Orthosurgical treatment including anchorage from a palatal implant to correct an infraoccluded maxillary first molar in a young adult

Tooth ankylosis during adolescence and early adulthood can lead to infraocclusion and several interrelated, adverse sequelae at the intra-arch and interarch levels. An orthosurgical treatment modality that includes surgical luxation and immediate orthodontic traction is recommended as a conservative approach in many patients. The key to success in this approach is the timely delivery of relatively heavy and continuous forces to the luxated tooth to prevent its reankylosis. Because high reactive forces are inevitably generated, it is crucial to create a reliable source of anchorage. This report describes the successful use of an osseointegrated orthodontic implant to reinforce the anchorage during the orthosurgical repositioning of an infraoccluded molar in a young adult.

Cessation of tooth eruption occurs without an apparent physical barrier and can lead to several side effects on the interarch and intra-arch levels. Although the mechanism that causes the cessation of tooth eruption has yet to be found, the consequences are well known: infraocclusion of the tooth with lessened development of the alveolar process, tipping of the adjacent teeth, overeruption of the opposing tooth, and midline shift. The earlier these phenomena occur, the more severe the consequences, especially when they occur in the permanent dentition during adolescence, a critical period for facial and dental development. Some researchers have described localized areas of ankylosis to explain the cessation of the tooth eruption, but others disagree and believe that there might not be ankylosis. Whatever the reason, it is believed that these teeth will not respond to conventional orthodontic forces.

This report describes the successful orthosurgical treatment of a severely infraoccluded maxillary first molar in an adolescent patient, by using skeletal anchorage and continuous forces.

Diagnosis and etiology

A 16-year-old girl was referred by her family dentist to the Department of Orthodontics of the Hebrew University-Hadassah School of Dental Medicine in Jerusalem, Israel, because of submergence of the maxillary right first molar. The patient had completed her orthodontic treatment 2 years before the referral. She had a well-balanced and symmetrical face, with a slightly convex profile. Intraorally, she had a Class I occlusion, with normal overbite and overjet. Several white spot lesions, observed on the labial side of the teeth in both arches and on the palatal side of the maxillary incisors, were presumed to have been related to the fixed appliances and the removable maxillary retainer during the first orthodontic treatment. The maxillary right first molar showed vital signs, but it emitted a sharp, solid sound on percussion. The occlusion showed marked disturbances that could be attributed to the influence of the ankylosed molar ( Fig 1 ): (1) there was a vertical height discrepancy of about 5 mm between the first molar and its neighboring teeth, (2) the adjacent teeth were tilted toward the affected tooth (especially the second premolar), (3) there were small spaces between the premolars mesial to the affected molar, and (4) the opposing molar showed only slight overeruption because of its occlusal contact with the tipped second premolar. The radiographic examination showed a vertical defect in the alveolar process in the immediate area of the affected tooth, caused by the cessation of molar eruption during the recent period in which significant vertical growth of the face and the jaws had occurred ( Fig 2 ).

Fig 1
Pretreatment intraoral photographs.

Fig 2
Pretreatment radiographs showing the infraoccluded maxillary right first molar.

Treatment objectives

The treatment objectives for this patient included (1) reopening space for the infraoccluded maxillary right first molar by distally tipping the mesially inclined second molar and closing the maxillary premolar spaces, (2) correcting the axial inclination of the adjacent teeth, (3) erupting the infraoccluded molar while maintaining its vitality, (4) generating alveolar bone in the area, and (5) improving the axial inclination of the maxillary incisor area.

Treatment objectives

The treatment objectives for this patient included (1) reopening space for the infraoccluded maxillary right first molar by distally tipping the mesially inclined second molar and closing the maxillary premolar spaces, (2) correcting the axial inclination of the adjacent teeth, (3) erupting the infraoccluded molar while maintaining its vitality, (4) generating alveolar bone in the area, and (5) improving the axial inclination of the maxillary incisor area.

Treatment alternatives

Six alternative therapeutic modalities for this scenario have been described in the literature: no treatment, surgical removal, prosthetic buildup, localized ostectomy, interalveolar segmental osteotomy, and orthosurgical treatment. After receiving a detailed explanation, the patient chose the orthosurgical approach, which entails surgical luxation of the ankylosed tooth with orthodontic extrusion. The risks are the possibility of tooth loss from crown, root, or alveolar fracture when the attempted luxation does not overcome an extensive ankylotic fusion, reankylosis with loss of anchorage and unwanted movement of the anchor teeth, and loss of vitality. Nevertheless, an important consideration with this option was that failure still left the other options open.

Treatment progress

Oral hygiene was much improved at the start of the second treatment. Nevertheless, the patient was treated under a strict regimen of regular professional fluoride application and mouth rinses to prevent further enamel decalcification.

The treatment stages were the following.

Apr 13, 2017 | Posted by in Orthodontics | Comments Off on Orthosurgical treatment including anchorage from a palatal implant to correct an infraoccluded maxillary first molar in a young adult
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