dentistry journal

Case Report
Camouflage Correction of Skeletal Class III Severe Open Bite
with Tooth Ankylosis Treated by Temporary Anchorage
Devices: A Case Report
Yuka Yashima 1 , Masato Kaku 2, *, Taeko Yamamoto 1 , Cynthia Concepcion Medina 1 , Shigehiro Ono 3 ,
Yosuke Takeda 4 and Kotaro Tanimoto 1

1 Department of Orthodontics and Craniofacial Developmental Biology, Graduate School of

Biomedical Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima 734-0037, Japan
2 Department of Anatomy and Functional Restorations, Division of Oral Health Sciences, Graduate School of
Biomedical Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima 734-0037, Japan
3 Department of Oral and Maxillofacial Surgery, Graduate School of Biomedical Sciences,
Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima 734-0037, Japan
4 Dental Practitioner, Yumemirai Dental & Orthodontic Clinic Saijo, 1172 Sukezane, Saijo,
Higashi Hiroshima 739-0021, Japan
* Correspondence: [email protected]; Tel.: +81-82-257-5442

Abstract: Tooth ankylosis is a disorder characterized by the fusion of tooth and alveolar bone. This
case report describes the treatment of a severe open bite due to tooth ankylosis. A 14-year-old
female patient with a chief complaint of masticatory dysfunction was diagnosed with skeletal Class
III severe anterior open bite and tooth ankylosis. She visited our university hospital with a chief
complaint of an anterior open bite. After the surgical luxation of the ankylosed maxillary right central
incisor, the tooth was orthodontically retracted using a nickel-titanium wire. The right mandibular
lateral incisor and canine were luxated and retracted using intermaxillary elastics from a temporary
anchorage device (TAD), which was inserted in the opposite jaw. During the treatment, skeletal
Class III malocclusion deteriorated due to anterior growth of the mandible. Therefore, TADs were
Citation: Yashima, Y.; Kaku, M.;
inserted into the retromolar pad on both sides of the mandible and retracted into the mandibular
Yamamoto, T.; Medina, C.C.; Ono, S.;
dental arch. Although the mandibular right canine was luxated several times, it could not be brought
Takeda, Y.; Tanimoto, K. Camouflage
to the occlusal line, and was thus extracted; the extraction space was replaced with a prosthesis.
Correction of Skeletal Class III Severe
Open Bite with Tooth Ankylosis
Consequently, a normal overjet and overbite with a straight profile were achieved. Extrusion of
Treated by Temporary Anchorage ankylosed teeth by intermaxillary elastics from a TAD is a valid treatment option for patients with
Devices: A Case Report. Dent. J. 2023, severe open bites.
11, 107. https://doi.org/
10.3390/dj11040107 Keywords: tooth ankylosis; open bite; surgical luxation; TAD; skeletal class III; camouflage treatment

Academic Editor: Piero Antonio

Zecca

Received: 20 March 2023 1. Introduction

Revised: 12 April 2023
Tooth ankylosis is generally characterized by the fusion of bony structures with
Accepted: 18 April 2023
one another [1]. This disorder is defined as the obliteration of the periodontal ligament
Published: 21 April 2023
(PDL); thus, the involved tooth is fused to the surrounding bone, preventing eruption and
orthodontic movement [1]. The dental ankylosis of permanent teeth is 10 times less frequent
than primary teeth, with mandibular and maxillary first molars being most frequently
Copyright: © 2023 by the authors.
ankylosed followed by maxillary canines and incisors [2]. In orthodontics, misdiagnosis or
Licensee MDPI, Basel, Switzerland. lack of recognition of ankylosed teeth leads to compromised treatment progress and results.
This article is an open access article Unfortunately, ankylosed teeth are difficult to diagnose, particularly in the early stages.
distributed under the terms and Key features for diagnosing dental ankylosis include a lack of mobility and orthodontic
conditions of the Creative Commons movement, a dull sound on percussion, tipping of adjacent teeth, ditching of the alveolar
Attribution (CC BY) license (https:// process, and severely infra-positioned occlusion. The frequency of ankylosis occurrence is
creativecommons.org/licenses/by/ 22.4% in Sweden [3], and permanent tooth ankylosis is reported to occur at approximately
4.0/). 10% of the frequency with which it occurs in deciduous teeth [4]. Ankylosis can be described

