AAO2016Manuscript Tae-Woo Kim...Distraction osteogenesis for implant site development using a novel orthodontic device: a case report. IntJ Periodontics Restorative Dent 2008;28:189-96

How to treat open bite or upper anterior protrusion cases with ankylosed teeth

Tae-Woo Kim DDS MSD PhDProfessor, Department of Orthodontics

School of DentistrySeoul National University

Seoul, Korea

Introduction

Interdisciplinary treatment

Review of Literatures

Open bite

Upper anterior protrusion

Summary

Introduction

Interdisciplinary

treatment


Open bite


Summary

Interdisciplinary Treatment

• Impaction (ankyloses) of lower molars

Case 1 Case 2

1) If there is an erupting lower third molar, it may be recommended to extract the impacted first or second molar as one of options.

Case 1 Case 2

1) If there is an erupting lower third molar, it may be recommended to extract the impacted first or second molar as one of options.

2) If there is an erupting upper third molar, the extruded or malpositionedupper second molar may be extracted.

3) Regarding the interdisciplinary approach, oral surgeons should be realized the possibility of second molar extraction.

Introduction



Open bite


Summary


1) 2013 https://www.aaoinfo.org/node/6252) 2014 https://www.aaoinfo.org/node/23823) 2015 https://www.aaoinfo.org/node/4792

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More questions are welcome

Etiology of Open bite

There are several causes of open bite.

Open

bite

Mouth

breathing

Tongue

thrusting

TMD

Macro-

glossia

Thumb

sucking

Ankylosed

incisors

Open-bite cases look very similar. All of open bites have different causes.

Open

bite

Mouth

breathing

Tongue

thrusting

TMD

Macro-

glossia

Thumb

sucking

Ankylosed

incisors

• Ankylosis or anchylosis (from Greek ἀγκύλος, bent, crooked) is a stiffness of a joint due to abnormal adhesion and rigidity of the bones of the joint, which may be the result of injury or disease.

(From Wikipedia, the free encyclopedia)

Open bite caused by an ankylosed central incisor

Traumatic injuries of the incisors cause several problems;

① avulsion,1

② pulp necrosis,1

③ crown fracture,2

④ tooth discoloration,2

⑤ external root resorption,1

⑥ intrusion,3

⑦ impaction,4 or ⑧ ankylosis.1

1. Hecova H, Tzigkounakis V, Merglova V, Netolicky J. A retrospective study of 889 injured permanent teeth. Dent Traumatol 2010;26:466-75.2. Chang HY, Chang YL, Chen HL. Treatment of a severely ankylosed central incisor and a missing lateral incisor by distraction osteogenesis and orthodontic treatment. Am J Orthod Dentofacial Orthop 2010;138:829-38. 3. Campbell KM, Casas MJ, Kenny DJ. Development of ankylosis in permanent incisors following delayed replantation and severe intrusion. Dent Traumatol 2007;23:162-6.4. Macías E. Posttraumatic impaction of both maxillary central incisors. American Journal of Orthodontics and Dentofacial Orthopedics 2003;124:331-8.

• Ankylosis is a common complication associated with the reimplantation of an avulsed maxillary incisor.3

• Ankylosis/replacement resorptions were observed in 21(42.9%) of 49 replanted teeth in Hecova’s retrospective study of 889 injured permanent teeth.1

1. Hecova H, Tzigkounakis V, Merglova V, Netolicky J. A retrospective study of 889 injured permanent teeth. Dent Traumatol 2010;26:466-75. 3. Campbell KM, Casas MJ, Kenny DJ. Development of ankylosis in permanent incisors following delayed replantation and severe intrusion. Dent Traumatol 2007;23:162-6.

• The anterior openbite may be limited only to the ankylosed incisor6-8,13-17 or involve the whole anterior teeth.2,5,8,10,12

Diagnosis of Ankylosis

1. Ankylosis often can be identified by the metallic sound when percussing the teeth,

2. the lack of mobility,3. the lack of periodontal space on the

radiographic examination.

Shafer WG, Hine MK, Levy BM. Textbook of oral pathology. 4th ed. Philadelphia: Saunders; 1983. p. 540-1.


1. Ankylosis often can be identified by the metallic sound when percussing the teeth,

• Shafer WG, Hine MK, Levy BM. Textbook of oral pathology. 4th ed. Philadelphia: Saunders; 1983. p. 540-1.• Campbell KM, Casas MJ, Kenny DJ, Chau T. Diagnosis of ankylosis in permanent incisors by expert ratings, Periotest and digital sound wave analysis. Dent

Traumatol 2005;21:206-12.

By using digital sound wave analysis, the ankylosed incisors will exhibit a higher proportion of their signal energy in high frequency bands, and this can be used for detection of the sound. But most of the time, the change in the percussion sound is hardly distinguishable.


2. Ankylosis often can be identified by the lack of mobility,

Shafer WG, Hine MK, Levy BM. Textbook of oral pathology. 4th ed. Philadelphia: Saunders; 1983. p. 540-1.

However, if the area of ankylosis is small or located on the buccal or lingual surface of the tooth, it is difficult to identify on a 2-dimensional radiograph.


3. Ankylosis often can be identified by the lack of periodontal space on the radiographic examination.

• Shafer WG, Hine MK, Levy BM. Textbook of oral pathology. 4th ed. Philadelphia: Saunders; 1983. p. 540-1.• Campbell KM, Casas MJ, Kenny DJ, Chau T. Diagnosis of ankylosis in permanent incisors by expert ratings, Periotest and digital sound wave analysis. Dent

Traumatol 2005;21:206-12.• Delmar DA. Ankylosis of teeth in the developing dentition. Quintessence Int 1986;17:303-8.

In addition, Periotest (Siemens/Medizintechnik-Gulden, Bensheim,Germany) can be used to assess tooth mobility. Ankylosedincisors have lower Periotest values. Unfortunately, clinical diagnosis of ankylosis, by mobility and percussion tests, is only reliable when at least 20% of the root surface is affected.


Accurate diagnosis is possible only through orthodontic force application as reported in several cases.5,7,11,16-18,25,30

5. Hwang DH, Park KH, Kwon YD, Kim SJ. Treatment of Class II open bite complicated by an ankylosed maxillary central incisor. Angle Orthod2011;81:726-35.7. Dolanmaz D, Karaman AI, Pampu AA, Topkara A. Orthodontic treatment of an ankylosed maxillary central incisor through osteogenic distraction. Angle Orthod 2010;80:391-5.11. Kofod T, Wurtz V, Melsen B. Treatment of an ankylosed central incisor by single tooth dento-osseous osteotomy and a simple distraction device. Am J Orthod Dentofacial Orthop 2005;127:72-80.16. Medeiros PJ, Bezerra AR. Treatment of an ankylosed central incisor by single-tooth dento-osseous osteotomy. Am J Orthod Dentofacial Orthop1997;112:496-501.17. Ohkubo K, Susami T, Mori Y, Nagahama K, Takahashi N, Saijo H, et al. Treatment of ankylosed maxillary central incisors by single-tooth dento-osseous osteotomy and alveolar bone distraction. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2011;111:561-7.18. McNamara TG, O'Shea D, McNamara CM, Foley TF. The management of traumatic ankylosis during orthodontics: a case report. J Clin Pediatr Dent 2000;24:265-7. 25. Takahashi T, Takagi T, Moriyama K. Orthodontic treatment of a traumatically intruded tooth with ankylosis by traction after surgical luxation. Am J Orthod Dentofacial Orthop 2005;127:233-41. 30. Moffat MA, Smart CM, Fung DE, Welbury RR. Intentional surgical repositioning of an ankylosed permanent maxillary incisor. Dent Traumatol2002;18:222-6.

