Surgical treatment of ankylosed and

infrapositioned reimplanted incisors

in adolescents

BARBRO MALMGREN, MIOMIR CVEK, MARGARETA LUNDBERG AND ANDERS

FRYKHOLM'

Departments of Pedodontics and Oral Roentgendiagnosis^, Eastmaninstitutet, Stockholm, Sweden

Malmgrcn B, Cvek M, Lundberg M, Frykholm A: Surgical treatment of ankylosed and

inirapositioned reimplanted incisors in adolescents. ScandJ Dent Res 1984; 92: 391-9.

Abstraci - A method for preserving the alveolar ridge of ankylosed and infrapositioned incisors
and improving conditions for a subsequent prosthetic therapy is described and evaluated clinically
and radiographically. The method involves removal of the crown and root filling from the root,
which is retained and covered with a mucoperiosteal flap. Clinically, there were no postoperative
complications and after the follow-up a satisfactory prosthetic restoration was performed in all
cases, regardless ofthe degree of infraposition before treatment. Radiographically, no pathologic
changes were observed apart from a continuous resorption and replacement of lost root substance
by bone. Alveolar bone level shifted only slightly between postoperative and 12-month follow-up
radiographs, in a majority of cases in a coronal direction.

Key words: ankylosis; infraposition; reimplantation; surgical treatment.

B. Malmgren, Department of Pedodontics, Easttnaninstitutet, Dalagatan 11, S-113 24 Stockholm,
Sweden. .
Accepted for publication 15 January 1984. . . ^ '

The most frequent complication after reim-
plantation of exarticulated teeth is resorption
of the root, associated with ankylosis and
continuous replacement of lost root sub-
stance by bone (1). No therapy has been
found for this condition. Providing no other
changes supervene, the ankylosed tooth can
be retained until the crown falls off or is
removed by forceps (2) when most ofthe root
substance has been replaced by bone.
In children and adolescents, however, the
ankylosis is accompanied by increasing in-
fraposition of the tooth, often with tilting of
neighboring teeth (3-5). Normally, such a
tooth should be removed before these
changes become so advanced that a satis-
factory prosthetic treatment is difficult to
perform. Clinical experience shows, how-
ever, that extraction ofthe tooth may involve
loss of ankylosed bone, particularly the thin
buccal plate ofthe maxilla. If infraposition is
allowed to progress, even an uncomplicated
extraction may lead to a further undesirable
lowering ofthe alveolar ridge (6). The litera-
392 MALMGREN ET AL.
ture gives no information on how or when an
ankylosed and infrapositioned incisor should
be removed.
Considering the nature of the resorption
process, however, it appears logical to as-
sume that the crown of an ankylosed tooth
can be removed and the root left in the
alveolus to be replaced by bone. Further-
more, it has been shown experimentally that
new marginal bone may form over the
coronal surface of submerged roots covered
with a mucoperiosteal flap (7-11). One
might therefore expect such a treatment to
preserve the alveolar ridge and improve the
conditions for subsequent prosthetic therapy.
Very few inflammatory changes were seen
when the vital roots had been submerged (7-
9), whereas this was a consistent finding
periapically and pericoronally in submerged
roots treated endodontically (9—11). Endo-
dontic sealers were considered to cause irri-
tation and guttapercha filling to be an ob-
stacle to complete bone healing and, possi-
bly, a pathway for contamination in inade-
quately filled root canals. These findings
suggest that an existing filling in ankylosed
teeth should be removed before the root is
covered with a mucoperiosteal flap. It has
been shown that the empty lumen in
polyethylene tubes (12, 13) and root (14)
implants as well as empty root canals can be
invaded by connective tissue, especially if a
Fig. I. A, mucoperiosteal flap is raised, coronal surface of root is lowered below c^\i^c (il ,il\i(il.ir boiu- and
root canal is filled with blood. B, the flap is pulled over alveolus and sutured; remodeled crown is attached
with composite material to adjacent teeth.
blood clot has formed previously (13, 15, 16).
The purpose of the present investigation
was, therefore, clinically and radiographi-
cally to study in young individuals the
changes of the alveolar ridge after the crown
of ankylosed and infrapositioned incisors has
been removed and the retained root covered
with a mucoperiosteal flap, with reference to
the outcome ofa subsequent prosthetic resto-
ration and changes in the alveolar bone level.
Material and methods
The material comprised 24 reimplanted maxillary
incisors in patients aged 11-19 yr (mean 15 yr),
selected consecutively from patients followed-up
routinely for traumatic injuries at Easlmaninsti-
tutet in Stockholm. Three teeth in which a second-
ary crown-root fracture was an intermediate rea-
son for treatment were included. The patients and
their parents consented to the treatment after
being informed about the nature ofthe ankylosing
process and conceivable positive or negative results
of treatment.
All teeth exhibited, clinically and radiographi-
cally, ankylosis and some degree of infraposition.
Radiographically, no other changes were seen
except in two teeth, which presented changes
resembling inflammatory root resorption (1) in the
cervical area. Due to buccal displacement or
correction of infraposition by reconstruction ofthe
crown, the degree of infraposition could not be
measured in some cases. It was therefore estimated
clinically and on plaster models and classified as a
fraction ofthe crown. It varied between one-fifth
 SURGICAL TREATMENT OF ANKYLOSED INCISORS 393

