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Journal of Orthodontics
1–9
DOI: 10.1177/1465312520956660
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Introduction
Tooth ankylosis results from anatomic fusion of the root
cementum or dentin to the adjacent alveolar bone. In per-
manent dentition, ankylosis usually happens in the anterior
region of the mouth as an outcome of severe intrusion or
replantation of avulsed incisors (Campbell et al., 2007).
The ankylosed tooth does not follow the normal vertical
growth of the alveolar process; by the time patient is at the
dental office, the tooth is usually dropped out of occlusion
(Isaacson et al., 2001). The extent of this gradually devel-
oping infraocclusion relates directly to the patient’s age at
the time of trauma (Kawanami et al., 1999). The most prev-
alent site of trauma during childhood is the anterior region
of maxilla where the aesthetic considerations are of the
utmost importance. This can be more crucial in patients
with excessive tooth show and gingival display while
smiling. Moreover, for a traumatised and ankylosed tooth
to be replaced by a dental implant, it is necessary to wait
until the patient’s growth is completed (Schwartz-Arad
et al., 2004).
A diagnosis of ankylosis is made according to clinical
observations and radiographic evidence. A sharp metallic
Miniscrew-assisted single-tooth
distraction osteogenesis to align an
ankylosed infraoccluded maxillary
central incisor: A case report
Atefe Saffar Shahroudi1,2
and Shima Golmohammadi3
Abstract
The ankylosis of permanent incisors is usually caused by trauma. In a growing patient, the ankylosed tooth fails to move
along with the vertical growth of the remaining alveolar process, which results in an infraoccluded tooth, gingival margin
disharmony and unaesthetic smile.
This case report presents an 23-year-old female patient whose maxillary right central incisor (tooth number 11) had
been traumatised eight years earlier. A vertical discrepancy of about 4 mm was exhibited between teeth 11 and 12.
To reposition the crown and gingival margins of the ankylosed tooth to an ideal level, single-tooth dento-osseous
osteotomy and distraction of the block of bone containing the tooth was planned. In order to separate the roots of
adjacent teeth for opening a space for osteotomy incision, fixed orthodontic treatment with multibracket appliances was
initiated on her maxilla. After five weeks, a single-tooth dento-osseous osteotomy was performed using a piezoelectric
device. To move the tooth in occlusal and buccal directions, two temporary anchorage devices (miniscrews) on her
mandible and interarch elastics were applied. Approximately three weeks later, the ankylosed tooth successfully had an
ideal position—relative to the adjacent teeth—and a harmonious gingival margin was achieved by minor gingivoplasty
on all incisors.
Keywords
distraction osteogenesis, incisor, orthodontic anchorage techniques, tooth ankylosis
Date received: 16 June 2020; revised: 28 July 2020; accepted: 3 August 2020
1

Dental Research Center, Dentistry Research Institute, Tehran
University of Medical Sciences, Tehran, Iran
2

Department of Orthodontics, Dental School, Tehran University of
Medical Sciences, Tehran, Iran
3

Department of Periodontics, Dental School, Islamic Azad University of
Borujerd, Borujerd, Iran
Corresponding author:
Shima Golmohammadi, Department of Periodontics, Dental School,
Islamic Azad University of Modarres Square, Borujerd 6813794465, Iran.
Email: Shimag221@gmail.com
956660JOO Journal of OrthodonticsSaffar Shahroudi and Golmohammadi
Clinical Section

2 Journal of Orthodontics
sound during percussion and lack of physiologic tooth
mobility are the clinical signs that could suggest ankylosis.
These clinical signs are more sensitive and more accurate
than radiographically observable changes associated with
the periodontal ligament width, since the area with ankylo-
sis might be too small to be detected on conventional radio-
graphs or it might be located on the buccal or lingual
surface of the root (Andersson et al., 1984). However,
three-dimensional (3D) imaging modalities might provide
a more reliable diagnostic aid, as it is more probable to
visualise the ankylosis on some of the sections acquired
from several projections around the tooth (Shetty et al.,
2014). Besides, the most definitive sign of ankylosis is the
failure of orthodontic tooth movement of the affected tooth
(Sanu and Isiekwe, 2003).
