Dental Traumatology 2015; 31: 184–189; doi: 10.1111/edt.

12166

Long-term follow up of 103 ankylosed

permanent incisors surgically treated with
decoronation – a retrospective cohort study

Barbro Malmgren1, Georgios Abstract – Background/Aim: Decoronation is a technique developed in

Tsilingaridis1,2, Olle Malmgren3 1984 to remove ankylosed teeth and increase marginal bone levels in
1
Department of Dental Medicine, Division of young, growing individuals. This retrospective cohort study evaluates mar-
Pediatric Dentistry, Karolinska Institutet, ginal bone development after decoronation in relation to gender and age at
Huddinge; 2Department of Paediatric Dentistry, treatment. Materials and methods: The study evaluated all 95 patients
Eastmaninstitutet, Stockholm; 3Orthodontic with 103 ankylosed permanent incisors treated with decoronation at the
Clinic Tandregleringen, Huddinge, Sweden Eastmaninstitutet Department of Pediatric Dentistry during 1978–1999.
Mean age of the patients was 10.7 years (6.8–17.8) at the time of trauma
and 14.9 years (9.3–22.0) at decoronation. The mean follow-up period was
4.6 years (1.0–19.3 years). The study evaluated development of the mar-
ginal alveolar bone level with a three-point scoring system: 1 = Unchanged
or reduced alveolar bone level, 2 = A moderate increase in alveolar bone
level, and 3 = A considerable increase in alveolar bone level. The final
group for statistical evaluation comprised 75 patients: 56 boys and 19 girls
Key words: decoronation; alveolar ridge;
implants who had only one tooth decoronated. Kappa statistics showed almost com-
plete agreement between the two observers (j = 0.90). Results: Bone level
Correspondence to: Barbro Malmgren, changes were significantly correlated (P < 0.05) to gender and age at treat-
Department of Dental Medicine, Division of
ment. In decoronations performed after the age of 16, bone levels were
Pediatric Dentistry, Karolinska Institutet, POB
4064, SE-14104 Huddinge, Sweden unchanged or reduced, while decoronations performed at a mean age of
Tel.: +46 73 9851788 14.6 years in boys and 13 years in girls yielded a considerable increase in
Fax: +46 8 7743395 bone levels. Conclusion: This study indicates that age at decoronation is
e-mail: [email protected] an important factor for favorable development of the alveolar ridge and
Accepted 4 January, 2015 that decoronation should be performed earlier in girls.

Traumatic injuries to the permanent dentition are crown and the root filling while maintaining the resorb-
most common in children 8–12 years of age, with a prev- ing root as a matrix for new bone development. This will
alence of 22% (1). Of these, 0.5–3.0% (2, 3) are avulsions preserve the volume of the marginal alveolar ridge, creat-
and 0.5%–1.9% are intrusive luxations (4, 5). ing better conditions for a future prosthetic solution.
A common complication after avulsion and intrusion Our research group published the first description of
injuries is dentoalveolar ankylosis, in which the alveo- decoronation treatment in 1984. The study examined the
lar bone fuses to the root substance. An ankylosed root material of 24 ankylosed permanent incisors (11). We
is continually resorbed and replaced by bone, eventu- demonstrated an increase of marginal bone, particularly
ally resorbing the entire root. The condition is progres- in patients treated before their pubertal growth. Several
sive, and the rate of this resorption seems to vary with case reports, as well as a recent study by Lin et al. (12),
age (6). To date, there is no means of arresting or support this finding, demonstrating that decoronation
reversing the process. If no other changes intervene, might preserve alveolar bone width and height (12–17).
the patient can retain the ankylosed tooth until the The aim of this retrospective cohort study was to evalu-
crown falls off or is removed by forceps (7). ate marginal bone development after decoronation in
By the 1970s, experiments had shown that new relation to gender and age at treatment.
marginal bone might form over the coronal surface of
submerged roots covered with a mucoperiosteal flap (8–
Materials and methods
10). When vital roots were submerged, very few inflam-
matory changes were found, whereas inflammatory We examined the decoronation of permanent anky-
changes occurred consistently, both periapically and losed incisors performed in 102 patients at the East-
pericoronally, in submerged, endodontically filled roots. maninstitutet Department of Pediatric Dentistry during
Based on these findings, a technique to remove anky- the period 1978–1999. Seven patients were excluded
losed teeth was developed. This technique is now known from the study due to incomplete records, or because
as decoronation, in which the goal is to remove the they moved away or did not show up for their dental

