Definition

• anomaly of eruption that involves anatomic fusion of alveolar bone with

cementum or dentin.
• Ankylosed teeth differ from impacted teeth in that their eruptive potential has
been destroyed.
• a.k.a submerged or infraoccluded
• Classification of ankylosis according to level of infra occluded tooth
- Slight: the entire occlusal surface is approximately 1mm below the expected
occlusal plane as judged from the two nearest non-ankylosed teeth in the
same quadrant
- Moderate: the entire occlusal surface is located with both marginal ridges
approximately level with or just cervical to the contact area of one or both
adjacent tooth surfaces. In instances of ankylosis of two adjacent primary
molars, the contact area of the first secondary molar is used for reference
- Severe: the entire occlusal surface located level with or below the
interproximal gingival tissue of one or both adjacent tooth surfaces
 Prevalence
• Any tooth deciduous or permanent may become ankylosed anywhere along its
eruptive path either before or after emergence
• Most commonly involved teeth in order of frequency are the mandibular primary
first molar, the mandibular primary second molar, the maxillary primary first
molar, and the maxillary primary second molar.
• Ankylosis of permanent teeth is uncommon.
• In the deciduous dentition, mandibular teeth are affected ten times as often as
the maxillary dentition.
• Usually occurs in mixed dentition stage
 Implications
• adjacent teeth often incline toward the affected tooth, frequently with the
development of subsequent occlusal and periodontal problems.
• the opposing teeth often exhibit overeruption.
• Occasionally, the ankylosed tooth leads to a localized deficiency of the alveolar
ridge or impaction of the underlying permanent tooth.
• An increased frequency of lateral open bite and crossbite is seen.
• inclination of adjacent teeth and local space loss
• risk of caries and periodontal disease of neighboring teeth because of difficulty
of cleaning,
• Longer arch length at the side with infraocclusion; the first permanent molar is
held in a more distal position
• food impaction,
• reduction in vertical height of teeth next to the infra occluded tooth with
extrusion of antagonist teeth and consequent alteration in occlusal plane,
• lateral open bite (lateral open occlusal relationship),
• tongue habits, and
• deviation of midline to the side of infra occluded tooth
• Delayed exfoliation
• Impaction and/or delayed eruption of permanent successor
• Tipping of adjacent teeth. There is often significant tipping of teeth adjacent to
severely infraoccluded deciduous tooth
• Denuding of proximal root surface
• Increased difficulty of extraction associated with a severely submerged
deciduous molar
• Overeruption of opposing teeth
• Displacement of dental center-line to the affected side
• Relative spacing of teeth of the affected side
• Abnormal position and development of permanent successors
• Damage to adjacent teeth e.g. caries associated with submerged tooth and/or
adjacent teeth
 Diagnosis
Clinical Features
• The occlusal plane of the involved tooth is
below that of the adjacent dentition
(infraocclusion) in a patient with a history of
previous full occlusion
• A sharp, solid sound may be noted on
percussion of the involved tooth in comparison
to a cushion sound in normal teeth but can be
detected only when more than 20% of the root
is fused to the bone.
• However only the absence of tooth movement during orthodontic force
application is considered a sure sign
Radiographic Features
• absence of the PDL space may be noted;
however, the area of fusion is often in the
bifurcation and interradicular root surface,
making radiographic detection most difficult
• Roots are less radiopaque, and as the
ankylosis progresses, they are less
distinguished from surrounding bone
 Etiology
• The pathogenesis of ankylosis is unknown and may be secondary to one of many
factors. Disturbances from changes in local metabolism, trauma, injury,
chemical or thermal irritation, local failure of bone growth, and abnormal
pressure from the tongue have been suggested.
• The periodontal ligament (PDL) might act as a barrier that prevents osteoblasts
from applying bone directly onto cementum.
• Ankylosis could arise from a variety of factors that result in a deficiency of this
natural barrier. Such loss could arise from trauma or a genetically decreased PDL
gap. Other theories point to a disturbance between normal root resorption and
hard tissue repair. Several investigators believe genetic predisposition has a
significant influence and point to monozygotic twins who demonstrate strikingly
similar patterns of ankylosis to support this hypothesis.
• The cause of tooth ankylosis may be one of the following:
1. A genetic or congenital developmental gap in the periodontal membrane.
2. Some random or accidental occurrence including trauma
3. Disturbed local metabolism
• A defective or discontinuous periodontal membrane is a condition precedent to
tooth ankylosis. This may occur because of an incomplete development of
periodontal membrane, because of local lysis, or because local ossification of
part of the membrane.
• Periodontal membrane normally intervenes between tooth and bone at all points,
so that for ankylosis to take place there must be some defect or gap in the
membrane.
• Familial pattern, traumatic injury of Hertwig’s epithelial root sheath, deficiency
in bone growth, a problem in local metabolism and inflammation, localized
infection, and chemical or thermal irritations
 Treatment & prognosis