An ankylosed central incisor in a growing child

• fails to erupt and the alveolar process adjacent to the ankylosed tooth also fails to grow vertically, causing anterior open bite.

• This phenomenon was presented in many case reports.2,5-12

2. Chang HY, Chang YL, Chen HL. Treatment of a severely ankylosed central incisor and a missing lateral incisor by distraction osteogenesis and orthodontic treatment. Am J Orthod Dentofacial Orthop 2010;138:829-38. 5. Hwang DH, Park KH, Kwon YD, Kim SJ. Treatment of Class II open bite complicated by an ankylosed maxillary central incisor. Angle Orthod2011;81:726-35.6. Alcan T. A miniature tooth-borne distractor for the alignment of ankylosed teeth. Angle Orthod 2006;76:77-83.7. Dolanmaz D, Karaman AI, Pampu AA, Topkara A. Orthodontic treatment of an ankylosed maxillary central incisor through osteogenic distraction. Angle Orthod 2010;80:391-5.8. Epker BN, Paulus PJ. Surgical-orthodontic correction of adult malocclusions- Single tooth dento-osseous osteotomies. Am J Orthod Dentofacial Orthop1978;74:551-63.9. Menini I, Zornitta C, Menini G. Distraction osteogenesis for implant site development using a novel orthodontic device: a case report. Int J Periodontics Restorative Dent 2008;28:189-96.10. Kinzinger GS, Janicke S, Riediger D, Diedrich PR. Orthodontic fine adjustment after vertical callus distraction of an ankylosed incisor using the floating bone concept. Am J Orthod Dentofacial Orthop 2003;124:582-90.11. Kofod T, Wurtz V, Melsen B. Treatment of an ankylosed central incisor by single tooth dento-osseous osteotomy and a simple distraction device. Am J Orthod Dentofacial Orthop 2005;127:72-80.12. Kim Y, Park S, Son W, Kim S, Mah J. Treatment of an ankylosed maxillary incisor by intraoral alveolar bone distraction osteogenesis. Am J OrthodDentofacial Orthop 2010;138:215-20.

Ankylosed central incisor (growing child)

Anterior open bite

2. Chang HY, Chang YL, Chen HL. Treatment of a severely ankylosed central incisor and a missing lateral incisor by distraction osteogenesis and orthodontic treatment. Am J Orthod Dentofacial Orthop 2010;138:829-38.

A 21-year-old woman with a chief complaint of an anterior open bite. She had a history of facial trauma when she was 8 years old.


Anterior open bite

CASE 1

The patient’s chief complaint was a progressive anterior open bite. His maxillary right central incisor had been extrusively subluxated by trauma 1 year earlier.


Anterior open bite

5. Hwang DH, Park KH, Kwon YD, Kim SJ. Treatment of Class II open bite complicated by an ankylosed maxillary central incisor. Angle Orthod2011;81:726-35.

CASE 2

The patient’s chief complaint was a progressive anterior open bite. This case was a 16-year-old girl with an ankylosed maxillary left central incisor. When she was nine years old, this tooth was broken and treated endodontically.


Anterior open bite

6. Alcan T. A miniature tooth-borne distractor for the alignment of ankylosed teeth. Angle Orthod 2006;76:77-83.

CASE 3

A 9-year-old boy presented about 10 hours after losing his maxillary right central incisor as a result of facial trauma. The patient had brought his lost tooth, which was apparently undamaged. No sign of injury was detected on the soft tissues surrounding the empty socket. The tooth was replanted and splinted. The replanted tooth remained firmly in place and the surrounding soft tissues appeared healthy at the follow-up visits for 7 years, but a progressive infraocclusion.


Anterior open bite

9. Menini I, Zornitta C, Menini G. Distraction osteogenesis for implant site development using a novel orthodontic device: a case report. Int J Periodontics Restorative Dent 2008;28:189-96.

CASE 4

The patient was first referred to our oral surgery clinic when she was 8 years 2 months old, after an accident in the swimming pool. Her traumatic injury included subluxation of a maxillary central incisor. The tooth was repositioned and stabilized with intramaxillary wire fixation.She returned to our clinic at age of 12 for orthodontic treatment. The injured incisor was ankylosed, and the radiograph showed apical root resorption of teeth, 11, 21and 22.


Anterior open bite

10. Kinzinger GS, Janicke S, Riediger D, Diedrich PR. Orthodontic fine adjustment after vertical callus distraction of an ankylosed incisor using the floating bone concept. Am J Orthod Dentofacial Orthop 2003;124:582-90.

CASE 5

The patient was 10 years old when orthodontic treatment began. She had a Class II Division 1 malocclusion with an overjet of 8 mm. The upper left central incisor had not completed eruption, and there was a history of trauma at age 5 to its predecessors.


Anterior open bite

11. Kofod T, Wurtz V, Melsen B. Treatment of an ankylosed central incisor by single tooth dento-osseous osteotomy and a simple distraction device. Am J Orthod Dentofacial Orthop 2005;127:72-80.

CASE 6

The patient was a girl, aged 11 years 11 months, who had bumped against the corner of a desk and damaged her maxillary incisors when she was 7 years old. The incisors were reimplanted, but the left central incisor eventually became ankylosed, preventing further growth of the alveolar bone, creating an open bite in the maxillary incisors.


Anterior open bite

12. Kim Y, Park S, Son W, Kim S, Mah J. Treatment of an ankylosed maxillary incisor by intraoral alveolar bone distraction osteogenesis. Am J OrthodDentofacial Orthop 2010;138:215-20.

CASE 7 An central incisor ankylosed after growing finished.

• There was no anterior open bite. Usually, only the labially displaced incisor was traumatized and ankylosed.

• This phenomenon was presented in a case report.7

7. Dolanmaz D, Karaman AI, Pampu AA, Topkara A. Orthodontic treatment of an ankylosed maxillary central incisor through osteogenic distraction. Angle Orthod 2010;80:391-5.

The patient was a 35-year-old woman.

7. Dolanmaz D, Karaman AI, Pampu AA, Topkara A. Orthodontic treatment of an ankylosed maxillary central incisor through osteogenic distraction. Angle Orthod 2010;80:391-5.

Ankylosed central incisor (after growing

finished)

No anterior open bite

CASE 1

Ankylosed central incisor (after growing

finished)

No anterior open bite

Case 749418 권영민

CASE 2

51 years old man

Treatment modalities in growing children

• Resection18

• Spontaneous re-eruption15

• Decoronation20,21

• Extraction and substitution with the adjacent tooth22

15. Schott TC, Engel E, Goz G. Spontaneous re-eruption of a permanent maxillary central incisor after 15 years of ankylosis - a case report. DentTraumatol 2011.18. McNamara TG, O'Shea D, McNamara CM, Foley TF. The management of traumatic ankylosis during orthodontics: a case report. J ClinPediatr Dent 2000;24:265-7.20. Malmgren B. Decoronation: how, why, and when? J Calif Dent Assoc 2000;28:846-54.21. 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;25:346-9.22. Janson G, Valarelli DP, Valarelli FP, de Freitas MR, Pinzan A. Atypical extraction of maxillary central incisors. Am J Orthod Dentofacial Orthop2010;138:510-7.

Resection• In the past, an ankylosed permanent

incisor was often surgically resected and replaced with a fixed or removable prosthetic tooth.18

18. McNamara TG, O'Shea D, McNamara CM, Foley TF. The management of traumatic ankylosis during orthodontics: a case report.

J Clin Pediatr Dent 2000;24:265-7.

A Caucasian female, aged 11 years and 5 months, was referred for orthodontic treatment of a marked Class II Div 1 malocclusion.

Resection

18. McNamara TG, O'Shea D, McNamara CM, Foley TF. The management of traumatic ankylosis during orthodontics: a case report. J Clin PediatrDent 2000;24:265-7.

