclusion, the vertical alveolar permanent molar.
bone growth may be hindered and lead to a poor It is recommendedthat the treatment of dentitions
periodontal prognosis for the succeeding bicuspid. with multiple ankylosed teeth be treated by employ-
For such teeth, extraction and appropriate space ing a combination of the approaches recommended
maintenance is recommended. above for individual molars. Siblings in the family
In instances where the primary molar is ankylosed should also be monitored, since a familial tendency
and the permanent molar is congenitally absent, early 5,1~
for the condition has been reported.
orthodontic and prosthodontic consultations should be
Acknowledgments
sought concerning the long-term treatment of the den-
tition. While the vertical and mesiodistal dimensions The assistance of Drs. David McKibbenand John Hinding
of the ankylosed molar can be maintained with res- in the initial clinical phasesof this studyis gratefldly, acknowl-
edged. This study ~vas supported in part by a BiomedicalRe-
torations throughout the mixed dentition, such res- search Support Grant from the National Institutes of Health.
torations can only be considered of interim nature.
Also, after the permanent dentition is established, the
steady remodelling throughout life of alveolar bone
supporting adjacent teeth is likely to require periodic References
replacement of such built-up restorations. Biederman
1. Owen,T. L.: "Ankylosis of Teeth," J Mich State Dent
(1968) -0 has observed that because of cessation of Assoc, 47:347-350,1965.
alveolar bone growth in the immediate area of the 2. Biederman, W.: "The Problemof the AnkylosedTooth,"
ankylosed tooth, the roots of adjacent teeth may be- Dent Clin North Am, July, 409-424, 1968.
come denuded of bone and the tooth lost. Such long- 3. Darling, A. I. and Levers, B. G. H.: "SubmergedHuman
term restorative and periodontal consequences sug- DeciduousMolars and Ankylosis," Arch Oral Biol, 18:
1021-2040,1973.
gest that early consideration be given to extraction of 4. Biederman,W.: "Etiology and Treatment of Tooth Anky-
the ankylosed tooth and space closure instituted in losis," Am] Orthod, 48:670-684, 1962.
conjunction with orthodontic treatment of the denti- 5. Via, W. F.: "Submer~edDeciduous Molars: Familial
tion. Tendencies," ] AmDent Assoc,-69:127-129,1964.
The findings of the present study suggest similar 6. Adamson,K. T.: "The Problem of Impacted Teeth in
Orthodontics," Aust ] Dent, 56:74-84, 1952.
approaches to treatment for both maxillary first and 7. Atrizadeh, F., Kennedy,J., and Zander,H.: "Ankylosisof
second primary molars. Maxillary second primary mo- TeethFollowingThermalInjury," I PeriodontRes, 6:159-
lars tend to show a relatively fast progression towards 167, 1971.
ANKYLOSEDPRIMARY MOLARS
46 MesserandCline
8. Finn, S. B.: Clinical Pedodontics, 4th Ed., Philadelphia: the Age of Fifteen Years," I AmDent Assoc, 20:397-427,
W. B. Saunders Co., 1973, p. 259. 1933.
9. Boyle, P. E., ed.: Histopathology of the Teeth and Their 25. Wheeler, R. C.: Dental Anatomy, Physiology and Occlu-
Surrounding Structures, 4th Ed., Philadelphia: Lea and sion, 5th Ed., Philadelphia: W. B. Saunders Co., 1974,
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