C L i n i l C A L P R A C T I C E 1 sY S T E MA T I c R E V I E W

Management of ankylosed primary molars

with premolar successors
A systematic review
Long D. Tieu, DDS, MSc; Stephanie L. Walker, DDS, BSc; Michael P. Major, DM, BSc;
Carlos Flores-Mir, DDS, DSc, FRCD(C)

uring a child's normal

D growth and development,

teeth continually erupt ver-
tically until they contact in
occlusion. The general practitioner
frequently is the first to encoun-
Background. The authors conducted a systematic review to
determine the chnical prognosis of and methods of managing
ankylosed primary molars with permanent successors.
Methods. The authors searched electronic databases (PuhMed,
ter developmental anomalies such Scopus, MEDLINE, Cumulative Index to Nursing and Al-
as infraocclusion. It is relatively lied Health Literature, Web of Science, Cochrane Database of
common to find an infraerupted Systematic Reviews and Google Scholar) up to April 2012 with
primary molar that has stopped the assistance of a librarian specializing in health sciences
erupting vertically, resulting in databases. They also searched the gray literature. They selected
marginal ridge discrepancies with clinical studies in which investigators assessed the prognosis of
adjacent teeth. In this scenario, ankylosed primary molars with permanent successors; they also
vertical growth of the adjacent teeth hand searched references of the selected articles to identify any
and alveolar processes continues; additional studies that the electronic search may have missed.
however, the affected tooth experi- Results. The authors identified 3,529 original articles from the
ences lack of alveolar bone growth electronic database search and none from the hand search. Once
resulting from its arrested erup- selection criteria were applied, only four articles met all inclu-
tion.^ Ankylosed primary molars sion criteria and were included. The number of patients studied
affect occlusal development by ranged from 15 to 107. The number of ankylosed primary molars
complicating eruption and develop- investigated ranged from 26 to 263.
ment of the permanent dentition. Conclusions. Ankylosed primary molars often manifest with
Among the complications, distal mild to moderate progressive infraocclusion. Conservative moni-
eruption of the second premolar is toring of ankylosed primary molars is recommended. The clini-
frequent, and a hooked or altered cian should consider extraction if the permanent successor has
radicular shape of the premolar an altered path of eruption, if the ankylosed primary molar is
underlying the ankylosed primary severely infraoccluded with the adjacent teeth tipping to prevent
molar has been reported,^ possibly the successor from erupting, or both. The ankylosed molar often
exfoliates spontaneously within six months; however, when ex-
Dr. Tieu is an orthodontic graduate student. Depart- foliation is more delayed, arch-length loss, occlusal disturbance,
ment of Dentistry, Faculty of Medicine and Dentistry,
University of Alberta, Edmonton, Alberta, Canada. hooked roots or impaction of permanent successors may occur.
Dr. Walker is an orthodontic graduate student. Depart- Practical Implications. Ankylosed primary molars initially
ment of Dentistry, Faculty of Medicine and Dentistry,
University of Alberta, Edmonton, Alberta, Canada.
should be monitored closely for up to six months. If they do not
Dr. Major is an orthodontic graduate student. Depart- exfoliate spontaneously, they should be removed, because arch-
ment of Dentistry, Faculty of Medicine and Dentistry, length loss, alveolar bone defects, impacted permanent succes-
University of Alberta, Edmonton, Alberta, Canada.
Dr. Flores-Mir is an associate professor and the head. sors and occlusal disturbances often occur when the removal is
Division of Orthodontics, Department of Dentistry, delayed.
Faculty of Medicine and Dentistry, 5-528 Edmonton Key Words. Dentition; decision making; dental arch; dental
Clinic Health Academy, 11405 87 Ave. N.W., 5th Floor,
University of Alberta, Edmonton, AB T6G 1C9, Canada, care for children; ankylosis.
e-mail [email protected]. Address reprint requests to JADA 2013;144(6):602-611.
Dr. Flores-Mir.