During Frankel appliance therapy, the patient experienced an acute traumatic episode to the maxillary incisor region following a fall from a bicycle. The maxillary right central incisor was avulsed and it was replanted.After extraction of four first premolars, orthodontic treatment was done. But the central incisor failed to move. The ankylosed incisor was immediately excuded from any further archwire mechanics.

Resection

18. McNamara TG, O'Shea D, McNamara CM, Foley TF. The management of traumatic ankylosis during orthodontics: a case report. J Clin PediatrDent 2000;24:265-7.

After orthodontic treatment, the clinical crown was reduced.

Resection

18. McNamara TG, O'Shea D, McNamara CM, Foley TF. The management of traumatic ankylosis during orthodontics: a case report.

J Clin Pediatr Dent 2000;24:265-7.

The crown was restored with a light cured composite resin material, using an incremental build-up technique. A long-term definitive restorative treatment using a single endosseousimplant, is planned.But a vertical alveolar defect makes an esthetic prosthetic replacement difficult and often results in a compromised esthetic outcome. In growing children the remaining vertical alveolar growth of adjacent teeth makes the treatment more difficult.

Spontaneous re-eruption

15. Schott TC, Engel E, Goz G. Spontaneous re-eruption of a permanent maxillary central incisor after 15 years of ankylosis - a case report.Dent Traumatol 2011.

In 1991, a 7-year-old boy suffered a traumatic intrusion leading to an infraposition of tooth 21 along with its immobility. Based on the clinical findings, including bright-sounding percussion testing, disappearance of the periodontal space and a failed attempt at orthodontic movement, a diagnosis of ankylosis was made.

2mm extrusion, for 3 years (2006)

Metal ceramic crown restoration (2003), when she was 19.

Resinrestoration

200218Y

200622Y


15. Schott TC, Engel E, Goz G. Spontaneous re-eruption of a permanent maxillary central incisor after 15 years of ankylosis - a case report.Dent Traumatol 2011.

Within a few months using a partial multibracket appliance in the maxilla (Fig. 3), the previously ankylosed tooth could be extruded by several millimeters.A wait-and-see strategy in anticipation of such spontaneous

elongation cannot be considered a valid treatment option, as the likelihood of this eventuality is very low. But spontaneous re-eruption after several years is an extremely rare finding.


19. Wigen TI, Agnalt R, Jacobsen I. Intrusive luxation of permanent incisors in Norwegians aged 6-17 years: a retrospective study of treatment and outcome. Dent Traumatol 2008;24:612-8.

Material and Methods: Fifty-one intruded permanent incisors were studied in 20 boys and 19 girls aged 6 to 17 years. Only three patients were over 12 years of age. Complete intrusion had occurred in 21 teeth, and 31 teeth were classified as immature. Re-eruption was awaited for 37 teeth. The remaining teeth were repositioned orthodontically (7 teeth) or surgically (7 teeth). Results: Re-eruption occurred in 35 out of 37 teeth over a period of 3–12 months.

Condition 6 days after trauma in a 10-year-old girl with complete intrusion of the right central incisor. The right lateraland left central incisor are partially intruded (>2 mm).



Results: After a mean observation period of 4 years rangingfrom 1–12 years, retained pulp vitality was recorded in 22 teeth (43%). Pulpnecrosis had developed in 57%, inflammatory resorption in 26% andreplacement resorption in 12%.In the analysis all orthodontic and surgical repositioned teeth were combined into an active treatment group. The non-active treatment group consisted of teeth allowed to re-erupt. The distribution of replacement resorption was significantly lower in teeth allowed to re-erupt than in teeth repositioned actively.

Conclusions: The best treatment of intruded incisors in 6–12 year-old children is to await re-eruption. The time interval between trauma and complete re-eruption varied from 3 to 12 months with a mean of 5.6 months. Should endodontic treatment be required before re-eruption has occurred, a gingivectomy can be performed to gain access to the root canal.



Fig. 3. Complete intrusion of left central incisor. Re-eruption was awaited. (a, b) Condition 5 days after injury, before start of endodontic treatment. A gingivectomy was performed to gain access to the root canal. (c, d) Partial re-eruption 1 month later. Pulp canal is filled temporarily with calcium hydroxide. (e, f) Complete re-eruption and permanent root filling 10 monthsafter trauma. (Delayed eruption of right incisor is due to supernumerary tooth).

Decoronation

20. Malmgren B. Decoronation: how, why, and when? J Calif Dent Assoc 2000;28:846-54.21. 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;25:346-9.

Decoronation is a surgical method for treating ankylosed incisors in children and adolescents. Decoronation preserves not only the width of the ridge but also the vertical height.20,21

Fig. 1. Intraoral occlusal view of the ankylosed right maxillarycentral incisor at the initial examination.(12-year old)

Fig. 2. Intraoral view of the wound edge approximation (overthe decoronated ankylosed root) and suturing without tension.

Decoronation


Fig. 3. Postoperative periapical radiograph of the decoronatedankylosed central incisor.

Fig. 4. Periapical radiograph of the alveolar bone ridge 5 years after decoronation. Notice the complete remodeling of the root to bone. Moderate apical root resorption of adjacent roots because of the orthodontic treatment is also noticeable.

5 years

Decoronation(12 year old)

(18 year old)

Fig. 6. Intraoral view of the alveolar bone ridge at the time of implant insertion. Notice the preservation of the alveolar boneridge.

Decoronation


We conclude that treatment of an ankylosed young permanent incisor by decoronation may maintain the alveolar bone ridge width, height and continuity, and assist future rehabilitation with minimal, if any, ridge augmentation procedures. The disadvantages are its surgical nature, which may be challenging in young children, and the necessity for a long-term esthetic space maintainer.21

Fig. 7. Intraoral view of the prosthetic porcelain crown on theday of cementation.

Fig. 8. Periapical radiograph of the implant and prostheticrestoration.

Extraction and substitution with the adjacent tooth

22. Janson G, Valarelli DP, Valarelli FP, de Freitas MR, Pinzan A. Atypical extraction of maxillary central incisors. Am J Orthod Dentofacial Orthop2010;138:510-7.

The option of extracting the maxillary central incisors followed by space closure, with lateral incisors substituting for the central incisors, may be considered in some growing patients and also in adults.22

A boy, aged 13 years 11 months.

He had a traumatic episode at age 11 years, and the maxillary left central incisor was avulsed. The tooth receivedendodontic treatment and was reimplanted.

Root resorption

Extraction and substitution with the adjacent tooth

22. Janson G, Valarelli DP, Valarelli FP, de Freitas MR, Pinzan A. Atypical extraction of maxillary central incisors. Am J Orthod Dentofacial Orthop2010;138:510-7.

Extraction of the maxillary central incisors is not a usual treatment protocol in orthodontics. However, in some patients with ankylosis of the maxillary centralincisors and wide maxillary anterior teeth, this might be a good alternative to preserve tooth structure and avoid permanent prostheses as long as the patient’s diagnostic characteristics will permit this plan.22

Extraction of maxillary central incisors and mandibular first premolars because of crowding and protrusion.

Gingivectomy and direct composite buildup of the maxillary lateral incisorsand canines transformed them into central and lateral incisors, respectively.

Lateral incisors

Treatment modalities in non-growing adolescents and adults.

