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Journal of Orthodontics, Vol. 36, No. 3, 186-189, September 2009 doi:10.1179/14653120723175
© 2009 British Orthodontic Society
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Clinical Section

Infraocclusion of secondary deciduous molars – an unusual outcome

Sirisha Ponduri, David J Birnie and Jonathan R Sandy

Queen Alexandra Hospital, Portsmouth, UK

Address for correspondence: Sirisha Ponduri, Maxillofacial Department, Queen Alexandra Hospital, Portsmouth, PO6 3LY, UK., Email: sirishaponduri{at}hotmail.com

Received 20 December 2007; accepted 6 June 2009


   Abstract
Top
 Abstract
Introduction
 Case history
 Discussion
 Summary
 References
 
Infraocclusion is a condition frequently associated with primary molars. The infraoccluded primary teeth remain in a fixed position, while the teeth adjacent to them continue to erupt, moving occlusally. It is generally accepted that the cause of the altered occlusal level is ankylosis of the affected tooth. This report describes a case in which a short course of interceptive treatment with a 2 x 4 fixed appliance resulted in resolution of the infrocclusion. Recreating space for a severely infraoccluded second deciduous molar resulted in ‘eruption’ of the tooth without the need for extraction.

Key words: Infraocclusion, submerged, ankylosed, deciduous molars


   Introduction
Top
 Abstract
 Introduction
Case history
 Discussion
 Summary
 References
 
Dental infraocclusion is a term which can be used to define teeth below the occlusal plane and is a condition frequently associated with primary molars. The terms ‘ankylosed’ and ‘submerged’ are often used synonymously with infraocclusion.

The cause of the infraocclusion remains unknown, although a number of factors have been indicated. These include local trauma causing damage to Hertwigs epithelial root sheath, disturbed local metabolism, localized infection, chemical or thermal irritation, deficient eruptive force, abnormal tongue pressure and forces exerting pressures on the dental arch squeezing the teeth into infraocclusion.1Go–7Go

The reported prevalence of infraoccluded primary molars ranges from 1.3 to 35.27%.8Go–13Go This large variation is related to the use of various diagnostic criteria, the ages of the children examined, and the influence of specific study populations. A significantly higher incidence of infraocclusion has been reported in siblings of children diagnosed with infraocclusion.8Go,14Go It appears that mandibular first primary molars are the most frequently affected teeth, followed by the second mandibular molars and second maxillary molars.10Go,11Go,14Go The infraocclusion usually occurs in the mixed-dentition stage.

The available evidence suggests that, although there may be a short delay in exfoliation of approximately 6 months, infraoccluded teeth will exfoliate naturally, provided they are not severely infraoccluded. The severity is usually measured by the relation of the crown of the infraoccluded tooth with the contact points of the adjacent teeth. If below the contact points it is difficult to see how the infraoccluded tooth can easily exfoliate. Those infraoccluded primary teeth with no successors reportedly, do not exfoliate.15Go,16Go

The infraoccluded primary teeth remain in a fixed position as a result of some disturbance in their periodontal ligament while the teeth adjacent to these teeth continue to erupt, moving occlusally.16Go–21Go This gives the appearance of the infraoccluded teeth becoming progressively more submerged in relation to their neighbours with time. Histological studies have reported a very high correlation between these clinical observations and ankylosis, and it is generally accepted that ankylosis is, in fact, the cause of the altered occlusal level.12Go,15Go,21Go

Sequelae
There are a number of adverse consequences related to submerged deciduous molars. Early ankylosis has a negative impact on normal occlusal development, and can lead to:

  1. delayed exfoliation,
  2. impaction and/or delayed eruption of the permanent successor,
  3. tipping of the adjacent teeth. There is often significant tipping of the teeth adjacent to a severely infraoccluded deciduous tooth,
  4. denuding of proximal root surface,
  5. increased difficulty of extraction associated with a severely submerged deciduous molar,
  6. overeruption of the opposing teeth,
  7. displacement of the dental centre-line to the affected side,
  8. relative spacing of the teeth of the affected side,
  9. an abnormal position and development of the permanent successors,
  10. damage to adjacent teeth, e.g. caries associated with the submerged tooth and/or adjacent teeth.