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due to the ankylosed primary molar's hlocking An ankylosed primary molar with a perma-
the eruption of the permanent tooth during root nent successor presents potential treatment
formation. Ankylosis commonly leads to delayed challenges for an orthodontist, and under these
exfoliation, impaction or delayed eruption of the circumstances, clinicians often face the dif-
permanent successor; tipping of adjacent teeth; ficult decision of whether to extract or monitor
or localized or generalized loss of arch length, the affected tooth. Data in the literature are
which collectively can result in malocclusion.^-^ contradictory, with some clinicians advocating
Investigators have reported the prevalence extraction with appropriate space manage-
of infraocclusion of primary molars to be 8 to ment^'^''" and others advising conservative moni-
14 percent in children aged 6 to 11 years,'^ with toring.'*'" It is important that practitioners have
primary mandibular molars affected more often a comprehensive understanding of the relative
than primary maxillary molars.^' The infraoc- advantages and disadvantages of extraction
cluded tooth often is believed to be immobile, versus monitoring so that they can decide which
owing to a bony union that exists hetween bone treatment would be most beneficial for their
and tooth, commonly referred to as ankylosis.'''* patients. To our knowledge, there have heen no
The exact etiology of ankylosis is not well un- systematic attempts to summarize the avail-
derstood^**; however, a numher of possibilities able information. In this systematic review, we
include genetic predisposition,^'" excessive analyzed the available literature to determine
masticatory pressure" and disturbance in local better the prognosis of ankylosed primary mo-
lars with permanent successors. In addition,
A clinician sometimes can diagnose an anky- we identified clinical factors that can affect the
losed tooth through radiographie appearance prognosis of an ankylosed primary molar to as-
showing osteoid tissue between the tooth and sist clinicians further in the critical determina-
alveolar bone^'" or changes in vertical alveolar tion of when to extract and when to monitor.
bone height."^''*^ When assessing the alveolar
bone radiographically, the clinician may oh- METHODS
serve an angular defect toward the ankylosed We used the Preferred Reporting Items for
tooth in conjunction with a step in the occlusal Systematic Reviews and Meta-Analyses 2009^^
plane.'" Detection hy means of radiography can checklist as a template for our methodology.
be challenging, because often only a small sec- Protocol and registration. No detailed re-
tion of the root is affected. The clinician also can view protocol or registration was availahle.
diagnose ankylosis hy means of a percussion Eligibility criteria. We used the Popula-
test,^'^ in which an ankylosed tooth produces tion, Intervention, Comparison, Outcome, Study
a high-pitched tone when struck with a metal Design format to define a clinical question with
instrument, whereas a normal tooth undergoing specific inclusion criteria.
the same test would not produce this tone. Not Population. Children were aged 3 to 15
all ankylosed teeth will emit a clear sound on years and had an ankylosed primary molar and
percussion and, because this test is quite subjec- a permanent successor.
tive, its reliability is debated. Intervention. The main intervention of in-
Clinicians have noted several phenomena terest was monitoring of the ankylosed tooth.
in association with ankylosed teeth, including Comparison. The main comparison of inter-
tipping of adjacent teeth, shifting of the dental est was extraction of the ankylosed tooth with
midline to the side of the infraoccluded tooth, or without subsequent space management.
relative spacing of teeth on the affected side of Outcome. The outcome was assessment of
the arch and alteration of the occlusal plane due clinical factors such as alveolar bone levels, tip-
to a reduction in vertical height of the teeth adja- ping of adjacent teeth, overeruption of opposing
cent to the infraoccluded tooth, and overeruption teeth, eruption time of the permanent tooth and
of opposing teeth. ""'^ The degree of infraocclusion eruption path of the permanent tooth.
can range from equal to or less than one-half the Study design. We assessed cohort studies
crown height of the actual primary molar when
compared with the occlusal level of the adjacent ABBREVIATION KEY. CINAHL: Cumulative Index to
teeth, to greater than one and one-half times Nursing and Allied Health Literature. EA: Extraction
the crown height of the primary molar when of ankylosed primary tooth. EBE: Extracted before
compared with the occlusal plane of the adjacent exfoliation. EOS: Exfoliated on schedule. MeSH:
teeth. ^^ Given the severity of the related maloc- Medical Subject Headings. OAE: Overretained and
extracted. SEA: Spontaneous exfoliation of ankylosed
clusion, ankylosis can have a significant effect on primary tooth. SEC: Spontaneous exfoliation of con-
orthodontic treatment planning for the patient. tralateral control.

