Dental Traumatology 2016; 32: 255–263; doi: 10.1111/edt.

12247

Effectiveness of decoronation technique in

the treatment of ankylosis: A systematic
review

Jhassu Varsha Naveena Mohadeb1,2,
Mirinal Somar3, Hong He1,2
1
The State Key Laboratory Breeding Base of
Basic Science of Stomatology (Hubei-MOST) &
Key Laboratory of Oral Biomedicine Ministry of
Education, School and Hospital of Stomatology,
Wuhan University; 2Department of Orthodontics,
School and Hospital of Stomatology, Wuhan
University; 3Department of Prosthodontics,
Wuhan School and Hospital of Stomatology,
Wuhan University, Wuhan, China
Key words: tooth ankylosis; growth;
decoronation
Correspondence to: He Hong, Professor and
Chair, Department of Orthodontics, School
and Hospital of Stomatology, Wuhan
University, 237 Luo Yu Road, Hongshan
District, Wuhan 430079, China
Tel: +008618971662305
Fax: +00862787873260
e-mail: drhehong@hotmail.com
Accepted 21 October, 2015
Abstract – Background: Dentoalveolar ankylosis in growing patients is
complex leading to continuing root replacement resorption, tooth infra-
position, or may even affect the development of alveolar ridge and adja-
cent teeth. While extraction of ankylosed teeth might be associated with
bone loss, decoronation of the offending tooth (removal of crown portion
and instrumentation of pulp canal to stimulate bleeding) has been sug-
gested as a more conservative approach of bone preservation until defini-
tive implant placement is planned. Objective: To primarily assess the
efficacy of bone width and height preservation around ankylosed perma-
nent teeth following decoronation. METHODS: Pubmed, Embase, Ovid
Medline, Thomson’s ISI Web of Science and Cochrane library were
searched from the year 1984 up to May 2015. Two authors conducted the
data extraction. To eliminate publication bias, Open Grey literature and
Pro-quest Dissertation Abstracts and Thesis database was also con-
sulted. Results: Through our strict selection criteria, only 12 articles were
considered for eligibility. No randomized controlled trials were identified.
Only one retrospective cohort study, four case series and seven case
reports, were analyzed. Conclusions: Following decoronation, preservation
of ridge height and ridge width were both noted. To maximize the benefits
of decoronation, a timely and wellmonitored intervention is required.
Treatment in patients, who have surpassed pubertal growth peaks, may
not yield maximum effective treatment outcomes.

Dental/dento-alveolar ankylosis refers to an anatomical
fusion of cementum with alveolar bone, occurring at
any time during the course of eruption (1). Although
traumatic injuries to teeth (intrusion, extrusive, or lat-
eral luxation) have been suggested as the primary etio-
logical factor for developing ankylosis (2), yet
idiopathic forms of this type of fusion have also been
identified (3). Severe trauma to the tooth root will
cause damage to PDL fibers, resulting in an inflamma-
tory process. Coupled with the loss of the intervening
root/bone barrier (PDL space), an increase mesenchy-
mal activity will follow at the affected area, and with
time lead to progressive replacement of the root sub-
stance by bone, hence resulting in ankylosis.
Unless previous treatment failures are identified or
patient complains of poor dental esthetics, diagnosis of
ankylosis (being asymptomatic) usually tends to be
missed out by the clinician. Radiographs will only
reveal presence of ankylotic areas if at least 20% of the
root surface is affected (4). Recently newer diagnostic
tools have been introduced namely digital sound wave
analysis, resonance frequency analysis and Periotest
(5–7). However, due to their fluctuating sensitivity and
poor acceptance among patients, their use has been
limited in clinical practice. In so saying, percussion and
mobility testing, has stood the test of time and is still
considered as a primary diagnostic tool. Upon percus-
sion of an ankylosed tooth, a characteristic metallic
dull sound will be noted.
Ankylosis in adults is not a major problem and can
be successfully managed through prosthodontics or
implant replacement. In contrast, ankylosed teeth in a
growing patient should not be left untreated. In those
cases, rate of replacement root resorption is more rapid
and eventually the affected tooth crown will fall off as
it is deprived of root support. As the affected tooth is
restricted to respond to the natural eruptive process,
sequela of ankylosis can range from a mild localized
infra-position of the tooth to a more severe form
resulting in an un-esthetic ridge deformity and tilting
of adjacent teeth (8).
Several attempts to manage ankylosed teeth in grow-
ing children have been proposed (9, 10); Surgical luxa-
tion, orthodontic distraction, auto-transplantation,
composite build-ups, or extraction followed by implant
replacement. While most techniques have been associ-
ated with an unpredictable prognosis, Malmgren in
1984, introduced a more conservative treatment option,