Management usually involves careful monitoring, and intervention at the first sign of any undesirable outcomes to prevent any significant problems later in dental development.

This report presents a case in which an unexpected and unusual resolution of the submerged deciduous molar resulted from intervention.


   Case history
Top
 Abstract
 Introduction
 Case history
Discussion
 Summary
 References
 
The patient, a male aged ten years and 11 months was referred to the Orthodontic department by his general dental practitioner concerned by his Class III incisor relationship and submerging upper right second deciduous molar. There was no relevant medical history reported.

The following teeth were present: Teeth present : 6 E D C 2 1|1 2 C D E 6

7 6 E D C 2 1|1 2 C D E 6 7

Oral hygiene was fair, and caries was noted mesially in the upper left second deciduous molar.

The patient had a Class I skeletal pattern with a class III incisor relationship. The lips were competent. It was noted on examination that the upper right second deciduous molar was severely infraoccluded and the lower left first and second deciduous molars and the lower right second deciduous molar were mildly infraoccluded. There was also some incisal wear on the upper incisors possibly as a result of the class III incisor relationship (Figure 1(a–e)Go).


Figure 1
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  		Figure 1 Pre-treatment intra-oral photographs

 
The panoramic radiograph confirmed the presence of all permanent successors including third molars. Radiographically, it was evident that the upper right second deciduous molar was severely submerged with its roots partially resorbed by the upper right second premolar (Figure 2Go). The upper right first permanent molar had tipped mesially into the upper right second deciduous molar space, making surgical access difficult.


Figure 2
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  		Figure 2 Pre-treatment OPT Radiograph

 
A course of interceptive orthodontic treatment with upper and lower 2 x 4 fixed appliances was planned, and Damon System appliances fitted in June 2006.

The primary aim of the treatment was to correct the class III incisor relationship. The secondary aim was to recreate space for the severely infraoccluded upper right second deciduous molar to improve access and allow extraction of the tooth.

The patient was seen 4–6 weekly as treatment progressed. Space was re-opened using push coil in the upper right quadrant. Class III elastics were prescribed to correct the class III incisor relationship. At review in October 2006, it was noted that space had been recreated for the upper right second deciduous molar and that this tooth had now ‘erupted’ into this space and was slightly mobile (Figure 3Go). The upper right second deciduous molar was kept under review and the general anaesthetic appointment which had been organized for removal of this tooth was cancelled.


Figure 3
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  		Figure 3 Mid-treatment upper occlusoal photograph showing ‘erupted’ URE

 
Patient compliance with class III elastics was initially poor, but improved later in treatment and a positive overjet and overbite were achieved. The upper right second deciduous molar exfoliated naturally without the need for surgical intervention and was followed by eruption of the second premolar (Figure 4(a,b)Go). The patient was debonded and arrangements made to review his dental development.


Figure 4
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  		Figure 4 Mid-treatment intra-oral photographs showing erupted URS and corrected incisor relationship

 

   Discussion
Top
 Abstract
 Introduction
 Case history
 Discussion
Summary
 References
 
Generally, provided the permanent successor is present and in a normal position, the expected future development of an ankylosed deciduous molar should be a 6-month delayed shedding compared with normal shedding time.12Go,22Go However, this is related to the degree of infraocclusion which is a function of time.6Go,12Go,23Go Restorative options for a mildly infraoccluded tooth include placement of a stainless steel crown or composite resin build-up of the occlusal surface to prevent tipping of the adjacent tooth and overeruption of the opposing tooth.1Go The recommended management of severely infraoccluded molars which have not exfoliated within the normal time limits is extraction to prevent any adverse sequelae.1Go–7Go

This course of interceptive treatment took 12 months and corrected the two main developing orthodontic problems (the class III incisor relationship and the infraoccluded deciduous molar) without the need for surgical intervention and general anaesthetic which had originally been planned. The permanent successor was present and in a normal position. Recreating the space for the upper right second deciduous molar and maintaining it allowed it to exfoliate naturally without any further intervention.