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and clinical trials. Data items. The two reviewers extracted the
Exclusions. We excluded individual case re- following information from each included trial:
ports or series of cases, cross-sectional studies, sample size, study design, patients' character-
traumatized teeth, anterior teeth, animal stud- istics (including age, sex, severity of ankylosis,
ies and studies with mixed data involving anky- method of diagnosis and location of ankylosed
losed teeth with no permanent successor. tooth), type of intervention (extraction or moni-
Information sources and search. We toring) and outcome (delay in permanent erup-
conducted a computerized search by using the tion, alteration in path of eruption, alveolar
following electronic databases: MEDLINE on bone levels, tipping of adjacent teeth, overerup-
OvidSP, PubMed, Web of Science (Thomson Re- tion of opposing teeth).
uters), Cumulative Index to Nursing and Allied Risk of bias of individual studies. We ap-
Health Literature (EBSCO), Scopus (Elsevier), praised selected studies according to a modified
Cochrane Database of Systematic Reviews (Wi- nonvalidated version of the Critical Appraisal
ley) and Google Scholar from their inception to Skills Programme checklist for cohort studies.^^
the end of the first week of April 2012. We also Synthesis of results and risk of bias
searched the gray literature. We selected the across studies. No meta-analysis was advis-
specific search terms with the help of a senior able owing to the unavailability of the appropri-
orthodontic resident (M.P.M.) and the help of a ate data for such an analysis.
senior librarian who specialized in health sci-
ences databases. Whenever possible, we limited RESULTS
the searches in the databases to only human Study selection. The figure is a flowchart
studies. eTable 1 in the supplemental data to depicting the selection process of articles at
the online version of this article (available at each stage of the systematic review. Searches of
http://jada.ada.0rg/content/i44/6/6O2/suppl/ the electronic databases yielded 5,294 articles;
DCl) shows the search strategies we used. In once duplicates were removed, there were 3,529.
addition, we hand searched the reference lists Phase 1 selection, which was based on title and
of the selected articles to identify any additional available abstract, reduced the 3,529 articles to
resources that the electronic database search 72. Phase 2 involved examining a large number
may have omitted. of full articles, as there were a number of older
Study selection. Two reviewers (L.D.T., articles cited for which only the title could be
S.L.W.) independently performed eligibility as- found or for which the available abstracts of-
sessment of the initial database searches. The fered no additional information. After phase 2,
reviewers initially determined articles' eligibil- we eliminated 68 articles owing to their failure
ity by reading the title and abstracts, if avail- to meet selection criteria or to our inability to
able, of each article identified by the initial elec- locate them (see eTable 2 in the supplemental
tronic search engine. All articles that met the data to the online version of this article [avail-
inclusion and exclusion criteria passed phase 1 able at http://jada.ada.0rg/content/i44/6/6O2/
screening, and the reviewers acquired the full- suppl/DCl]). In the end, the selection process
text articles for the next phase. In addition, we yielded four articles that satisfied our search
obtained the full text of any articles that had no criteria for inclusion in the systematic review.
abstracts or in which the abstract provided in- Study characteristics. Table V-^-'^-^ (pa
sufficient information to facilitate an informed 606-607) provides a summary of important
decision. In phase 2, the two reviewers indepen- methodological data and study results. All four
dently re-evaluated the selected full articles in articles included were written in English, and
terms of the eligibility criteria. In phase 3, the all were prospective cohort studies. These stud-
reviewers hand searched the reference lists of ies were performed between 1980 and 1991,
the articles accepted in phase 2 to identify any and the number of patients studied ranged from
additional resources that may have been over- 15 to 107. The number of ankylosed primary
looked in the electronic database search. The molars investigated ranged from 26 to 263; pa-
reviewers discussed and resolved disagreements tients' mean age was 4.6 to 20.0 years.
by reaching a consensus agreement after each Risk of bias. The quality of reported meth-
phase of selection. odology was mostly good, with moderate risk of
Data collection process. The two reviewers bias owing to the inherent problems of cohort
extracted the data independently and compared studies (Table 2, page 608).'•'•''•^'•^* Table 3'-''''-^'
their findings for accuracy. They discussed (page 609) provides a summary of the potential
and re-examined any discrepancies until they bias and limitations of the studies. In cohort
reached agreement. studies, assessment of selection bias aimed spe-