Several surgical treatment protocols

1. Single tooth osteotomy8,16,23

2. Surgical luxation24-27

3. Corticotomy5

4. Distraction osteogenesis (DO)2,6,9-14,23,26,28

2. Chang HY, Chang YL, Chen HL. Treatment of a severely ankylosed central incisor and a missing lateral incisor by distraction osteogenesis and orthodontic treatment. Am J Orthod Dentofacial Orthop 2010;138:829-38.5. Hwang DH, Park KH, Kwon YD, Kim SJ. Treatment of Class II open bite complicated by an ankylosed maxillary central incisor. Angle Orthod 2011;81:726-35.6. Alcan T. A miniature tooth-borne distractor for the alignment of ankylosed teeth. Angle Orthod 2006;76:77-83.8. Epker BN, Paulus PJ. Surgical-orthodontic correction of adult malocclusions- Single-tooth dento-osseous osteotomies. Am J Orthod Dentofacial Orthop 1978;74:551-63.9. Menini I, Zornitta C, Menini G. Distraction osteogenesis for implant site development using a novel orthodontic device: a case report. Int J Periodontics Restorative Dent 2008;28:189-96.10. Kinzinger GS, Janicke S, Riediger D, Diedrich PR. Orthodontic fine adjustment after vertical callus distraction of an ankylosed incisor using the floating bone concept. Am J Orthod Dentofacial Orthop 2003;124:582-90.11. Kofod T, Wurtz V, Melsen B. Treatment of an ankylosed central incisor by single tooth dento-osseous osteotomy and a simple distraction device. Am J Orthod Dentofacial Orthop 2005;127:72-80.12. Kim Y, Park S, Son W, Kim S, Mah J. Treatment of an ankylosed maxillary incisor by intraoral alveolar bone distraction osteogenesis. Am J Orthod Dentofacial Orthop 2010;138:215-20.13. Im JJ, Kye MK, Hwang KG, Park CJ. Miniscrew-anchored alveolar distraction for the treatment of the ankylosed maxillary central incisor. Dent Traumatol 2010;26:285-8.14. Razdolsky Y, El-Bialy TH, Dessner S, Buhler JE, Jr. Movement of ankylosed permanent teeth with a distraction device. J Clin Orthod 2004;38:612-20.16. Medeiros PJ, Bezerra AR. Treatment of an ankylosed central incisor by single-tooth dento-osseous osteotomy. Am J Orthod Dentofacial Orthop 1997;112:496-501.23. Kim Y, Kim S, Son W, Park S. Orthodontic treatment of an ankylosed tooth; application of single tooth osteotomy and alveolar bone distraction osteogenesis. Korean J Orthod 2009;39:185-98.24. Salas Cordova J, Yokozeki M, Moriyama K. An unusual ankylosis in an orthodontic case. J Clin Orthod 2001;35:763-6.25. Takahashi T, Takagi T, Moriyama K. Orthodontic treatment of a traumatically intruded tooth with ankylosis by traction after surgical luxation. Am J Orthod Dentofacial Orthop 2005;127:233-41.26. Son W, Chung IK, Shin SH. Surgically assisted orthodontic treatment of ankylosed maxillary incisor. Korean J Orthod 2002;32:257-64.27. Im DH, Nahm DS, Chang YI. The treatment of an ankylosed canine: luxation and forced eruption. Korean J Orthod 2002;32:395-400.28. Isaacson RJ, Strauss RA, Bridges-Poquis A, Peluso AR, Lindauer SJ. Moving an ankylosed central incisor using orthodontics, surgery and distraction osteogenesis. Angle Orthod 2001;71:411-8.

Single tooth osteotomy8,16,23

8. Epker BN, Paulus PJ. Surgical-orthodontic correction of adult malocclusions- Single-tooth dento-osseous osteotomies. Am J Orthod Dentofacial Orthop 1978;74:551-63.16. Medeiros PJ, Bezerra AR. Treatment of an ankylosed central incisor by single-tooth dento-osseous osteotomy. Am J Orthod Dentofacial Orthop 1997;112:496-501.23. Kim Y, Kim S, Son W, Park S. Orthodontic treatment of an ankylosed tooth; application of single tooth osteotomy and alveolar bone distraction osteogenesis. Korean J Orthod 2009;39:185-98.


• move the dento-osseous segment into the desired position with adequately attached mucoperiosteal pedicles in order to maintain the blood supply to the tooth-bone segment

• Sufficient interdental space must exist so that a fine cut (osteotomy) can be made between adjacent teeth without injury to them

8. Epker BN, Paulus PJ. Surgical-orthodontic correction of adult malocclusions- Single-tooth dento-osseous osteotomies. Am J Orthod Dentofacial Orthop 1978;74:551-63.


The patient was 10 years old when orthodontic treatmentbegan. She had a Class II, Division 1 malocclusionwith an overjet of 8 mm. The upper left central incisor hadnot completed eruption, and there was a history of traumaat age 5 to its predecessor

16. Medeiros PJ, Bezerra AR. Treatment of an ankylosed central incisor by single-tooth dento-osseous osteotomy. Am J Orthod Dentofacial Orthop 1997;112:496-501.


The surgical luxation was performed with an elevator (301 type), and good mobilization was obtained. One day after this procedure, the coil spring was reactivated for 8 months with 50 gm of orthodontic force. However, instead of leveling the central incisor, the other teeth began intrusion and the bite opened.

Clinical aspect before surgical procedure.



Schematic drawing showing soft tissue incisions slightly divergent and osteotomies parallel to each other (dashed lines).

Immediate postoperative view after stabilization of segment.

With a thin osteotome, the cuts involving the medullary and the palatal bone werecompleted.

After adequate mobilization, the segment was displaced inferiorly and attached to the arch wire.




Periapical radiograph 8 months after procedure.

Clinical aspect 18 months after procedure.

The dento-osseous segment was kept wired to the arch for 4 weeks.

The best time to perform this type ofosteotomy would be after the facial growth has been completed. We had to consider that the tooth may not stay at the same level of the central incisor and this situation might require a crown restoration for elongation.

Surgical luxation24-27

24. Salas Cordova J, Yokozeki M, Moriyama K. An unusual ankylosis in an orthodontic case. J Clin Orthod 2001;35:763-6.25. Takahashi T, Takagi T, Moriyama K. Orthodontic treatment of a traumatically intruded tooth with ankylosis by traction after surgical luxation. Am J Orthod Dentofacial Orthop 2005;127:233-41.26. Son W, Chung IK, Shin SH. Surgically assisted orthodontic treatment of ankylosed maxillary incisor. Korean J Orthod 2002;32:257-64.27. Im DH, Nahm DS, Chang YI. The treatment of an ankylosed canine: luxation and forced eruption. Korean J Orthod 2002;32:395-400.


25. Takahashi T, Takagi T, Moriyama K. Orthodontic treatment of a traumatically intruded tooth with ankylosis by traction after surgical luxation. Am J Orthod Dentofacial Orthop 2005;127:233-41.

He had a dental history of trauma at age 10 years 2 months on the bilateral maxillary central incisors (teeth 11 and 21), the right maxillary and mandibular lateral incisors (teeth 12 and 42), and the right mandibular central incisor (tooth 41). Teeth 11 and 41 had suffered from crown fracture, and tooth 41 had been restored by composite resin bonding. Both teeth had been treated endodontically. Ankylosis was suspected on teeth 12 and 42, because of severe intrusive luxation (tooth 12) and replantation after traumatic avulsion (tooth 42). The intruded tooth 12 had been observed for a year after injury, and no spontaneous eruption had occurred.



Orthodontic forces were applied to teeth 12 and 42. A traction spring fromthe maxillary lingual arch was used to attempt eruption of tooth 12; after 3 months with no extrusive movement, a definitive diagnosis of ankylosis was made, and the surgical luxation was performed.

At age 12 years 8 months

Surgical luxation was performed again.



A periapical radiograph of tooth 42, taken after leveling, showed that the root filling material (calcium hydroxide) had disappeared, and replacement root resorption had occurred. Consequently, the application of orthodontic force was stopped immediately.



A periapical radiograph of tooth 42, taken after leveling, showed that the root filling material (calcium hydroxide) had disappeared, and replacement root resorption had occurred. Consequently, the application of orthodontic force was stopped immediately.

