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Journal of Prosthetic Dentistry

Periodontal plastic surgery for the management of an ankylosed permanent maxillary lateral incisor: A clinical report with 5-year follow-up

  • Edgar Grageda
    Correspondence
    Corresponding author: Dr Edgar Grageda, Medica Sur Hospital, Puente de Piedra #150 Torre 1 Int 905-913, Tlalpan, Mexico City CP 14050, MEXICO
    Affiliations
    Associate Professor, Department of Restorative Dentistry, Technological University of Mexico UNITEC, Medica Sur Hospital, Mexico City, Mexico

    Professor, Department of Prosthodontics, National Autonomous University of Mexico UNAM, Mexico City, Mexico

    Private practice, Medica Sur Hospital, Mexico City, Mexico
    Search for articles by this author
  • Enrique Grageda
    Affiliations
    Professor, Department of Orthodontics, National Autonomous University of Mexico UNAM, Mexico City, Mexico

    Private practice, Medica Sur Hospital, Mexico City, Mexico
    Search for articles by this author
Published:November 13, 2020DOI:https://doi.org/10.1016/j.prosdent.2020.06.024

      Abstract

      Anterior maxillary tooth ankylosis disturbs the development of the alveolar bone process, leading to discrepancies between the cervical gingival margin and incisal edge position of the affected tooth, and therefore, the esthetics is compromised. Proposed treatments in adults and growing patients have been used successfully, but they have disadvantages and are contraindicated in some circumstances. This article proposes an alternative treatment for an ankylosed permanent maxillary anterior tooth with a slow replacement resorption rate in an adult patient, for whom a combination of a periodontal plastic surgery procedure and a fixed dental prosthesis was used to correct the esthetics. This treatment has less risk of complications, preserves the ankylosed tooth as long as possible, creates an optimal gingival contour, and maintains the alveolar bone for further treatment should the tooth be lost.
      Ankylosis occurs when a tooth loses its periodontal ligament, leaving the cementum of the tooth in contact with bone. At this point, a progressive noninflammatory remodeling process, called replacement resorption, occurs.
      • Wu Y.
      • Yuan X.
      • Perez K.C.
      • Hyman S.
      • Wang L.
      • Pellegrini G.
      • et al.
      Aberrantly elevated Wnt signaling is responsible for cementum overgrowth and dental ankylosis.
      The etiology of dental ankylosis includes trauma, genetic factors, and viral infections.
      • Campbell K.M.
      • Casas M.J.
      • Kenny D.J.
      Ankylosis of traumatized permanent incisors: pathogenesis and current approaches to diagnosis and management.
      • Dewhurst S.
      • Harris J.
      • Bedi R.
      Infraocclusion of primary molars in monozygotic twins: report of two cases.
      • Becktor K.B.
      • Bangstrup M.I.
      • Rølling S.
      • Kjaer I.
      Unilateral primary or secondary retention of permanent teeth and dental malformations.
      Clinical signs of ankylosis are lack of mobility, an altered percussion sound, failure of the tooth to move with orthodontic force, infraocclusion, and gingival discrepancy.
      • Campbell K.M.
      • Casas M.J.
      • Kenny D.J.
      • Chau T.
      Diagnosis of ankylosis in permanent incisors by expert ratings, periotest and digital sound wave analysis.
      ,
      • Kawanami M.
      • Andreasen J.O.
      • Borum M.K.
      • Schou S.
      • Hjørting-Hansen E.
      • Kato H.
      Infraposition of ankylosed permanent maxillary incisors after replantation related to age and sex.
      Traditional 2-dimensional radiographic examination is of limited value, and computed tomography can be more useful when looking for resorption rate, extension, and position of the ankylotic area.
      • Ducommun F.
      • Bornstein M.M.
      • Bosshardt D.
      • Katsaros C.
      • Dula K.
