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Lvia Barbosa Loriato
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CASE REPORT
From the Department of Orthodontics, School of Dentistry, Pontifcia Universidade Catolica, Belo Horizonte, Minas Gerais, Brazil.
a
Postgraduate student.
b
Associate professor.
The authors report no commercial, proprietary, or financial interest in the products or companies described in this article.
Reprint requests to: Lvia Loriato, Av. Nossa Senhora da Penha, 570/802, Praia
do Canto, Vitoria, Esprito Santo, Brazil 29055-130; e-mail, lbloriato@yahoo.
com.br.
Submitted, December 2006; revised, March 2007; accepted, April 2007.
0889-5406/$36.00
Copyright 2009 by the American Association of Orthodontists.
doi:10.1016/j.ajodo.2007.04.040
nent teeth or eruption delay.9 Becker and KarneiRem10-12 also added midline shift to the ankylosed
side and extrusion of the antagonist tooth, increasing
the risk of occlusion problems.
Kofod et al6 pointed out that, in a growing child, the
ankylosed tooth does not follow the normal vertical
growth of the alveolar process, and a deficiency occurs,
causing the tooth to be even more impacted.
Diagnosis of dental ankylosis is generally established
through clinical findings, but radiographs can sometimes
add some information. As suggested by Mullally et al,8
although a clinical diagnosis can be made by infraocclusion, percussion, and mobility testing, sometimes lack of
orthodontic movement can confirm the diagnosis.
Since dentoalveolar ankylosis can cause deleterious
effects on occlusal development, early diagnosis and an
effective treatment plan are fundamental to prevent further eruption deviations and more severe malocclusion.
Our aim in this article was to present a patient in the
mixed dentition with dentoalveolar ankylosis of a deciduous molar in which the diagnosis was not made at the
correct time, resulting in a severe malocclusion. As a result, when the diagnosis was established, longer and
more complex treatment was necessary. Although the
treatment was effective, it was not efficient because of
its long duration and biomechanical complexity, caused
by the late diagnosis.
DIAGNOSIS AND ETIOLOGY
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801
apically, between the ankylosed deciduous roots. Cephalometrically, the sagittal and vertical skeletal patterns
were within normal standards, according to the analysis
of Sassouni.13
TREATMENT OBJECTIVES
Phase 1 treatment (interceptive approach) was designed to begin with uprighting the mandibular right
first permanent molar, followed by extraction of the
mandibular right second deciduous molar and space
802 Loriato et al
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803
well as other methods that would not require patient cooperation during the tooth uprighting. However, considering
the patients age and his mixed dentition phase with only 1
first deciduous molar in the right side and not enough anchorage teeth, it was not the first choice for interceptive
treatment.
If none of these alternatives had achieved good results, we could have planned to use mini-implants or
miniscrews for permanent molar uprighting. Although
these have often been used recently, at the time of this
treatment, we had no access to these accessories.
Another problem was eruption deviation of the mandibular right second premolar. Waiting for the spontaneous eruption of this tooth after regaining the space and
extracting its deciduous ankylosed tooth was the conservative alternative. It can be considered that this is the
ideal approach because spontaneous eruption enhances
the possibility of favorable periodontal results. If the expected result was not achieved, surgical exposure and
orthodontic traction with fixed or removable appliances
would be another alternative.
TREATMENT PROGRESS
Phase 1
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805
The interceptive approach corrected the malocclusion caused by the mandibular deciduous molar ankylosis. Of course, this initial orthodontic treatment phase
lasted extremely long. However, the effectiveness of
the phase 1 approach was good, since the interceptive
objectives were obtained.
At the end of phase 2, a favorable facial result was
obtained with the maintenance of normal characteristics
806 Loriato et al
In this patient, late diagnosis of mandibular deciduous molar ankylosis led to several alterations, mainly
transseptal fibers, which are reoriented diagonally downward in the direction to the infraoccluded ankylosed tooth.
There is no consensus in the literature about the
ideal time to start orthodontic treatment. According to
Proffit,14 the gold standard for the right time to begin
orthodontic treatment is the final phase of the mixed
dentition, with early treatment started before this and
late treatment after this. Some situations require early
treatment; one of them is dentoalveolar ankylosis.
In this way, the appropriate treatment after dentoalveolar ankylosis diagnosis should mitigate the
consequences and damages caused by this alteration.
Kurol9 stated that it is easier to implement early treatment, because of the shorter treatment duration and
lower cost.
The orthodontic interceptive approach (phase 1) is
important in the process. According to Ackerman and
Proffit,15 interceptive procedures are intended to eliminate interferences with the normal development of the
occlusion.
According to Starnes,16 phase 1 should ideally begin
between the ages of 6 and 8 years. Between 7 and 9 years
of age, according to Freeman,17 interception of any condition that can influence the growth pattern, tooth development, and eruption should be accomplished.
In this context, Kurol9 pointed out that deviated
eruption requires early diagnosis to intervene at the
ideal moment and intercept the problem. It should
have been done in our patient if the diagnosis was established immediately after the clinical findings.
Another advantage of 2-phase treatment started in
the mixed dentition is that, generally, the patient tends
to be more cooperative. This characteristic was essential
to the success of our case. The relatively complex mechanics and the long treatment time required the
patients efforts and compliance with the therapy.
Loriato et al
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ankylosed tooth is submucosal with considerable deficiency in the alveolar process, the restoration would
have no benefit for the already established sequelae.
This treatment success was partially due to the
patients dentofacial growth pattern (Class I).
Late diagnosis of dentoalveolar ankylosis of a deciduous tooth can have a fundamental impact on the effectiveness and efficiency of orthodontic treatment. An
effective treatment is defined as one with satisfactory results. On the other hand, the term efficiency is applied to
effective treatments that were concluded in the minimum amount of time.21
According to these guidelines, this treatment was effective, having achieved excellent dental, skeletal, and
facial results, both esthetically and functionally. However, it was not efficient. The amount of time to complete
phase 1 therapy was too longmore than 4 years
because of the late diagnosis and the interceptive treatment.
CONCLUSIONS
This clinical case illustrates the importance of monitoring the development of dental occlusion, from
deciduous dentition on, because of the risk that a late
diagnosis can impact the efficiency of the orthodontic
therapy, even when it does not alter its effectiveness.
REFERENCES
1. Consolaro A. Reabsorcoes dentarias nas especialidades clnicas.
Sao Paulo, Brazil: Dental Press Editora; 2002.
2. Moyers RE. Handbook of orthodontics. Chicago: Year Book
Medical Publishers; 1988.
3. Proffit WR, Fields HW. Contemporary orthodontics. St Louis:
C.V. Mosby; 1999.
4. Graber TM, Vanarsdall RL. Orthodontics: current principles and
techniques. St Louis: C.V. Mosby; 2000.
5. Mancini G, Francini E, Vichi M, Tollaro I, Romagnoli P. Primary
tooth ankylosis: report of case with histological analysis. ASDC J
Dent Child 1995;62:215-9.