Corticotomy5

5. Hwang DH, Park KH, Kwon YD, Kim SJ. Treatment of Class II open bite complicated by an ankylosed maxillary central incisor. Angle Orthod 2011;81:726-35.

Distraction osteogenesis (DO)2,6,9-14,23,26,28

31. Ilizarov GA. The tension-stress effect on the genesis and growth of tissues: Part II. The influence of the rate and frequency of distraction. Clin Orthop Relat Res 1989:263-85.

32. Chin M, Toth BA. Distraction osteogenesis in maxillofacial surgery using internal devices: review of five cases. J Oral Maxillofac Surg 1996;54:45-53

• History2

The distraction osteogenesis technique was first successfully applied to long bones by Ilizarov in 1988,31 subsequently employed in the alveolar bone by Chin and Toth.32


• History2

and reported for a single-incisor dentoalveolardistraction by Isaacson et al and others.2,6,9-14,23,26,28

This technique involves a segmental osteotomy, followed by distraction osteogenesis to reposition the ankylosed tooth, the adjacent alveolar bone and the gingival tissue.

2. Chang HY, Chang YL, Chen HL. Treatment of a severely ankylosed central incisor and a missing lateral incisor by distraction osteogenesis and orthodontic treatment. Am J Orthod Dentofacial Orthop 2010;138:829-38.6. Alcan T. A miniature tooth-borne distractor for the alignment of ankylosed teeth. Angle Orthod 2006;76:77-83.9. Menini I, Zornitta C, Menini G. Distraction osteogenesis for implant site development using a novel orthodontic device: a case report. Int J Periodontics Restorative Dent 2008;28:189-96.10. Kinzinger GS, Janicke S, Riediger D, Diedrich PR. Orthodontic fine adjustment after vertical callus distraction of an ankylosed incisor using the floating bone concept. Am J Orthod Dentofacial Orthop 2003;124:582-90.11. Kofod T, Wurtz V, Melsen B. Treatment of an ankylosed central incisor by single tooth dento-osseous osteotomy and a simple distraction device. Am J Orthod Dentofacial Orthop 2005;127:72-80.12. Kim Y, Park S, Son W, Kim S, Mah J. Treatment of an ankylosed maxillary incisor by intraoral alveolar bone distraction osteogenesis. Am J Orthod Dentofacial Orthop 2010;138:215-20.13. Im JJ, Kye MK, Hwang KG, Park CJ. Miniscrew-anchored alveolar distraction for the treatment of the ankylosed maxillary central incisor. Dent Traumatol 2010;26:285-8.14. Razdolsky Y, El-Bialy TH, Dessner S, Buhler JE, Jr. Movement of ankylosed permanent teeth with a distraction device. J Clin Orthod 2004;38:612-20.16. Medeiros PJ, Bezerra AR. Treatment of an ankylosed central incisor by single-tooth dento-osseous osteotomy. Am J Orthod Dentofacial Orthop 1997;112:496-501.23. Kim Y, Kim S, Son W, Park S. Orthodontic treatment of an ankylosed tooth; application of single tooth osteotomy and alveolar bone distraction osteogenesis. Korean J Orthod 2009;39:185-98.26. Son W, Chung IK, Shin SH. Surgically assisted orthodontic treatment of ankylosed maxillary incisor. Korean J Orthod 2002;32:257-64.28. Isaacson RJ, Strauss RA, Bridges-Poquis A, Peluso AR, Lindauer SJ. Moving an ankylosed central incisor using orthodontics, surgery and distraction osteogenesis. Angle Orthod 2001;71:411-8.


2. Chang HY, Chang YL, Chen HL. Treatment of a severely ankylosed central incisor and a missing lateral incisor by distraction osteogenesis and orthodontic treatment. Am J Orthod Dentofacial Orthop 2010;138:829-38.6. Alcan T. A miniature tooth-borne distractor for the alignment of ankylosed teeth. Angle Orthod 2006;76:77-83.9. Menini I, Zornitta C, Menini G. Distraction osteogenesis for implant site development using a novel orthodontic device: a case report. Int J Periodontics Restorative Dent 2008;28:189-96.10. Kinzinger GS, Janicke S, Riediger D, Diedrich PR. Orthodontic fine adjustment after vertical callus distraction of an ankylosed incisor using the floating bone concept. Am J Orthod Dentofacial Orthop 2003;124:582-90.11. Kofod T, Wurtz V, Melsen B. Treatment of an ankylosed central incisor by single tooth dento-osseous osteotomy and a simple distraction device. Am J Orthod Dentofacial Orthop 2005;127:72-80.12. Kim Y, Park S, Son W, Kim S, Mah J. Treatment of an ankylosed maxillary incisor by intraoral alveolar bone distraction osteogenesis. Am J Orthod Dentofacial Orthop 2010;138:215-20.13. Im JJ, Kye MK, Hwang KG, Park CJ. Miniscrew-anchored alveolar distraction for the treatment of the ankylosed maxillary central incisor. Dent Traumatol 2010;26:285-8.14. Razdolsky Y, El-Bialy TH, Dessner S, Buhler JE, Jr. Movement of ankylosed permanent teeth with a distraction device. J Clin Orthod 2004;38:612-20.16. Medeiros PJ, Bezerra AR. Treatment of an ankylosed central incisor by single-tooth dento-osseous osteotomy. Am J Orthod Dentofacial Orthop 1997;112:496-501.23. Kim Y, Kim S, Son W, Park S. Orthodontic treatment of an ankylosed tooth; application of single tooth osteotomy and alveolar bone distraction osteogenesis. Korean J Orthod 2009;39:185-98.26. Son W, Chung IK, Shin SH. Surgically assisted orthodontic treatment of ankylosed maxillary incisor. Korean J Orthod 2002;32:257-64.28. Isaacson RJ, Strauss RA, Bridges-Poquis A, Peluso AR, Lindauer SJ. Moving an ankylosed central incisor using orthodontics, surgery and distraction osteogenesis. Angle Orthod 2001;71:411-8.

• Indication2

With a severely displaceded (ankylosed) tooth, the tooth cannot be moved the entire distance necessary to reach the occlusal plane,

because of the stretching limitations of the attached soft tissue during the surgery, additional undermining of the soft tissue was not an option because of the risk of interfering with the blood supply to the tooth and the alveolar segment.


11.. Kofod T, Wurtz V, Melsen B. Treatment of an ankylosed central incisor by single tooth dento-osseous osteotomy and a simple distraction device. Am J Orthod Dentofacial Orthop 2005;127:72-80.

• Three stagesDistraction osteogenesis consists of 3 sequential

periods: latency, distraction, and consolidation. Latency is the period from bone division to the onset

of traction and is the time allowed for callus formation.

During the distraction period, gradual traction is applied, and new bone, or distraction regenerate, is formed.

The consolidation period allows maturation of the regenerate bone after the traction forces are discontinued.11


The latency periods for the distraction of the dento-osseous block

varied considerably for different case reports from 4 days,11 5 days,12,14 one week,2,10,13 and two weeks.14,28

In most cases, after a latency period of one week , distraction of the dentoalveolar segment began.2,13

2. Chang HY, Chang YL, Chen HL. Treatment of a severely ankylosed central incisor and a missing lateral incisor by distraction osteogenesis and orthodontic treatment. Am J Orthod Dentofacial Orthop 2010;138:829-38. 10. Kinzinger GS, Janicke S, Riediger D, Diedrich PR. Orthodontic fine adjustment after vertical callus distraction of an ankylosed incisor using the floating bone concept. Am J Orthod Dentofacial Orthop 2003;124:582-90.11. Kofod T, Wurtz V, Melsen B. Treatment of an ankylosed central incisor by single tooth dento-osseous osteotomy and a simple distraction device. Am J Orthod Dentofacial Orthop 2005;127:72-80.12. Kim Y, Park S, Son W, Kim S, Mah J. Treatment of an ankylosed maxillary incisor by intraoral alveolar bone distraction osteogenesis. Am J OrthodDentofacial Orthop 2010;138:215-20.13. Im JJ, Kye MK, Hwang KG, Park CJ. Miniscrew-anchored alveolar distraction for the treatment of the ankylosed maxillary central incisor. Dent Traumatol 2010;26:285-8.14. Razdolsky Y, El-Bialy TH, Dessner S, Buhler JE, Jr. Movement of ankylosed permanent teeth with a distraction device. J Clin Orthod 2004;38:612-20.18. McNamara TG, O'Shea D, McNamara CM, Foley TF. The management of traumatic ankylosis during orthodontics: a case report. J Clin Pediatr Dent 2000;24:265-7.