184 © 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
 Ankylosed incisors treated with decoronation 185

appointments. The study group thus comprised 95 determined by two of the authors (BM and OM) had
patients with 103 decoronated permanent incisors. near perfect agreement (j = 0.90). All data were ana-
Their age at trauma ranged from 6.8 to 17.8 years lyzed with STATISTICA v. 12 (StatSoft, Scandinavia AB,
(mean 10.7; median 10.4), and their age at decorona- Uppsala, Sweden).
tion from 9.3 to 22.0 years (mean 14.9; median 15.0).
The average follow-up period was 4.6 years (range
Results
1.0–19.3). Four patients received auto-transplantation
of a premolar to the incisor region, while ongoing Considerable increases in alveolar bone level (score 3)
orthodontic treatment in nine patients made correct occurred in 20 boys and nine girls, moderate increases
evaluation of radiographs difficult. Furthermore, seven (score 2) in 20 boys and seven girls, and unchanged or
patients had more than one tooth decoronated. We reduced bone levels (score 1) in 16 boys and three girls.
evaluated this group of 20 patients, but did not include Boys with a considerable increase in bone level were
them in the statistical analysis. The final group for sta- significantly younger (mean age 14.6 years, SD 2.6)
tistical evaluation comprised 75 patients, the 56 boys than those with a moderate (mean age 15.1 years,
and 19 girls who had only one tooth decoronated. Of SD 2.3), P = 0.03, or unchanged bone level (mean age
the 75 teeth evaluated, 21 had been included in our 16.8 years, SD 2.2), P = 0.01. Girls with a considerable
earlier study (11). increase in bone level were significantly younger (mean
In the 1984 study, we followed up 14 of the 24 teeth age 13.0 years, SD 2.6) than those with an unchanged
radiographically; exposures of the alveolar ridge were bone level (mean age 17.3 years, SD 1.2), P = 0.02
made at predefined time points using a device that (Table 1). Furthermore, a gamma correlation (G) also
ensured the same position was used each time. The demonstrated that patient age at decoronation has a
device consisted of the radiographic cone and a film significant effect on alveolar bone level for boys
holder, adjusted parallel to the long axis of the tooth (G = 0.34, P < 0.05) and for girls (G = 0.55,
in a fixed position (11). We traced the apical or coronal P < 0.05). This indicates more favorable outcomes in
surface of the postoperative bone level in a digitizer younger boys and girls, but particularly in girls.
connected to a Nord-10 computer and calculated the Four patients had both central incisors decoronated;
surface area according to Grenn’s formula. These resorption of the sharp edges of the bone at the suture
radiographs became templates for measuring alveolar had occurred, with no vertical bone growth, but there
ridge changes. A standardized long-cone radiographic was a successive formation of new marginal bone at the
technique was used to evaluate the remaining 81 teeth. mesial surfaces of the laterals (Fig. 2). In the three
We used a three-point scoring system to assess the patients where a central incisor and a lateral incisor were
vertical shift in alveolar bone level on radiographs decoronated, no such resorption could be seen (Fig. 3).
taken with the standardized long-cone radiographic At the last follow up, 29 patients had reached the
technique: 1 = Unchanged or reduced alveolar bone age of 20 years. Eighteen of these had received
level, 2 = A moderate increase in alveolar bone level, implants. In six patients, root remnants were still pres-
and 3 = A considerable increase in alveolar bone level ent at the time of insertion. In four of these, the
(Fig. 1). Differences in bone level were evaluated in implants were inserted in contact with the roots. This
relation to the cementum–enamel junction of the did not impede insertion of the implants or the healing
homolog on the most reliable radiographs. process (Fig. 4a–b). Fourteen of the 18 implant
patients received no ridge augmentation.
Statistical analysis
Discussion
Analysis evaluated bone levels in relation to age at dec-
oronation and gender using nonparametric correlation, The main finding in this study is that age at decorona-
gamma statistics, and a t-test, all with a significance tion is an important factor for favorable development
level of P < 0.05. We randomly selected 20 cases from of the alveolar ridge. Furthermore, the time when the
the material for double determination of the bone development of the alveolar ridge is most favorable
level classification, using Kappa statistics. The scores differs significantly between boys and girls.

(a) (b) (c)

Fig. 1. Estimation of changes in bone level in the vertical direction. (a) Score 1 = Unchanged or reduced alveolar bone level. (b)
Score 2 = A moderate increase in alveolar bone level. (c) Score 3 = A considerable increase in alveolar bone level.

© 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
186 Malmgren et al.

Table 1. Alveolar bone level after decoronation of 75 teeth in 56 boys and 19 girls in relation to age at operation
Age at decoronation
Alveolar bone level Number of teeth Mean SD
Boys 1. Unchanged or reduced 16 16.8 2.2
N = 56 2. Moderate 20 15.1 2.3
3. Considerable 20 14.6 2.6
Girls 1. Unchanged or reduced 3 17.3 4.6
N = 19 2. Moderate 7 14.2 1.8
3. Considerable 9 13.0 1.2

(a) (b)

Fig. 2. Decoronation of both central

incisors. (a) A 15-year-old girl
immediately after decoronation. (b)
Result after 2 years. Note resorption of
the sharp edges of the bone at the
suture.

(a) (b)

Fig. 3. Decoronation of right upper

lateral and central incisors. (a) A
16-year-old boy immediately after
decoronation. (b) Result after 3 years.
Note increase of bone in vertical
direction and formation of lamina dura.