Several treatment modalities have been proposed for the
management of ankylosed teeth including extraction, surgi-
cal luxation, surgical repositioning, restoration and retention
with or without coronal modiﬁcations (Alcan, 2006).
Extraction of an ankylosed tooth is a challenging process, as
it usually results in a large vertical defect and compromises
the final aesthetic outcome, while replacing the tooth with
fixed or removable prosthesis. Although implant-supported
restoration is a viable treatment alternative, soft and hard
tissue augmentations are necessary to achieve the optimum
results; however, the success rate of these augmentations is
not 100% (Dolanmaz et al., 2010). Some authors have tried
to break the fusion by surgical luxation and attempt ortho-
dontic tooth movement. However, the repair process after
surgery might lead to the recurrence of ankylosis (Isaacson
et al., 2001). The conventional way of surgical tooth reposi-
tioning was to surgically replace the tooth to obtain sym-
metrical and pleasing aesthetic results. However, there is
always a high risk of necrosis for a small-replaced segment
due to the compromised blood supply. Furthermore, dishar-
mony in the gingival level may occur as the speed of gingi-
val proliferation might fall behind immediate repositioning
of the tooth. This is especially important in cases where
replacing a single traumatised maxillary incisor is the ulti-
mate goal (Dolanmaz et al., 2010).
Recently the technique of distraction osteogenesis (DO)
has been applied for moving multiple or single ankylosed
teeth (particularly central incisors) (Epker and Paulus,
1978; Im et al., 2010; Isaacson et al., 2001; Kinzinger et al.,
2003; Kofod et al., 2005; Medeiros and Bezerra, 1997) and
also to correct a unilateral open bite caused by multiple
ankylosed teeth (Susami et al., 2006). Bone distraction, ini-
tially introduced in 1905 by Codvilla (Codivilla, 1905) and
further explained by Ilizarov (Ilizarov, 1971), was first used
for the treatment of malformities in the peripheral skeleton.
Since the first report of craniofacial distraction osteogene-
sis by Synder et al. in 1973 (Snyder et al., 1973), it has been
successfully used for the treatment of patients with cleft lip
and palate (Liou et al., 2000) and hemifacial micrososmia
(Huisinga-Fischer et al., 2003).
For single tooth movement, a single tooth osteotomy
would be the primary step, which requires a very fine and
precise surgical procedure. Ultrasonic surgery, also known
as piezo, has been recently introduced in the field of oral
surgery to substitute routine burs with the advantage of
fine and precise cuts, minimising the surgical trauma and
a fast tissue healing response (Vercellotti et al., 2005).
After the surgery, the alveolar segment containing the
tooth needs to be moved to an appropriate position.
Various DO devices have been designed and applied for
this purpose (Alcan, 2006; Dolanmaz et al., 2010;
Kinzinger et al., 2003; Kofod et al., 2005). However, most
of the DO devices are expensive, complicated and uncom-
fortable for the patients, and they would only be promis-
ing if the segment could be moved by the application
of another orthodontic appliance such as different types
of temporary anchorage devices (Papadopoulos and
Tarawneh, 2007).
This case report presented the treatment of a 23-year-
old female patient who had a 4-mm infraoccluded central
incisor due to an ankylosis caused by an old head trauma.
The orthodontic treatment included single tooth distrac-
tion osteogenesis with the aid of miniscrews.
Diagnosis and aetiology
A 23-year-old woman was referred to our Ortho-Perio pri-
vate clinic with the request of replacing an ankylosed
infraoccluded right maxillary central incisor with a dental
implant. By then, several dentists had visited her with differ-
ent treatment plans. The patient’s chief complaint was her
malposed tooth with a higher gingival line relative to the
adjacent teeth, which had resulted in an undesirable appear-
ance. She presented with a history of trauma to her front
teeth seven years previously that had led to enamel fracture
associated with teeth 12 and 11. Gradually, symptoms of
pulpal necrosis had developed associated with tooth number
12 and it had been treated by root canal therapy.