The latency periods In my cases, following a seven-day latency

period, distraction was begun on the day of stich-out. The authors noted that it would be safe and convenient to start distraction on the day of stich-out after primary healing of soft tissue.


Rates of distraction For dento-alveolar distraction of a single tooth,

various rates of distraction have been used previously from 0.5 mm to 1.0 mm per day.2,6,9-14,17,28

2. Chang HY, Chang YL, Chen HL. Treatment of a severely ankylosed central incisor and a missing lateral incisor by distraction osteogenesis and orthodontic treatment. Am J Orthod Dentofacial Orthop 2010;138:829-38.6. Alcan T. A miniature tooth-borne distractor for the alignment of ankylosed teeth. Angle Orthod 2006;76:77-83.9. Menini I, Zornitta C, Menini G. Distraction osteogenesis for implant site development using a novel orthodontic device: a case report. Int J Periodontics Restorative Dent 2008;28:189-96.10. Kinzinger GS, Janicke S, Riediger D, Diedrich PR. Orthodontic fine adjustment after vertical callus distraction of an ankylosed incisor using the floating bone concept. Am J Orthod Dentofacial Orthop 2003;124:582-90.11. Kofod T, Wurtz V, Melsen B. Treatment of an ankylosed central incisor by single tooth dento-osseous osteotomy and a simple distraction device. Am J Orthod Dentofacial Orthop 2005;127:72-80.12. Kim Y, Park S, Son W, Kim S, Mah J. Treatment of an ankylosed maxillary incisor by intraoral alveolar bone distraction osteogenesis. Am J OrthodDentofacial Orthop 2010;138:215-20.13. Im JJ, Kye MK, Hwang KG, Park CJ. Miniscrew-anchored alveolar distraction for the treatment of the ankylosed maxillary central incisor. Dent Traumatol 2010;26:285-8.14. Razdolsky Y, El-Bialy TH, Dessner S, Buhler JE, Jr. Movement of ankylosed permanent teeth with a distraction device. J Clin Orthod 2004;38:612-20.17. Ohkubo K, Susami T, Mori Y, Nagahama K, Takahashi N, Saijo H, et al. Treatment of ankylosed maxillary central incisors by single-tooth dento-osseous osteotomy and alveolar bone distraction. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2011;111:561-7. 28. Isaacson RJ, Strauss RA, Bridges-Poquis A, Peluso AR, Lindauer SJ. Moving an ankylosed central incisor using orthodontics, surgery and distraction osteogenesis. Angle Orthod 2001;71:411-8.


Rates of distraction In an animal study, bone regenerate produced

by dentoalveolar distraction rates of 1 and 2 mm per day were similar in quality and quantity.34

34. Spencer AC, Campbell PM, Dechow P, Ellis ML, Buschang PH. How does the rate of dentoalveolar distraction affect the bone regenerate produced? Am J Orthod Dentofacial Orthop 2011;140:e211-21.



• Methods2

The traction of the single-tooth osteotomy block can be repositioned to the desired position by vertical extrusion bends, vertical elastics, a coil spring, a nickel-titanium wire,or a simple distraction device.


Advantages of using a distraction device

• Recently, many distractors have been invented and reported. The advantages of using a distraction device is that the displacement of the dento-alveolar block gradually increases in accurate amounts and the patient can extend the distractor at home.


Disadvantages of using a distraction device• Placing a distractor during surgery was a difficult

task for the maxillofacial surgeon, because the distractor was unidirectional.

• Furthermore, lengthening occurs only in a linear direction, with no possibility of 3-dimensional alignment of the osteotomized segment.

• The secondary surgery to remove the distractor is the main disadvantage of the bone-borne distractor.


Disadvantages of using a distraction device• if the bulky device is placed in the vestibule, it

is irritable to the vestibular gingival, and if placed incisally, it is unesthetic.


Consolidation of the bone segment• The stability of the dento-osseous block after the

distraction may be considered a key determinant in bone formation within the gap.35

• For consolidation of the bone segment, a passive heavy archwire has been left in place for 6 weeks,2,28

12 weeks,11 or up to 5 months.9

2. Chang HY, Chang YL, Chen HL. Treatment of a severely ankylosed central incisor and a missing lateral incisor by distraction osteogenesis and orthodontic treatment. Am J OrthodDentofacial Orthop 2010;138:829-38. 9. Menini I, Zornitta C, Menini G. Distraction osteogenesis for implant site development using a novel orthodontic device: a case report. Int J Periodontics Restorative Dent 2008;28:189-96.11. Kofod T, Wurtz V, Melsen B. Treatment of an ankylosed central incisor by single tooth dento-osseous osteotomy and a simple distraction device. Am J Orthod Dentofacial Orthop2005;127:72-80.28. Isaacson RJ, Strauss RA, Bridges-Poquis A, Peluso AR, Lindauer SJ. Moving an ankylosed central incisor using orthodontics, surgery and distraction osteogenesis. Angle Orthod2001;71:411-8.35. Saulacic N, Zix J, Iizuka T. Complication rates and associated factors in alveolar distraction osteogenesis: a comprehensive review. Int J Oral Maxillofac Surg 2009;38:210-7.


Consolidation of the bone segment• Kinzinger et al reduced the consolidation period

(only seventeen days of consolidation) to move the incisor into the final position by applying orthodontic forces early (“floating bone concept”), because the tooth was not moved to the desired position using the bone-borne distractor.10

35. Saulacic N, Zix J, Iizuka T. Complication rates and associated factors in alveolar distraction osteogenesis: a comprehensive review. Int J Oral Maxillofac Surg 2009;38:210-7.


Complication• In the review article by Saulacic et al regarding

alveolar distraction osteogensis, the most common complication was insufficient bone formation following the consolidation period (22 cases of 256 patients, 8%), followed by regression of distraction distance (18 cases, 7%).35 Incorrect design of the vertical osteotomy lines may also impede the movement of the transport segment.35

35. Saulacic N, Zix J, Iizuka T. Complication rates and associated factors in alveolar distraction osteogenesis: a comprehensive review. Int J Oral Maxillofac Surg 2009;38:210-7.


Complication• The overcorrection concept was emphasized by

Saulacic et al,36 for relapse of the distraction-generated bone typically occured during the later period of healing, leading to a loss of approximately 1.6~1.8 mm or 20% of the distracted bone height (6.1~6.2mm).

36. Saulacic N, Somoza-Martin M, Gandara-Vila P, Garcia-Garcia A. Relapse in alveolar distraction osteogenesis: an indication for overcorrection. J Oral Maxillofac Surg 2005;63:978-81.


Complication• Because ankylosis-related external replacement

resorption always led to complete root resorption,9,19 it was notified to the patient and her parents that external resorption would be a complication leading eventually to tooth loss.

