Good news is there are no signs of infection but bad news is signs of external root resorption, which is very difficult to arrest ones started. At this stage my personal opinion is not to do either orthodontic or surgical intervention. Rather aesthetic smile design can be carried out over clinical crowns. The external resorption is inevitably going to consume the root but this replacement resorption is going to fill the socket with abundant healthy bone, which can later be used for implants and fortunately by that time child will be an adolescent or a adult and will be the right time for implant delivery..., 

You have already made a very good summary of the different alternatives Yango. I have in similar cases chosen decoronation and waiting for remodelleing and later done implant treatment when growth is completed. It works on a 16 year old boy and preserves the crest very good horizontally, but also a little bit vertically. A root undergoing replacement resoption is probably the best bone replacing material available and will turn into bone by time.

Dear Prashant Battepati,

yes, we are happy that there is at least no infection which would result in a severe loss of tissues. This is however predictable if the endo is done prophylactically: If the root canal is filled then there is no chance for microorganisms to enter the root canal, thus there is no risk for an infection and infection related resorption. The conventional approach starts the endo when infection related resorptions have already been established... We are just preparing a paper on intrusion, you might want to read our paper on tooth avulsion, where we also use this strategy (paper is also updated at the moment).

https://www.researchgate.net/publication/7960856_Results_after_replantation_of_avulsed_permanent_teeth._I._Endodontic_considerations?ev=prf_pub

Yes, you are right that the alveolus is filled with bone, however, the infraposition and therefore the marginal bone level are fixed. Since the patient is still growing, the situation will even get worse. This would require vertical augmentation which is definitely something which I want to avoid...

All the other options are intended to minimize the amount of vertical bone deficit.

Article Results after replantation of avulsed permanent teeth. I. En...

Hi Lars,

thank you for your comment. Yes, decoronation is probably the best solution. However, orthodontic movement is also very promising. It could comprise complete space closure, or just the movement of the lateral incisors to the central position, then placement of implants in the lateral region. Or the movement of additional teeth (canine to molars), the last being replaced by an implant.

Or, the lateral is moved to regenerate bone, and then moved back. Our orthodontists are quite convinced that this would work, however, it would require orthodontic implants and quite some time - but the patient is a little impatient...

From this perspective premolar transplantation would be an interesting option, but carries the risk for ankylosis, which is said to be 30 to 40%. But this means a 60 to 70% chance of functional healing and much better conditions compared to implants. For the case of ankylosis there should be a plan B, however. Any experiences with distraction in such cases? What can be expected if we expect ankylosis of transplanted premolars, but the pm are immediately/soon extruded by orthodontic forces? Will bone and soft tissues follow the teeth?

I'm totally exhausted from searching the best solution....

Hi Yango

Orthodontic space closure is interesting alternative but esthetically less favorable in unilateral losses but good when two central incisors are lost.The prognosis for transplantation is higher in the literature for premolars to the anterior teeth than for other transplants.

I recommend an article we wrote some years ago elucidating these problems

Andersson L, Malmgen B. The problem of Dentoalveolar ankylosis and subsequent replacement resorption in the growing patient.

Australian Endodontic Journal 1999; 25:57-61 I attach a pdf file

Interesting thoughts on moving and moving back a tooth if the patient is patient. Reminds me of transport distraction osteogenesis which functions very well but takes time. You should publish such a case if you are doing this treatment. Please keep us updated Yango

Best regards

Lars

I completely agree with explanation given by Lars Andersson.

as i could understand with the description that teeth are free from pathology and ankylosed. now the main concern is open bite. In my opinion intra-oral mini distractors should be used to bring the 11 21 segment incisally.

If active growth has not yet finished the results will be excellent.

Dear Amit Nagar,

thank you for your answer, to which I only can respond with a 'yes and no':

There is no infection, but ankylosis is accompanied by (progressive) replacement resorption, and the autologous root is already reduced to a height of about 2 and 4 mm. The boy has not finished growth, and there is concern that facial growth may continue for some more years, as it seems to be finished clearly later than body growth. I expect that root substances might be completely resorbed earlier than the end of growth. There are several experiences that the crowns may be retained for about several years beyond the time when root substances have been more or less completely resorbed, most probably because the crowns are cemented on that titanium post (which is inserted from retrograde direction up into the crown). However, I am afraid that by placing the distractor I would open pathways for microorganisms which could easily reach the delicate region where the foreign material titanium post enters the crown, and where also the resorption lacunae at the bottom of the crown could be infected....

Nevertheless, this might be an option if we transplant premolars and one or both show ankylosis...