Dent. J. 2023, 11, 107. https://doi.org/10.3390/dj11040107 https://www.mdpi.com/journal/dentistry

Dent. J. 2023, 11, 107 2 of 14

as punctate, planar, or three-dimensional, in order of increasing severity; if progression

occurs from one form to another, it may proceed slowly or rapidly. Ankylosis is caused by
several factors including local metabolic changes, genetic predisposition, dental trauma,
dislocation disorder, apical infection, post-excision transplantation, scientific or thermal
stimulation, and surgical orthodontic treatment [5]. Clinical signs include a cusp tip/incisal
edge lower than those of the adjacent teeth, indistinguishability between the root and
surrounding bone in the PDL as observed on radiographs, and clear percussion sound [6].
However, the percussion sound is difficult to objectively evaluate because it is affected by
the mass of the tooth and the physical normality of the periodontal tissue. It is also difficult
to recognize bone adhesions on radiographs [7], and only approximately 30% of ankylosed
teeth can be identified radiographically from animal experiments [8].
Recently, newer diagnostic tools have been introduced, namely digital soundwave
and resonance frequency analyses [9,10]. However, because of fluctuating sensitivity and
poor acceptance among patients, these tools have seen limited use in clinical practice.
Therefore, percussion and mobility testing are still considered the primary diagnostic tools,
and many researchers agree that it is almost impossible to determine tooth ankylosis using
any method other than confirming the degree of dental movement [8,11,12].
Orthodontic treatments for tooth ankylosis include: (1) retraction after luxation [13];
(2) alveolar osteotomy [14–18]; (3) alveolar osteotomy and bone distraction [19–24];
(4) alveolar osteotomy and autologous transplantation [25]; and (5) alveolar osteotomy
and repositioning methods [26]. Among these, retraction after luxation is frequently used
because it is surgically less invasive [13]. However, even when tooth retraction is performed
after luxation, the affected tooth may reattach after some time and unexpected reactions
may occur [13]. In this case report, we aim to describe a case of ankylosed tooth resolved
by using temporary anchorage devices (TADs) after luxation, with no adverse reactions.

2. Materials and Methods

2.1. Chief Complaints
A Japanese girl aged 14 years and 7 months visited the Hiroshima University Hospital
with a chief complaint, “I cannot bite anything with my front teeth”.

2.2. History of Present Illness

Her pretreatment facial appearance revealed a concave profile and the mandible
shifted to the right side (Figure 1). The initial intraoral photographs (EOS R, CANON,
Tokyo, Japan) revealed a 0.5 mm overjet and a −6.0 mm anterior open bite with occlusal
contact only between the first and second molars on the right side. The molar occlusal
relationship was classified as Class I. There was no crowding in the upper arch, but some
spaces were found in the lower arch. The lower dental midline had shifted to the right by
4.0 mm, whereas the upper midline coincided with the facial midline (Figure 2).

2.3. History of Past Illness

She fell on the ground and landed on her upper and lower right anterior teeth when
she was 9 years old. Particularly, she severely hit the upper right central incisor and lower
right canine region. The patient did not have any history of systemic illness.

2.4. Personal and Family History

She and her parents did not have any history of systemic illness.