and three-fourths of the homologuc crown's
length.
Sixteen teeth were root-filled with guttapercha,
seven with calcium hydroxide, and one tooth was
vital, showing formation of hard tissue in the
pulpal lumen.
Clinical procedures
Local anesthesia (Xylocain-2% adrenalin, Astra)
was administered and a marginal incision made
palatally, followed by loosening of periosteum
from the alveolar bone. Buccally, the marginal
incision was extended over adjacent teeth and
continued at a right-angle over the alveolar crest
(Fig. 1). The buccal mucoperiosteal flap was then
raised and the crown removed at the enamel-
eementum junction with a diamond bur in an air-
turbine hand-piece, using water spray. Thereafter,
the root surface was carefully ground down to a
level 1.5-2.0 mm below the edge of the marginal
bone. This was done with a cylindrical diamond
bur, rotating from the root canal outwards, during
continuous flushing of the area with sterile saline.
The root filling was then removed, guttapercha
with root canal reamers and calcium hydroxide
with files, and the canal was thoroughly rinsed
with saline. Thereafter, the canal was allowed to
nil with blood. Finally, the mucoperiosteal flap
was pulled over the alveolus and sutured with
single sutures (Mersilene—Ethicone, Johnson &
Johnson). Extension of the mucoperiosteal flap by
horizontal incisions in the periosteum was not
performed in order to avoid undesirable shorten-
ing of the mucobuccal fold (7). Care was taken to
ensure that a blood clot formed in the gap between
buccal and palatal mucosa, which persisted in
most cases. The treatment was completed by
remodeling the removed crown with a composite
material and using it as a temporary pontic, fixed
to adjacent teeth by acid-etching and enamel
composite bond. In three teeth this was not
possible and a removable prosthetic appliance was
inserted.
At the end of the follow-up a composite retained
onlay bridge was performed in all cases.
Follow-up
The patients were seen clinically after 1, 3 and 12
wk and thereafter in connection with radiographic
follow-ups. The radiographs were taken immedi-

Fig. 2. A, infiaposition judged as l/5th of crown. B, C and D, 3 wk and 3 and 6 months after treatment.
Note downgrowth of gingiva over alveolus. Patient was wearing removable prosthetic appliance.
394 MALMGREN ET AL.

Fig, 3. A, infraposition for about l/4th of crown. B and C, 3 wk and 3 months after treatment. Remodeled
crown was used as a pontic and on the latter occasion removed and shortened in order to allow further
downgrowth of gingiva. D, result 12 months after treatment.

ately before and after treatment and then after 6,
12 and 18 months. Three patients who received
orthodontic treatment and seven under the age of
13 yr who did not have fully erupted canines, were
followed by routinely obtained radiographs. In an
attempt to obtain periodically identical exposures
ofthe alveolar ridge in the remaining 14 cases, a
device was designed by one of us (A.F.). An acrylic
splint resting on fully erupted molars and canines
was prepared for each patient. The splint was
firmly connected by an attachment to the device,
which kept the radiographic cone and a holder for
film, adjusted parallel to the long axis ofthe tooth,
in a fixed position. When repeated exposures were
taken on a phantom model, the vertical movement
of a cervically placed horizontal line was at most
0.1 mm. The radiographs obtained immediately
after treatment and at 6 and 12 month follow-ups
were magnified 5 times in a photographic en-
larger, and the marginal outline of the alveolar
bone and the shape of adjacent teeth were traced
on transparent paper. The images obtained from
the follow-up radiographs were superimposed on
the image from the radiograph taken immediately
after treatment, and the differences were registered
in two ways.
One involved measuring the bone level's verti-
cal difference in the middle of the alveolar ridge,
i.e. the place where most bone resorption can be
expected to occur after extraction. This was
measured with a millimeter rule to the nearest half
or whole millimeter, so that the maximum reading
error was 0.25 mm. The values were then divided
by the magnifying factor 5, i.e. the reading error
was reduced to 0.05 mm.
The other registration method involved measur-
ing the surface between the outlines of the mar-
ginal bone level in postoperative and follow-up
radiographs. The surface apical or coronal of the
postoperative bone level was traced in a digitizer
connected to a Nord-10 computer and the surface
area calculated according to the formula of GREEN
(17). To reduce the reading error, each tracing
was performed three times and the mean value was
used. The values obtained in mm^ were divided by
25.
 SURGIGAL TREATMENT OF ANKYLOSED INGISORS 395