I don't have own experiences with distractions, but from congresses and literature I have the information that it is not that easy in the upper jaw, since the palatal mucosa is quite stable and may result in forcing the segment palatally...

Which system do you use? Any unwanted observations, like described above?

Hi,

just had a closer look into decoronation:

https://www.researchgate.net/publication/273957838_Long-term_follow_up_of_103_ankylosed_permanent_incisors_surgically_treated_with_decoronation__a_retrospective_cohort_study

Seems that this procedure is not helpful in patients of 16 years and older (decrease of bone height), while bone level increases in younger patients...

Sad....

Article Long-term follow up of 103 ankylosed permanent incisors surg...

Dear Yango,

Its a tricky situation. Orthodontic intervention may seems inevitable. You may require site development at some stage if planning implants. Moving lateral incisors back and forth may predispose them to resorption.

Dear Arshad,

yes, it is very tricky. By this question I try to gather enough information to chose the best option. But it is a complex and difficult situation, and data for an objective decision are missing.

Concerning orthodontic movement and resorptions: yes, there is a risk, but

1. is it relevant for survival of these teeth, assuming that this resorption type is not progressive by itself, but stops, if the orthodontic movement is stopped?

2. Are there any data on the risk, that these resorptions occur, at this age?

It is difficult to answer if I couldn't see the situation of the patient.

I would not do invasive therapy in the age of 16. Perhaps you can make a interim treatment with non-prep-veneers or with a plastic filling.

You can look here:

Quintessence Int 46 (2015), Nr. 4, Seite 281-285, doi:10.3290/j.qi.a33400, PubMed:25642458

Non-prep restoration of an ankylosed incisor: A case report

Piwowarczyk, Andree / Blum, Jasmin / Abendroth, Holger

Best regards

Rudolf Ritt

Dear Yango   Pohi,

I agree with RudolfRitt and  clinical picture should have been there to give a proper treatment plan.

Dear Yango Pohi,

Yes it is a very difficult case. There is one more option maybe, but I don't have much experience with this. Need multibracket appliance treatment. Just before starting treat extrusion of critical incisors, send patient to oral surgeon. Ask him to make luksation of the incisors and immediately after this surgical intervention connect brackets of the incisors to NiTi wire and try to extrude them very gently. Oral surgeon should be experienced to do this carefully.

Good luck!

Nenad N.

With an Xray picture will be easy for us to help you.... regards and good luck.

Dear colleagues,

sorry, I was not aware that pictures can be uploaded.

The picture shows the open front bite, due to ankylosis of teeth 11 and 21.

The ugly discoloration is due to the sealer (sealapex) which we used for some time when Diaket was no longer available: While we did not record any discoloration with Diaket, even in the long run, several  months after replantation the teeth got grey if sealapex was used. We use now another sealer (Aptalharz, or AH26), on a similar basis like Diaket, and since then this problem is solved.

While we in nearly every case try to transplant primary canines or premolars to prevent this deleterious bone deficit, we missed this patient somehow.

Dear Nenad Nedeljkovic,

to my experience after 4 years of ankylosis there is a so tight "interlocking" between tooth and bone that it is most unlikely that the teeth could be extracted without breaking into pieces.

Nevertheless, this might be an option, as well as the repeated extraction and  a reposition into a somewhat extruded position, if done earlier..

.

 Please explain what was the treatment performed in the radiograph

Dear Ahmed,

we used a so-called auto-/allo-alloplastic replantation, as we always do since 20 to 30 years:

The alloplastic post (titanium, in earlier days ceramics, inserted from a retrograde direction) and the autologous (= vital) or alloplastic (= avital) root are replanted (in case of avulsion, intrusion, extrusion, lateral dislocation) or transplanted (premolars or primary canines).

Here we did that in the expectation of functional healing (normal/cemental) in a at that time 12 years old boy who showed up with a severe intrusion of both central upper incisors. Unfortunately, it turned out that both of these teeth ankylosed.

This treatment is done to prevent any infection in the root canal, which is related to infection related resorptions, which themselves are related to early tooth loss, as indicated by several authors of animal experiment studies (Andreasen, Andersson, Matsson, Nasjileti) or clinical studies (Andreasen, Coccia, Pohl).

Normally, we submit our patients with these complications to a premolar (or, in younger patients, primary canine) transplantation, however, we somehow overlooked this patient.

If there is alveolar bone discrepancy, then extraction and implants following growth is one option. Some case reports have been published of dentoalveolar distraction in posterior teeth

The ankylosis with consequent infraposition, .. .nnñ is usually a matter of decoronation, if this tecnique is not accepted by the inuuried person, at the age appropriate will be done GBR and implant tecnique.