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Oral Surgery ISSN 1752-2471

CASE REPORT

Management of ankylosed young permanent incisors after trauma and prior to implant rehabilitation
J.A. Calasans-Maia1, A.S. Neto2, M.M.D. Batista3, A.T.N.N. Alves4, J.M. Granjeiro5 & M.D. Calasans-Maia6
1 2

Orthodontic Department, Fluminense Federal University, Nova Friburgo, Brazil Prived Prosthodontic Practice, Niteroi, Brazil 3 Endodontics Department, Gama Filho University, Rio de Janeiro, Brazil 4 Oral Pathology Department, Gama Filho University, Rio de Janeiro, Brazil 5 Cell Therapy Center and Biology Institute, Fluminense Federal University, Niteroi, Brazil 6 Oral Surgery Department, Fluminense Federal University, Niteroi, Brazil

Key words: decoronation, dental implants, dental trauma, grafts Correspondence to: Professor MD Calasans-Maia Departamento de Odontoclnica, Faculdade de Odontologia Universidade Federal Fluminense Rua Mario Santos Braga, 30 24020-140 Niteroi Brasil Tel.: +55 21 26299910 Fax: +55 21 26299911 email: monicacalasans@vm.uff.br Accepted: 25 April 2013 doi:10.1111/ors.12047

Abstract
The objective of this clinical report is to present decoronation of young permanent ankylosed incisors as an option to preserve the alveolar process in young people where implant rehabilitation is not yet indicated. A 13-year-old patient presented with intrusive luxation of the permanent maxillary lateral incisor and lateral luxation of both permanent maxillary central incisors. During 6 months, clinical and radiographic evaluation showed progressive root replacement resorption, and surgical decoronation was recommended for all three incisors and left for a period of 6 years until the implant and grafting procedures be performed. Decoronation in young teeth is a reliable technique in terms of preservation of the width and height of the alveolar process, and improves the aesthetic conditions after installation of the provisional prosthetics. Decoronation may be considered an alternative strategy for complex posttraumatic clinical scenarios, such as young ankylosed incisors.

Clinical relevance
Dental trauma is most common in children between 8 and 14 years old, during the early mixed dentition, a period of incomplete root development and dynamic jaw development. In children and adolescents, ankylosis is accompanied by increasing relative infraposition of the tooth, and a satisfactory outcome prosthetic therapy may be very difcult to achieve. Decoronation is a simple and safe surgical procedure for preservation of alveolar bone prior to implant placement in ankylosed young permanent incisors. It must be considered as a treatment option for teeth affected by replacement resorption where the implant rehabilitation is not yet indicated.
Oral Surgery 7 (2014) 4551. 2013 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd

Introduction
Ankylosis related replacement resorption is frequently observed after severe dental trauma of permanent incisors1. It can be diagnosed after avulsion, lateral luxation, intrusion and root fracture1,2. Factors that predispose the young population to dental trauma include protruded maxillary incisors and incompetent lip closure3. The replacement resorption rate is variable, and is inuenced by age, basal metabolic rate, treatments performed on root surface prior to replantation, the stage of root development at the time of the trauma, severity of the trauma and the extent of periodontal ligament necrosis4,5. In young children, progressive
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infraposition develops gradually6, and in patients 716 years old, the tooth can be lost within 37 years after the onset of root resorption5. In adolescents at the age of between 12 and 14, tooth transplantation is no longer recommended, mostly due to orthodontic reasons1. However, in adults, this process is slower, and the tooth may remain in place for more than 20 years5. The complications that develop as a consequence of ankylosis of a permanent incisor in children and adolescents are the inevitable early loss of the traumatised tooth, the local arrest of alveolar bone development7, the aesthetic deciency, orthodontic complications due to arch irregularity, lack of mesial drift, tilting of adjacent teeth and arch length loss710. In an attempt to avoid such posttrauma complications, ankylosed or heavily resorbed young permanent teeth should not be extracted or surgically removed, but rather treated by decoronation and space maintenance until further treatment is provided811. This technique allows for preservation of the width and height of the alveolar process. In addition, vertical bone apposition is frequently observed on top of the decoronated root8. In view of subsequent implant placement, the bone volume is well preserved, and ridge augmentation procedures may be avoided or only minimal ridge augmentation may be later necessary. Treatment options that consider the extraction of an ankylotic incisor are not routinely recommended since extraction is frequently accompanied by extensive alveolar bone loss, particularly in the presence of a thin maxillary buccal plate. Vertical and horizontal loss of alveolar bone will potentially compromise future surgical and prosthetic treatments12. This clinical report presents an 8-year follow-up of a 13-year-old car accident victim with three ankylosed permanent maxillary incisors. The treatment described was the preservation of the alveolar ridge, and rehabilitation with two implants associated with a xenograft and three-supported porcelain crowns. Decoronation was used to preserve the alveolar bone, and enabled the placement of two implants and a graft insertion after a total of 7 years of dental trauma.