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cifically at random
sequence generation Records identified through
and allocation con- searching of databases (PubMed, Additional records identified
through Google Scholar and gray
cealment typically is Scopus, MEDLrNE, CINAHL, Web
Science, Cochrane Database)
of
literature
not possible. In one (N = S,294) (n = 0)

study,^ the sequence

generation was de-
termined by a coin I
flip. Also, owing to Records after duplicates removed
the nature of the (n = 3,529)

study, it was impos-

sible to mask evalua-
tors when they were
comparing extraction
Records excluded on basis
with monitoring for Records screened
(n = 3,529) of title or abstract
ankylosed primary (n = 3,457)
teeth. Other common
weaknesses of the
included studies were
lack of justification
for sample sizes, lack
of detailed descrip- Full-text articles assessed
for eligibility
Full-text articles excluded,
with reasons
tion of statistical (n = 72) (n = 68)
methods and failure
to identify study limi-
tations. The inherent
nature of cohort stud-
ies produces a moder-
ate risk of bias; how- Studies included in
ever, for the purposes systematic review
of this systematic (n=4)

review, these stud-

ies were the highest
level available in the
literature.
Figure. Flowchart of selection process. CINAHL: Cumulative Index to Nursing and Allied Health
Synthesis of re- Literature. Cochrane Database: Cochrane Database of Systematic Reviews.
sults. The results
from the included studies in this systematic re- tion. Concerns regarding arch-length space loss,
view were heterogeneous and did not allow for a vertical alveolar bone defect or overeruption
meta-analysis because none of the investigators of opposing teeth appear transient and do not
reported any information regarding risk and seem to be chnically significant once the perma-
odds or relative risk. nent successor is erupted. Therefore, available
evidence suggests the appropriate clinical action
DISCUSSION is simply monitoring for six to 12 months from
Summary of evidence. Our goal in this the expected time of exfoliation.
systematic review was to analyze the available The size difference between the primary
literature to assess the prognosis of ankylosed first molar and the succeeding permanent first
primary molars with permanent successors. premolar is minimal, whereas the size differ-
More specifically, in this review, we attempted ence between the primary second molar and
to highlight clinical parameters for clinicians the succeeding permanent second premolar is
to consider before making treatment decisions. greater. The primary second molars seem to cre-
The results suggest that most ankylosed prima- ate greater problems than do the primary first
ry molars manifest with mild to moderate infra- molars. The maxillary primary second molar
occlusion and display progressive infraocclusion is far less commonly problematic than is the
with time. The data suggest monitoring these one in the mandibular arch. In the maxilla, the
teeth because they often exfoliate spontaneously permanent first molar rotates forward, whereas
on time or within six months of expected exfolia- in the mandible the permanent first molar tips

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and moves lingually. TABLE I