• Although the ankylosed incisor will eventually be lost, the tooth can be used for several years with conservation of alveolar bone. Even if the root of the ankylosed tooth is progressively resorbed, our treatment could be an excellent way to prepare the site for future implant treatment.9

9. Menini I, Zornitta C, Menini G. Distraction osteogenesis for implant site development using a novel orthodontic device: a case report. Int J Periodontics Restorative Dent 2008;28:189-96.19. Wigen TI, Agnalt R, Jacobsen I. Intrusive luxation of permanent incisors in Norwegians aged 6-17 years: a retrospective study of treatment and outcome. Dent Traumatol 2008;24:612-8.



• Bone-borne distraction devices10

The patient was first referred to our oral surgery clinic when she was 8 years 2 months old, after an accident in the swimming pool. Her traumatic injuryincluded subluxation of a maxillary central incisor (#11) and fracture of the buccal processus alveolaris. The tooth was repositioned and stabilized with intramaxillarywire fixation. She returned to our clinic at age 12 for orthodontic treatment




Several treatment alternatives were explored.1. Perform a conventional osteotomy and augment the alveolar ridge vertically by removing autogenous bone or by using xenogenousmaterials. Secondary soft tissue surgery might be required later.2. Extract the ankylosed tooth and replace it with an implant or a bridge.3. Perform a segmental osteotomy with vertical callus distraction of the ankylosed tooth, using the floating bone concept; surgery would be preceded and followed by orthodontic treatment.Option 3 was selected.




1. Preliminary orthodontic treatment with fixed appliances was initiated to create sufficient interradicular distance in the projected region of the osteotomy

TREATMENT PROGRESS




1. Preliminary orthodontic treatment with fixed appliances was initiated to create sufficient interradicular distance in the projected region of the osteotomy

TREATMENT PROGRESS




After the segmental osteotomy, a single-tooth distractor(Gebrüder Martin GmbH & Co KG, Track 1.0, Tuttlingen, Germany) was placed surgically.

TREATMENT PROGRESS




After a 7-day latency period, a distractor was applied to change the vertical incisor position, with activation during the 8-day distraction phase at a rate of 0.6 mm/day and a frequency of 2 activations/day (15 activations). The total distraction distance achieved was 4.5 mm.

TREATMENT PROGRESS


Although sufficiently deep vertical adjustment of tooth 11 was obtained, there was clinically a marked palatal deviation.


The decision was then made to reduce the consolidation phase and, by using the floating bone effect, to move the tooth-supporting segment into the therapeutically desired position.


Seventeen days later, before final consolidation of the newly formed bone, the distractor was removed. During surgery, the tooth-supporting bone segment and the callus could be visualized from the vestibular aspect after removing the distractor.



TREATMENT PROGRESS


Four days postoperatively, movement of the osteotomy segment into its final position was started by applying orthodontic forces and moments to the tooth in the segment. A bracket was bonded onto tooth 11 and, in addition to the passive bypass archwire, a superelastic 0.016x 0.022-in copper-nickel-titanium segmented archwire was placed.

At start of floating bone effect

After 8 days

After 18

Floating bone effect.


After only 18 days, 3-dimensional positioning of the tooth-supporting segment had been achieved with the floating bone effect, and the dental arch in the anterior region had been leveled sufficiently to allow a continuous 0.016x0.022-in stainless steel archwire to be placed for stabilization.

Floating bone effect.

At start of floating bone effect

After 8 days

After 18


Posttreatment (retention period; 1.5 years later) intraoral photographs.




Posttreatment (retention period; 1.5 years later).



Skeletal and somatic maturity was determined by hand-wrist analysis according to Hägg and Taranger. The patient was found to be at the radius stadium R-IJdevelopment stage, suggesting that the potential for future growth was limited.In general, the vertical callus distraction of an ankylosed tooth should not be attempted until the patient has finished growing.




Adavantages1. Hard and soft tissues are gradually expanded simultaneouslyover a period of several days, and this normally results in a clear-cut gain in alveolar mucosa.

the callus could be visualized from the vestibular aspectafter removing the distractor




Disadavantages1. a clinical study by Krafft showed that in alveolar crest distraction, especially in the maxilla, the palatal mucosa followed the distraction to only a minor extent, thus producing a deviation of the distraction axis to the palatal.2. Dental distractor during surgery thus becomes a difficult task for the maxillofacial surgeon because the intraorally applied distractor has a unidirectional impact.




Disadavantages3. Furthermore, lengthening occurs only in a linear direction, with no possibility of 3-dimensional alignment of the osteotomizedsegment.4. Ready-made alveolar distractors are expensive and require a second surgery to remove the device.




Floating bone effectKrafft described a means of exerting a limited influence on the direction of the newly formed alveolar bone after removing the distractor: he found that the still soft, newly formed bone matrixcould be slowly moved by applying firm, constant pressure with the finger. However, because the alveolar segment sprang back to the palatal after this manipulation, it had to be held buccally in the desired position with small metal plates. This procedure entails a longer retention phase and another surgery to remove the metal plates.In addition, the mobilization period was brief. At the same time, 3-dimensional alignment of the tooth-supporting segment was completed quickly, with a multiband apparatus and appropriate biomechanics.



• Wire2

21-year-old woman with a chief complaint of an anterior open bite.she had a history of facial trauma when she was 8 years old.Her maxillary left lateral incisor was missing at that time. Avulsion of the maxillary right and left central incisors occurred from this trauma. These teeth were replanted and fixed with wire and resin.



• Wire2

A,B. Single-tooth dental-osseous osteotomy was performed under local anesthesia.C,D. Downward repositioning was attempted (an archwire was modified and placed in the bracket on the partially repositioned tooth, and the soft tissue was closed



• Wire2

Another issue in distraction is the 3-dimensional problem of moving a dental-osseous segment. In this patient, the bony cuts were slightly divergent occlusallyand facially, so the segment could be rotated to obtain adequate anterior labial root torque.



• Wire2

The maxillary left central incisor during the distraction osteogenesis: A, 1 week after surgeryB, 2 weeks after surgery C, 3 weeks after surgery D, 5 weeks after surgery



The Posttreatment intraoral photographs


• Tooth-borne distraction devices6,11-14,23

6. Alcan T. A miniature tooth-borne distractor for the alignment of ankylosed teeth. Angle Orthod 2006;76:77-83.11. Kofod T, Wurtz V, Melsen B. Treatment of an ankylosed central incisor by single tooth dento-osseous osteotomy and a simple distraction device. Am J OrthodDentofacial Orthop 2005;127:72-80.12. Kim Y, Park S, Son W, Kim S, Mah J. Treatment of an ankylosed maxillary incisor by intraoral alveolar bone distraction osteogenesis. Am J Orthod Dentofacial Orthop 2010;138:215-20.13. Im JJ, Kye MK, Hwang KG, Park CJ. Miniscrew-anchored alveolar distraction for the treatment of the ankylosed maxillary central incisor. Dent Traumatol 2010;26:285-8.14. Razdolsky Y, El-Bialy TH, Dessner S, Buhler JE, Jr. Movement of ankylosed permanent teeth with a distraction device. J Clin Orthod 2004;38:612-20.23. Kim Y, Kim S, Son W, Park S. Orthodontic treatment of an ankylosed tooth; application of single tooth osteotomy and alveolar bone distraction osteogenesis. Korean J Orthod 2009;39:185-98.