Four ways:
1. Build up; level with occlusal plane
2. Luxation; surgical luxation to help resume eruption or for orthodontic
movement
3. Extraction; early extraction and space maintenance
4. No treatment; monitor the ankylosed tooth

There are several treatment procedures according to the age of the patient, the
amount of tilting of adjacent teeth, and the condition of the permanent successor
as follows:
• Monitoring the ankylosed tooth
• early extraction and space maintenance
• restoration of occlusal height
• luxation

According to Lim et al, there are five treatment approaches;

1. no treatment; might be an option when the infra occlusion is mild
and the tooth can be periodically observed
2. orthodontic treatment; combined with luxation (surgical luxation to
help resume eruption or for orthodontic movement) might be
acceptable option although there is risk of fracture, recurrence of
ankylosis and need for endodontic treatment
3. prosthetic buildup; if infra occlusion less than 5 mm, may cause
interference with opposing supra erupted tooth. Opposing tooth
need to be intruded and the neighboring teeth need to be uprighted
4. segmental osteotomy; alveolar bone including the affected tooth is
sectioned and repositioned to bring the tooth to the occlusal plane,
and
5. extraction; for non restorable tooth with severe infra occlusion and
tipping of adjacent teeth, often results in exaggerated bony defect.

Treatment and Prognosis

Because they are fused to the adjacent bone, ankylosed teeth fail to respond to
normal orthodontic forces, with attempts to move the ankylosed tooth
occasionally resulting in intrusion of the anchor teeth.
 Treatment & prognosis
Recommended therapy for ankylosis of primary molars is variable and often is
determined by the severity and timing of the process.
• When an underlying permanent successor is present, extraction of the ankylosed
primary molar should not be performed until it becomes obvious that exfoliation
is not proceeding normally or adverse occlusal changes are developing. After
extraction of an ankylosed molar, the permanent tooth will erupt spontaneously
in the majority of cases.
• In permanent teeth or primary teeth without underlying successors, prosthetic
buildup can be placed to augment the occlusal height.
If the onset is not too early, the tooth may be built up to restore occlusal and
proximal contacts after maturity is reached. Such a build-up is possible only when
ankylosis occurs late and the restoration should be done at maturity. It must not be
done too long before maturity.

