Case Repo
Deco ona ion: An Al e na i e T ea men o
Replacemen Roo Reso p ion
Ma ianne Sala, Asunción Mendoza-Mendoza, and Rosa-Ma ía Yañez-Vico
Depa men o S oma ology, School o Den is y, Uni e si y o Se ille, Se ille, Spain
Co espondence should be add essed o Rosa-Ma ´
ıa Ya˜
nez-Vico; osaya[email p o ec ed]m
Recei ed 28 Feb ua y 2017; Re ised 11 Ap il 2017; Accep ed 18 Ap il 2017; Published 10 May 2017
Academic Edi o : Jiiang H. Jeng
Copy igh © 2017 Ma ianne Sala e al. This is an open access a icle dis ibu ed unde he C ea i e Commons A ibu ion License,
which pe mi s un es ic ed use, dis ibu ion, and ep oduc ion in any medium, p o ided he o iginal wo k is p ope ly ci ed.
In oduc ion. Ankylosis and dis up ed o al e ed oo de elopmen a e equen complica ions associa ed wi h in usi e luxa ion
and oo h a ulsion lesions. Va ious o ms o ea men ha e been desc ibed acco ding o he se e i y o he auma and oo
de elopmen . The li e a u e shows ha deco ona ion is an ideal ea men in cases whe e eplacemen eso p ion occu s. Me hods.
Two clinical cases a e p esen ed: in ol ing in usi e luxa ion [15-yea -old emale pa ien wi h an a ec ed maxilla y le la e al inciso
(2.2)] and a eplan ed a ulsed oo h [8-yea -old male pa ien wi h a ulsion o he igh maxilla y cen al inciso (1.1)]; bo h cases
p esen ed ad anced oo eso p ion so ha deco ona ion wi h a p os he ic oo h eplacemen was decided as he inal ea men
op ion. Resul s. In he sho - e m ollow-up, pa ien s we e asymp oma ic and had no unc ional p oblems. Radiog aphs showed
ha c es al bone heigh had been p ese ed. Conclusions. P ese ing he deco ona ed oo in he al eola p ocess no only helps o
main ain bone olume bu also enables e ical bone g ow h and acili a es he u u e inse ion o an implan .
1. In oduc ion
In usi e luxa ion is de ined as he apical displacemen o
he oo h in o he al eola bone. I is conside ed o be
one o he mos se ious ypes o den al auma, causing
se e e a ec a ion o he pe iodon al ligamen , pulp issue
in he oo and causing po en ial al eola bone loss and
g ow h es ic ion. In pe manen ee h, i is an uncommon
inju y, ep esen ing 0.5–1.9% o all den al inju ies [1–5]. The e
is,howe e ,noconsensusabou heop imal he apy o
minimizing he isk o complica ions [5–7].
A ulsion, in which he oo h is comple ely displaced om
i ssocke asa esul o auma,isano he ypeo inju y
no commonly ound in pe manen ee h. I ep esen s some
0.5–3% o all den al inju ies [8]. None heless, i is one o he
mos complica ed auma ic inju ies o ea [9, 10].
In he majo i y o cases, eimplan a ion is he ea -
men o choice, al hough his canno always be ca ied ou
immedia ely and is no indica ed in ce ain cases (e.g., in
pa ien s wi h ca ies and pe iodon al p oblems and hose who
a e immunosupp essed) [11, 12]. The e is also he dange o
eplacemen oo eso p ion occu ing. Managemen o he
den al eme gency and he ea men plan a e e y impo an
o a good p ognosis, since he long- e m su i al a e o
eimplan ed ee h is low [11, 12].
The objec i e o eimplan ing ee h wi h imma u e oo
de elopmen is o acili a e he possible e ascula iza ion o
he pulp chambe . Howe e , he isk o de eloping eplace-
men oo eso p ion, o ankylosis, should be weighed agains
he possibili y o e ascula iza ion [11, 13].
Acco ding o he IADT, signs ha sugges a nega i e
p ognosis o a eplan ed a ulsed imma u e pe manen oo h
wi h an open apex include [11] symp oma ic, excessi e, o
no mobili y (ankylosis) and p oduce a sha p pe cussi e
sound, adiog aphic e idence o eso p ion (in lamma o y
o eplacemen ), and he absence o con inued oo de elop-
men .