      Diagnosis of tooth ankylosis using panoramic views, cone beam computed tomography, and histological data; a retrospective observational case series.
      ,
      • Andersson L.
      • Blomlöf L.
      • Lundskog S.
      • Feiglin B.
      • Hammarström L.
      Tooth ankylosis, clinical, radiographic and histological assessments.
      The anterior maxillary permanent teeth are most frequently affected, commonly traumatized in schoolchildren.
      • Dighe K.
      • Kakade A.
      • Takate V.
      • Makane S.
      • Padawe E.
      • Pathak R.
      Prevalence of traumatic injuries to anterior teeth in 9-14 year school-going children in Mumbai, India.
      ,
      • Soriano E.P.
      • Caldas Jr., A.de.F.
      • Diniz de Calvalho M.V.
      • Amorin Filho H.A.
      Prevalence and risk factors related to traumatic dental injuries in Brazilian schoolchildren.
      Therefore, it is not uncommon to see patients in the dental practice with a permanent ankylosed anterior tooth (PAAT) seeking treatment, with gingival discrepancy and infraocclusion affecting their esthetics.
      • Panchali B.
      • Anika D.
      • Imam A.
      • Ragini M.
      • Ashu B.
      Impact of altered gingival characteristics on smile esthetics: laypersons' perspectives by Q sort methodology.
      Objective esthetic parameters in relation to the gingival contour levels of the maxillary anterior teeth include even gingival zenith levels of the central incisor and the canine and a gingival zenith level of the lateral incisor between 0.5 and 1 mm below the gingival zenith line between the central incisor and the canine.
      • Chu S.J.
      • Tan J.
      • Stappert C.
      • Tarnow D.
      Gingival zenith positions and levels of the maxillary anterior dentition.
      ,
      • Charruel S.
      • Perez C.
      • Foti B.
      • Camps J.
      • Monnet-Corti V.
      Gingival contour assessment: clinical parameters useful for esthetic diagnosis and treatment.
      Treatment alternatives have been proposed for this condition, and the appropriate treatment depends on the degree of replacement resorption, the severity of infraocclusion, and the age of the patient.
      • Biederman W.B.
      Etiology and treatment of tooth ankylosis.
      ,
      • Lin S.
      • Ashkenazi M.
      • Karawan M.
      • Teich S.T.
      • Gutierrez Z.
      Management of ankylotic root resorption following dental trauma: a short review and proposal of treatment protocol.
      Although the prognosis of a PAAT is considered hopeless, the replacement resorption rate is variable in every patient and is dependent on factors including age, basal metabolic rate, extra-alveolar time, severity of the trauma, amount of root dentin at the time of the trauma, and the extent of periodontal ligament necrosis.
      • Lenstrup K.
      • Skieller V.
      A follow up study of teeth replantation after accidental loss.
      ,
      • Ebeleseder K.A.
      • Friehs S.
      • Ruda C.
      • Perti C.
      • Glockner K.
      • Hulla H.
      A study of replanted permanent teeth in different age groups.
      Andersson et al
      • Andersson L.
      • Bodin I.
      • Sorensen S.
      Progression of root resorption following replantation of human teeth after extended extraoral storage.
      reported that the resorption rate in adults was slower and that the affected tooth may survive for decades and possibly throughout life. This slower replacement resorption rate in adults favors retaining the tooth as long as possible because it will maintain the alveolar bone volume and facilitate future treatment.
      Malmgren and Malmgrem
      • Malmgren B.
      • Malmgrem O.
      Rate of infraposition of reimplanted ankylosed incisors related to age and growth of children and adolescents.