Severe cases in primary teeth are treated best with extraction and space
maintenance.
Restorative options for a mildly infraoccluded tooth include placement of
stainless steel crown or composite resin build-up of occlusal surface to prevent
tipping of adjacent tooth and overeruption of the opposing tooth
Luxation of affected permanent teeth may be attempted with extraction forceps in
an effort to break the ankylosis. It is hoped that the subsequent inflammatory
reaction results in the formation of a new fibrous ligament in the area of previous
fusion. In these cases, reevaluation in 6 months is mandatory.
It is suggested that ankylosis might be corrected by surgically luxating the tooth,
thereby breaking the bony bridge of ankylosis and permitting the resumption of
normal tooth eruption.
Luxation technique
It is almost identical with the preliminary steps of tooth extraction. After anesthesia
has be administered, the tooth should be grasped firmly with appropriate forceps
and rocked buccolingually, the axis of arc of movement being essentially through
the apices. On occasion mesiodistal luxation by means of elevators may be
cautiously employed. The important objective is to break the bony bridge of
ankylosis without injury to the nutrient vessels at the apices. Once the bony bridge
is broken, the usual consequence of inflammation follow and the fibrous tissue
formed in the reparative process becomes coextensive with the periodontal
membrane in effect, restoring its continuity. At the same time, bone surface is
restored making surface deposition possible and hence allowing tooth eruption to
be resumed.
 Treatment & prognosis
The response to this luxation technique may not me immediate. If no change is
apparent after 6 months, the procedure should be repeated. If luxation is
unsuccessful a second time the tooth should be extracted.

Finally, several reports have documented successful repositioning of an ankylosed

permanent tooth with a combination of orthodontics, segmental osteotomy, and
distraction osteogenesis

Since tooth ankylosis is a progressive anomaly, the earlier the onset the more
severe and profound will be the consequences; hence the necessity of a prompt
diagnosis. Once this diagnosis is made, immediate extraction is the general but not
absolute rule. This applies particularly if the ankylosed tooth is a deciduous one
whose permanent successor is present. Extraction breaks the fusion, the sire of lost
surface, and this restoration of free surface makes normal bone growth possible
once more. With the ankylosed tooth out of the way, its permanent successor erupts
into position, although a space maintainer may be needed.
If ankylosis occurs after maturity, no growth potential is destroyed and hence
extraction is unnecessary. If an ankylosed deciduous tooth becomes “submerged”
and its successor escapes impaction but erupts into proper occlusion, such
“submerged” tooth should not be disturbed.
Indications for tooth extraction are infection or interference with occlusion,
immediate or potential. Timing therefore is most important.
The recommended management of severely infraoccluded molars which have
not exfoliated within the normal time limits is extraction to prevent any adverse
sequelae

1. Tooth ankylosis the fusion of bone and cementum is a progressive anomaly of

tooth eruption which usually has a profound effect on the occlusion
2. Deciduous teeth become ankylosed far more frequently than do permanent
teeth, the ratio being better than 10 to 1 , and lower teeth are ankylosed more
than twice as often as upper teeth
3. Tooth ankylosis exhibits selectively as to site (nearly all ankylosed teeth are
molars, deciduous or permanent) and selectively as to physiologic time (nearly
all ankyloses occur in the deciduous or mixed dentitions)
4. Tooth ankylosis is not likely to be random or accidental origin; nor is excessive
or traumatic pressure a probable cause, although the latter enjoys wide
acceptance as a possible explanation. Tooth ankylosis may be due to a
disturbed metabolism
 Treatment & prognosis
5. Treatment depends upon whether the ankylosed tooth is deciduous or
permanent, the time of onset, the time of diagnosis, and the location of the
affected tooth. There are six possible situations:
A. If the ankylosed tooth is deciduous and has a successor, the general rule is
to extract immediately and, if necessary, to insert an appropriate space
maintainer
B. If the tooth is deciduous and without a successor and the onset is early so
that “submergence” is threatened, treatment involves extraction and space
maintenance
C. If the tooth is deciduous and without successor and the onset is late,
proximal and occlusal contacts may be built up at maturity
D. If the ankylosed tooth is permanent and the onset is early, the tooth should
be luxated. If repeated luxation proves ineffective, the tooth should be
extracted. It should not be permitted to “submerge”
E. If the onset of ankylosis is late, the permanent tooth should be luxated. If
the attempt is unsuccessful and the tooth does not “submerge”, it may be
built up at maturity
F. A deeply “submerged” ankylosed tooth, deciduous or permanent should be
left undisturbed unless it is infected or constitutes an immediate or potential
threat to the occlusion