2.5. Clinical Examination

The patient’s oral hygiene was poor (plaque control record: 67%, probing pocket depth
was less than 3 mm without bleeding on probing). Therefore, continuous teeth brushing
instruction was performed. To test the mobility of teeth around the open bite region, a
resonance frequency analyzer was used (Periotest, Gulden-Medizinteknik, Eschenweg,
Modautal, Germany). Periotestometry was repeated 3 times for each tooth and the mean
Dent. J. 2023, 11, 107 3 of 14

values were shown in Table 1. The Periotest values (PTV) were found to be small in the
upper right central incisor and the lower right canine and lateral incisor. Therefore, the
upper right central incisor and the lower right canine and lateral incisor were identified
Dent. J. 2023, 11, x FOR PEER REVIEW 3 of left
as ankylosed. The PTV of the lower right incisor was smaller than that of the lower 16
Dent. J. 2023, 11, x FOR PEER REVIEW
incisor (Table 1). 3 of 16

A B C
A B C

Figure 1. Pre-treatment facial photographs. (A) Front view; (B) smile view; (C) lateral view.
Figure 1. Pre-treatment facial photographs. (A) Front view; (B) smile view; (C) lateral view.
Figure 1. Pre-treatment facial photographs. (A) Front view; (B) smile view; (C) lateral view.

A B C
A B C

D E F
D E F

Figure 2. Pre-treatment intraoral photographs. (A) Right side view; (B) front view; (C) left side view;
(D) upper
Figure occlusal view;intraoral
2. Pre-treatment (E) lower occlusal view;
photographs. (A)(F) incisal
Right sideview.
view; (B) front view; (C) left side view;
Figure 2. Pre-treatment intraoral photographs. (A) Right side view; (B) front view; (C) left side view;
(D) upper occlusal view; (E) lower occlusal view; (F) incisal view.
(D) upper occlusal view; (E) lower occlusal view; (F) incisal view.
2.3. History of Past Illness
2.3. History
She fellofon
Past
theIllness
ground and landed on her upper and lower right anterior teeth when
She9fell
she was on old.
years the ground and landed
Particularly, on herhit
she severely upper and lower
the upper right right anterior
central incisorteeth when
and lower
she was 9 years old. Particularly, she severely hit the upper right central
right canine region. The patient did not have any history of systemic illness. incisor and lower
right canine region. The patient did not have any history of systemic illness.
2.4. Personal and Family History
2.4. Personal
She andand
herFamily
parentsHistory
did not have any history of systemic illness.
She and her parents did not have any history of systemic illness.
 small in the upper right central incisor and the lower right canine and lateral incisor.
Therefore, the upper right central incisor and the lower right canine and lateral incisor
were identified as ankylosed. The PTV of the lower right incisor was smaller than that of
the lower left incisor (Table 1).

Dent. J. 2023, 11, 107 Table 1. Periotest value. 4 of 14

Tooth
(FDI 13 12 11 31 32 41 42 43 44
Table 1. Periotest value.
System)
Periotest
Tooth (FDI System) 13 12 11 31 32 41 42 43 44
value 8.0
Periotest value (PTV) 17.5 8.0 1.7
17.5 19.9
1.7 20.0
19.9 17.6
20.0 17.64.5 4.5 −1.7 −1.7 5.1 5.1
(PTV)

2.6. Imaging Examinations

2.6. Imaging Examinations
AApanoramic
panoramicradiograph (Hyper-X,Asahi
radiograph (Hyper-X, AsahiRoentgen,
Roentgen,Kyoto,
Kyoto, Japan)
Japan) revealed
revealed lossloss
of of
the PDL cavity in the upper right central incisor, lower right lateral incisor,
the PDL cavity in the upper right central incisor, lower right lateral incisor, and lower and lower right
canine.
right canine. Although the root of the upper and lower anterior tooth was relatively short,the
Although the root of the upper and lower anterior tooth was relatively short,
association withwith
the association the the
ankylosis
ankylosiswas not
was notclear.
clear.There
There was
was nonoabnormal
abnormalcondition
condition in in
bothboth
the
the right and left temporomandibular joint (Figure 3). A skeletal Class III relationship of of
right and left temporomandibular joint (Figure 3). A skeletal Class III relationship
the
theangle
angleofofpoint
pointA-nasion-point
A-nasion-point B B (ANB; 0.2◦ )and
(ANB; 0.2°) andaasteep
steepFrankfort-mandibular
Frankfort-mandibular plane
plane
angle (FMA; 36.2 ◦ ) with lingual inclination of the lower incisors of incisor-mandibular
angle (FMA; 36.2°) with lingual inclination of the lower incisors of incisor-mandibular
plane ◦ ) were noted in the Hiroshima University cephalometric analyses
planeangle
angle(IMPA;
(IMPA;79.579.5°) noted in the Hiroshima University cephalometric analyses
(CX-150
(CX-150W, W,Asahi
AsahiRoentgen,
Roentgen,Kyoto,
Kyoto, Japan, Figure
Figure 44and
andTable
Table2).2).