-f T Y

Fig. 4. A, infraposition for about l/3rd of crown. Note open bite. B, result 12 months after present and
concomitant orthodontic treatment. Fig. 5. A, infraposition for about 3/4ths of crown. B, result 12 months
after treatment.

alveolar segment's clinical height was ob-

Results
Clinically, there were no postoperative
complications. The wound healed normally
in all cases but one. In that case a narrow
fold of mucosa that could be probed to a
depth of about 2 mm persisted in the middle
of the alveolar ridge; at the 6-month follow-
up this fold was excised, after which the
mucosa healed by first intention. During
follow-up, a thickening or "downgrowth" of
the mucosa over the alveolus was clearly
visible in most cases (Fig. 2). In seven pa-
tients wearing a composite retained pontic,
this thickening was so advanced that the
pontic, becoming an obstacle, had to be
removed and shortened (Fig. 3). There was
no difference in relation to the age of the
patients. In seven patients treated before the
^ge of 13 yr, no further lowering of the
served during the observation period. At the
end of the follow-up, an aesthetically and
functionally satisfactory prosthetic restora-
tion could be performed in all cases (Figs. 3 -
5).
Radiographically, no pathologic changes
were observed apart from a continuous re-
sorption of the root and replacement of lost
substance by bone. After 18 months, the
remnants of the root were still present in 13
patients, while in 11 patients only normal
alveolar bone was seen in the radiographs.
Results on the vertical shift of the alveolar
bone level in the middle of the alveolus are
shown in Table 1 together with those for the
surface between the outlines of the alveolar
bone levels in postoperative and follow-up
radiographs, for 14 patients followed
through periodically identical exposures.
396 MALMGREN ET AL.

Table I
Distribution of 14 maxillary incisors, followed with periodically identical radiographs, according to age and degree of
infrapo.sition before treatment, vertical difference and surface area between outlines ofalevolar bone level in postoperat
and 6- and 12-month follow-up radiographs in coronal ( -i-) or apical ( — ) direction, and the time of noticed (n) or
completed (c) formation of lamina dura

Changes in alveolar bone level

Infraposition Formation of
Age as fraction Vertical shift Surface area (mm^) lamina dura
Tooth yr of crown (mm) at 12 m at 6 m (6-12 m)* at 12 m n c

11 15 1/5 + 1.0 + 5.8 (+1.3) + 7.1 6 12

21 14 1/5 + 1.0 + 4.6 ( + 1.4) + 6.0 6 12
21 16 1/3" + 0.8 + 2.6 (+1.5) + 4.1 6 12
11 14 1/2 + 0.6 + 2.9 ( + 0.6) + 3.5 6 12
11 16 1/4 + 0.6 - 0.3 ( + 3.0) + 2.7 12 18
21 16 1/4 + 0.5 + 0.4 ( + 2.5) + 2.9 6 12
21 17 1/2 + 0.3 + 8.7 (-1.3) + 7.4 6 12
11 16 1/3 + 0.3 + 2.1 (-0.9) + 1.2 6 12
21 13 1/4 0.0 + 1.2 ( + 0.9) + 2.1 6 12
11 17 1/5 0.0 + 3.4 (-0.7) + 2.7 6 12
21 16 1/3 0.0 - 0.3 (-0.8) - 1.1 6 12
11 19 1/5 -0.3 - 4.8 ( + 2.7) - 2.1 6 12
11 19 3/4 -0.8" -11.1 ( + 0.4) -10.7 12 18
21 19 1/3 -1.3 -14.4 ( + 4.2) -10.2 12 18

* Diiference between 6- and 12-nionth follow-ups.

" Vital tooth.
'' Removable prosthetic appliance.