Un il 1984, ex ac ion was he gene ally accep ed op ion
o his kind o complica ion. Malmg en e al., howe e , sug-
ges ed deco ona ion o he ankylosed oo h as an al e na i e
ea men [12], indica ing ha , in ea ly mixed den i ion, i
had obepe o medwi hin2yea so hediagnosiso be o e
he g ow h spu , in o de o enable he p ese a ion o he
su ounding al eola bone and o p e en in aocclusion and
subsequen al e a ions in smile es he ics [12, 14]. Deco ona-
ion can be conside ed as an ideal ea men in cases whe e
Hindawi
Case Repo s in Den is y
Volume 2017, A icle ID 2826948, 7 pages
h ps://doi.o g/10.1155/2017/2826948
2Case Repo s in Den is y
(a)
(b)
(c)
(d)
Figu e 1: (a) In ao al pho og aph o he pa ien a he clinic ollowing auma o he 4 inciso s, wi h in usion o he uppe le la e al
inciso . (b) In ao al pho og aph o he pa ien ollowing wo weeks awai ing spon aneous ee up ion o 22, showing insu icien ee up ion.
(c) Pe iapical adiog aphic p ojec ion o he o hodon ic ex usion ca ied ou a e he ailu e o spon aneous ee up ion, wi h comple e
ex usion o 22 and oo de elopmen isibly indica ed. (d) Radiog aphic p ojec ion 6 yea s a e he auma, in which a es ed oo g ow h
and bone issue g owing inside he oo canal can be obse ed on one o he con ol pe iapical adiog aphs aken a e o hodon ic ea men .
he e is eplacemen eso p ion. I has been shown ha i
helps p ese e he es ibula -pala al wid h o he al eola
bone o yea s, while a he same ime allowing o e ical
g ow h, so ha i could be used as an al e na i e ea men
in cases wi h se e e oo eso p ion [15, 16]. The aim o he
p esen case epo pape is o illus a e he deco ona ion
ea men a e wo di e en auma ic inju ies, he in usi e
luxa ion and oo h a ulsion lesion.
2. Clinical Cases
2.1. Case 1. The i s case in ol ed a 15-yea -old emale
pa ien wi h eplacemen oo eso p ion seconda y o an
in usion o he maxilla y le la e al inciso (2.2) (Figu e 1(a))
a e a auma ic inju y o he 4 uppe inciso s when she
was eigh yea s old, which included so - issue lace a ion. In
acco dance wi h he IADT p o ocol in o med consen was
ob ained and we wai ed o wo weeks, in o de o assess
whe he he e had been any oo h mo emen , indica ing he
onse o spon aneous ee up ion o 2.2 (Figu e 1(b)). This did
no happen and o hodon ic ex usion o he a ec ed oo h
was ca ied ou . (Figu e 1(c)).
Clinical and adiog aphic moni o ing was pe o med
a e 1 week, 15 days, 1 mon h, 6 mon hs, and 1 yea and hen
annuallyup o5yea s.A e 6yea s,i wasobse ed ha
he oo had s opped g owing and ha he e was bone-like
issue g ow h in he oo canal (Figu e 1(d)). A e 7 yea s
o clinical and adiological moni o ing, i was con i med
ha oo de elopmen had s opped and ha eso p ion
hadsp ead om hece icala ea op ac ically heen i e
oo (Figu e 2(a)). The clinical appea ance o he oo h was
comple ely no mal (Figu e 2(b)).
When we saw hese clinical and adiog aphic compli-
ca ions, we conside ed he bes ea men op ion. Since he
pa ien was s ill g owing, i was decided o deco ona e he
oo h and hen i an adhesi e b idge.
A e local anes hesia, he deco ona ion p ocedu e began
wi h he aising o a ull- hickness lap o gain di ec access o
heankylosed oo h.Then,usingadiamondbu ,odon osec-
ion o he c own was pe o med abo e he cemen oenamel
junc ion, aking pa icula ca e no o lea e any enamel
esidue in he oo o he deco ona ed oo h (Figu e 2(c)).
A e emo ing he c own, a K- ile was used o ex ac he
illing om he oo , which was hen washed wi h a saline
solu ion, allowing he canal o ill wi h blood (i he e is no
bleeding, i should be s imula ed by inse ing a K- ile h ough
he canal in o he apical bone). Finally p ima y closu e was
ob ained by co onal eposi ioning o he lap (Figu e 2(d))
[12, 17, 18].