Intraoral examination revealed a discrepancy of 4 mm
between the incisal edges of teeth 11 and 21 with relatively
the same amount of discrepancy between those teeth’s gin-
gival contours. Excessive gingival display was also
observed in her smile, which made the uneven gingiva even
more noticeable (Figure 1).
Tooth number 11 had a metallic sound upon percussion
and the absence of normal physiologic mobility. Tooth 11
was asymptomatic without discoloration or any sensitivity
to percussion and palpation. Pretreatment radiographs are
shown in Figure 2.
When the patient was referred to the orthodontist at our
office, the following were observed. In the frontal view, the
patient had good facial symmetry with proportionate facial
thirds. In the profile view, she had a relatively straight face
with no anteroposterior discrepancy. Intraorally, she had an

Saffar Shahroudi and Golmohammadi 3
Angle Class I molar and canine relationship on both the right
and left sides. Mild crowding was observed in both the upper
and lower dental arches and both arches were symmetric and
ovoid in shape. The patient had a 1-mm overjet with a 0.5-
mm overbite in the region of the left central incisors, while
open bite with no overjet existed in the right central incisor
region, which was due to apically and slightly palatally posi-
tioned maxillary right central incisor (Figure 3).
The lateral cephalometric radiograph showed a
skeletal Class I relationship (SNA = 81.2°, SNB = 78.4°,
ANB = 2.8°), slight vertical growth pattern (GoGn-SN =
34.3°), and the upper and lower incisors had a relatively
normal inclination with their apical bases (upper incisor to
palatal plane = 109.3°, lower incisor to mandibular plane
= 91.4°).
Treatment alternatives
Considering the age of the patient and the fact that no more
pronounced vertical alveolar growth was expected, the
Figure 1. The patient’s smile view. The gingival margin and incisal edge discrepancy of central incisors due to an ankylosed right
central incisor.
Figure 2. Pretreatment pre-apical, panoramic and cone beam computed tomography radiographs.

following treatment alternatives were discussed with the
patient and her parents:
1. Fabricating a crown restoration on the ankylosed
tooth with pink porcelain glazed onto the gingival
portion to compensate uneven gingiva. The patient
was informed that the aesthetic could be compro-
mised since the pink porcelain cannot be exactly the
same as the adjacent gingiva.
2. Resecting the ankylosed tooth surgically and replac-
ing it with a dental implant which would have required
ridge augmentation before the dental implant therapy.
The patient was informed that the result of ridge aug-
mentation surgery is unpredictable.
3. Breaking the fusion between the root of the anky-
losed tooth and the alveolar bone by surgical luxa-
tion and moving the tooth by orthodontic treatment.
This would have been an aggressive procedure with
low probability of success since the area of fusion
might have been too vast. Moreover, there would
have been a risk of root fracture and tooth re-ankylo-
sis during the orthodontic tooth movement.
4. Segmental osteotomy to mobilise the ankylosed
tooth and move the segment by means of a DO
device. This treatment option could have been more
expensive and less precise compared to orthodontic
tooth movement with the aid of the miniscrew treat-
ment option but was considered as the main alterna-
tive treatment for this patient. Finally, the last option
was chosen for the patient.
Treatment objectives
The established treatment objectives for this patient
included: (1) alignment of the maxillary arch excluding
tooth number 11 to facilitate inserting a heavy base arch
wire; (2) diverging the roots of adjacent teeth (teeth 12 and
21) to make enough space for surgical bone incision to pre-
vent any damage to the mentioned teeth’s roots; (3) seg-
mental osteotomy to mobilise the ankylosed tooth with the
surrounding alveolar bone without the elevation of the pal-
atal mucosa; (4) extruding the ankylosed tooth to the level
of adjacent teeth with the aid of two mini-screws inserted in
mandibular alveolar process; (5) realignment and levelling
of the maxillary dental arch to achieve root parallelism and
appropriate overjet and overbite; and (6) correcting the gin-
gival margin of the anterior teeth to improve the smile
aesthetics.