Figure 3. Pre-treatment panoramic radiograph.

Figure 3. Pre-treatment panoramic radiograph.

Table 2. Summary of cephalometric measurements.

Measurements Pre-Treatment Post-Treatment

SNA (◦ ) 81.5 81.5
SNB (◦ ) 81.3 82.8
ANB (◦ ) 0.2 −1.3
FMA (◦ ) 36.2 36.5
FMIA (◦ ) 64.3 74.6
IMPA (◦ ) 79.5 68.9
U1-SN (◦ ) 110.9 106.9
U1 to A-Pog (mm) 7.7 6.2
L1 to B-Pog (mm) 7.1 4.0
E-line: Upper (mm) 0.1 −0.9
E-line: Lower (mm) 2.4 0.1
Dent. J.J. 2023,
Dent. 11, x107
2023, 11, FOR PEER REVIEW 5 5ofof 16
14

A B

Figure 4. Pre-treatment cephalometric radiograph. (A) Front view; (B) lateral view.
Figure 4. Pre-treatment cephalometric radiograph. (A) Front view; (B) lateral view.
Table 2. Summary of cephalometric measurements.
2.7. Diagnosis
Based on this information,
Measurements this patient was diagnosedPost-Treatment
Pre-Treatment to have a skeletal Class III open
bite with mandibular
SNA (°) deviation,
81.5 with ankylosis of the upper right81.5
central incisor and lower
right canine
SNB (°) and lateral incisor, in
81.3 addition to a spaced lower arch.
82.8She was recommended
orthodontic treatment with orthognathic surgery, but the patient did not accept receiving
ANB (°) 0.2 −1.3
the surgery.
FMA (°) 36.2 36.5
Informed consent was obtained from the patient and her parents prior to the start of
FMIA (°) 64.3 74.6
orthodontic treatment.
IMPA (°) 79.5
The treatment objectives were as follows: (1) to diagnose 68.9
which tooth is actually
U1-SN (°) 110.9 106.9
ankylosed; (2) to retract the ankylosed teeth via luxation; (3) to achieve normal overjet and
U1 to A-Pog
overbite with(mm)
ideal occlusion.7.7The treatment plan was as follows:6.2
L1
1. toFixed rigid lingual arch devices were cemented on both the4.0
B-Pog (mm) 7.1 upper and lower jaws to
E-line:
assistUpper
with both anchorage and eruption of the ankylosed teeth.
0.1 −0.9
2. (mm)
All teeth were moved orthodontically to diagnose the ankylosed teeth.
3. E-line: Lower
Surgical luxation was performed
2.4 on the ankylosed maxillary 0.1 right central incisor,
(mm) by orthodontic retraction using a nickel-titanium (NiTi) wire.
followed
4. The right mandibular lateral incisor and canine were luxated and retracted by inter-
2.7. Diagnosis
maxillary elastics from a TAD that was inserted on the buccal alveolar bone between
the right
Based maxillary
on this lateral this
information, incisor and was
patient canine.
diagnosed to have a skeletal Class III open
bite with mandibular deviation, with ankylosis of the upper right central incisor and
2.8. Treatment Procedures
lower right canine and lateral incisor, in addition to a spaced lower arch. She was recom-
mendedAfter bonding the
orthodontic brackets with
treatment to allorthognathic
teeth (Clear Bracket,
surgery,Metal
but theBracket, and
patient didBuccal Tube,
not accept
JM Ortho, Tokyo, Japan),
receiving the surgery. leveling was initiated to alleviate the lower occlusal plane on both
the upper and lower dentitions. Lingual arches were set on both the upper and
Informed consent was obtained from the patient and her parents prior to the start of lower dental
arches to assist
orthodontic with the anchorage and to prevent further distortion of the occlusal planes.
treatment.
After initial
The treatment leveling of thewere
objectives maxillary dentition
as follows: (1) towith a 0.016-inch
diagnose whichNiTi (Sentalloy,
tooth is actuallyTomy
an-
International, Tokyo, Japan), the upper right central incisor, lower right lateral incisor,
kylosed; (2) to retract the ankylosed teeth via luxation; (3) to achieve normal overjet and
and lower right canine were diagnosed as ankylosed teeth because they did not show
overbite with ideal occlusion. The treatment plan was as follows:
tooth movement. Then, the tooth was luxated and a 0.014-inch NiTi (Sentalloy, Tomy
1. Fixed rigid
International, lingual
Tokyo, arch wire
Japan) devices
waswere
usedcemented
to retract on
theboth the upper
ankylosed and
teeth lower5).
(Figure jaws to
Next,
assist with both anchorage and eruption of the ankylosed teeth.
Dent. J. 2023, 11, 107 6 of 14

