Indian Journal of Dental Research

: 2015  |  Volume : 26  |  Issue : 3  |  Page : 315--319

Stability of interceptive/corrective orthodontic treatment for tooth ankylosis and Class II mandibular deficiency: A case report with 10 years follow-up

Carlos Henrique Guimarães1, José Fernando Castanha Henriques1, Guilherme Janson1, Wilana S Moura2,  
1 Department of Orthodontics, Bauru Dental School, University of São Paulo, Bauru, Brazil
2 Department of Orthodontics, Dental School, São Leopoldo Mandic, São Paulo, São Paulo, Brazil

Correspondence Address:
Carlos Henrique Guimarães
Department of Orthodontics, Bauru Dental School, University of São Paulo, Bauru


The purpose of this article is to present the treatment of a 8-year-old boy with tooth ankylosis in teeth 85 and Class II division 1 malocclusion and to report a 10-year follow-up result. The patient was initially treated with a sagittal removable appliance, followed by an eruption guidance appliance and braces. The interceptive orthodontic treatment performed to recover the space lost by ankylosis of a deciduous tooth allowed a spontaneous eruption and prevented progression of the problem. The use of an eruption-guidance appliance corrected the dentoskeletal Class II, thus improving the patient's appearance. Besides the treatment producing a good occlusal relationship with the Class I molar, the correction of the overjet and overbite was stable over a ten-year period.

How to cite this article:
Guimarães CH, Henriques JC, Janson G, Moura WS. Stability of interceptive/corrective orthodontic treatment for tooth ankylosis and Class II mandibular deficiency: A case report with 10 years follow-up.Indian J Dent Res 2015;26:315-319

How to cite this URL:
Guimarães CH, Henriques JC, Janson G, Moura WS. Stability of interceptive/corrective orthodontic treatment for tooth ankylosis and Class II mandibular deficiency: A case report with 10 years follow-up. Indian J Dent Res [serial online] 2015 [cited 2021 Oct 26 ];26:315-319
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Full Text

The appropriate age to start orthodontic treatment has been debated since thefirst congress of orthodontics. Early treatment is reported to be easy to perform, less time-consuming, and less costly to the patient. Two main reasons for early treatment are to avoid disturbing tooth eruption and development and to prevent complications, such as root resorption, bone loss, and poor positioning due to the lack of the eruption of some teeth.[1]

Tooth ankylosis is an anomaly that may impede the normal development of teeth. Therefore, it is important to diagnose the problem early and intercede in order to avoid progression of the problem.[2]

One of the most common malocclusions is the Class II division 1 mandibular deficiency. For many years, functional appliances have been used to treat these malocclusions and to promote normal maxillary and mandibular growth and improve dental relationships and muscles.[3]

The eruption guidance appliance (EGA) (Occlus-o-Guide, Ortho-Tain, Toe Alta, Puerto Rico) is considered a combination of a functional appliance and a tooth positioner. The EGA is able to advance the mandible thus correcting the Class II relationship while also performing minor tooth movements. This appliance is prefabricated in 13 different sizes and is used, as one of its functions, to treat Class II-associated with a deep overbite and overjet in the mixed dentition period.[3],[4][5][6][7]

The objective of this paper was to report the treatment of a patient with tooth ankylosis in teeth 85 and Class II division 1 malocclusion. The patient was initially treated with a sagittal removable appliance, followed by an eruption guidance in combination with high-pull headgear. The patient continues to be stable 10 years after the treatment began.

 Etiology and Diagnosis

An 8-year-old Brazilian boy sought treatment due to his family's concerns about the prominence of his upper teeth, difficulty in closing his lips, and his facial appearance. He was in the late period of mixed dentition and had no oral habits or swallowing problems. He also had normal functional movements, including movements of the temporomandibular joint and no history of significant medical problems. He had a skeletal and dental Class II malocclusion, convex profile, deep bite, large midline diastema, and lip incompetence, with mandibular deficiency and severe eversion of the lower lip [Figure 1].{Figure 1}

The intraoral examination showed a dental Class II, division 1 malocclusion, proclined and protruded maxillary incisors, 10.2 mm overjet, 5.7 mm overbite, and midline inferior deviation of 3 mm to the right [Figure 2]. A panoramic radiograph revealed an ankylosis in element 85 that was impacting element 45 with the loss of space in this region because of the mesial tipping of thefirst molar [Figure 3].{Figure 2}{Figure 3}

The cephalometric analysis confirmed the relationship of a skeletal Class II malocclusion and revealed a normal growth pattern and retrognathic mandible. Furthermore, the maxillary incisors were vestibularized and protruded [Figure 4] and [Table 1].{Figure 4}{Table 1}

 Treatment Objectives

The treatment objectives were to: (1) Allow the eruption of element 45, which was impacted; (2) achieve bilateral Class I canine and molar relationships; (3) correct the deep overbite and the increased overjet; and (4) improve facial appearance and labial sealing.