Treatment progress
The result of the endodontic consultation stated that tooth
11 was vital but since the root canal was obliterated there
was no possibility of root canal therapy. However, further
follow-ups were recommended. Fixed orthodontic treat-
ment was initiated by means of pre-adjusted brackets with
0.018 × 0.022 slots on the upper arch only. The reason that
the treatment was confined to the upper arch was the mild
crowding in the lower arch with a perfect posterior occlu-
sion. On the other hand, the patient desired to decrease her
treatment expenses as much as possible.
Figure 3. Pretreatment facial and intraoral photographs.

The teeth were aligned by sequential Nickel-Titanium
(NiTi) archwires to facilitate inserting a heavy stainless-
steel base arch. Positioning the brackets of teeth 12 and 21
was done so that their roots became divergent after align-
ment and provided the necessary space for bone cuts. When
a 0.019 × 0.025-inch stainless-steel rectangular archwire
was inserted and enough space was prepared (five months
later), the ankylosed tooth was bonded and two orthodontic
miniscrews (1.4 mm in diameter and 8 mm in length)
(Dual-top Anchor System 20-G2-010; Guro-Gu, Seoul,
Korea) were placed in the mandibular alveolar process
between the roots of teeth 33 and 32 as well as between
teeth 42 and 43; the patient was subsequently referred for a
single-tooth osteotomy.
Surgical procedure
Under local anaesthesia, the mucoperiosteal (or full thick-
ness) flap was elevated after sulcular incisions extending
from tooth 12 to tooth 21 along with two releasing incisions
at the very distal and mesial sites of the surgical area. An
interdental osteotomy line was made using a piezo electric
device (Piezosurgery®, Mectron Medical Technology,
Carasco, Italy) up to the nasal floor (about 1 mm above the
apex of the ankylosed tooth). The osteotomy was com-
pleted with a fine osteotome to ensure the green stick frac-
ture was made. The fractured segment was then mobilised
by keeping the palatal mucosa in place to maintain the
blood supply. Finally, the flaps were closed to achieve pri-
mary closure of the wound site (Figure 4).
After a latency period of four days to allow for callus
formation, active orthodontic treatment was restarted to
distract the alveolar block containing the ankylosed tooth.
A traction force was exerted from the archwire to the den-
toalveolar block by means of an elastomeric chain while
the patient was asked to wear intermaxillary rubber elastics
(two elastics, each exerting an orthodontic force of 75 g
(2.5 oz, 7.95 mm, 0.31 inch) from the adjacent teeth to the
miniscrews to prevent their intrusion. After a few days, the
results indicated that the amount of force might be not suf-
ficient. Therefore, the patient was asked to apply the elas-
tics directly from the miniscrews to the ankylosed tooth
while a 0.014 NiTi overlay was also added. Since the anky-
losed tooth was positioned palatally relative to the adjacent
teeth, a force vector in the buccal direction should have
been added. Thus, a step-out bend was formed on the base
archwire (Figure 5A and B).
The elastics were changed every day and the patient was
checked every two days to monitor the gradual movement
of the dentoalveolar block. On day 15, the tooth reached an
appropriate level relative to the adjacent teeth. The dis-
tracted block was then fixed by being ligated to the base
archwire and the patient was advised not to bite with her
front teeth. The whole process of healing was completed
without any complications associated with the alveolar dis-
traction. After the consolidation phase (10 weeks) was
elapsed, the fixed orthodontic treatment began with reposi-
tioning the brackets of teeth 12 and 21 to achieve ideal root
parallelism. The remaining spaces were closed using an
elastomeric chain (Figure 5C and D). After 12 weeks, when
Figure 4. Surgical procedure for single-tooth osteotomy and mobilisation of the tooth-containing block.

an ideal alignment and levelling were achieved, the brack-
ets were debonded and a fixed orthodontic retainer was fab-
ricated by a 0.0175-inch multi-stranded wire on the palatal
surface of the six front teeth. Subsequently, gingivoplasty
on the anterior maxillary teeth was performed in order to
achieve harmonious gingival margins.
