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Fırat University Medical Journal of Health Sciences
2023, Cilt 37, Sayı 3, Sayfa(lar) 265-268
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Ankiloze Bir Maksiller Santral Kesici Dişin Kişiye Özel Aygıt Kullanılarak Distraksiyon Osteogenezis Yöntemi Yeniden Konumlandırılması: Bir Olgu Sunumu
Serkan DÜNDAR1, Recai TEMİZKAN2, Alihan BOZOĞLAN1, Erdem HATUNOĞLU3, Cansu Büşra UZUN4, Nurullah SÖKMEN5
1Firat University, Dentistry Faculty, Department of Periodontology, Elazig, TURKIYE
2Private Practice Physician, Orthodontics, Elazig, TURKIYE
3Private Practice Physician, Orthodontics, Kahramanmaras, TURKIYE
4T.R. Ministry of Health, Atasehir Oral and Dental Health Hospital, Periodontology Istanbul, TURKIYE
5T.R. Ministry of Health, Alanya Oral and Dental Health Center, Periodontology, Antalya, TURKIYE
Anahtar Kelimeler: Alveolar distrasiyon osteogenezis, dentoosseos distraksiyon osteogenezis, osteojenik distraksiyon, ankiloz, ankiloz dişler
Özet
Diş ankilozu, çiğneme fonksiyonunda anormalliğe ve kötü bir ısırmaya yol açarak estetik açıdan tatmin edici olmayan bir gülümseme çizgisine neden olabilir. Dentoalveolar distraksiyon osteogenez yöntemi dişin hem sert hem de yumuşak oluşumunu ve yeniden konumlandırılmasını kolaylaştıran ankiloze dişlerin tedavisi için iyi bir seçenektir. Ankiloze dişlerin başarılı bir şekilde yeniden konumlandırılması hem işlevi hem de estetiği iyileştirir. Bu klinik vaka raporunda, 21 yaşındaki bir bayan hastada ankiloze maksiller santral dişin kişiye özel üretilmiş, diş destekli ağıziçi distraktör kullanılarak tedavisi anlatılmaktadır. Distraktörün yapımında genişletme zembereği ve paslanmaz çelik tel kullanılmıştır. Bu ağız içi aparat, osteotomi sonrası dentoalveolar segmentin hareketini sağlamıştır. Distraksiyon osteogenez prosedürü ile santral kesici dişin yeniden konumlandırılmasından sonra çiğneme fonksiyonu ve gülümseme estetiğinde iyileşme sağlanmıştır. Diş destekli distraksiyon aygıtı kullanılan dentoalveolar distraksiyon osteogenez yöntemi, diş ankilozu olan hastalarda iyi sonuçlar verebilir.
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    Ankylosis, which refers to pathological fusion between the alveolar bone and cementum of teeth hinders both physiological and orthodontic tooth movement. It is most seen with deciduous molars. In addition, embedded canine teeth and traumatized maxillary first and second incisors can be affected by ankylosis. The absence of normal physiological tooth movement, such as chewing, and occlusal contact can cause ankylosis. Ankylosis may also be the result of trauma and subsequent dental splinting preventing physiological tooth movement1-4. Ankylosis and infraocclusion, leading to tipping of neighboring teeth and insufficient alveolar bone development, can lead to orthodontic problems, such as an anterior and/or posterior open bite, midline shift, vertical dimension inadequacy, occlusal incompatibility, and chewing disorders, all of which can result in a non-esthetic facial appearance and smile line1-7.

    The treatment of teeth with ankylosis is usually tooth extraction1-7. There are various treatment options for ankylosis in adults, including prosthetic treatment, luxation, and surgical positioning, depending on the size and position of the tooth. Surgical repositioning of a single tooth can be achieved by performing an osteotomy, alone or in conjunction with distraction osteogenesis1-9.

    In this clinical case report, we describe the treatment of an ankylosed maxillary central incisor tooth using the Ilizarov distraction osteogenesis method in an adult female patient.

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    A 21-year-old female presented to the orthodontist with the complaint of an anterior open bite (Figure 1A,B,C,D). The patient had received conventional orthodontic treatment for the anterior open bite, except for the maxillary right central incisor tooth. No orthodontic movement was achieved, despite the application of force to the maxillary right central incisor. The patient did not mention any trauma history but reported a finger sucking habit history. A radiographic and clinical examination raised the suspicion of ankylosis (March 8, 2018). Force was applied to the tooth for 6 months, but tooth movement was not achieved. Accordingly, a diagnosis of ankylosis was made (Figure 1E,F,G,H). In fixed orthodontic treatment, the anterior teeth were extruded, and the posterior teeth were intruded. Extraction treatment also reduced the open bite. Extraction of teeth 14, 24, and 34 was planned. The space of tooth right mandibular first molar was not closed to prevent slipping into the lower midline.