We subsequen ly ca ied ou es he ic ehabili a ion using
an adhesi e b idge wi h 0.9 mm wi e and a composi e pon ic,
aking special ca e o lea e a space o a leas 1 mm be ween
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Case Repo s in Den is y 3
(a)
(b)
(c)
(d) (e)
( )
Figu e 2: (a) Rou ine adiog aphic p ojec ion 7 yea s a e he auma, in which a es ed oo de elopmen can be obse ed and eplacemen
oo eso p ion in 22 ex ends om he ce ical a ea down p ac ically he whole o he oo . (b) Pho og aph o he an e io a ea. No e he
clinical aspec o he oo h wi h sui able aes he ic appea ance in ha mony wi h he adjacen ee h. (c) Pho og aph o 22 du ing deco ona ion,
a e cu ing o he c own a he bone ma gin. (d) Pho og aph o 22 a he comple ion o he deco ona ion p ocedu e, when he ull- hickness
lap was placed o e he al eolus and su u ed wi h in e up ed s i ches. (e) Radiog aphic p ojec ion o 22 a e deco ona ion, showing he oo
emaining a he le el o he bone c es and he wi e o p os he ic ehabili a ion. ( ) In ao al pho og aph o aes he ic ehabili a ion achie ed
ia a b idge a ached wi h 0.9 mm wi e and a composi e pon ic, achie ing a sa is ac o y es he ic esul .
he mucous memb ane and he pon ic o a oid in e e ing
wi h la e al eola bone emodeling (Figu e 2(e)). This ga e
he pa ien sa is ac o y unc ional and es he ic in eg i y
(Figu e 2( )). Rehabili a ion will con inue un il he pa ien
is ully g own and he necessa y condi ions o inse ing an
implan a e ul illed.
2.2. Case 2. In o med consen was ob ained om an 8-yea -
oldmalepa ien ha came o heclinica e su e ingaden al
auma o he igh maxilla y cen al inciso (1.1) wo weeks
ea lie ha had led o i s a ulsion, which was eimplan ed
s aigh away a e being kep d y o abou 40 minu es.
Despi e poo p ognosis eimplan a ion was conduc ed in
o de o p ese e e ical and buccolingual bone pala al
wid ho heal eola c es inayoungpa ien .A e heclinical
examina ion, mode a e in aocclusion was diagnosed wi h
no discolo a ion (Figu e 3(a)). Radiog aphs showed a es ed
oo g ow h and eplacemen oo eso p ion (Figu e 3(b)).
A e se e al clinical and adiological e iews, we consid-
e ed he bes ime o ca ying ou deco ona ion, which was
e en ually pe o med 2 yea s a e diagnosis, when he pa ien
was 10 yea s old. The deco ona ion p ocedu e ollowed he
me hodology desc ibed o case 1 (Figu es 3(c) and 3(d)).
A e wa ds, p o isional aes he ic ehabili a ion was ca ied
ou , using an adhesi e b idge, which will emain un il an
implan can be inse ed (Figu es 4(a) and 4(b)).
3. Discussion
Acco ding o And easen and Pede sen [19], any damage o
he a ec ed oo h o ac o s associa ed wi h he inju y can
in luence hep ognosis o healing.These ac o sincludeage
o he pa ien , s age o oo o ma ion, oo h ype, po en ial
c own ac u es, ex en o displacemen , p esence o absence
o gingi al lace a ion, and he numbe o in uded ee h. The
s ageo oo de elopmen isconside ed obeoneo hemos
impo an ac o s [19, 20].
And easen e al. [21] came o he conclusion ha he
possibili y o spon aneous ee up ion had o be allowed
o in in uded ee h wi h imma u e oo de elopmen .
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4Case Repo s in Den is y
(a)
(b)(c) (d)
Figu e 3: (a) F on al in ao al pho og aph o he pa ien a e a auma o he uppe le cen al inciso [11], which occu ed 2 weeks ea lie
and caused an a ulsion ha was immedia ely eimplan ed. Obse e in aocclusion wi h espec o 2.1 and 1.2. (b) Pe iapical con ol adiog aph
pe o med 2 weeks a e einse ion o 11, in which in usion and ankylosis a e appa en . (c) In ao al pho og aph du ing deco ona ion as he
ull- hickness lap is aised a ound he ankylosed oo h. (d) In ao al pho og aph du ing deco ona ion, as he pulp issue is emo ed om
he oo canal using an endodon ic K- ile.
