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Inside Dentistry
October 2018
Volume 14, Issue 10

What Treatment Options Are Available To Manage Trauma- Induced Dentoalveolar Ankylosis in the Growing Individual?

Sonia Leziy, DDS | Sean P. Avera, DDS, MS | Jim Janakievski, DDS, MSD | David French, DDS

Sonia Leziy, DDS, maintains a full-time practice in Vancouver, British Columbia, is an associate clinical professor at the University of British Columbia, and is the vice president of clinical affairsfor the Seattle Study Club.

Sean P. Avera, DDS, MS, maintains a private practice specializing in periodontics and implant dentistry in Auburn and Grass Valley, California.

Jim Janakievski, DDS, MSD, maintains a private practice in Tacoma, Washington, is an affiliate assistant professor at the University of Washington, and teaches at Spear Education in Scottsdale, Arizona.

David French, DDS, maintains a full-time private practice focused on surgical implant dentistry in Calgary, Alberta, and is a part-time clinical faculty member at the University of British Columbia.

Sonia Leziy, DDS: Trauma sustained by young, growing patients presents a treatment planning dilemma because traditional bridges and implants cannot be considered until growth is complete. Severe injuries to permanent teeth such as avulsion (ie, separation injury) and intrusion (ie, crushing injury), result in damage to the periodontal ligament, triggering an inflammatory process and necrosis of its cells. Progenitor cells from the bone, which are involved in its breakdown and deposition, override the ability of "root-oriented" cells to repopulate the root surface, resulting in dentoalveolar ankylosis and replacement resorption. Teeth associated with these complications have low reported 5-year survival rates,1,2 and their eventual loss cannot be prevented.

Diagnosis of early ankylosis involves an assessment for the absence of mobility (eg, Miller index, Periotest to quantify movement) and the presence of a high-pitched sound on percussion that is not made by the adjacent healthy teeth. Although a traditional, 2-dimensional radiographic examination is generally only valuable in late diagnosis, a 3-dimensional  cone-beam computed tomography image may assist with earlier identification. Infraocclusion and gingival margin discrepancies are both late indicators of the problem. Early detection and management in children and adolescents is essential to reduce the esthetic problems associated with soft- and hard-tissue changes and identify the immediate, transitional, and long-term restorative and surgical steps required to improve the treatment outcomes. Several review articles provide insights on diagnosis, treatment planning considerations, and treatment options.3-5

In addition to solutions involving surgical management, clinicians must also consider transitional prosthetic treatment options that do not interfere with growth and tissue development. Where autotransplantation or space closure is not possible, unilateral bonded restorations or removable prostheses are generally recommended.

Sean P. Avera, DDS, MS: Currently, there are several options to manage the negative sequalae associated with blunt force trauma to the dentoalveolar complex when reimplantation results in ankylosis. Unfortunately, dental trauma usually affects the premaxillary segment and occurs primarily within the first and second decades of life.6 Approximately 1% to 16% of all dental trauma involves avulsed teeth.7 Therefore, depending on demographics, this event may occur more often in certain practices.

Proper management of this event is paramount to avoid negative sequalae as the patient matures. The lack of a proper protocol or the inability to follow protocol will result in delayed reimplantation and loss of the viability of the periodontal complex. As mesenchymal cells compete to repopulate the reimplanted root surface, ankylosis ensues. The resulting cessation of tooth migration causes infrapositioning and arrested development of the surrounding alveolar bone. As a consequence, at the time of maturation, the patient will be subjected to a myriad of functional and esthetic challenges in the dentogingival complex that require interdisciplinary dental care.

Depending on the age of the patient, the practitioner is obligated to use the treatment option that provides the most conservative, reliable, predictable, and cost-effective procedure to treat these cases8. If autotransplantation is not an option or if reimplantation results in ankylosis, decoronation of the tooth9 may provide such a remedy. Research has shown that vertical growth of the socket takes place in patients with residual vertical alveolar growth when the tooth is decoronated.10-12 As this collagen fiber-driven maturation of the ridge occurs, the residual root will continue to experience resorption and maintain ridge topography.