      devised a severity score index for the infraocclusion of ankylosed permanent incisors in which the homologous maxillary incisors with healthy periodontal ligaments were used as reference teeth. The severity score index ranges from minimal to extreme and provides a useful guide for determining a treatment plan because severe infraocclusion might call for a more invasive procedure.
      Treatment options for growing patients include extraction and orthodontic space closure, autotransplantation, and decoronation.
      • Zachrisson B.U.
      Improving orthodontic results in cases with maxillary incisors missing.
      • Czochrowska E.M.
      • Stenvik A.
      • Album B.
      • Zachrisson B.U.
      Autotransplantation of premolars to replace maxillary incisors: a comparison with natural incisors.
      • Malmgren B.
      Decoronation: how, why, and when?.
      Treatment options for adults include composite resin incisal edge restoration, extraction and fixed replacement, and repositioning of the ankylosed tooth either by surgical luxation, segmental osteotomy, or distraction osteogenesis.
      • Jacobs S.
      Ankylosis of permanent teeth: a case report and literature review.
      • Davarpanah M.
      • Szmucler-Moncler S.
      Unconventional implant treatment: I. Implant placement in contact with ankylosed root fragments. A series of five case reports.
      • You K.H.
      • Min Y.S.
      • Baik H.S.
      Treatment of ankylosed maxillary central incisors by segmental osteotomy with autogenous bone graft.
      • Chang H.Y.
      • Chang Y.L.
      • Chen H.L.
      Treatment of a severely ankylosed central incisor and a missing lateral incisor by distraction osteogenesis and orthodontic treatment.
      Such treatments for adults have been used with considerable success. However, they face several disadvantages and can be contraindicated for some patients. Segmental osteotomy and distraction osteogenesis are indicated for severe or extreme infraocclusion but are contraindicated for severely tilted or crowded teeth and may produce loss of tooth vitality, avascular necrosis in the bone segment, gingival recession, loss of crestal bone, or pocket formation. Repositioning the tooth with surgical luxation could lead to fracture of the root when applying force and having to redo the procedure because of rebound, loss of tooth vitality, and unpredictable esthetic results. Extraction may lead to a severe alveolar bone defect, compromising the esthetics of an implant-supported crown or fixed partial denture unless further regenerative procedures are performed. A composite resin restoration would not resolve the gingival discrepancy.
      The gingival discrepancy of a PAAT leads to a similar clinical scenario as Miller Class I and II gingival recession.
      • Miller Jr., P.D.
      A classification system of marginal tissue recession.
      The bilaminar technique, a perioplastic surgery procedure consisting of a coronal advanced flap plus a connective tissue graft (CAF + CTG), is a well-documented procedure for these classes of gingival recession.
      • Cortellini P.
      • Tonetti M.
      • Baldi C.
      • Francetti L.
      • Rasperini G.
      • Rotundo R.
      • et al.
      Does placement of a connective tissue graft improve the outcomes of coronally advanced flap for coverage of single gingival recessions in upper anterior teeth? A multi-centre, randomized, doubled-blind, clinical trial.
      • Chambrone L.
      • Tatakis D.
      Periodontal soft tissue coverage procedures: a systematic review from the AAP regeneration workshop.
      • Oates T.W.
      • Robinson M.
      • Gunsolley J.C.
      Surgical therapies for the treatment of gingival recession. A systematic review.
      This article describes an alternative for treating a PAAT in an adult patient with a gingival discrepancy, moderate infraocclusion, and slight radiographic signs of root resorption. A (CAF + CTG) was used to correct the cervical gingival margin discrepancy, and a ceramic fixed dental prosthesis (CFDP) was placed to correct the incisal edge position.