 Treatment Alternatives

The recovery of lost space by mesial inclination of thefirst permanent right molar's crown could be accomplished using several removable appliances, such as the Lip Bumper and the Hawley appliance with springs. However, the effectiveness of these devices depends on the patient's cooperation. In addition, the lip bumper produces unwanted bilateral effects, and the springs associated with the Hawley appliance can make it less stable. Some devices associated with fixed appliances such as the open springs and lingual arch may also be employed. However, these devices require a greater amount of support than possible because of the age of the patient and the stage of the dentition since the abutment teeth may not have erupted sufficiently. Another alternative would be to use mini-implants, but they require surgical procedures that make them a less desirable option for children.[2]

The treatment of Class II malocclusion with mandibular retrusion in the mixed dentition involves the use of devices capable of promoting mandibular advancement, called mandibular protrusive. The literature cites several devices for this purpose, some of which are removable, such as the Bionator appliance, Frankel appliance, Twin Block appliance, Bass appliance, and high-pull headgear. Fixed appliances, such as the Herbst and Jasper Jumper appliance, also have been described.[8] Comparative studies of these devices show that they yield similar results,[9][10][11][12] although less patient compliance is needed with fixed mandibular advancement procedures.

 Treatment Plan

The patient and his parents were highly motivated because of the complexity of the malocclusion, so they were fully willing to cooperate in the use of removable appliances. Considering this, the following treatment plan was prepared: Initially, for correction of the inclination of the tooth 46 due to ankylosis of 85, the Maurício expander, a removable sagittal appliance consisting of an acrylic plate with occlusal coating and a screw expander located in the mesial of the tooth element 46, with the purpose of straightening the tooth was used.

Then, was used an association removable functional appliances (EGA and high-pull headgear) to promote mandibular advancement, reduce the anteroposterior skeletal discrepancy, and improve the patient's facial appearance. The objective of the association was to intensify these effects. Moreover, the eruption-guide device works as a positioner to guide tooth eruption and allows the collagenous fiber, which to stabilize the correction. It also exercises the patient's muscles and is more comfortable than other functional appliances. In addition, the device changes color according to the time the patient uses it, thus allowing the practitioner to assess the patient's cooperation.

After removing the removable functional appliances, straight wire appliance Nanda prescription slot 0.022 × 0.028 (Ortho Organizers, Carlsbad, CA, USA) were installed in order to align and level the teeth and gain an ideal occlusal relationship.

 Treatment Progress

The patient was referred to an oral surgeon, who extracted the ankylosed tooth 85 and installed the removable sagittal appliance to promote the straightening of the molar. For 3 months, the device was activated approximately 1 mm/month in order to recover the lost space and allow the spontaneous eruption of impacted tooth 45.

In order to make the corrections, three successive sagittal eruption-guidance appliances were employed. Thefirst EGA, size 5G [Figure 5] was used for 3 months in order to initiate the diastema closure and reduce the overjet and overbite; the second, size 4 ½ G, was used for 7 months; and the last one, size 4G, was used for 1-year. The size of these devices was selected according to the manufacturer's instructions and with the aid of a special measuring device. The patient was instructed to use the Occlus-o-Guide for 2 h/day and to use the high-pull headgear at night. During this period, he was monitored weekly during the 1st month, and then monthly until all his permanent teeth had erupted. After therapy with the functional appliance, the upper and lower fixed appliances were installed.{Figure 5}

The leveling and alignment of dental arches progressed according to the sequence of wires (0.019 × 0.025 rectangular stainless steel wire). Mechanical Class II elastics and elastic intercuspation were used to adjust the occlusion. After 1-year, the fixed appliance was removed.