    Büyütmek İçin Tıklayın
    Figure 1: A. Frontal facial view and B. Intraoral frontal view of the patient at the beginning of the first orthodontic treatment. C. Right side and, D. Left side intraoral view of the patient at the beginning of the first orthodontic treatment E. Cephalometric and F. Panoramic films taken at the beginning of orthodontic treatment. G. Panoramic film taken after the first orthodontic treatment. Ankylosis of the right first incisor can be seen. H. Despite the force applied to the right first incisor, no orthodontic tooth movement was observed after the first orthodontic treatment.

    Distractor Design and Surgical Applications: Before the distraction osteogenesis procedure, a custom-made, tooth-borne rigid distractor consisting of an apparatus with a slow expansion screw and bands and brackets was applied. After the model was taken, the central incisor tooth was brought to the desired position in the model, and the set-up process was applied. The band was then attached to the central incisor tooth. Satinless-stell wire (1.2 mm diameter) was then bent appropriately and soldered to the tube bands that would come to the molars and the band on the central tooth. The slow expansion screw of the apparatus was opened before soldering and closed again after soldering. In this tooth-borne custom-made distractor, each rotation corresponded to 0.2 mm of movement (Figure 2A,B,C,D).


    Büyütmek İçin Tıklayın
    Figure 2: Archwire shaped according to the distractor apparatus A. Occlusal and B. Frontal view. C. Distractor and arch wire made with thick steel wire. D. The molar bands are soldered.

    All surgical procedures were performed under local anesthesia in Fırat University, Faculty of Dentistry, Department of Periodontology, Elazig, Turkiye. Local anesthetic was applied to the vestibular mucosa. A linear incision was made from the junction line of the keratinized gingiva and lip mucosa and from the canine tooth in the right maxilla to the lateral tooth in the left maxilla, by taking bone contact1-4. The mucoperiosteal flap was lifted, exposing the anterior maxilla, including the piriform opening. The nasal mucosa was elevated on the right side. The right maxillary central incisor was ankylosed at the base of the nose. Bone tissue was reached with subperiosteal tunnels in the interdental area. Vertical osteotomies of the mesial and distal parts of the right maxillary central incisor were performed using a thin steel bur. These vertical osteotomies were combined with a horizontal osteotomy under the base of the nose and priform edge. After the osteotomies, mobility of the bone segment was achieved using a chisel and curved osteotome. During the osteotomies, care was taken to protect the periosteum layer on the palatinal side to prevent malnutrition and tissue necrosis. After achieving mobilization of the segment, the mechanism of the custom-made distractor was controlled (Figure 3A,B,C,D). The mucoperiosteal flap was repositioned in its original position and sutured with 3-0 silk suture. An antibiotic (penicillin), analgesic (dexketoprofen), and chlorhexidine mouthwash solution were prescribed after the surgical procedures to prevent infection and pain1-7.


    Büyütmek İçin Tıklayın
    Figure 3: After raising the mucoperiosteal flap, subapical osteotomy was performed, and it was checked that the distractor moved the segment. A. Extraoral and B. Intraoral views of the patient in frontal angle. C. Extraoral and D. Intraoral views of the patient in occlusal plane. E. Intraoral frontal and F. Intraoral occlusal views of the patient after the distraction period of the patient’s in various angle. G. Extraoral views of the patient after the treatment protocol fully. H. Panaromic radiograph after the treatment protocol fully. I. Demonstration of the subapical osteotomy line during surgery and distraction direction.

    Distraction Protocol: Four days after the surgery, the distraction procedure was started. The distraction rate was 0.6 mm per day. The distractor was activated twice a day for 8-hour periods. The positon of the segment was 1 mm overcorrected. The distraction phase was ended on the 14th day. The moved segment was fixed with arch wires, and the consolidation period then commenced. After 12 weeks of fixation, the arch wires were removed, and orthodontic treatment was completed1-7. A Class I occlusion, with a normal overjet and overbite was obtained. An improved smile profile was obtained by ensuring that the anterior maxillary teeth were placed in the Class I occlusion. Panoramic and cephalometric films taken after the treatment confirmed healthy bone tissue formation around the moving segment (Figure 3E,F,G,H,I).

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    Various treatment methods, including surgical luxation, are available for ankylosed teeth. However, surgical luxation can cause reankylosis and damage and intrusion of neighboring teeth during the application of force. Reimplantation after tooth extraction is another treatment option. However, reimplantation causes root resorption. Extraction of ankylosed teeth and prosthetic treatment with either implants or conventional methods can also be considered. However, esthetic concerns are a major consideration with this treatment method. In ankylosis, the alveolar segment does not develop sufficiently in the vertical direction. Thus, both hard and soft tissue deficiencies may occur. As a result, prosthetic treatment methods may not yield desired results. Mobilizing an ankylosed tooth, together with the bone tissue surrounding the tooth with interdental osteotomies and then fixing. Total mobilization of the segment poses a risk of palatal mucosal damage and impaired blood flow and nutrition of the segment. In addition, the gingival tissue may not be able to follow the movement of the tooth-bone segment, which can cause gingival recession and undesirable esthetic results at the gingival level1-7. The advantage of distraction osteogenesis is that it can bring the positions of the clinical crown, incisal edge, and gum edge into line with those of adjacent teeth. The distraction osteogenesis method can be performed to treat ankylosed teeth using orthodontic tooth-borne distractors, internal bone supported screw distractors, or arch wires1-7. In the present case, we used an orthodontic tooth-borne distractor.