   Summary
Top
 Abstract
 Introduction
 Case history
 Discussion
 Summary
References
 
The natural exfoliation of the severely infraoccluded deciduous molar is a surprising outcome as these teeth usually require extraction to allow eruption of the permanent successor. This treatment outcome avoided the need for a general anaesthetic and surgical intervention. We have not found any other published reports of severely submerged deciduous molars correcting in this manner.


   References
Top
 Abstract
 Introduction
 Case history
 Discussion
 Summary
 References
 
1 Noble J, Karaiskos N, Wiltshire WA. Diagnosis and management of the infraerupted primary molar. Br Dent J 2007; 203: 632–34.[CrossRef][Medline]

2 Biederman W. Etiology and treatment of tooth ankylosis. Am J Orthod 1962; 48: 670–84.[CrossRef]

3 Adamson KT. The problem of impacted teeth in orthodontics. Aust J Dent 1952; 56: 74–84.

4 Atrizadeh F, Kennedy J, Zonder H. Ankylosis of teeth following thermal injury. J Periodont Res 1971; 6: 159–67.[CrossRef][Medline]

5 Dixon DA. Observations on submerged deciduous molars. Dent Pract Dent Rec 1963; 13: 303–16.

6 Kurol J, Thilander B. Infraocclusion of primary molars and the effect on occlusal development, a longitudinal study. Eur J Orthod 1984; 6: 277–93.[Abstract/Free Full Text]

7 Andlaw RJ. Submerged deciduous molars: a review, with special reference to the rationale of treatment. J Int Assoc Dent Child 1974; 5: 59–66.[Medline]

8 Via WF Jr. Submerged deciduous molars: Familial tendencies. J Am Dent Assoc 1964; 69: 127–29.[Medline]

9 Lamb KA, Reed MW. Measurement of space loss resulting from tooth ankylosis. J Dent Child (Chic) 1968; 35: 483–87.

10 Brearly LJ, McKibben DH. Ankylosis of primary molar teeth I. Prevalence and characteristics. J Dent Child (Chic) 1973; 40: 54–63.

11 Krakowiak FJ. Ankylosed primary molars. J Dent Child (Chic) 1978; 45: 288–92.

12 Kurol J, Koch G. The effect of extraction of infraoccluded deciduous molars: a longitudinal study. Am J Orthod 1985; 87 : 46–55.[CrossRef][Medline]

13 Koyoumdjisky-Kaye E, Steigman S. Ethnic variability in the prevalence of submerged primary molars. J Dent Res 1982; 61: 1401–04.[Abstract/Free Full Text]

14 Kurol J. Infraocclusion of primary molars: an epidemiologic and familial study. Community Dent Oral Epidemiol 1981; 9: 94–102.[CrossRef][Medline]

15 Kurol J, Thilander B. Infraocclusion of primary molars with aplasia of the permanent successor, a longitudinal study. Angle Orthod 1984; 54: 283–94.[Medline]

16 Kurol J. Infraocclusion of primary molars. An epidemiological, familial, longitudinal, clinical and histological study. Swed Dent J (Suppl) 1984; 21: 1–67.

17 Biederman W. The ankylosed tooth. Dent Clin North Am 1964; 8: 493–508.

18 Brown ID. Some further observations on submerging deciduous molars. Br J Orthod 1981; 8: 99–107.[Abstract]

19 Darling AI, Levers BGH. Submerged human deciduous molars and ankylosis. Arch Oral Biol 1973; 18: 1021–1040.[CrossRef][Medline]

20 Darling AI, Levers BGH. The pattern of eruption of some human teeth. Arch Oral Biol 1975; 20: 89–96.[CrossRef][Medline]

21 Kurol J, Magnusson BC. Infraocclusion of primary molars: a histologic study. Scand J Dent Res 1984; 92: 564–576.[Medline]

22 Kurol J. Early treatment of tooth-eruption disturbances. Am J Orthod Dentofacial Orthop 2002; 121: 588–91.[CrossRef][Medline]

23 Messer LB, Cline JT. Ankylosed primary molars: results and treatment recommendations from an eight-year longitudinal study. Pediatr Dent 1980; 2: 37–47.[Medline]





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