(a) (b)
Figu e 4: (a) Radiog aphic p ojec ion o 11 showing he oo emaining a e deco ona ion and he wi e o p os he ic ehabili a ion. No e he
absence o he pe iodon al ligamen space. (b) In ao al pho og aph showing aes he ic ehabili a ion using a b idge a ached wi h a 0.9 mm
wi e and a composi e pon ic, gi ing an accep able aes he ic appea ance and lea ing a 2 mm space be ween he mucous memb ane and he
pon ic so as no o in e e e wi h bone emodeling.
In ee h wi h ma u e oo de elopmen (12–17 yea s old),
howe e , spon aneous ee up ion migh be allowed o , while
in pa ien s wi h ma u e oo s (>17 yea s), o hodon ic o
su gical eposi ioning should be pe o med. O he au ho s,
such as Wigen e al. [22], ecommend a pe iod o obse a ion
o pa ien s be ween 6 and 12 yea s old, i espec i e o
oo de elopmen , while wai ing o spon aneous ee up ion.
Wha is clea is ha ea men should be di ec ed owa ds
elimina ing o educing seconda y complica ions o he
inju y. The li e a u e desc ibes ha , in such cases, he new
e up ion p ocess may las om 1 o 8 mon hs [23, 24]. In case
1, we ollowed he IADT p o ocol and wai ed wo weeks o
spon aneous ee up ion, since he oo h oo was imma u e
and ough o ha e e ained i s po en ial o e up ion. When
we ca ied ou clinical and adiological con ols a e 2 weeks,
no oo h mo emen was obse ed in he al eola p ocess and
so we op ed o o hodon ic ac ion.
O hodon ic ex usion is one o he al e na i e he -
apies o choice o in uded pe manen ee h, because i
allows o he emodelingo heboneand hepe iodon al
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Case Repo s in Den is y 5
appa a us[25,26].Thein uded oo hcanbeo hodon ically
eposi ioned o endodon ic ea men la e , i necessa y,
wi hin a ime scale ha may a y be ween 2 and 3 weeks
ollowing ac i a ion [27].
Al hough bo h spon aneous ee up ion and o hodon ic
eposi ioning cause less damage o he su ounding issues,
he e is no gene al ag eemen abou he choice o one o o he
ea men [21]. Some au ho s [28] ha e ecommended ha
only in cases whe e he e is e y sligh in usion should we
wai and see i he e is spon aneous ee up ion. O he s ha e
sugges ed ha moni o ingshouldcon inueun il hepa ien is
17 yea s old, independen ly o he in usion [21]. I ee up ion
does no occu , o ced o hodon ic e up ion may be applied,
whichiswhy,incase1,a e wai ing o woweeksand
ailing o obse e any ee up i e mo emen , we pe o med
o hodon ic ac ion as he second ea men op ion [27].
Howe e , nei he o hese op ions p e en ed he in e up ed
oo de elopmen and subsequen ankylosis (Figu e 1(c)).
When he pe iodon al ligamen (PDL) is damaged, he e
a e 4 possible sequelae o healing o nonhealing. One o
hese is eplacemen oo eso p ion, o ankylosis, o osseous
eplacemen eso p ion. His ologically speaking, hese a e
a eas whe e he den in can be obse ed as used wi h he su -
ounding bone, wi h eso p ion pi s whe e he mul inuclea ed
os eoclas s a e ac i ely eso bing he den in, and he PDL and
cemen ha e been los . Radiog aphically, he oo appea s o
me ge wi h he su ounding bone, wi h he comple e absence
o he PDL [29–32]. Bo h ou clinical cases de eloped his
complica ion. In case 1, six yea s a e he ini ial auma, oo
eso p ion wi h bone-like issue g ow h in he oo canal
was obse ed on a adiog aph a one o he pa ien ’s annual
check-ups o o hodon ic ea men . In case 2, ankylosis
was obse ed on he con ol adiog aph (Figu e 3(a)) a ew
mon hs a e he auma and as a di ec esul o i . The
main challenge p esen ed by his kind o eso p ion is ha
he e is no way o s opping i once i has s a ed. Endodon ic
ea men is no ecommended o ankylosis unless he e a e
signs and symp oms consis en wi h pulp nec osis [29–32].