As the patient reaches maturation, restorative procedures may commence and, if needed, these can be accompanied by hard- and soft-tissue augmentation to achieve both functional and esthetically pleasing results using contemporary osseointegration protocols.

Decoronation of ankylotic teeth in the growing patient can provide a relatively predictable solution to probable ridge discrepancies and functional abnormalities.

Jim Janakievski, DDS, MSD: Trauma-induced dentoalveolar ankylosis of an anterior tooth in a growing patient creates a challenge for the dental team. If the tooth is left in position, it will result in infraocclusion and a compromised alveolar ridge once the child enters a growth phase. A decision must be made about the best way to manage the ankylosed tooth. Treatment options usually focus on extraction and decoronation. In later adolescence, a segmental osteotomy with orthodontic distraction may be possible.

Another option that is not often considered is tooth autotransplantation. This involves extraction of the ankylosed tooth and transplantation of a premolar tooth to the incisor position. Autotransplantation can provide a natural functional tooth replacement for young patients, allowing the alveolus to grow as all of the teeth erupt and develop.

To execute this treatment with favorable outcomes, the dental team must be aware of some specific treatment protocols. The ankylosed tooth is extracted first, then an osteotomy is prepared within the socket. Next, the premolar tooth must be harvested without excessive injury to the periodontal ligament. The most optimal time to harvest the donor tooth is when it has an open apex and is approximately one-half to three-quarters of the way developed. It is immediately placed in the recipient site and stabilized with sutures.

After several months of healing, the transplanted tooth will develop a periodontal ligament and a revascularized pulp. At this time, it can be moved into an ideal position orthodontically. Following orthodontic movement, a composite resin restoration can be used to transform the premolar into a central incisor.

Many clinicians are not aware of this option; thus, it is not usually considered when deciding how to treat a growing patient with an ankylosed incisor. Long-term studies have concluded that the success rate for this procedure is above 90%. With a successful outcome, the young patient will have a functional tooth that allows for alveolar development during his or her growth years and beyond.

David French, DDS: Although ankylosis is rare, congenitally missing teeth, which have a prevalence between 3% and 7%,13can serve as examples of management of totally ankylosed teeth by removal because even when a primary tooth is not present, the alveolus erupts with adjacent teeth due to the transeptal fibers. These cases are routinely treated with dental implants once growth is complete; however, they typically require horizontal bone augmentation. Following tooth extraction, transeptal fibers reform as part of the socket remodeling process, and the removal of ankylosed teeth results in a similar process.14

Vertical bone augmentation is difficult and has a limited evidence base,15 so the removal of ankylosed teeth before infraocclusion occurs is critical among growing patients to prevent vertical alveolar growth restriction.16 Removal can be accomplished by drilling centrally into the root and hollowing it out to where it meets either periodontal ligament or bone. This maintains the socket dimension and can be done using a flapless approach.

The potential benefit of socket grafting after the removal of ankylosed teeth is less clear, especially considering that socket grafting is not even part of the standard of care following conventional extractions. When compared with ungrafted sockets, socket grafting has been shown to achieve only 1.6 mm of ridge preservation,17 and there are no studies that provide long-term (ie, more than 5-year) outcomes for implants.18 Furthermore, the use of socket grafting in a growing patient has never been evaluated, and it is doubtful that the 1.6 mm of bone "gained" would be retained after years of remodeling. Although a nonresorbing graft could be used, the particulate remnants may inhibit the transeptal fibers that allow vertical growth. The bone deficiency expected after ankylosed tooth removal and growth will require horizontal bone augmentation, but this type of augmentation has been well-proven in prospective studies of greater than 5 years,18 and systematic reviews report survival rates of greater than 95%.19

References

1. Barrett EJ, Kenny DJ. Survival of avulsed permanent maxillary incisors in children following delayed replantation. Endod Dent Traumatol. 1997;13(6):269-275.