Treatment results
The post-treatment facial photographs (Figure 6) and radio-
graphs (Figure 7) showed that the vertical discrepancy
between the two maxillary central incisors was completely
corrected and the anterior aesthetics were also improved.
Correct occlusion of the patient was preserved with a Class
I canine and molar relationship on both sides, although the
fixed orthodontic treatment was just bonded on the upper
jaw. The follow-up pictures after four years confirmed sta-
ble results (Figure 8).
Discussion
In this article, the successful treatment of a patient with
ankylosis and infraocclusion of a previously traumatised
maxillary right central incisor was presented. Among dif-
ferent treatment options that had been proposed for an
ankylosed tooth, decoronation is advantageous in prevent-
ing further vertical discrepancy and preserving bone for
future dental implant (Malmgren, 2013). However, in this
case the ankylosis had occurred seven years beforehand
and the vertical discrepancy had already occurred. Thus, in
the case of replacing the tooth by a dental implant, vertical
ridge augmentation was necessary, which is a technically
sensitive procedure with unpredictable outcomes (Mayne
et al., 2017). One alternative procedure is to move the
ankylosed tooth with its surrounding bone by surgery.
Although there are several reports of successful tooth
movement by segmental surgery, there is always a risk of
necrosis when the segment is too small, such as in single-
tooth osteotomy (Dolanmaz et al., 2010). It has been
reported that alveolar DO could be an effective and reliable
method for the reconstruction of alveolar vertical defects
(Chang et al., 2010; Kim et al., 2010; Ohkubo et al., 2011;
Susami et al., 2006). Therefore, it was the treatment option
of choice for our treatment and, consequently, an intraoral
distractor was required. Kinzinger et al. and Alcan applied
bone-born and tooth-born distractors, respectively (Alcan,
2006; Kinzinger et al., 2003). Alcan believed that since a
tooth-born appliance is attached to the tooth and archwire
rather than the bone, it would be easier to insert and remove
it (Alcan, 2006). However, these distractors could only
work in a linear direction while we needed to reposition the
segment three-dimensionally in both the occlusal and labial
directions. There have been few successful reports of dis-
tracting a tooth-containing segment by orthodontic meth-
ods (Dolanmaz et al., 2010; Im et al. 2010; Ohkubo et al.,
2011). Isaacson et al. (2001) applied continuous step bends
in the base archwire after the surgery, which took more than
four weeks for the segment to reach the ideal vertical
Figure 5. Traction forces to move the tooth-containing bone block in the occlusal and labial directions. (A) Miniscrews were
used as indirect anchorage; (B) miniscrews were used as direct anchorage. (C, D) When the ankylosed tooth reached an ideal
position, the remaining spaces were closed using an elastomeric chain.

position. However, it is believed that in DO the segment
should be moved with a higher rate to prevent callus forma-
tion (Alcan, 2006). Mayne et al. (2017) applied intra-arch
elastics for vertical extrusion, which resulted in occlusal
movement of the ankylosed segment, but the lower incisors
were extruded and retroclined as a side-effect of those
elastics. Thus, we needed heavier forces along with a more
powerful anchorage. Recently, few studies have applied
temporary anchorage devices for the DO procedure (Im
et al., 2010; Şenışık et al., 2014). Şenışık et al. inserted a
miniscrew in the ankylosed-tooth-containing segment,
since there had been already a severe replacement root
resorption and most of the root structure had been replaced
Figure 8. Photographs at four-year follow-up.
Figure 6. Post-treatment facial and intraoral photographs.
Figure 7. Post-treatment panoramic and lateral
cephalometric radiographs.

by alveolar bone. Vertical elastics between the miniscrew
and the lower archwire were used in our case (Şenışık et al.,
2014), the root was intact without any noticeable external
resorption, which left little space for inserting a miniscrew
in the mobilised segment. On the other hand, the lower arch
was not supposed to undergo any fixed orthodontic treat-
ment. Accordingly, it was planned to insert two miniscrews
in the alveolar bone of the anterior mandibular arch and a
bracket was bonded on the ankylosed tooth. The selected
mechanism of force application was intra-arch elastics
between the bonded ankylosed tooth and the miniscrews
followed by interarch power chain between the tooth and
the maxillary base archwire.