In this systematic Summary of articles that met inclusion criteria. |
review, conservative
STUDY STUOY INTERVENTION SAMPLE SIZE, NO. OF ANKYLOSED
monitoring of the DESIGN TOTAL NO. PRIMARY TEETH
ankylosed primary (MALE:FEMALE)
tooth is recommended Messer Prospective Monitoring and Short term n = 263
regardless of the and Cline,' cohort extraction (4 years): n = 107 Mandible: 149 first molars,
tooth number (the 1980 (45:62) 77 second molars
Maxilla: 21 first molars,
primary first or sec- 16 second molars
ond molar) or tooth
location (maxilla or
mandible). Typically Long term n = 116
(8 years): n = 46 Mandible: 64 first molars,
with exfoliation of (23:23) 41 second molars
the primary molar, Maxilla: 7 first molars,
the mesial component 4 second molars
of the eruptive force
of the permanent
NA NA
molars helps to close
spaces resulting from
the size difference
between the primary
and the permanent n = 56, Unilateral, n = 26
Kurol and Prospective Monitoring and
dentition. If this me- Thilander," cohort extraction subdivided into Mandible: 4 first molars,
sial force is disrupted 1984 unilateral 9 second molars
(23 [14:9]) and Maxilla: 3 first molars,
because of an anky- bilateral 10 second molars
losed primary molar, (33 [12:21])
there may be more
space to be closed if
the ankylosed tooth
NA Bilateral, n = 123
is a primary second Mandible: 44 first molars,
molar as opposed to a 57 second molars
primary first molar. Maxilla: 8 first molars,
14 second molars
According to re- NA NA
sults from the in-
cluded cohort studies,
ankylosis occurs more
frequently in the Prospective Monitoring and n = 15(12:3) n = 46, all in mandible
Kurol and
mandible (73.7 per- Koch,' 1985 cohort extraction 20 first molars,
cent,2^ 76.5 percent,^' 26 second molars
23 monitored,
85.9 percent^) than 23 extracted
in the maxilla (26.3 n = 68 (36:32) n = 133
Kurol and Prospective Monitoring and
percent,^'' 23.5 per- Olson,'« cohort extraction Mandible: 98 second molars
cent,^** 14.1 percent^). 1991 Maxilla: 35 second molars
87 SEAU, 24 SEC*, 22 EA**
These findings are in
agreement with those
of other studies.«'25'2«
Although it is clear
that ankylosis of pri- * NA: Not applicable.
mary molars usually t EOS: Exfoliated on schedule.
t EBE: Extracted before exfoliation.
occurs in the man- § OAE: Overretained and extracted.
dible, there still is 11 SEA: Spontaneous exfoliation of ankylosed primary tooth.
debate about whether **# EA: SEC: Spontaneous exfoliation of contralateral control.
Extraction of ankylosed primary tooth.
thefirst^'^'^'^^or second
affected most commonly. Similarly whereas investigators in another study reported
with the systematic review, investigators in one the second molar as being the most commonly
study reported the mandibular first primary affected. ^'^ Researchers have suggested that the
molar as the tooth most commonly affected,^ mandibular first primary molar is the tooth

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TABLE 1 (COniTIMUED)

MEAN (RANGE) PATIENT ACE AT RESULTS

DIAGNOSIS OF PRIMARY TEETH,
IN YEARS
Mandible: first molar, 7.1 (5.2-9.2); Degree of infraocclusion of primary molars
second molar, 8.0 (5.1-10.4) Mandible
Maxilla: first molar, • First molar: 75% slight, 24% moderate, 1% severe
6.2 (4.7-8.6); second molar, 4.6 (3.0-9.4 • Second molar: 47% slight, 4 1 % moderate, 12% severe
Maxilla
• First molar: 43% slight, 48% moderate, 9% severe
• Second molar: 37% slight, 44% moderate, 19% severe
NA* Outcome
Mandible
• First molar: 83% EOS,^^ 14% EBE,* 3% OAE5
• Second molar: 44% EOS, 42% EBE, 14% OAE
Maxilla
• First molar: 100% EBE
• Second molar: 100% EBE
NA Characteristics of succedaneous premolars
• Presence of ankylosed molar not likely to affect coronal morphology/mineralization
• Premolars preceded by an ankylosed molar are more likely to demonstrate
inadequate mesiodistal space and exhibit coronal rotations
• Premolars succeeding ankylosed molars appear to exhibit periodontal pathology,
especially if molar was overretained or required extraction
9.4(4.2-11.3) • Exfoliated on time: 7 of 26
• Six-month delay in exfoliation: 12 of 26
• 12-month delay in exfoliation: 6 of 26
• Extracted owing to severity of infraocclusion leading to tipping of adjacent teeth
and space loss: 1 of 26
• Overerupted, but after exfoliation and eruption of successors, displayed normal
vertical relationship: 6 of 26
• Displayed mesial tipping of permanent molar: 6 of 26
• Spontaneous uprighting noted with eruption of premolar: 26 of 26
9.9 (5.8-12.8) • Exfoliated spontaneously: 119 of 123
• Extracted owing to unfavorable path of eruption of successor and lack of résorption
of infraoccluded molar; after extraction, spontaneous uprighting of premolar
observed, with eruption slightly palatal to arch: 4 of 123

NA Unilateral and bilateral

• Showed progressive infraocclusion: 92 of 149
• Exfoliated normally within expected range of time: 144 of 149
• Extracted: 5 of 149 (1 owing to deep infraocclusion and severe tipping and space
oss; 4 owing to unfavorable path of permanent tooth eruption)
10.1 (8.1-13.0) No difference in eruption time of successor, marginal alveolar bone height after
eruption of successors, frequency of residual roots between extraction and
nonextraction