Case report
A 13-year-old boy presented to the emergency room with oral and facial traumatic injuries approximately 2 h after trauma. After medical evaluation, dental examination was required and revealed an intrusive luxation of the permanent maxillary lateral incisor and lateral luxation of both permanent maxillary central incisors. Both central incisors were reduced. Nothing
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was done to the intruded tooth, and no xation was performed after the central incisors reduction. Three months later, the patient was referred to the oral surgery department of Fluminense Federal University. No root canal therapy had been undertaken. The patients chief complaint was the poor appearance of the malpositioned lateral incisor tooth. Hence, an orthodontic device was applied in an attempt to extrude the intruded lateral incisor (Fig. 1A,B). However, the orthodontic extrusion was not successful, and the extraction with intentional reimplantation was carried out and endodontic therapy was initiated for all three incisors, with placement of calcium hydroxide (Fig. 2A,B). For a period of 6 months, the endodontic therapy continued with calcium hydroxide replacement every other 23 weeks. During this period, clinical and radiographic evaluation showed progressive root replacement resorption. At this moment, the patient was almost 14 years old, and surgical decoronation was recommended based on clinical aspects, such as the vertical difference between the ankylosed and adjacent teeth, the future orthodontic treatment planned, space maintenance, aesthetic needs and expectation, and treatment cost (Fig. 3A,B). Under local anaesthesia, a full buccal and palatal mucoperiosteal ap was reected, and the crowns of the right and left maxillary central incisors and the left lateral incisor were removed using diamond burs. The roots were cut 1 mm under the buccal alveolar bone crest, ush with the palatal surface. As the root canal was lled with a blood clot, a periosteum-releasing incision enabled wound edge approximation without tension. The ap was sutured with 4-0 vicryl sutures using the horizontal mattress suturing for primary closure. Implant therapy was initiated 6 years after decoronation of the ankylosed upper lateral and central incisors, and after developmental facial growth completion (Fig. 4A). Computed tomography showed three ankylosed roots with partial resorption, and vertical bone apposition was observed on top of the decoronated roots (Fig. 4B) and clinical aspect during surgery (Fig. 5A). The removal of the ankylosed teeth required ap elevation with a papilla-sparing incision. Horizontal bone deciency was observed after bone exposure. Then, a one 15-mm long, 3.4-mm wide implant (Revolution, SIN, So Paulo, Brazil) was placed in the right upper central incisor region, and one 13-mm long, 3.25-mm wide implant (Try-on, SIN, So Paulo, Brazil) was placed in the left lateral upper incisor region (Fig. 5B). Both tapered screw-type implants were placed using a two-stage surgical protocol and were
Oral Surgery 7 (2014) 4551. 2013 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd

Calasans-Maia et al.

Decoronation of ankylosed young permanent incisors

(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).

inserted in a correct three-dimensional position, resulting, as expected, in a two-wall defect. A xenograft (Osseous, SIN, So Paulo) particulate material was mixed with blood and applied to cover the exposed implant surface (Fig. 5C).
Oral Surgery 7 (2014) 4551. 2013 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd

After 3 months, the implants were surgically exposed, and provisional resin crown were adjusted to facilitate aesthetic healing of the soft tissues. The prosthetic rehabilitation was nished with three splinted porcelain crowns supported by two implants (Fig. 6A,B).
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(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.

Discussion
Although decoronation of ankylosed teeth is considered the rst treatment option for young growing patients, many professionals still do not accept it as a therapeutic option. The damage inicted on the periodontal structures by intrusive and lateral luxation injuries can result in various types of root surface resorption, which are dependent on the severity of the trauma and if imme48

diate treatment was provided1. In the present case, the intruded lateral incisor was expected to re-erupt spontaneously, and therefore no immediate treatment was performed. However, no clinical change was observed after 3 months, and therefore the patient was referred for orthodontic extrusion. This second approach was also unsuccessful. The tooth was surgically reposition by intentional luxation as an attempt to maintain the natural tooth aesthetics, but the surgically repositioned tooth became ankylosed in its new position presenting
Oral Surgery 7 (2014) 4551. 2013 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd

Calasans-Maia et al.