 Treatment Results

Photographs taken after treatment showed improvement in the patient's facial profile and lip relationship as a result of decreased maxillary incisor proclination and redirection of mandibular growth [Figure 6]. The occlusal posttreatment evaluation revealed a Class I molar and canine relationship on the left side and 1/4 Class II molar and canine relationship on the right side, normal overjet and overbite, and good intercuspation [Figure 6]. A panoramic radiograph revealed good positioning and good periodontal health of the teeth, especially impacted element 45 [Figure 7].{Figure 6}{Figure 7}

Follow-up radiographs and a cephalometric analysis can be seen in [Figure 8] and [Table 1]. Correction of the skeletal Class II was evident while there were no changes in the maxillary vertical position. Other outcomes of the treatment included protrusion of the lower incisors, lingual inclination, and retrusion of the upper incisors.{Figure 8}

Ten years after the treatment had begun stable positive changes were evident, and the patient continued to have a pleasant facial profile with an acceptable facial lip seal. Normal spacing was maintained, and the occlusion remained stable [Figure 9]. The analysis of radiographs and cephalometric measurements obtained after 10 years showed no morphological changes of the relationship of the maxilla and mandible or changes in the positioning of teeth [Figure 8] and [Table 1]. It is apparent that the treatment plan was successful implementing various procedures, which resulted in the maintenance of the final stability [Figure 10].{Figure 9}{Figure 10}


Dentoalveolar ankylosis is an anomalous eruption characterized by the union of the root of the tooth to the alveolar bone, the causes of which are not well-defined. Ankylosis is associated with dental trauma, metabolic disorders, genetic tendency, and a deficiency in vertical-bone growth.[2] Especially, when this anomaly is in deciduous teeth, it often leads to infraocclusion of the ankylosed tooth, inclination of the teeth adjacent to the space, and consequent impaction of the permanent successor tooth.[1] In this situation, early interceptive orthodontic treatment is recommended in order to promote the recovery of the lost space and allow the eruption of permanent teeth.[1] In a reported case, this simple approach provided positive results, with space recovery and the eruption of thefirst element 45.

In this patient, the anteroposterior correction resulted in an improved facial appearance, with decreased profile convexity. Such a favorable result has been reported also in an evaluation of soft-tissue changes in Class II division 1 malocclusion treated with functional appliances.[13]

The dentoskeletal results obtained with the appliance are related to its mechanism of eruption guidance, which promotes mandibular advancement and redirection of maxillary growth. Similar increases in the length of the jaw with other functional appliances have been reported, although these results were clinically insignificant.[14][15][16] Results that also are mentioned include correction of the skeletal Class II relationship (without changing the patient's growth pattern), protrusion of the lower incisors, and retrusion and lingual inclination of the upper incisors.[3],[4]

Prospective studies conducted in 2008[5],[6] with eruption guidance in the early mixed dentition concluded that these devices are effective in the treatment of Class II malocclusion and can correct the Class II molar relationship as well as the overjet and the overbite. The results in this report were consistent with those results.

In an evaluation of the stability of treatment of Class II malocclusion with eruption-guidance appliances, Janson et al.,[7] found that correction of overjet and Class II molar relationship were stable over time. However, the correction of overbite and anterior mandibular crowding had relapses. In this treatment obtained similar results for overjet and Class II molar relationships, but no relapse of overbite or anterior mandibular crowding. More favorable results can be attributed to the early correction of malocclusion, which allowed the bone tissue to adapt better, thus ensuring periodontal and dental stability.

Although the good results reported in the literature by Occlus-o-Guide,[5][6][7] high-pull headgear was used to maintain the patient's normal growth pattern. Furthermore, the headgear helped to restrain maxillary growth, distally tip the maxillary teeth, and restrain the eruption of the posterior maxillary teeth.[17]


The interceptive orthodontic treatment performed to recover the space lost by ankylosis of a deciduous tooth was simple and effective, especially because of the permanent impact the treatment had in allowing for a spontaneous eruption. The use of an eruption-guidance appliance in association with high-pull headgear corrected the dentoskeletal Class II, thus improving the patient's appearance, producing a Class I good occlusal relation which resulted in a stable overjet and overbite over a 10 years period.

Source of funding

Dr. Earl Bergensen for your teachings

Conflict of interest

There are no conflict of interest.


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