      Clinical report

      A healthy 18-year-old woman presented to the Medica Sur Dental Clinic complaining of the appearance of her right maxillary lateral incisor and with a history of lateral luxation and orthodontic treatment. Clinical examination revealed well-aligned maxillary and mandibular teeth; Class 1 molar and Class 1 canine occlusal relationship; 3 mm of cervical gingival margin discrepancy; 3 mm of infraocclusion with a light buccal displacement on the right maxillary lateral incisor; a small fracture on the right maxillary central incisal edge; 4 mm of probing depth on the facial cervical gingival margins on both maxillary central incisors; and 3 mm of probing depth on the other teeth (Fig. 1A). The affected tooth produced a dull sound and orthodontic force had not induced movement. A panoramic radiograph showed mesial root tipping of the right maxillary lateral incisor, with slight signs of replacement resorption on the root (Fig. 1B). A cold vitality test with ethyl chloride was positive. She declined existing treatment alternatives for an ankylosed permanent anterior tooth in the adult population, eliciting a new proposal: to retain the affected tooth, perform a CAF + CTG, fabricate a CFDP, perform a 1-mm gingivectomy on the facial cervical gingival margins on both maxillary central incisors, and a composite resin restoration on the incisal edge of the right maxillary central incisor.
      Figure thumbnail gr1
      Figure 1Ankylosed right maxillary lateral incisor. A, Frontal view. B, Panoramic radiograph.
      Local anesthetic (4 mL Articaine with epinephrine 1/100000; Medicaine Septodont) was applied at 3 sites: the anterior superior alveolar nerve, the nasopalatine nerve, and the greater palatine nerve. The surgery began with an intrasulcular incision at the buccal aspect of the affected tooth with a 15C blade (Ambiderm; Huaiyin Medical Instruments Co, Ltd), followed by 2 horizontal incisions of about 2 mm in length placed 3 mm below the highest point of the adjacent papilla at the mesial and distal sites and 2 slightly divergent vertical incisions on both sites that were extended to the mucolabial fold, creating a trapezoidal flap (Fig. 2A). A split-full-split designed flap was raised beyond the mucogingival junction to facilitate passive coronal displacement of the flap.
      • De Sanctis M.
      • Zuchelli G.
      Coronally advanced flap: a modified surgical approach for isolated recession type defects: three-year results.
      The adjacent papillae were de-epithelialized with surgical scissors. Using a diamond rotary instrument (TR-13; Mani. Inc), 3 mm of enamel was then removed from the cementoenamel junction (CEJ) toward the incisal edge until dentin was visible. This diminished the slight buccal displacement of the tooth, moved the CEJ coronally, and left dentin as a recipient site for the CTG (Fig. 2B). A 1.5-mm-thick CTG was harvested from the palate in the premolar area using the trap-door approach.
      • Edel A.
      Clinical evaluation of free connective tissue graft used to increase the width of keratinized gingival.
      A gentle dentin-root debridement was performed with a curette, and the root surface was conditioned with 24% ethylenediaminetetraacetic acid (EDTA) for 2 minutes to remove the smear layer and to produce a more biocompatible surface.
      • Blomlöf J.
      • Lundskog S.
      Root surface texture and early cell and tissue colonization after different etching modalities.
      The CTG was positioned at the level of the new CEJ and was stabilized to the periosteum with single interrupted sutures (Coated Vicryl Braided 3-0; Ethicon) (Fig. 2C). Finally, the recipient flap was displaced coronally and sutured to cover the CEJ and the CTG completely (Nylon 4-0; Atramat) (Fig. 2D).
      • Langer B.
      • Langer L.
      Subepithelial connective tissue graft technique for root coverage.
      At 3 months, a lithium disilicate crown was fabricated and cemented. The restorative margin was placed subgingivally with a chamfer finishing line, taking care not to invade the biologic width (Fig. 3). A composite resin restoration on the mesial incisal edge of the right maxillary central incisor and a 1-mm gingivectomy on the cervical gingival margin of the 2 maxillary central incisors with a diode laser (Odyssey Navigator; Ivoclar Vivadent AG) were also performed (Fig. 4). Post-treatment follow-up involved yearly evaluation of occlusion, evaluation of the replacement resorption rate with periapical radiographs, probing depth, gingival margin stability, oral hygiene, and patient satisfaction. At the 5-year follow-up, the gingival margin was stable but inflamed, the replacement resorption rate continued to be slow, she was satisfied, and fracture of the composite resin restoration on the maxillary central incisor was observed (Fig. 5).
      Figure thumbnail gr2
      Figure 2Periodontal plastic surgery procedure. A,Trapezoidal flap. B, Enamel removal with new CEJ location. C, Connective tissue graft sutured at new CEJ location. D, Flap sutured coronally to new CEJ. CEJ, cementoenamel junction.
      Figure thumbnail gr3
      Figure 3Periapical radiograph showing bone crest and finish line.
      Figure thumbnail gr4
      Figure 4Definitive result with new ceramic crown.