Earlier studies have established a relationship between Clinical experience shows that extraction of an anky-
infraposition of an ankylosed tooth and growth of the losed tooth may involve loss of attached bone, particu-
alveolar bone. Infraposition is caused by local arrest of larly the thin buccal plate of the maxilla, which
the dentoalveolar bone, and its severity depends on the jeopardizes socket healing, causing bone defects in both
development of occlusion and facial growth. These fac- the horizontal and vertical dimensions (18). The anky-
tors vary individually. Thus, monitoring the patient is losed tooth should therefore be removed in time to pre-
important. In general, it is recommended to remove an vent these adverse effects. Decoronation preserves the
ankylosed tooth before severe infraocclusion and tilting alveolar width and rebuilds the lost vertical bone of the
of neighboring teeth develop (18, 19). alveolar ridge in growing individuals. The biological

© 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
 Ankylosed incisors treated with decoronation 187

(C) (D)
(a)

(A) (B)

(H) (I)

(b)

(E) (F) (G)

Fig. 4. (a) A 16-year-old boy before and after decoronation. (b) Implant insertion 14 years after decoronation. Radiographs
before and after insertion. Note root remnants at the arrows and the marginal bone prominence.

explanation for this is that the decoronated root serves periosteum consists of two layers, an outer fibrous
as a matrix for new bone development during resorption layer containing blood vessels and an inner cellular
of the root and that the lost vertical alveolar bone is osteogenic layer (22). During decoronation of the two
rebuilt during eruption of adjacent teeth. A new perios- central incisors, the fibers of the outer layer are cut off
teum is first formed over the decoronated root, allowing and extend into the suture, so that no uniting perios-
vertical alveolar growth. The interdental fibers severed teum layer is formed. Thus, stimulation for new bone
by the decoronation procedure are then reorganized formation is lost. When a central incisor and a lateral
between adjacent teeth. The continued eruption of these incisor are decoronated, however, new marginal bone
teeth mediates marginal bone apposition via the dental- is formed and bone level increases (Fig. 5).
periosteal fiber complex. The erupting teeth are linked It is well known that the resorption of the alveolar
with the periosteum covering the top of the alveolar process after tooth extraction in both jaws is signifi-
socket and indirectly via the alveolar gingival fibers, cantly greater on the buccal aspect than on the lingual
which are inserted in the alveolar crest and in the lamina or palatal (23–26). The decoronation technique mini-
propria of the interdental papilla. Both structures can mizes bone loss, and the ankylosed root is successively
generate a traction force resulting in bone apposition on resorbed and replaced with bone. An important part of
top of the alveolar crest. This theoretical biological this treatment is that the root canal fills with a blood
explanation is based on known anatomical features, clot; as the blood clot is organized from the surround-
known eruption processes, and clinical observations ing bone tissue, bone will be created in the canal. It is
(18). In the present study, we found considerable mar- therefore important to remove a root filling. A recent
ginal bone development when decoronation was per- case study did not perform root filling removal, and
formed at an average age of 14.6 years in boys and favorable alveolar bone development failed (27). Lin
13 years in girls. This corresponds well with studies of et al. measured the bucco-palatal alveolar dimensions
the craniofacial complex, agreeing with both Thilander’s of the alveolar ridge at the mid-mesio-distal distance
(19) description of an age difference of 2 years between after decoronation on study casts (12). They found a
boys and girls in this age interval and the growth velocity reduction of only 1 mm in the bucco-palatal dimension
curves presented by Taranger and H€ agg (20). The age at the mid-decoronation area compared with the
distribution within the groups was large. As shown ear- contralateral homologous tooth. This reduction is
lier, different changes in bone level can also be explained significantly less than in the findings by Lam who mea-
by varying growth patterns, such as vertical vs horizon- sured alveolar change in the same way after extractions
tal growers, as well as growth intensity (21). and found a reduction of 3–5.5 mm (28).
When two central maxillary incisors were decoronat- Four cases received implants with contact to the
ed, we found no increase in bone at the suture, but root remnants. The remnants did not impede insertion
instead found a resorption and rounding of the suture of the implants or the healing process (Fig. 5). Earlier
edges. A possible explanation for this may be a split of studies have demonstrated implant integration in root
the uniting periosteum layer covering the suture. The substances without ridge augmentation (17, 29, 30).

© 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
188 Malmgren et al.

(a) (b) (c)

Fig. 5. Schematic drawing showing the two layers of the periosteum. (a) The suture is bridged over by the outer united layer. (b)
The outer layer is cut off during the decoronation procedure. (c) The two parts extend from both sides down into the suture.

Furthermore, we demonstrate that 14 of 18 implant 5. Borssen E, Holm AK. Traumatic dental injuries in a cohort
patients did not receive ridge augmentation, indicating of 16-year-olds in northern Sweden. Endod Dent Traumatol
a preserved bone volume suitable for dental implants. 1997;13:276–80.
6. Andersson L, Bodin I, Sorensen S. Progression of root
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Like ankylosed teeth, osseointegrated implants do not 7. Ravn JJ, Helbo M. Replantation of accidentally lost teeth. A
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odontically treated roots. Oral Surg Oral Med Oral Pathol
adulthood, especially between the ages of 20–30 (35).
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