Articles - Forum Implantologicum

Article

Feature Article

DE FR IT ES 日本語中文 TR PT

Feb 08, 2023 // 11 min read

Treatment Options in the Case of Ankylosis After Traumatic Dental Injuries in Growing Individuals

Simon Storgård Jensen

Eva Fejerskov Lauridsen

DOI: 10.3290/iti.fi.45703

ankylosis traumatic dental injury complications treatment planning bone regeneration

Abstract

Ankylosis may occur after traumatic dental injuries and especially after luxation-type injuries. Ankylosis may progress slowly or fast but will eventually lead to loss of the tooth. In growing individuals, ankylosis leads to infraposition of the affected tooth. For the same reason, implant treatment is not recommended before alveolar growth has terminated to avoid implant infraposition. In selected cases, orthodontic space closure or autotransplantation of a premolar may be the ideal permanent tooth replacement when ankylotic teeth are lost in childhood or early adolescence. In other cases, different interceptive treatment options exist to limit the dimensional changes of the alveolar ridge and to preserve hard and soft tissue in the case of ankylosis. These include decoronation, sandwich osteotomy and ridge preservation. This article discusses characteristics of clinical scenarios suitable for each treatment alternative, and presents a decision tree that can be applied when ankylosis is identified.

Epidemiology

More than one billion people currently alive have experienced traumatic dental injuries (TDI), and the prevalence of TDI in the primary and permanent dentition are 22.7% and 15.2%, respectively. This would rank TDIs fifth if included on the WHO list of the world’s most frequent acute/chronic diseases and injuries (Petti et al. 2018). Males are affected more often than females (1.5:1) and the highest frequency of TDIs in the permanent dentition is observed at between 8 and 12 years of age (Skaare & Jacobsen 2003).

More than 75% of TDIs involve the maxillary anterior teeth and thus affect what is usually termed “the esthetic zone” (Skaare & Jacobsen 2003). Fortunately, most TDIs have a good prognosis if adequately diagnosed and treated (dentaltraumaguide.org). However, luxation injuries in terms of avulsions and intrusions are particularly characterized by an increased risk of developing healing complications (Andreasen et al. 2006).

Fig. 1: Repair-related resorption. Periapical radiograph of a left central maxillary incisor. On the mesial aspect repair-related resorption can be observed as an irregularity of the root surface with an intact periodontal ligament space

Fig. 2: Infection-related resorption. Periapical radiograph of a right central maxillary incisor. On the mesial and distal aspects of the root surface irregularities can be observed with corresponding radiolucencies in the alveolar bone

Fig. 3: Ankylosis. A series of periapical radiographs of a previously avulsed left central maxillary incisor over an observation period of 10 years in an adult patient. The root substance is gradually replaced by alveolar bone with clear signs of infraposition

Fig. 4a: Ankylosis. Clinical presentation of ankylosed right central maxillary incisors: Infraposition has led to tilting of the adjacent teeth towards the ankylosed tooth

Fig. 4b: Ankylosis. Clinical presentation of ankylosed right central maxillary incisors: Severe infraposition with a clinically significant shift in the facial mucosal margin compared to the healthy un-injured adjacent central incisor. A composite build-up of the incisal part of the crown has been performed to mask the shift in incisal edge

Fig. 5a: Orthodontic closure. Clinical presentation after surgical removal of ankylosed 11 and 21 after previous avulsion and replantation. Note the anterior open bite due to the previous infraposition of the two central incisors

Fig. 5b: Orthodontic closure. Periapical radiographs of the anterior maxilla after surgical removal of 11 and 21. There are no radiographic signs of injuries to 12 or 22

Fig. 5c: Orthodontic closure. Clinical presentation after orthodontic mesialization of the entire upper dentition supported using a palatal temporary anchorage device (TAD) and after providing 12 and 22 with full-ceramic crowns

Fig. 5d: Orthodontic closure. Periapical radiograph after final prosthetic restoration. Observe the severe resorption of 12 and 22 that prevented complete mesialization to the position of the central incisors. As a result, the ideal design of the ceramic restoration is compromised

Fig. 6: Decoronation. Periapical radiographs of a boy with previous luxation injuries to 12, 11 and 21 at the age of 10. a: At the age of 11 after endodontic treatment of 11; b: At the age of 12. Ankylosis of 11 was diagnosed through developing infraposition of 11 and high sound on percussion. A decoronation was performed including removal of the root canal filling; c: At the age of 14. Continuous vertical; alveolar growth coronal to the root of 11. Obliteration of 12 is observed and 21 has been endodontically treated; d: At the age of 15. Ongoing osseous replacement of the root 11 is observed

Fig. 7a: Sandwich osteotomy. Clinical presentation of 19-year-old male with previous avulsion and replantation of 11. The clinical crown of 11 is considered suitable to serve as a long-term provisional. However, infraposition including an apical shift in the facial mucosal margin suggests the tooth is ankylosed

Fig. 7b: Sandwich osteotomy. Periapical radiograph of 11 showing osseous replacement of the endodontically treated root of 11. No close proximity to the roots of adjacent teeth is observed

Fig. 7c: Sandwich osteotomy. Incision in the mobile mucosa, periosteal elevation in the apical direction and osteotomy around the ankylosed root of 11

Fig. 7d: Sandwich osteotomy. The transport segment is mobilized

Fig. 7e: Sandwich osteotomy. An interpositional xenogenic block graft is placed to stabilize the transport segment in the new position

Fig. 7f: Sandwich osteotomy. An osteosynthesis plate is applied for additional stabilization in the correct position

Fig. 7g: Sandwich osteotomy. Clinical presentation five years after sandwich osteotomy

Fig. 7h: Sandwich osteotomy. Periapical radiograph showing slow ongoing osseous replacement of the ankylosed root

Fig. 8a: Ridge preservation. Clinical presentation of an 18-year-old female with ankylosed 21 after a previous avulsion of 21 and lateral luxation of 22

Fig. 8b: Ridge preservation. Close-up of infrapositioned 21 with grayish discoloration of the crown. The gingival papilla facing 22 appears inflamed

Fig. 8c: Ridge preservation. Periapical radiograph of 21 and 22 showing ankylosis on the distal aspect of 21. Intact periodontal ligament space around endodontically treated 22

Fig. 8d: Ridge preservation. Collagen-containing xenogenic bone substitute material

Fig. 9a: Autotransplantation. Clinical presentation 37 years after autotransplantation of a mandibular second premolar to the region 11. The transplanted tooth is prosthetically rehabilitated with a full-ceramic crown and the surrounding soft tissue appears healthy

Fig. 9b: Autotransplantation. Periapical radiograph 37 years after autotransplantation of a mandibular second premolar to the region 11. The root canal is obliterated, the periodontal ligament space is within normal range and there are no signs of root resorption or periapical inflammation

Fig. 10: Decision tree when ankylosis is diagnosed. Decision tree with factors related to growth, clinical and radiographic parameters that may influence the choice of treatment