Tee h ha a e eimplan ed in child en who de elop anky-
losis a e a auma can be used o p ese e he heigh /wid h
o he al eola bone [12]. The mechanism o ac ion o his
bene icial e ec could be associa ed wi h an ac i e pe ios eum
o ming o e he eso bed oo , which allows he oo o se e
as a sca old o al eola bone neogenesis simila o ha o he
adjacen e up ing oo h [17].
The success o his echnique has been clinically desc ibed
in 77 pa ien s wi h oo h ankylosis a e a ulsion [33]. In
almos hal o he pa ien s, al eola bone was de ec ed 1.5
yea s a e deco ona ion; in 61%, emnan s o he oo we e
s ill p esen . In hose pa ien s who had unde gone his p o-
cedu e du ing he pube al g ow h spu , no in aposi ion o
he bone segmen was seen du ing moni o iza ion ollowing
he p ocedu e. Howe e , e ical bone le el inc eased and
he pa ien s main ained he al eola bone in he labiopala al
dimension in he long- e m ollow-up, as lea ned om
excellen epo s [23, 34, 35].
In he clinical cases p esen ed, we show wo p o iles
o di e en ages in which we op ed o deco ona ion as a
ea men o ankylosis. In his ega d, wo successi e s udies
p esen edbyMalmg ene al.[12,17]ha esugges ed ha ,
in ea ly mixed den i ion (7–10 yea s), deco ona ion should
be pe o med wi hin 2 yea s o he diagnosis o be o e he
g ow h spu . In case 2, wo and a hal yea s a e he ini ial
auma and 2 yea s a e he i s sign o ankylosis, we decided
o pe o m deco ona ion be o e he ollowing g ow h spu
because o he mode a e in aposi ion o 1.1 and also o
p e en he bone de ec om becoming mo e appa en . In
la e mixed den i ion (10–12 yea s), disc e ion should be used,
depending on each case, and in e ening soone a he han
la e . I ankylosis occu s du ing he g ow h spu , which
implies in aocclusion, deco ona ion should be ca ied ou as
soon as he p oblem is diagnosed. This highligh s he c i ical
impo ance o clinical and adiog aphic moni o iza ion in
such ype o auma ic cases. In case 1, deco ona ion was
pe o med when he pa ien was 15 yea s old (du ing pube al
g ow h), o ake ull ad an age o he se e al millime e s
inc easein he e icalbonele eland hep ese a iono he
buccopala al wid h o he al eola c es . Su gical in e en ion
o deco ona ion demands excellen managemen o child en
beha io especially in young child en, ha is, case 2 (8
yea s old); ne e heless his ype o p ocedu e does no
di e excessi ely om o he he apeu ic op ions in e ms o
pa ien s’ pe cei ed anxie y o pain [36, 37].
This p ocedu e enables us o a oid a la e cos ly in asi e
su gical p ocedu e o augmen he al eola idge. Howe e i
is s ill a su gical in e en ion, which can pose a challenge o
young child en. A “ empo a y” eplacemen o he missing
ee h will also be equi ed o a long pe iod [29]. In spi e o
hese disad an ages, he e a e good indica ions ha he bone
ha o ms in he eplacemen oo eso p ion a ea is o good
quali y. Placing implan s in socke s when he indi idual is
ully de eloped is a ela i ely easy and uncomplica ed ma e
[12]. The main limi a ions o he p esen epo eside in i s
me hodological na u e ha is jus a case epo s udy so no
di ec e idence based conclusions migh be de i ed om his
illus a i e epo .
4. Summa y
O he possible op ions, deco ona ion is an al e na i e ea -
men ha o e s a good clinical ou come. I has been shown
ha i his p ocedu e is ca ied ou a he igh ime, he
buccopala al al eola dimensions can be p ese ed o yea s,
while a he same ime allowing o ex a e ical g ow h,
which makes es o a ion possible la e wi h an implan .
This is an easy sa e p ocedu e ha ep esen s a conse a-
i e app oach o ex ac ing ankylosed ee h when compa ed
o a majo su gical in e en ion. Solid s udies a e equi ed
in he u u e o enable us o de e mine how p edic able and
success ul deco ona ion is in he long- e m as a ea men
a e ankylosis in he an e io ee h.
Con lic s o In e es
The au ho s decla e ha he e a e no con lic s o in e es
ega ding he publica ion o his pape .
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6Case Repo s in Den is y
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