Managemnt of Ankylosed Young Permanent Incisors After Trauma

C A S E R E P O R T

Management of ankylosed young permanent incisors after traumaand prior to implant rehabilitationJ.A. Calasans-Maia1, A.S. Neto2, M.M.D. Batista3, A.T.N.N. Alves4, J.M. Granjeiro5 & M.D. Calasans-Maia6

1Orthodontic Department, Fluminense Federal University, Nova Friburgo, Brazil2Prived Prosthodontic Practice, Niteroi, Brazil3Endodontics Department, Gama Filho University, Rio de Janeiro, Brazil4Oral Pathology Department, Gama Filho University, Rio de Janeiro, Brazil5Cell Therapy Center and Biology Institute, Fluminense Federal University, Niteroi, Brazil6Oral Surgery Department, Fluminense Federal University, Niteroi, Brazil

Key words:decoronation, dental implants, dental trauma,

grafts

Correspondence to:Professor MD Calasans-Maia

Departamento de Odontoclínica, Faculdade de

Odontologia

Universidade Federal Fluminense

Rua Mario Santos Braga, 30

24020-140 Niteroi

Brasil

Tel.: +55 21 26299910

Fax: +55 21 26299911

email: [email protected]

Accepted: 25 April 2013

doi:10.1111/ors.12047

Abstract

The objective of this clinical report is to present decoronation of youngpermanent ankylosed incisors as an option to preserve the alveolar processin young people where implant rehabilitation is not yet indicated. A13-year-old patient presented with intrusive luxation of the permanentmaxillary lateral incisor and lateral luxation of both permanent maxillarycentral incisors. During 6 months, clinical and radiographic evaluationshowed progressive root replacement resorption, and surgical decoronationwas recommended for all three incisors and left for a period of 6 years untilthe implant and grafting procedures be performed. Decoronation in youngteeth is a reliable technique in terms of preservation of the width and heightof the alveolar process, and improves the aesthetic conditions after instal-lation of the provisional prosthetics. Decoronation may be considered analternative strategy for complex posttraumatic clinical scenarios, such asyoung ankylosed incisors.

Clinical relevance

Dental trauma is most common in children between 8and 14 years old, during the early mixed dentition, aperiod of incomplete root development and dynamicjaw development. In children and adolescents, ankylo-sis is accompanied by increasing relative infraposition ofthe tooth, and a satisfactory outcome prosthetic therapymay be very difficult to achieve. Decoronation is asimple and safe surgical procedure for preservation ofalveolar bone prior to implant placement in ankylosedyoung permanent incisors. It must be considered as atreatment option for teeth affected by replacementresorption where the implant rehabilitation is not yetindicated.

Introduction

Ankylosis related replacement resorption is frequentlyobserved after severe dental trauma of permanentincisors1. It can be diagnosed after avulsion, lateralluxation, intrusion and root fracture1,2. Factors thatpredispose the young population to dental traumainclude protruded maxillary incisors and incompetentlip closure3.

The replacement resorption rate is variable, and isinfluenced by age, basal metabolic rate, treatmentsperformed on root surface prior to replantation, thestage of root development at the time of the trauma,severity of the trauma and the extent of periodontalligament necrosis4,5. In young children, progressive

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Oral Surgery ISSN 1752-2471

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© 2013 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd

infraposition develops gradually6, and in patients 7–16years old, the tooth can be lost within 3–7 years afterthe onset of root resorption5. In adolescents at the ageof between 12 and 14, tooth transplantation is nolonger recommended, mostly due to orthodontic rea-sons1. However, in adults, this process is slower, andthe tooth may remain in place for more than 20years5.

The complications that develop as a consequence ofankylosis of a permanent incisor in children and ado-lescents are the inevitable early loss of the traumatisedtooth, the local arrest of alveolar bone development7,the aesthetic deficiency, orthodontic complications dueto arch irregularity, lack of mesial drift, tilting of adja-cent teeth and arch length loss7–10. In an attempt toavoid such posttrauma complications, ankylosed orheavily resorbed young permanent teeth should not beextracted or surgically removed, but rather treated bydecoronation and space maintenance until furthertreatment is provided8–11. This technique allows forpreservation of the width and height of the alveolarprocess. In addition, vertical bone apposition is fre-quently observed on top of the decoronated root8. Inview of subsequent implant placement, the bonevolume is well preserved, and ridge augmentationprocedures may be avoided or only minimal ridgeaugmentation may be later necessary. Treatmentoptions that consider the extraction of an ankyloticincisor are not routinely recommended since extrac-tion is frequently accompanied by extensive alveolarbone loss, particularly in the presence of a thin maxil-lary buccal plate. Vertical and horizontal loss of alveolarbone will potentially compromise future surgical andprosthetic treatments12.