      Discussion

      As shown at the 5-year follow-up, the CAF + CTG combined with CFDP was a successful treatment for the gingival discrepancy present in a PAAT. This result was expected because the gingival discrepancy was similar to a tooth with Miller Class I and II gingival recession. The CAF + CTG has been established as the gold standard of treatment for gingival recession, especially when an increase in keratinized tissue and long-term stability of the graft are needed.
      • Cairo F.
      • Pagliaro U.
      • Nieri M.
      Treatment of gingival recession with coronally advanced flap procedures: a systematic review.
      ,
      • Han J.S.
      • John V.
      • Blanchard S.B.
      • Kowolik M.J.
      • Eckert G.J.
      Changes in gingival dimensions following connective tissue grafts for root coverage: comparison of two procedures.
      This technique is contraindicated in patients with anatomic limitations such as marginal frenula, high muscle pull, and shallow vestibule.
      • Zucchelli G.
      • Mounssif I.
      Periodontal plastic surgery.
      The healing between the root surface and the overlying gingival tissue from the CAF + CTG is predominantly a repair, consisting of the formation of a long junctional epithelium and a connective tissue attachment with fibers running parallel to the root, rather than a true periodontal regeneration.
      • Majzoub Z.
      • Landl L.
      • Grusovin M.G.
      • Cordioli G.
      Histology of connective tissue graft. A case report.
      • Carnio J.
      • Camargo P.M.
      • Kenney E.B.
      • Shenk R.K.
      Histological evaluation of 4 cases of root coverage following a connective tissue graft combined with an enamel matrix derivative preparation.
      • Cummings L.C.
      • Kaldahl W.B.
      • Allen E.P.
      Histologic evaluation of autogenous connective tissue and acellular dermal matrix grafts in humans.
      Clinically, this repair results in long-term maintenance of function and is resistant to probing.
      • McGwire M.K.
      • Scheyer E.T.
      • Nunn M.
      Evaluation of human recession defects treated with coronally advance flaps and either enamel matrix derivative or connective tissue: comparison of clinical parameters at 10 years.
      ,
      • Graziano A.
      • Cirillo N.
      • Pallotti S.
      • Cricenti L.
      • Romano F.
      • Aimmetti M.
      Unexpected resilience to experimental gingivitis of subepithelial connective tissue grafts in gingival recession defects: a clinical-molecular evaluation.
      The presence of inflammation, without attachment loss, on the gingival margin at the 5-year follow-up could be because of one or a combination of the following factors: plaque accumulation, the subgingival restorative margin, or the slight overcontouring of the CFPD in relation to the recipient tooth.
      • Padbury Jr., A.
      • Eber R.
      • Wang H.-L.
      Interactions between the gingiva and the margin of restaurations.
      The slight overcontouring on the cervical portion of the CFPD was unavoidable because the finish line was placed along the middle, flat portion of the clinical crown. This also made it more prone to plaque accumulation. For esthetic purposes, the restorative margin was placed approximately 0.5 mm subgingivally by placing a single displacement cord at the time of tooth preparation and a double displacement cord for impression making. Therefore, the presumed newly formed long junctional epithelium may have been invaded. An equidistant or a supragingival restorative margin may have had a more optimal outcome, since coronal shifting of the gingival margin has been reported at a rate of 0.09 mm per year when CAF + CTG is implemented.
      • Rasperini G.
      • Acunzo R.
      • Pellegrini G.
      • Pagni G.
      • Tinneti M.
      • Pini Prato G.
      • et al.
      Predictor factors for long-term outcomes stability of coronally advance flap with or without connective tissue graft in the treatment of a single maxillary gingival recession: 9 years result of a randomized controlled clinical trial.
      ,
      • Pino Prato G.
      • Cairo F.
      • Nieri M.
      • Franceschi D.
      • Rotundo R.
      • Cortelinni P.
      Coronally advance flap versus connective tissue graft in the treatment of multiple gingival recessions: a split-mouth study with a 5-year follow-up.

      Summary

      The CAF + CTG in combination with CFDP is a treatment option for adults with an ankylosed permanent incisor with gingival discrepancy, minimal or moderate infraocclusion, and slight signs of replacement resorption. This treatment creates the optimal gingival contour and maintains alveolar bone volume for further treatment, including implant therapy or FDP in the case of tooth loss.

      Acknowledgments

      The authors thank the 2 anonymous reviewers for their valuable comments and the Journal of Prosthetic Dentistry editors.

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