At first radiographie examination, • In 132 of 133 teeth, normal periodontal conditions existed in permanent mandibular
12.3 (6.1-16.3); at last radiographie irst molar
examination, 20.0 (14.9-25.5) • Ankylosed primary tooth extracted, bitewing radiograph showed a mesial alveolar
:)one loss of 4 millimeters and etiology of bone loss not clear: 1 of 133
No pocket formation found at the mesial surface of the permanent first molar;
distribution of residual roots in cases involving extraction and cases involving
pontaneous exfoliation was about equal; degree of infraocclusion or presence of
esidual root fragments did not affect bone development: all teeth

most commonly affected, but because this tooth dibular second primary molar as being the most
usually shows only slight infraocclusion and commonly affected because it often is more
typically exfoliates on schedule, clinicians may infraoccluded.^
miss ankylosis in this tooth and note the man- To extract or to monitor. When presented
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TABLE 2
Modified Critical Appraisal Skills Programme checklist for cohort
studies.*^
QUESTION STUDY
Messer Kuroi and Kuroi and Kuroi
and Thiiander/' Koch,' 1985 and
Cline,' 1984 Oison,»
198O 1991

1. Did the study address a clearly focused issue? • • •

2. Did tiie autiiors use an appropriate metiiod to answer tiieir • • •
question?
3. Was the cohort recruited in an acceptable way? • • •
4. Was the exposure accurateiy measured to minimise bias? • • •
5. Was the outcome accurateiy measured to minimize bias? • • • •

6. X
X X X
A. Have the authors identified ail important confounding factors?* • • •
B. Have they taken account of the confounding factors in the design •
and/or analysis?*
7. •
A. Was the foliow-up of subjects complete enough? • •
• • • •
B. Was the follow-up of subjects long enough?
8. • •
A. Do you believe the results? •
B. Did the results report risk and odds or relative risk? X X X X

9. Can the resuits be applied to the local population? • • • •

10. Do the resuits of this study fit with other available evidence? • • • •
* Source: Critical Appraisal Skills Programme.^'
t / : yes; X; no. , j. u 4. i. .j
t The study investigators did not directly identify confounding factors; however, participants m cohort studies can be matched,
which limited the influence of confounding variables.

with an ankylosed primary molar, clinicians foliation was not possihle.iä They reported that
often face the decision of whether to extract 96.7 percent of the ankylosed primary molars
the tooth and manage the space or monitor the exfoliated spontaneously and only 3.3 percent
tooth. In cases with a permanent successor, data required extraction. Of the teeth extracted, one
from the systematic review advocate conserva- was removed hecause of a deep infraocclusion
tive monitoring, as these teeth often exfoliate with severe tipping of adjacent teeth and space
spontaneously. Investigators in one study re- loss, and the other four were extracted because
ported that 62 percent of ankylosed primary mo- of an unfavorable path of permanent tooth erup-
lars exfoliated on time, whereas 38 percent re- tion resulting in a lack of résorption of the infra-
quired extraction.' Out of concerns about loss of occluded molar.
arch length, overretention of the primary tooth Monitoring appears to be a conservative
and localized lack of vertical hone, these authors method of managing ankylosed primary molars;
advocated extraction "if the ankylosed tooth however, it is important for clinicians to assess
became moderately infraoccluded and/or mesial each tooth on a case-by-case basis. Clinicians
tipping of mandibular first permanent molar should consider extraction with appropriate
is imminent or if the molar fails to exfoliate on space management if the permanent successor
schedule.''^ These authors hypothesized that the has an altered path of eruption or if the primary
bias toward interceptive extractions (extraction molar has a delayed exfoliation or is severely in-
of the ankylosed primary tooth without clinical fraoccluded with notahly tipped adjacent teeth.
indication, other than suspected ankylosis) may Tipping and infraocclusion. Severely
have resulted in an underreporting of the num- infraoccluded primary molars with tipping of
ber of spontaneous exfoliations. adjacent teeth leading to clinically significant
Investigators in another study continued to arch-length loss has been suggested to be a rea-
monitor a tooth even after its expected exfolia- son to extract; however, the specific amount of
tion time and engaged in interceptive treatment infraocclusion and tipping has not heen reported
only when they decided that spontaneous ex- explicitly. To assess the effect of extracting or