    In the present case, we describe the successful treatment of an ankylosed central incisor by integrating orthodontics and surgery using a modified expansion device. Direction control is an important issue in alveolar distraction If the the distractor is fixed to bone or maxillary teeth, it is difficult to change the direction of the distraction apparatus. In the present case, we used 0.9 mm stainless steel wire supported by the upper jaw teeth to fix the distractor and ensure what in terms of the direction and position of the distractor4,5. The alveolar structure adjacent to the ankylosed tooth was reconstructed by dento-osseous segment distraction osteogenesis. A number of studies have shown that the distraction osteogenesis method using a tooth-borne device is a viable treatment option to achieve optimum occlusal and esthetic results 1-7,9,10.

    Retention appliances play an important role in bone maturation after orthodontic treatment and distraction osteogenesis11-15. Essix or Hawley retainers are generally preferred after orthodontic treatment. In the present case, because of the open bite, we choose Hawley appliances. The use of Essix plates could have led to increasing the interdental distance in the posterior region and recurrence of the open bite. In addition, a lingual retainer was attached to the lower and upper anterior teeth. At the last stage of the treatment, prosthetic treatment of tooth number 16 was planned2,5,6.

    Distraction osteogenesis is an effective treatment option for vertical alveolar tissue deficiencies, as it can aid the formation of both soft and hard tissue 16-18. The ankylosed tooth can act as an anchor for the distraction device. In the present case, repositioning of an ankylosed maxillary central incisor in an adult patient was achieved using a simple, custom-made device connected directly to the tooth.

    Conflict of Interest
    The authors declerate there is no conflict of interest.

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    1) Shahroudi AS, Golmohammadi S. Miniscrew-assisted single-tooth distraction osteogenesis to align an ankylosed infraoccluded maxillary central incisor: A case report. J Orthod 2020; 47: 345-353.

    2) 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.

    3) Kinzinger GS, Jänicke 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.

    4) Kofod T, Würtz 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.

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

    6) Senışık NE, Koçer G, Kaya BÜ. Ankylosed maxillary incisor with severe root resorption treated with a single-tooth dento-osseous osteotomy, vertical alveolar distraction osteogenesis, and mini-implant anchorage. Am J Orthod Dentofacial Orthop 2014; 146: 371-84.

    7) Ohkubo K, Susami T, Mori Y, 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: 561-567.

    8) Chancharoen S, Santiwong P, Seriwatanachai D, Khantachawana A, Chintavalakorn R. A Novel Alveolar Distractor Incorporating Nickel-Titanium Alloy Springs: A Preliminary In Vitro Study. Materials (Basel) 2022; 15: 5151.

    9) Li K, Guilleminault C, Amat P. Maxillomandibular Advancement for OSA: A 25-year perspective. Orthod Fr 2022; 93: 79-92.

    10) McCarthy JG, Schreiber J, Karp N, Thorne CH, Grayson BH. Lengthening the human mandible by gradual distraction. Plast Reconstr Surg 1992; 89: 1-8.

    11) Akbulut Y, Gul M, Dundar S, et al. Evaluation of effects of systemic zoledronic acid application on bone maturation in the consolidation period in distraction osteogenesis. J Craniofac Surg 2021; 32: 2901-2905.

    12) Acikan I, Mehmet G, Artas G, et al. Systemic melatonin application increases bone formation in mandibular distraction osteogenesis. Braz Oral Res 2018; 32: e85.

    13) Dundar S, Artas G, Acikan I, et al. Comparison of the effects of local and systemic zoledronic acid application on mandibular distraction osteogenesis. J Craniofac Surg 2017; 28: e621-e625.

    14) Al-Dubai SAS, Abdel-Rahman FH, Ahmed WMAS, Tawfik MA. Comparison between modified bone-splitting technique and distraction osteogenesis in horizontal alveolar ridge expansion: Randomized clinical study. J Contemp Dent Pract 2022; 23: 1008-1015.

    15) Li K, Guilleminault C. Surgical and non-surgical maxillary expansion: expansion patterns, complications and failures. Orthod Fr 2022; 93: 35-46.

    16) Lee H, Kim EY, Lee UL. Vertical augmentation of a severely atrophied posterior mandibular alveolar ridge for a dental implant using a patient-specific 3D printed PCL/BGS7 scaffold: A technical note. J Stomatol Oral Maxillofac Surg 2023; 124: 101297.

    17) Salmoria I, de Souza EC, Furtado A, Franzini CM, Custodio W. Dentoskeletal changes and their correlations after micro-implant-assisted palatal expansion (MARPE) in adults with advanced midpalatal suture ossification. Clin Oral Investig 2022; 26: 3021-3031.

    18) Mülayim Ö, Uzuner F, Işık Aslan B. Dudak damak yarıklı hastalarda alveoler distraksiyon osteogenez uygulamaları: Literatür derlemesi. Acta Odontologica Turcica 2016; 33: 102-108.

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