the wire was changed to a 0.016 × 0.022-inch Co-Cr wire (Blue Elgiloy JM Ortho, Tokyo,
Japan). The lower right canine was retracted toward the occlusal plane using the lower
lingual arch with an attached hook as an anchorage point. Six months after beginning the
treatment, the overjet changed to −2.0 mm with both Angle Class III molar relationships
due to the flattening of the lower occlusal plane and the anterior growth of the mandible.
To achieve appropriate overjet and overbite, TADs (1.6 mm in diameter and 8 mm in
length, Dual Top Auto Screw; Jeil Medical Corp., Seoul, Republic of Korea) were implanted
bilaterally on the mandibular retromolar pads to retract the lower dental arch. The TAD was
also inserted on the buccal side of the alveolar bone adjacent to the upper right lateral incisor
and canine to retract the ankylosed teeth using intermaxillary elastics (Figures 6 and 7).
Surgical luxation of the ankylosed teeth was performed using anterior after local anesthesia.
Luxation of the teeth was repeated several times whenever the teeth showed ankylosis.
However, because the lower right canine erupted only halfway to the occlusal plane, the
tooth was extracted and after healing the periodontal tissue, the resulting space was closed
with a ceramic crown using the right lateral incisor as a single retainer. After 50 months of
active orthodontic treatment, all orthodontic appliances, including TADs, were removed,
and bonded lingual retainers were adapted on the lingual side of both the upper and lower
anterior dentition (from upper right canine to left canine, and from lower right lateral
incisor to left canine, Penta Cat Wire, Tomy International, Tokyo, Japan). Moreover, a
wraparound retainer was placed on the upper and lower dentitions.
 Dent. J. 2023, 11, x FOR PEER REVIEW 7 of 16
Dent. J. 2023, 11, 107 7 of 14

A B C

D E F

Figure 5. Leveling after surgical luxation of ankylosed teeth. (A) Right side view; (B) front view; (C) left side view; (D) upper occlusal view; (E) lower occlusal
Figure 5. Leveling after surgical luxation of ankylosed teeth. (A) Right side view; (B) front view; (C) left side view; (D) upper occlusal view; (E) lower occlusal view;
view; (F) incisal view.
(F) incisal view.
Dent.
Dent.J. J.2023,
2023,11,
11,107
x FOR PEER REVIEW 88 ofof1416
Dent. J. 2023, 11, x FOR PEER REVIEW 8 of 16

Figure6.6.Intraoral
Figure Intraoralphotographs
photographsafter
afterinsertion
insertionofofTADs.
TADs.(A)
(A)front
frontview;
view;(B)
(B)lower
lowerocclusal
occlusal view.
view. Arrows
Arrows indicate
indicate TADs.
TADs.
Figure 6. Intraoral photographs after insertion of TADs. (A) front view; (B) lower occlusal view. Arrows indicate TADs.