There are several considerations in the surgical proce-
dure of the segmental osteotomy. The inter-radicular dis-
tance should be at least 2 mm to leave enough bone width
on both sides and maintain a safe distance from adjacent
roots (Bousquet et al., 2016). The precise surgery for fine
osteotomy is best achieved by slim profile ultrasonic tips
(Vercellotti et al., 2005). The cuts should be parallel or
occlusally divergent and the palatal mucosa should remain
intact to insure adequate blood supply.
The DO protocol that was applied in this case was
mostly according to a study by Kofod et al. (2005) in which
the surgery is followed by a latency period. The duration of
this phase was different in the literature and is in the range
of 0–14 days (Alcan, 2006; Bousquet et al., 2016; Isaacson
et al., 2001). Bousquet et al. started the distraction immedi-
ately after surgery, believing that it would be helpful when
orthodontic force was applied rather than distractors
(Bousquet et al., 2016). Isaacson et al. and Alcan waited for
two weeks and one week, respectively (Alcan, 2006;
Isaacson et al., 2001). Based on the contemporary DO pro-
tocol, we chose a period of four days (Kofod et al., 2005).
According to similar studies, a force of approximately 600
gr was exerted by intraoral elastics and it was gradually
increased by adding an interarch power chain from the
tooth to the step-down bend of the archwire regarding the
fact that the force exerted on miniscrews should not surpass
900 gr (Büchter et al., 2005). Since the rate of the segment’s
movement decreases with time, it is recommended to reach
the ideal position in the minimum possible time.
Accordingly, the fixed orthodontic treatment had already
proceeded up to a heavy base archwire (0.021 × 0.025-inch
stainless steel). During the distraction phase the segment
was remobilised once, under local anaesthesia. The same
procedure was reported in a study by Şenışık et al., albeit
for several times rather than once (Şenışık et al., 2014).
When the segment reached the appropriate position, it
was stabilised by getting ligated to the base archwire for a
consolidation phase. Isaacson et al. (2001) and Medeiros
and Bezerra (1997) recommended six and four weeks,
respectively, and it is believed that microscopic bony con-
nection forms after six weeks. Bousquet et al. (2016) let the
passive archwire remain in place for six months and contin-
ued the orthodontic treatment until the adjacent teeth got
aligned and root parallelism was re-established. Some stud-
ies did overtreatment to compensate for any further vertical
alveolar growth, which is believed to continue to the age of
approximately 18 years, in girls (Riolo, 1974). However,
since our patient was a 23-year-old woman, no overtreat-
ment was required in her case. In fact, it is prudent to post-
pone such treatment until the cessation of alveolar growth.
Although this case was treated successfully with the
maximum possible aesthetic results, clinicians should take
several risk factors into consideration when choosing this
method such as: the possibility of miniscrew loosening;
damage to the adjacent teeth’s roots during the surgical pro-
cedure; insufficient patient’s compliance; single tooth seg-
ment necrosis; and root or crown fracture during distraction
especially in cases that the tooth has got fragile due to inter-
nal root resorption. One concern about this case was that
she had a gummy smile that made achieving a perfect gin-
gival aesthetic more crucial. Moreover, she insisted on one
jaw orthodontic treatment. In spite of these limitations,
proper occlusion was achieved and the final gingival aes-
thetics were established by a minor gingivoplasty six weeks
after debonding.
Conclusion
DO to move a block of alveolar bone containing an anky-
losed tooth could be a viable treatment to align an infraoc-
cluded tooth, especially in the aesthetic region, to gain a
harmonious gingival level. This method could be facilitated
by means of miniscrews and applying orthodontic forces
rather than using complicated DO devices.
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of this
article.
Funding
The author(s) received no financial support for the research,
authorship, and/or publication of this article.
ORCID iD
Shima Golmohammadi https://orcid.org/0000-0001-8766-1917
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