Part III: Treating Children With Ankylosed Permanent Teeth

PA R T I I I : T R E AT I N G C H I L D R E N WITH ANKYLOSED PERMANENT TEETH

THE ANKYLOSIS PATIENT

The tooth most likely ankylosed at age 11 to 12

The patient is now 15

The patient is female

Prior to figuring out what we should do, there are still a few questions that we need to address:

How fast is the resorption occurring? As can be seen from the radiographs that the patient brought, the rate of resorption seems to be progressing very slowly. (Figure 2)

Where is the smile line? The patient has a very low smile line and does not show the FGM. (Figure 3)

Where is she in relationship to her growth? Females generally are done growing at the age of 17. Given that she is 15 years of age now, it is anticipated that she is near the end of her growth phase. Figure 2

TREATMENT OPTIONS AND CONCERNS FOR THE ANKYLOSED TOOTH

The treatment options are:

Extract the tooth and prepare for implant placement

Subluxate the tooth and orthodontically reposition

Use a segmental osteotomy to orthodontically reposition to the desired area

Leave the tooth in its current position and restore the esthetics

If the tooth is extracted, she will need hard tissue augmentation, will have to wait until she is 17-years-old to have an implant placed, and we will need to provide an interim tooth replacement option throughout this time period. The downside of this option, as far as the ankylosis patient and her family are concerned, is that this is a very formidable time in her life. Managing appointments, schedules and interim

tooth replacement would be difficult.

Figure 3

Subluxating the tooth and orthodontically repositioning it into the desired position will have limited success depending on how much of the tooth is ankylosed. This option typically works better on teeth that only have partial or spot ankylosis.

Using a segmental osteotomy to reposition the desired tooth can be successful depending on the surgical approach, but could be very problematic if necrosis of the segment were to occur.

What about leaving the ankylosed tooth for now and improving the esthetics by adding to the incisal edge? Will this create more problems? What we already know is:

The replacement resorption is occurring slowly (so it could possibly be maintained for another 5-10 years)

The patient is 15 and near the end of her growth phase (so the defect created by the ankylosis shouldn’t appreciably increase)

The patient has a low smile (so you don’t see the gingival margin discrepancy) Although the tooth could be extracted now in preparation for a single tooth implant, the decision was made to leave the tooth and restore the incisal edge length with composite. (Figure 4)

Figure 4

The ankylosis patient and her family knew that the composite was an interim restoration and that the tooth would require extraction and implant placement in the future. The question of when depends on the rate that the resorption progresses. In this patient, the tooth lasted another 10 years before it required extraction. (Figure 5)

Figure 5

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PA R T I V : T H E U S E OF DECORONATION

Typically when managing ankylosis in permanent teeth in children, it is advisable to remove the ankylosed tooth prior to significant growth so that the subsequent eruption of the natural teeth during growth doesn’t create a significant hard and soft tissue defect. However, as surgeons know all to well, trying to extract ankylosed teeth can be a difficult undertaking.

In this example, we have an 11-year-old male who received trauma to the maxillary anterior when he was 10 years old and subsequently had ankylosis of tooth #8. (Figure 1)

Figure 1

As can be seen radiographically, the root resorption is occurring at a significant rate given that the trauma only occurred approximately one year ago. At this time though, there hasn’t been much change in the incisal edge or FGM positions. With this in mind, the tooth can be monitored.

The parents are informed that continued recalls are imperative so that the tooth can be extracted prior to formation of a significant hard and soft tissue defect. This must be stressed to the parents because if the patient gets lost in the system or doesn’t return for recalls the defect will become greatly amplified and the treatment needed to correct it will be more difficult. At the age of 12, a change in the incisal edge position and FGM location can be seen. (Figure 2)