This clinical report presents an 8-year follow-up of a13-year-old car accident victim with three ankylosedpermanent maxillary incisors. The treatment describedwas the preservation of the alveolar ridge, and reha-bilitation with two implants associated with axenograft and three-supported porcelain crowns.Decoronation was used to preserve the alveolar bone,and enabled the placement of two implants and a graftinsertion after a total of 7 years of dental trauma.

Case report

A 13-year-old boy presented to the emergency roomwith oral and facial traumatic injuries approximately2 h after trauma. After medical evaluation, dentalexamination was required and revealed an intrusiveluxation of the permanent maxillary lateral incisor andlateral luxation of both permanent maxillary centralincisors. Both central incisors were reduced. Nothing

was done to the intruded tooth, and no fixation wasperformed after the central incisors reduction. Threemonths later, the patient was referred to the oralsurgery department of Fluminense Federal University.No root canal therapy had been undertaken. Thepatient’s chief complaint was the poor appearance ofthe malpositioned lateral incisor tooth. Hence, anorthodontic device was applied in an attempt toextrude the intruded lateral incisor (Fig. 1A,B).However, the orthodontic extrusion was not success-ful, and the extraction with intentional reimplantationwas carried out and endodontic therapy was initiatedfor all three incisors, with placement of calciumhydroxide (Fig. 2A,B).

For a period of 6 months, the endodontic therapycontinued with calcium hydroxide replacement everyother 2–3 weeks. During this period, clinical andradiographic evaluation showed progressive rootreplacement resorption. At this moment, the patientwas almost 14 years old, and surgical decoronation wasrecommended based on clinical aspects, such as thevertical difference between the ankylosed and adjacentteeth, the future orthodontic treatment planned, spacemaintenance, aesthetic needs and expectation, andtreatment cost (Fig. 3A,B).

Under local anaesthesia, a full buccal and palatalmucoperiosteal flap was reflected, and the crowns ofthe right and left maxillary central incisors and the leftlateral incisor were removed using diamond burs. Theroots were cut 1 mm under the buccal alveolar bonecrest, flush with the palatal surface.

As the root canal was filled with a blood clot, aperiosteum-releasing incision enabled wound edgeapproximation without tension. The flap was suturedwith 4-0 vicryl sutures using the horizontal mattresssuturing for primary closure.

Implant therapy was initiated 6 years after decoro-nation of the ankylosed upper lateral and central inci-sors, and after developmental facial growth completion(Fig. 4A). Computed tomography showed three anky-losed roots with partial resorption, and vertical boneapposition was observed on top of the decoronatedroots (Fig. 4B) and clinical aspect during surgery(Fig. 5A). The removal of the ankylosed teeth requiredflap elevation with a papilla-sparing incision. Horizon-tal bone deficiency was observed after bone exposure.Then, a one 15-mm long, 3.4-mm wide implant(Revolution®, SIN, São Paulo, Brazil) was placed in theright upper central incisor region, and one 13-mmlong, 3.25-mm wide implant (Try-on®, SIN, São Paulo,Brazil) was placed in the left lateral upper incisor region(Fig. 5B). Both tapered screw-type implants wereplaced using a two-stage surgical protocol and were

Decoronation of ankylosed young permanent incisors Calasans-Maia et al.

46 Oral Surgery 7 (2014) 45–51.


inserted in a correct three-dimensional position,resulting, as expected, in a two-wall defect. A xenograft(Osseous®, SIN, São Paulo) particulate material wasmixed with blood and applied to cover the exposedimplant surface (Fig. 5C).

After 3 months, the implants were surgically exposed,and provisional resin crown were adjusted to facilitateaesthetic healing of the soft tissues. The prostheticrehabilitationwasfinishedwith three splintedporcelaincrownssupportedbytwoimplants (Fig. 6A,B).

(A) (B)

Figure 1 Upper right lateral incisor intruded and orthodontic extrusion without success, clinical (A) and radiographic aspects (B).

(A) (B)

Figure 2 Lateral incisor after the surgical repositioned and established with orthodontic device, clinical (A) and radiographic aspects (B).