A B C
A B C

Figure 7. Retraction of the ankylosed lower right canine using intermaxillary elastics. (A) Right side view; (B) front view; (C) left side view.
Figure 7. Retraction of the ankylosed lower right canine using intermaxillary elastics. (A) Right side view; (B) front view; (C) left side view.
Figure 7. Retraction of the ankylosed lower right canine using intermaxillary elastics. (A) Right side view; (B) front view; (C) left side view.
Dent. J. 2023, 11, 107 9 of 14

Dent. J. 2023, 11, x FOR PEER REVIEW 9 of 16

3. Results
After orthodontic treatment, the arch alignment was well corrected, the overbite in-
creased to 2.2 mm, and the overjet improved to 2.0 mm. There was no major change in the
3. Results
post-treatment facial profile compared to the pretreatment profile. The left molar relation-
After orthodontic treatment, the arch alignment was well corrected, the overbite in-
ship was
creased to 2.2Class
Angle mm, and I, whereas
the overjet that on the
improved right
to 2.0 mm.was
ThereAngle
was no Class III. The
major change space of lower
in the
right canine was repaired
post-treatment facial profilebycompared
direct bonding right after
to the pretreatment theThe
profile. debonding of all orthodontic
left molar relation-
ship was
appliances. TheAngle Class I, whereas
mandibular thatmidline
dental on the right wasshift
right Anglechanged
Class III. The space
to 2.0 mm of lower
(Figures 8 and 9).
right canine was repaired by direct bonding right after the debonding of all orthodontic
The post-treatment panoramic radiograph did not show severe root resorption (Figure 10).
appliances. The mandibular dental midline right shift changed to 2.0 mm (Figures 8 and
On the9).cephalometric
The post-treatment pre-treatment and post-treatment
panoramic radiograph did not show severe superimposition, the ANB angle
root resorption (Figure
had changed
10). On thefrom 0.2◦ to −pre-treatment
cephalometric 1.3◦ . The mandibular anterior
and post-treatment teeth tipped
superimposition, the lingually
ANB (FMIA;
angle◦ had
from 64.3 changed
to 74.6 ◦ ) in from
order0.2°to to −1.3°. an
obtain Theappropriate
mandibular anterior
overjet.teeth
U1tipped lingually
to A-Pog decreased from
7.7 mm(FMIA;
to 6.2from
mm, 64.3°
and to L1
74.6°)
to in orderdecreased
B-Pog to obtain anfromappropriate
7.1 mm overjet.
to 4.0U1mm.
to A-Pog
Before de-and after the
creased from 7.7 mm to 6.2 mm, and L1 to B-Pog decreased from 7.1 mm to 4.0 mm. Before
treatment, the upper lip changed from 0.1 mm to −0.9 mm and the lower lip changed from
and after the treatment, the upper lip changed from 0.1 mm to −0.9 mm and the lower lip
2.4 mm to 0.1
changed frommm2.4compared
mm to 0.1 mm to the E-lineto(Figures
compared the E-line 11–13,
(FiguresTable
11–13, 2).
Table 2).

A B C

Dent. J. 2023, 11, x FOR PEER REVIEW 10 of 16

Figure 8. Post-treatment facial photographs. (A) Front view; (B) smile view; (C) lateral view.
Figure 8. Post-treatment facial photographs. (A) Front view; (B) smile view; (C) lateral view.