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TABLE 3

1 Summary of potential bias and limitations.

ASPECT OF STUDY STUDY
Messer and Kuroi and Kuroi and Kuroi and
Ciine,' 1980 Tiiiiander," 1984 Kocii,' 1985 Oison,'« 1991
Selection Bias (Random Sequence NA*; NA NA; NA
Generation; Aliocation Concealment) xnx NA; NA

Performance Bias (Masicing of /;/ X;X X;X X;x

Participants; Masking of Personnei)
Detection Bias (Masking of Outcome X X
Assessment) X X

Attrition Bias (Incomplete Outcome Data) X X X X

Reporting Bias (Seiective Reporting) X X X X
Limitations (Did tiie Authors Discuss ?» ? •s ?
Limitations of tiie Study?)
'^ JNA: Not applicable. ^
t / : No or low risk.
t ?: Unclear.
§ • : Yes or high risk. Small study of only mandibular teeth; further larger studies, including maxillary teeth and comparison
of infraoocluded and normal teeth, are required to assess the effect of primary molar infraocclusion on occlusal development

monitoring an ankylosed tooth, investigators warranted if the clinicians feel that the tipping
in one study in the systematic review exam- of adjacent teeth will cause clinically significant
ined patients with bilateral ankylosed primary arch-length loss and prevent the eruption of the
molars and randomly opted to extract on one permanent successor.
side, performing no space management, and to Timing of exfoliation. Spontaneous exfo-
monitor the contralateral side.'* Fourteen of 15 liation of ankylosed primary molars appears
patients experienced space loss on the extrac- common; however, clinicians also should have
tion side, but only two of 15 had definite space reasonable expectations about when they will
deficiency when the premolars erupted. On the exfoliate. Investigators in one study in this sys-
nonextraction side, six of 15 patients experi- tematic review assessed unilateral infraocclud-
enced space loss, but no major space loss was ed primary molars and compared that side with
evident when premolars erupted.^ The findings the normal contralateral side.^^ They reported
suggest that arch-length loss may be transient that 73.1 percent of ankylosed teeth exfoliated
and that with normal exfoliation of the anky- either on time or within a six-month delay. Fur-
losed molar and eruption of the premolar, there thermore, they reported that an additional 23.1
often is no space loss. This study also highlights percent exfoliated after the clinicians waited
the importance of space management when ex- an additional six months, for a total delay of 12
tracting teeth. months. With this information, clinicians should
Results of the studies in this systematic re- consider monitoring ankylosed primary molars
view suggest that the vast majority of ankylosed that have no initial clinical indicator for extrac-
primary molars initially are mildly to moderate- tion and later consider extracting the teeth if
ly infraoccluded,^ with mean values of 2.6 to 3.7 exfoliation is delayed substantially or if the
millimeters, i'^ With the child's continual growth, clinical appearance changes.
progression of infraocclusion commonly is re- Bone-level recovery. Advocates of early
ported, with a mean annual increase of 0.5 mm extraction of ankylosed primary molars as an
in the mandible and 0.8 mm in the maxilla.^^ interceptive strategy believe treatment will im-
Collectively, results from these studies suggest prove marginal alveolar bone height for the suc-
that ankylosed primary molars should become cessor, the adjacent permanent molar or both;
progressively more infraoccluded; this should will maintain arch length by minimizing space
not prevent the tooth from exfoliating spontane- loss resulting from tipping of adjacent teeth;
ously, but it may delay exfoliation. The exact and will minimize the potential for malocclu-
amount of infraocclusion or degree of tipping sion.ä'25 Some investigators reported that infra-
at which a clinician should extract is not clear occluded primary molars had decreased margin-
in the literature, and, because of this, clini- al bone levels at the level of the cementoenamel
cians should be cautious about extracting solely junction; however, with normal exfoliation and
because of infraocclusion. Extractions may be eruption of the permanent successor, they noted