2. Humphrey JM, Kenny DJ, Barrett EJ. Clinical outcomes for permanent incisor luxations in a pediatric population. I. Intrusions. Dent Traumatol. 2003;19(5):266-273.

3. Andersson L, Malmgren B. The problem of dentoalveolar ankylosis and subsequent replacement resorption in the growing patient. Aust Endod Jo. 1999;25(2):57-61.

4. Campbell KM, Casas MJ, Kenny DJ. Ankylosis of traumatized permanent incisors: pathogenesis and current approaches to diagnosis and management. J Can Dent Assoc. 2005;71(10):763-768.

5. Day P, Duggal M. Interventions for treating traumatized permanent front teeth: avulsed (knocked out) and replanted. Cochrane Database Syst Rev. 2010;1:CD006542.

6. Gassner R, Bösch R, Tuli T, et al. Prevalence of dental trauma in 6000 patients with facial injuries: implications for prevention. Oral Surg Oral Med Oral Path Oral Radiol Endod. 1999; 87(1):27-33.

7. Cohen S, Burns RC. Pathways to the Pulp. 6th ed. Maryland Heights, Missouri. Mosby-Year Book;1994.

8. Cohenca N, Stabholz A. Decoronation - a conservative method to treat ankylosed teeth for preservation of alveolar ridge prior to permanent prosthetic reconstruction: literature review and case presentation. Dent Traumatol. 2007;23(2):87-94.

9. Malmgren, Cvek M, Lundberg M, et al. Surgical treatment of ankylosed and infrapositioned reimplanted incisors in adolescents. Scand J Dent Res. 1984;92(5):391-399.10. Malmgren B. Decoronation: how, why, and when? J Calif Dent Assoc. 2000;28(11):846-854

11. Andreasen JO, Malmgren B, Bakland LK. Tooth avulsion in children: To replant or not. Endodontic Topics. 2006;14(1):28-34.

12. Malmgren O, Malmgren B. Orthodontic Management of the Traumatized Dentition. In: Andreasen JO, Andreasen FM, Andersson L, eds. Textbook and Color Atlas of Traumatic Injuries to the Teeth. 4th ed. Oxford, UK: Blackwell Publishing Ltd;2007:669-715.

13. Polder BJ, Van't Hof MA, Van der Linden FP, et al. A meta-analysis of the prevalence of dental agenesis of permanent teeth. Community Dent Oral Epidemiol. 2004;32
(3):217-226.

14. Chase SW, Revesz JD. Reestablishment of Transseptal Fibers Following Extraction. J Dent Res. 1944;23(5):333-336.

15. Aghaloo TL, Moy PK. Which hard tissue augmentation techniques are the most successful in furnishing bony support for implant placement? Int J Oral Maxillofac Implants. 2007;22(Suppl):49-70.

16. Elnayef B, Monje A, Gargallo-Albio J, et al. Vertical Ridge Augmentation in the Atrophic Mandible: A Systematic Review and Meta-Analysis. Int J Oral Maxillofac Implants. 2017;32(2):291-312.

17. Van der Weijden F, Dell'Acqua F, Slot DE. Alveolar bone dimensional changes of post-extraction sockets in humans: a systematic review. J Clin Periodontol. 2009;36(12):1048-1058.

18. Vignoletti F, Matesanz P, Rodrigo D, et al. Surgical protocols for ridge preservation after tooth extraction. A systematic review. Clin Oral Implants Res. 2012;23(Suppl 5):22-38.

19. Buser D, Chappuis V, Bornstein MM, et al. Long-term stability of contour augmentation with early implant placement following single tooth extraction in the esthetic zone: a prospective, cross-sectional study in 41 patients with a 5- to 9-year follow-up. J Periodontol. 2013;84(11):1517-1527.

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