Decoronation of ankylosed young permanent incisors

(A)

(B)

(C)
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.

Oral Surgery 7 (2014) 4551. 2013 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd

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Decoronation of ankylosed young permanent incisors

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progressive infraocclusion over time. At this stage, the patient was almost 14 years old, and the nal treatment option was coronal amputation and implant placement. Decoronation in young teeth is a reliable technique in terms of preservation of the width and height of the alveolar process1315. The bone apposition following decoronation is well described in the literature as simpler and more economic than block ridge augmentation, and it results in the improvement of aesthetic conditions after installation of the provisional prosthetics1315. Such improvement was gained in this clinical case after decoronation and before full rehabilitation with implant-supported prosthesis. The correct three-dimensional placement of dental implants following dental/alveolar trauma requires a bone volume that is often less than ideal due to posttrauma ridge alterations. Crestal bone dehiscences may be managed with implant placement and simultaneous peri-implant bone augmentation provided that the implant can be inserted with sufcient primary stability in a restorable position, and that the peri-implant bone defect has a morphology with at least two bone walls16. Xenografts derived from natural bone sources have been extensively investigated in multiple experimental and clinical studies17,18. To eliminate the risk of immunological reactions and disease transmission, the organic component is removed by heat treatment, by chemical extraction method or by a combination of the two. Since the rst reports of bovine spongiform encephalopathy, there has been a particular preoccupation on the ability of these extraction methods to completely eliminate protein from the bovine bone source17. Previous clinical reports have described cases of prosthetic implant rehabilitation after decoronation. One of these cases has shown that decoronation itself did not preserve the alveolar bone volume. In such case, a bone augmentation procedure was performed with a xenograft, followed by implant placement approximately two and half years after the grafting procedure19. In this case, we described decoronation that was performed 6 years after trauma. Residual roots were removed simultaneous to implant installation, and xenograft procedures were performed for additional horizontal bone augmentation. The xenograft employed 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 ridge is desired to a level corresponding to that of the adjacent teeth. Maxillary skeletal and dental growth results in evident changes in all three dimensions during active development. In this case, the three decorona50

tions were performed 9 months after the trauma. Since the patient was almost 14 years old, denitive rehabilitation through ossoeintegrated implant treatment would not be appropriate once these do not present the compensatory growth mechanism of natural dentition. Therefore, the skeletal maturity and not the chronological age of the patient was considered to avoid an undesirable aesthetic outcome of the implantsupported nal prosthesis. This case report supports the belief that replacement resorption following severe dental trauma may be treated by decoronation, even though other treatment approaches were unsuccessful. This surgical procedure is a simple and conservative technique to avoid bone loss, aesthetic disturbances and excessively invasive treatments.

References
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Oral Surgery 7 (2014) 4551. 2013 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd

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Decoronation of ankylosed young permanent incisors

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Andreasen FM, Andersson L, editors: Textbook and Color Atlas of Traumatic Injuries to the Teeth, 3rd edition. Copenhagen: Munksgaard, 2007:587635. Kohavi D. Dental implants. In: Birnstein E, Needleman HL, Karimbux N, Van Dyke TE, editors: Periodontal and Gingival Health and Diseases: Children, Adolescents and Young Adults, 1st edition. London: Informa Healthcare, 2001:27580. Filippi A, Pohl Y, von Arx T. Treatment of replacement resorption with Emdogain-preliminary results after 10 months. Dent Traumatol 2001;17:1348. Sapir S, Kalter A, Sapir MR. Decoronation of an ankylosed permanent incisor: alveolar ridge preservation and rehabilitation by an implant supported porcelain crown. Dent Traumatol 2009;25:3469. Filippi A, Pohl Y, von Arx T. Decoronation of an ankylosed tooth for preservation of alveolar bone prior to implant placement. Dent Traumatol 2001;17:935.

16. von Arx T, Buser D. Horizontal ridge augmentation using autogenous block grafts and the guided bone regeneration technique with collagen membranes: a clinical study with 42 patients. Clin Oral Implants Res 2006;17:35966. 17. Wenz B, Oesch B, Horst M. Analysis of the risk of transmitting bovine spongiform encephalopathy through bone grafts derived from bovine bone. Biomaterials 2001;22:1599606. 18. Calasans-Maia MD, Ascoli FO, Novellino ATNA, Rossi AM, Granjeiro JM. Comparative histological evaluation of tibial bone repair in rabbits treated with xenografts. Acta Ortopedica Brasileira 2009;17:3403. 19. 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;23:8794.

Oral Surgery 7 (2014) 4551. 2013 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd

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