Calasans-Maia et al. Decoronation of ankylosed young permanent incisors

47Oral Surgery 7 (2014) 45–51.


Discussion

Although decoronation of ankylosed teeth is consid-ered the first treatment option for young growingpatients, many professionals still do not accept it as atherapeutic option.

The damage inflicted on the periodontal structuresby intrusive and lateral luxation injuries can result invarious types of root surface resorption, which aredependent on the severity of the trauma and if imme-

diate treatment was provided1. In the present case, theintruded lateral incisor was expected to re-erupt spon-taneously, and therefore no immediate treatment wasperformed. However, no clinical change was observedafter 3 months, and therefore the patient was referredfor orthodontic extrusion. This second approach wasalso unsuccessful. The tooth was surgically repositionby intentional luxation as an attempt to maintain thenatural tooth aesthetics, but the surgically repositionedtooth became ankylosed in its new position presenting

(A) (B)

Figure 3 (A) Clinical aspects of the infraposition of the ankylosed teeth; (B) infraposition shows one eighth of the homologous tooth crown.

(A) (B)

Figure 4 (A) Intraoral aspect 5 years after decoronation; (B) Computed tomography scan showing the vertical bone augmentation after decoronation

procedure.


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(A)

(C)

(B)

Figure 5 (A) Clinical reminiscent roots (arrows); (B) both implants placed and (C) particulate xenograft covering the buccal implants dehiscences.

(A) (B)

Figure 6 Six months after prosthetic rehabilitation with a porcelain bridge supported by two implants. (A) and (B) Clinical aspect of the gingival levels.


49Oral Surgery 7 (2014) 45–51.


progressive infraocclusion over time. At this stage,the patient was almost 14 years old, and the finaltreatment option was coronal amputation and implantplacement.

Decoronation in young teeth is a reliable techniquein terms of preservation of the width and height ofthe alveolar process13–15. The bone apposition follow-ing decoronation is well described in the literatureas simpler and more economic than block ridge aug-mentation, and it results in the improvement of aes-thetic conditions after installation of the provisionalprosthetics13–15. Such improvement was gained in thisclinical case after decoronation and before full reha-bilitation with implant-supported prosthesis.

The correct three-dimensional placement of dentalimplants following dental/alveolar trauma requires abone volume that is often less than ideal due to post-trauma ridge alterations. Crestal bone dehiscences maybe managed with implant placement and simultaneousperi-implant bone augmentation provided that theimplant can be inserted with sufficient primary stabilityin a restorable position, and that the peri-implant bonedefect has a morphology with at least two bone walls16.Xenografts derived from natural bone sources havebeen extensively investigated in multiple experimentaland clinical studies17,18. To eliminate the risk of immu-nological reactions and disease transmission, theorganic component is removed by heat treatment, bychemical extraction method or by a combination of thetwo. Since the first reports of bovine spongiformencephalopathy, there has been a particular preoccu-pation on the ability of these extraction methods tocompletely eliminate protein from the bovine bonesource17. Previous clinical reports have described casesof prosthetic implant rehabilitation after decoronation.One of these cases has shown that decoronation itselfdid not preserve the alveolar bone volume. In suchcase, a bone augmentation procedure was performedwith a xenograft, followed by implant placementapproximately two and half years after the graftingprocedure19. In this case, we described decoronationthat was performed 6 years after trauma. Residual rootswere removed simultaneous to implant installation,and xenograft procedures were performed for addi-tional horizontal bone augmentation. The xenograftemployed has been tested in laboratory models(rabbits) and presented osteoconduction18.

The timing of the decoronation procedure is critical,particularly when vertical growth of the alveolar ridgeis desired to a level corresponding to that of the adja-cent teeth. Maxillary skeletal and dental growth resultsin evident changes in all three dimensions duringactive development. In this case, the three decorona-

tions were performed 9 months after the trauma. Sincethe patient was almost 14 years old, definitive reha-bilitation through ossoeintegrated implant treatmentwould not be appropriate once these do not present thecompensatory growth mechanism of natural dentition.Therefore, the skeletal maturity and not the chrono-logical age of the patient was considered to avoidan undesirable aesthetic outcome of the implant-supported final prosthesis.

This case report supports the belief that replacementresorption following severe dental trauma may betreated by decoronation, even though other treatmentapproaches were unsuccessful. This surgical procedureis a simple and conservative technique to avoid boneloss, aesthetic disturbances and excessively invasivetreatments.

References

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Managemnt of Ankylosed Young Permanent Incisors After Trauma

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