After 12 months, the shift of the alveolar
bone level in a coronal direction ranged from
0.2 to 1.0 mm in eight cases, and in an apical
direction from 0.3 to 1.3 mm in three cases.
In three cases the alveolar bone level did not
differ between postoperative and follow-up
radiographs. The surface area coronal to the
postoperative bone level ranged from 2.1 to
7.4 mm^ in 10 patients and apically from 1.1
to 10.7 mm^ in four patients.
Some formation of alveolar bone was ob-
served in all patients (Figs. 6-10). In relation
to changes in the alveolar bone level, two
patterns of bone formation were observed in
the radiographs. When the alveolar bone
level moved coronally, the formation of new
marginal bone was clearly seen coronal to
the retained root (Figs. 6, 7), sometimes
distinguished from its coronal surfaee (Fig.
8). In eases in which the alveolar bone level
remained unchanged (Fig. 9) and in those in
which the level moved apically (Fig. 10), the
formation of bone merely involved differenti-
ation of lamina dura marginally across the
alveolus. Once the formation of lamina dura
had been completed, no further changes in
the alveolar bone level were observed.
Discussion
The results of this investigation show that
with the present method the alveolar bone
around the retained root of ankylosed and
infrapositioned incisors can be preserved and
conditions for subsequent prosthetic therapy,
improved. A satisfactory prosthetic restora-
 SURGICAL TREATMENT OF ANKYLOSED INGISORS 397

% . 6. A and B, before and iniincdialrly after treatment. C and 1), 6 and \2 months after treatment. Note
shortened pontic and formation of new marginal bone coronal to root remnants. Vertical shift of
alveolar bone level 1.0 mm; area of newly formed bone 6.0 mm^ Fig. 7. A, infraposilion for about 1/2 of
crown. Note cervical inflammatory resorption. B, immediately after treatment. C and D, 6- and 12-
month follow-ups. Shift of alveolar bone level in middle of alveolus in coronal direction 0.3 mm; area of
newly formed bono 7.4 mm^. Fig. 8. A, calcium hydroxide in root canal, cervical crown-root fracture. B,
immediately after treatment. C and D, 6- and 12-month follow-ups. Successive formation of new
marginal bone (7.1 mm^) over retained root but distinguished from its coronal surface.
398 MALMGREN ET AL.

Fig. 9. A and B, before and after treatment. C and D, 6 and 12 months after; unchanged alveolar bone
level and differentiation of lamina dura at alveolar margin. Fig. 10. A and B, before and imtnediately after
treatment. C and D, 6- and 12-month follow-ups: alveolar bone level shifted apically 0.8 mm; area of lost
bone substance 10.7 mm^. Same patient as in Fig. 5. The patient was wearing a removable prosthetic
appliance.

tion could be performed in all cases, regard-
less of the degree of infrapo.sition before
treatment. Replacement of resorbed root
substance, placing a mucoperiosteal flap
over the alveolus, and formation of new
marginal bone in most cases, may all have
contributed to this result. Removal of endo-
dontic fillings from the root canal caused no
adverse reactions.
The reason for the clinically observed
thickening or "downgrowth" of the mucosa
over the alveolus could not be investigated.
Reorganization of the mucoperiosteal flap
and, possibly, formation of new bone could
be a conceivable explanation.
When evaluating the results obtained by
measuring changes of the alveolar bone, it
should be kept in mind that the error in-
volved in taking identical radiographs in
patients may have been greater than with a
phantom model. For ethical reasons, i.e.
repeated exposure to X-rays, such an error
could not be assessed in patients but it could
hardly exceed the values of recorded
changes. These changes, e.g. in respect of
alveolar bone level, were small, but indicate
a preserved, and in a majority of cases a
coronally increased, height of the alveolar
ridge which is of prosthetic significance.
In the patients treated before the age of 13
 SURGICAL TREATMENT OF ANKYLOSED INCISORS
yr, i.e. before or during pubertal periods of
growth, no further infrapositioning of the
alveolar segment occurred during the ob-
servation period but conditions were im-
proved for the subsequent prosthetic
therapy. In these patients, changes in the
alveolar bone level were not evaluated
because a follow-up with periodically identi-
cal radiographs could not be performed for
practical reasons.
The clinical findings suggest, however,
that the removal of the crown and a part of
the root to which the circular ligament was
attached may have enabled the alveolar
segment to adapt to further maxillary devel-
opment even though the ankylosed root was
left in the alveolus. This point will be discus-
sed in a following paper.
While the findings in the present study
seem to warrant the conclusion that all
ankylosed teeth can be treated by the
method described, they give no indication as
to when the treatment should be performed.
It appears logical, however, that the infrapo-
sition should not be allowed to progress too
far, not just for aesthetic reasons but because
treatment of extreme cases may give less
satisfactory results. Furthermore, the treat-
ment should be considered for patients with a
rapidly progressing infraposition, tendency
to buccal displacement ofthe tooth and a risk
of tilting of neighboring teeth. This occurs
most frequently in children injured before or
during the pubertal growth spurt. In such
cases, the discomfort of wearing a temporary
appliance should be weighed against the
benefits of early treatment to ensure success-
ftil prosthetic restoration later.
Acknowledgment - The investigation was supported
by a grant from Stockholms lans landsting 15. NYGAARD-OSTBY B. The role ofthe blood clot
(TandvardsnSmnden TA 8004-0604, 1980).
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