A B C

D E F

Figure 9. Post-treatment intraoral photographs right after debonding all orthodontic appliances. (A)
Figure
Right Post-treatment
9.side view; (B) front intraoral photographs
view; (C) left side view; (D)right after
upper debonding
occlusal view; (E) all orthodontic
lower appliances.
occlusal view;
(A) (F)
Right side
incisal view; (B) front view; (C) left side view; (D) upper occlusal view; (E) lower occlusal
view.
view; (F) incisal view.
Dent. J. 2023, 11, 107 Figure 9. Post-treatment intraoral photographs right after debonding all orthodontic appliances. (A)
10 of 14
Right side view; (B) front view; (C) left side view; (D) upper occlusal view; (E) lower occlusal view;
(F) incisal view.

Dent. J. 2023, 11, x FOR PEER REVIEW 11 of 16

Figure
Figure 10.
10. Post-treatment
Post-treatment panoramic
panoramic radiograph.
radiograph.

A B

Figure 11.
Figure 11. Post-treatment
Post-treatment cephalometric
cephalometric radiograph.
radiograph. (A)
(A) Front
Front view;
view; (B)
(B) lateral
lateral view.
view.
OR PEER REVIEW

Dent. J. 2023, 11, 107 11 of 14

A B
R PEER REVIEW
Figure 12. Posterior–anterior
Figure 12. Posterior–anterior cephalometric cephalometric
tracing. (A) Pre-treatment (14 y 7tracing.
m); (B)(A) Pre-treatment
post-treatment (18(14
y 1 ym).
7 m); (B) post-treatment
(18 y 1 m).

S-N (S) NF (ANS)

Pre-treatment (14 y 7 m) MP (Me)

Post-treatment (18 y 1 m)
Figure 13. Lateral cephalometric superimposition. S-N (S): Superimposition on sella-nasion at sella;
Figure 13. Lateral cephalometric superimposition. S-N (S): Superimposition on sella-nasion at sella; MP (Me): superimposition on the mandibular plane a
NF (ANS): superimposition on the MP (Me):
nasal superimposition
floor at anterior nasal on the mandibular plane at menton; NF (ANS): superimposition on the
spine.
nasal floor at anterior nasal spine.
Dent. J. 2023, 11, 107 12 of 14