© 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd 255

256 Mohadeb et al.
which was termed as decoronation (11). Decoronation
involves a coronectomy of the ankylosed tooth beneath
the level of the CEJ and instrumentation of the pulp
canal to stimulate bleeding at the peri-apical area.
Through its potential role in bone preservation or bone
augmentation, invasiveness of implant surgery at a
later date, has been claimed to be minimal.
In light of the apparent success of decoronation
technique, this study was designed to systematically
review the available evidence on this topic. As a pri-
mary objective, the efficacy of decoronation in bone
preservation will be discussed. Additionally, other fac-
tors influencing success will be highlighted.
Material and methods
To the extent feasible, reporting of this systematic
review was done in accordance with the PRISMA
statement checklist (12). With reference to Table 1, our
PIO question was formulated so as to primarily assess
the efficacy of using decoronation technique to preserve
bone (horizontal, vertical) around ankylosed permanent
teeth.
Search strategy
A systematic computerized search was conducted using
several databases extending from 1984 to May 2015 to
identify articles related to decoronation of ankylosed
permanent teeth. The following databases were
searched: Pubmed, Embase, Ovid Medline, Thomson’s
ISI Web of Science and Cochrane library. To eliminate
publication bias, Open Grey literature and Pro-quest
Dissertation Abstracts and Thesis database was also
consulted.
As far as possible, similar key words were used dur-
ing the search. Terms were truncated and combined
appropriately (Table 2). The reference lists of all
Table 1. PIO question
Parameters Description
P = Patient/Problem Young patients presenting with ankylosis of
1 or more permanent teeth
I = Intervention Undergoing decoronation technique to maintain
implant site
O = Outcome 1 To assess the efficacy of ridge height
preservation
2 To assess the efficacy of ridge width
preservation
Table 2. Search strategy
1 Ankyl* OR ankylosis OR infraocclusion OR infraposition
2 Tooth OR teeth OR root OR dental OR alveol* OR dentoalveolar
3 Trauma* OR avuls* OR replacement resorption OR resor* OR luxa*
4 Temporomandibular OR arthritis OR jaw OR joint OR spondy*
OR spine OR hip OR elbow
5 (1 and 2 and 3) NOT 4
6 Decorona* OR decoronation OR ridge preservation
7 5 AND 6
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selected articles were also hand searched to identify
any potential articles that may have been missed in the
electronic search.
Eligibility criteria
Randomized controlled trials and prospective
controlled studies represented the primary targets for
inclusion. However, case-series or case reports were
also considered for eligibility. Only English-written arti-
cles were included, with a clear description of the
pretreatment and post-treatment changes following the
use of decoronation technique.
Exclusion criteria were set as follows: (i) letters, edi-
torials, un-retrievable full-text articles (ii) studies
reporting treatment of ankylosis achieved by other
means, other than decoronation, (iii) experimental
studies in animals, and (iv) articles with an apparent
source of bias.
Study selection and data extraction
Once the computerized search was completed, selection
of studies involved a 2-stage procedure. Initially 1
reviewer (JVNM) was recruited for screening of article
titles, removal of duplicates and/or reading of article
abstracts. In the second stage, articles were retrieved in
full-text and independently reviewed by two authors
(JVNM and MS). Any disagreement during this phase
was discussed, and a third reviewer (HH) was consulted
when necessary.
The variables for which data were sought are tabu-
lated in Table 3 and 4.
Results
Through our computerized search, a total of 137 arti-
cles discussing decoronation as a treatment option for
ankylosed permanent teeth, were identified. After filter-
ing through titles, elimination of duplicates and reading
of abstracts, 110 articles were rejected. From the
remaining 27 articles, only 14 full-text articles tallied
with our inclusion criteria, to which one pertinent arti-
cle was added following the hand-searching procedure
(refer to PRISMA flowchart Fig. 1).
Out the 15 retrieved articles (11, 13–26), two articles
by Sapir (13, 14); two articles by Malmgren (15, 16);
and two other papers by Malmgren (17, 18) were com-
bined and treated as one study each, to prevent dupli-
cation of data.
Finally, a total of 12 studies including one retrospec-
tive cohort study, seven case reports, and four case ser-
ies, were analyzed for the purpose of this review.
Quality assessment:
Quality assessment was carried out separately for the
case reports/case series and the cohort study following
the CARE guidelines (27) (Table 5 and 6) and New-
castle-Ottawa scale (Table 7) respectively. Three case
reports/case series were considered to be of moderate
quality, while the remaining eight studies were rated as
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Effectiveness of decoronation technique 257