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 , . « • • « • » • O B A C T I C E IS Y S T E M A T I C R E V I E W

no differences in marginal bone cohort studies inherently have a moderate risk

Findings of a study in which investigators as- of bias compared with the lower risk in well-
sessed alveolar bone mesial to the first perma- designed prospective clinical trials.
nent molar with an adjacent ankylosed primary In our systematic review, three of the four
second molar showed that 99.2 percent of these included articles had a common author, so there
teeth had normal bone levels.'' There was one is an inherent potential for bias in the collected
case of reported bone loss; however, the cause data. Also, we excluded several good studies
is not clear. Although the investigators noted because their results contained mixed data for
the bone loss, the probing depths they recorded ankylosed primary molars with no permanent
were normal, suggesting a long connective- ccessors.
tissue attachment. These original authors noted The methodologies the investigators used to
that although the tooth had bone loss, a normal measure and evaluate exfoliation of primary
probing depth makes the argument that the molars and amount of infraocclusion were not
tooth is no worse off chnically Investigators in standardized in terms of measurement and
another study reported that premolars succeed-
ing ankylosed primary molars appeared to be analysis, so we did not conduct a meta-analysis.
more susceptible to alveolar bone loss, with 9 This systematic review consisted of four studies;
percent showing some loss.^ Of the 10 reported however, in some cases we made conclusions on
cases, eight involved extractions, whereas only the basis of only the information available from
two involved ankylosed teeth that spontane- one study.
ously exfoliated. The extraction technique can In this article, we did not discuss manage-
affect bone levels, and because it was unclear ment of the succedaneous premolars in the
whether or not the ankylosed teeth were ex- rare cases in which extraction of the ankylosed
tracted surgically, we excluded arbitrarily cases primary molar was indicated, because it is not
involving extractions. According to this ratio- a question we asked specifically in this system-
nale, the data suggest that changes to alveolar atic review. We focused this systematic review
bone are transient and that once the dentition only on the management of ankylosed primary
has made the transition from mixed to perma- molars that had permanent successors. In
nent, bone levels are normal. situations involving congenital agenesis of the
permanent premolar, the management of the
In a case-control study, Dias and colleagues^" ankylosed primary molar often is more compli-
reported that vertical alveolar growth between cated. Also, management of clinically significant
the first permanent molar and the second pre- posterior ankylosis with concomitant open bite
molar adjacent to the infraoccluded tooth was because of tongue thrusts could be challenging.
less than that in areas adjacent to teeth with We identified no study in this review that ad-
normal occlusion. Unlike in the longitudinal dressed this scenario.
study by Kurol and Olson,^* in which the au- There are many articles about the manage-
thors assessed bone levels by using periapical ment of ankylosed primary molars. However,
or bitewing radiographs, Dias and colleagues'^ the numbers decrease substantially when one
assessed bone levels by using subtraction radi- focuses on longitudinal studies. The available
ography on panoramic radiographs. The mean studies provide a great deal of information. Ad-
time between radiographs in the Dias and col- ditional studies from different research groups
leagues study was just over two years, whereas using similar standardized measurement and
it was 7.7 years in the Kurol and Olson'" study. evaluation standards would help reinforce the
This time difference may account for the differ- currentfindings.Additional studies to investi-
ence in vertical bone heights observed in the gate monitoring versus extraction in bilateral
two studies. cases involving maxillary teeth would be benefi-
Limitations. In this systematic review, we cial, because the current literature clearly lacks
attempted to access a number of databases to this information.
obtain all articles available on this topic. We
identified several studies that may be relevant, CONCLUSIONS
but despite our best attempts, we could not re- Our systematic review led to the following
trieve them. findings:
Only cohort studies were available for inclu- — Ankylosed primary molars often manifest
sion in this systematic review. Although cohort with mild to moderate infraocclusion and usu-
studies represent the best currently available ally become progressively worse with time,
evidence for this topic and the included studies i" Ankylosed primary molars often, but not al-
were of acceptable quality, it is recognized that ways, exfoliate spontaneously on time or within
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 C L I N I C A L P R A C T I C E ISYSTEMATIC RE V I FW

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Disclosure. None of the authors reported any disclosures.
22. Moher D, Liberati A, Tetzlaff J, Altman DG; PRISMA Group.
The authors acknowledge the assistance of Linda Seale, librarian Preferred reporting items for systematic reviews and meta-analyses:
University of Alberta, Edmonton, Alberta, Canada.
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