4. Discussion
Ankylosis is a direct connection between a tooth and the alveolar bone without the
intervening PDL, and ankylosed teeth cannot show natural eruption and orthodontic tooth
movement. The criteria for determining how to deal with ankylosed teeth are as follows: the
patient’s growth stage, indication for a tooth extraction case or a non-extraction case as an
orthodontic treatment, and the types of teeth involved and the degree of tooth ankylosis. As
orthodontic treatments, some approaches to correct ankylosed teeth include retraction after
luxation [13], alveolar osteotomy [14–18], tooth extraction, and preservation (conservative
treatment or replacement of the extraction space with a prosthesis). Because the patient, in
this case, was in a growing stage, an alveolar osteotomy could not be performed. Moreover,
with sufficient space to align all teeth, luxation of ankylosed teeth and retraction were
chosen. Tooth retraction after luxation is frequently used for ankylosed teeth because it
is less surgically invasive than other treatments, and many successful cases have been
reported [27–31]. In this case, three ankylosed teeth were identified, all of which were
moved by retraction after luxation. Although intermaxillary elastics have often been used
for an open bite, the extent of the open bite, in this case, was too large. Furthermore, there
was a possibility that an adverse reaction to the opposite jaw could occur, such as distortion
of the occlusal plane due to ankylosed teeth. Therefore, the TAD was set on the opposite
jaw to use intermaxillary elastics. Previous reports showed that the areas between the
first and second premolars in the maxilla had the highest success rate of TADs [32]. These
results suggested that root proximity might affect the success rate of TADs. In the present
case, TAD was inserted on the buccal side of the alveolar bone adjacent to the upper right
lateral incisor and canine which has sufficient space for the insertion of TAD. Sfondrini
et al. demonstrated that a minimum TAD diameter of 1.7 mm could be considered in order
to reduce risks of bending and fracture. However, it was also shown that there were no
significant differences between diameters of 1.6 mm and 1.7 mm, for both bending and
maximum loads [33]. Therefore, in the present case, we used TADs with 1.6 mm in diameter.
Resultantly, we succeeded in preventing adverse reactions during the retraction of the
ankylosed teeth. However, although the right lower canine was luxated several times, the
tooth erupted to only half of the adjacent tooth length and could not reach the occlusal line;
thus, the tooth was extracted, and prosthetic treatment was administered.
To anchor the prosthesis, we applied direct bonding prosthesis because the patient’s
satisfaction was greater than those with a removable partial denture in young people. As
it is expected that vertical development of natural teeth in young females will occur even
after adulthood, a dental implant could not be applied at this time [34]. Pjetursson showed
that survival rates of both dental implants and restorations in a combined tooth–implant-
supported prosthesis were lower than those in a solely implant-supported prosthesis [35].
Hence, they recommended that prosthetic rehabilitation should be applied with a solely
implant-supported prosthesis. In this case, since the lower right lateral incisor was the
ankylosed tooth, we decided to set direct bonding prosthesis as a single retainer because
the difference in the degree of displacement between the healthy right first premolar and
the ankylosed lateral incisor is the same as dental implants. The prosthetic device was
esthetically pleasing, and patient satisfaction was very high, although this device did
not participate in the occlusive relationships in order to avoid debonding and fracturing.
Therefore, we are going to replace this device with a dental implant to improve occlusal
function after the patient’s skeletal changes are complete.
In this case, the treatment period was longer than four years because residual growth
of the mandible occurred, and retraction of the mandibular molars was required during
treatment. Orthodontic treatment for most skeletal Class III patients should be initiated
after the end of the major period of mandibular growth. However, early treatment was
required to retract the ankylosed teeth, and long-term treatment was required in this
case. To achieve appropriate overjet and overbite, TADs were implanted bilaterally on
the mandibular retromolar pads to retract the lower dental arch. Previous systematic
reviews demonstrated that the most common complication with the insertion of TAD is
Dent. J. 2023, 11, 107 13 of 14

the occurrence of lesions at the root during interradicular insertion and perforation of the
maxillary sinus and nasal cavity [36]. As mandibular retromolar pads are the safety area
to avoid root injuries and they are the appropriate site to allow correct force direction for
retraction of the lower dental arch, final camouflage treatment could be achieved in the
present case. Sometimes, skeletal Class III patients cannot obtain facial esthetics and ideal
occlusion with camouflage orthodontic treatment. In the present case, the best treatment
plan would be the combination of orthodontics and orthognathic surgery to achieve an
ideal occlusion and good esthetic result. However, the treatment result of the present
case showed remarkable improvement in occlusal function, with total patient satisfaction.
Therefore, it is concluded that the use of TADs was useful for the retraction of ankylosed
teeth and distalization of the lower arch for camouflage skeletal Class III treatment without
any adverse reactions. However, a long-term follow-up will be necessary for occlusal
stability and root resorption of ankylosed teeth by radiograph examination.

Author Contributions: Conceptualization, Y.Y. and M.K.; methodology, M.K., S.O. and Y.T.; software,
T.Y.; validation, C.C.M.; investigation, Y.Y. and Y.T.; writing—original draft preparation, Y.Y. and
M.K.; writing—review and editing, C.C.M.; supervision, K.T. All authors have read and agreed to the
published version of the manuscript.
Funding: This research received no external funding.
Institutional Review Board Statement: Not applicable.
Informed Consent Statement: Written informed consent has been obtained from the patient(s) to
publish this paper.
Data Availability Statement: Not applicable.
Acknowledgments: We would like to thank Aikawa in Department of Oral and Maxillofacial Surgery,
Hiroshima University Graduate School of Biomedical Sciences.
Conflicts of Interest: The authors declare no conflict of interest.

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