Alcan T. A miniature tooth-borne distractor6

Kofod T, Wurtz V, Melsen B.11



Kim Y, Park S, Son W, Kim S, Mah J. 12

6. Alcan T. A miniature tooth-borne distractor for the alignment of ankylosed teeth. Angle Orthod 2006;76:77-83.11. Kofod T, Wurtz V, Melsen B. Treatment of an ankylosed central incisor by single tooth dento-osseous osteotomy and a simple distraction device. Am J Orthod Dentofacial Orthop2005;127:72-80.12. Kim Y, Park S, Son W, Kim S, Mah J. Treatment of an ankylosed maxillary incisor by intraoral alveolar bone distraction osteogenesis. Am J Orthod Dentofacial Orthop2010;138:215-20.13. Im JJ, Kye MK, Hwang KG, Park CJ. Miniscrew-anchored alveolar distraction for the treatment of the ankylosed maxillary central incisor. Dent Traumatol 2010;26:285-8.14. Razdolsky Y, El-Bialy TH, Dessner S, Buhler JE, Jr. Movement of ankylosed permanent teeth with a distraction device. J Clin Orthod 2004;38:612-20.23. Kim Y, Kim S, Son W, Park S. Orthodontic treatment of an ankylosed tooth; application of single tooth osteotomy and alveolar bone distraction osteogenesis. Korean J Orthod 2009;39:185-98.


• SAS distraction devices13

6. Alcan T. A miniature tooth-borne distractor for the alignment of ankylosed teeth. Angle Orthod 2006;76:77-83.11. Kofod T, Wurtz V, Melsen B. Treatment of an ankylosed central incisor by single tooth dento-osseous osteotomy and a simple distraction device. Am J Orthod Dentofacial Orthop 2005;127:72-80.12. Kim Y, Park S, Son W, Kim S, Mah J. Treatment of an ankylosed maxillary incisor by intraoral alveolar bone distraction osteogenesis. Am J Orthod Dentofacial Orthop 2010;138:215-20.13. Im JJ, Kye MK, Hwang KG, Park CJ. Miniscrew-anchored alveolar distraction for the treatment of the ankylosed maxillary central incisor. Dent Traumatol 2010;26:285-8.14. Razdolsky Y, El-Bialy TH, Dessner S, Buhler JE, Jr. Movement of ankylosed permanent teeth with a distraction device. J Clin Orthod 2004;38:612-20.23. Kim Y, Kim S, Son W, Park S. Orthodontic treatment of an ankylosed tooth; application of single tooth osteotomy and alveolar bone distraction osteogenesis. Korean J Orthod 2009;39:185-98.

Im JJ, Kye MK, Hwang KG, Park CJ. 13











Razdolsky Y, El-Bialy TH, Dessner S, Buhler JE, Jr. 14

6. Alcan T. A miniature tooth-borne distractor for the alignment of ankylosed teeth. Angle Orthod 2006;76:77-83.11. Kofod T, Wurtz V, Melsen B. Treatment of an ankylosed central incisor by single tooth dento-osseous osteotomy and a simple distraction device. Am J Orthod Dentofacial Orthop2005;127:72-80.12. Kim Y, Park S, Son W, Kim S, Mah J. Treatment of an ankylosed maxillary incisor by intraoral alveolar bone distraction osteogenesis. Am J Orthod Dentofacial Orthop 2010;138:215-20.13. Im JJ, Kye MK, Hwang KG, Park CJ. Miniscrew-anchored alveolar distraction for the treatment of the ankylosed maxillary central incisor. Dent Traumatol 2010;26:285-8.14. Razdolsky Y, El-Bialy TH, Dessner S, Buhler JE, Jr. Movement of ankylosed permanent teeth with a distraction device. J Clin Orthod 2004;38:612-20.23. Kim Y, Kim S, Son W, Park S. Orthodontic treatment of an ankylosed tooth; application of single tooth osteotomy and alveolar bone distraction osteogenesis. Korean J Orthod 2009;39:185-98.









Segmental osteotomies Five days after surgery Distractor activated 180° by patient three times per day with hex wrench.





After two weeks of distraction

Fixed appliances placed to stabilize incisor after removal of distractor

After removalof fixed appliances.


• Tooth-borne distraction devices6











Advantages

No second surgery is required to remove the device.





Disadvantages

Anchorage teeth were intruded.

Introduction



Open bite


Summary

Open bite

• Case 1; When ankylosis happens to an central incisor at a growing stage, alveolar bone around the tooth doesn’t grow vertically.After growing up, the patient presented anterior open bite.

Black arrow indicates the gingival margin. A pink resin was added to look like a gingiva and a tooth-colored resin was added incisal edge for camouflage by her dentist.

Pretreatment intraoral photos (18 years and 8 months old)

Figure D shows the ankylosed maxillary left central incisor. The white arrow indicates the external resorption.

Pretreatment radiographs and cephalometric tracing

In the maxillary arch, MEAW (Multi-loop edgewise archwire, .018 x .022 stainless steel) was ligated. In the mandibular arch a .019 x .025 stainless steel archwire with shoe hooks was engaged. Class II elastics (5/16” 6oz) and up-and-down elastics (3/16” 6oz) were applied.

Progress intraoral photographs, 5 months after start of treatment (2008-11-28).

After open bite was resolved well except of the ankylosed incisor, two mini-implants were placed (1.6 x 6.0 mm mini-implant between #12 & #11 and # 22 & 23). On the maxillary upper left incisor, a new temporary crown was cemented over the ankylosed incisor for esthetics. Stainless steel wires (0.9 mm in diameter) were bonded for indirect anchorage.

Progress intraoral photographs, 12 months after start of treatment (2009-6-26)

Schematic drawing to explain the procedure

To keep the palatal mucosa intact for blood supply, only the labial bone

was opened and osteotomy was done.

The temporary crown was removed before surgery.

Seven days after osteotomy (2009-7-7)

Two small holes were made on the incisal resin of the crown to insert a surgical wire.By twisting and tightening the wire everyday, distraction was done.

Distraction 3 days (2009-7-10)

a soft 0.020-in stainless steel surgical wire (Stainless Steel Soft Wire. HL-03309-3, Hanil Dental Ind. Co., Seoul, Korea)


Resin was removed from the incisal edge as the incisor was extruded.

An average of 0.8 mm (0.5~1 mm) was distracted everyday.

Distraction was stopped. The incisor was fixed to the archwire by bonding resin on the incisal edge for consolidation.


Distraction was stopped. The incisor was fixed to the archwire by bonding resin on the incisal edge for consolidation.


Mini-implants were removed and a bracket was bonded on the maxillary left central incisor. In the mandibular arch .019 x 025 TMA with a root lingual torque on a mandibular right central incisor.

Progress intraoral photographs, 1 year and 10 months after start of treatment (2010-4-14)

Posttreatment intraoral photographs (2010-7-21). 21 years old. 2 years and 1 month after start of Treatment.

24 years and 1 month old. 3 years 1 month after debonding (2013.8.30).

2013.8.30 Post-retention3 years 1 month .

Introduction



Open bite


Summary


• Case 2; When trauma happens to the protruded central incisors in a nongrowing persons, there will be no open bite.

2013.6.18 First visit

Cervical abrasion was treated before starting orthodontic treatment.

2013.6.18 First visit

Lower third molars were extracted.

2014.5.2

At the initial leveling stage, #11 was diagnosed as ’ankylosis’, because it was not moved at all. Spaces were gained for the osteotome.

2014.7.2 19 days after segmental osteotomy

6.13: Segmental osteotomy

016”NT

2014.7.52014.7.2

Slight retraction of upper right central incisor.

2014.12.17

Introduction



Open bite


Summary

Summary• When the ankylosis happened during growth stage, it

brought open bite. This open bite was treated with distraction osteogenesis.

• When the ankyloses was brought after growth finished and the distance of displacement is not great, segmental osteotomy, movement and fixation was used.

• Even after the consolidation, the position of tooth could be adjusted shortly by an arch wire, ‘Floating bone concept’.

• Interdisciplinary work with good oral surgeonsunderstanding the direction & treatment plan of orthodontic treatment is recommended.

Documents

AAO2016Manuscript Tae-Woo Kim...Distraction osteogenesis for implant site development using a novel orthodontic device: a case report. IntJ Periodontics Restorative Dent 2008;28:189-96