Table 3. General descriptive data of included studies

Case presentation
Author Study type N (M/F) Tooth no Infra occlusion Ankylosis RRR
Malmgren (19) (2015) Retro-spective Cohort 75 (56/19) 11,12,21,22 Index I, II, III (+) (+)
Mahak- unakorn (20) Case report 1F 11, 21 Index III (+) (+)
(2014) Affecting apical and cervical
areas
Tsuki-boshi (21) (2014) Case series 3 (2/1) 11, 21 Index I, II, III (+) (++)
Severe buccal root resorption
reaching upto the pulp canal
but no cervical root resorption.
Lin (22) (2013) Case series 12 (9/3) 12,11 Index I (+) (+)
21,22
Calasans Maia (23) (2013) Case report 1M 12,11 Index IV, severe (+) (+)
21 ridge deformity present
Sapir (13,14) (2009) Case report 1M 11 Index III, with a (+) (++)
buccal displacement Advanced Resorption
Diaz (24) (2007) Case report 1M 11 Index II (+) (++)
Pulp canal Advanced Resorption
obliterated
Cohenca (25) (2007) Case report 1M 11 Index IV, with a severe (+) (+)
ridge deformity
Malmgren (15,16) (2006) Case series 2M 11, 21 Index II Index II (+) (+)
(+) (+)
Filippi (26) (2001) Case report 1F 11 Index I (+) (++)
Advanced resorption
Malmgren (17,18) (2000) Case report 1F 21 Index II (+) (+)
Malmgren (11) (1984) Case series 14 (NS) 11, 21 Index I, II, III (+) (+)

high quality. Additionally, only a low risk of bias was
associated with the included retrospective cohort, con-
firming reliability of the results.
Throughout the selection procedure, decisions were
made after mutual agreement between both authors,
with inconsistencies arising rarely.
Discussion
By screening through the literature, it is evident that
very little amount of information exists on this topic.
Even after 30 years of its introduction, only one retro-
spective cohort, seven case reports, four case series, few
review articles and one Cochrane review article (28)
were documented so far. Geographically, the clinical
application of decoronation technique to manage anky-
losed teeth, has been poorly popularized worldwide.
This in part could be attributed to the lack of scientific
evidence documenting its success rate or also possibly
due to placing greater emphasis on medicaments (29)
to arrest the process of ankylosis. By preconditioning
roots of avulsed teeth with Emdogain, possibility of
cementogenesis has been reported (30), consequently
eliminating the risk of developing dental ankylosis. As
confirmed through a personal interview of some col-
leagues working in the pediatric department at our uni-
versity, management of ankylosed permanent teeth in
growing patients is usually delayed till jaw growth is
completed or in cases where intervention is necessary,
surgical extraction/subluxation is usually advocated.
From Table 3, it can be observed that decoronation
has been primarily used to treat ankylosed anterior
teeth, with the objectives of both ridge preservation
prior to implant placement and also to correct un-
esthetic ridge defect. Etiologically, all patients undergo-
ing treatment reported a positive history of previous
traumatic dental injury resulting in lateral tooth luxa-
tion, intrusion or avulsion. Of the 12 studies included
in this review, two authors (22, 26) reported a milder
amount of infra-position (Index I), while the rest
showed a more severe degree of infra-position (Index
II, III, IV). Amount of infra-occlusion is rated as Index
I (minimal) where amount of infra-position is <1/8 of
the crown height of the adjacent teeth. Index II (mod-
erate) amount of infra-position is ≥1/8 but <1/4 of the
crown height of the adjacent teeth. Index III (severe)
amount of infra-position is ≥1/4 but <1/2 of the crown
height of the adjacent teeth. Index IV (extreme)
amount of infra-position is ≥1/2 of the crown height of
the adjacent teeth. Presence of ankylosis was confirmed
both on percussion and disappearance of PDL space
radiographically. Unlike other studies relying on con-
ventional radiographs for diagnosis, Tsukiboshi
through the use of CBCT scans demonstrated a more
extensive amount of active root replacement resorption
which even extended up to the pulp canal with severe
buccal bone resorption.
Efficacy of bone preservation
As a primary outcome of this review, the effectiveness
of decoronation technique in ridge preservation was
assessed in the vertical and horizontal dimension
(Table 4). However, since quantitative data was poorly
reported by most studies, no meta-analytic study could
be undertaken.
Within an average of 2–3 years following decoronation
of an ankylosed tooth, it was noted that not only bone

© 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
 258

Table 4. Treatment outcomes

Observation
Age at Follow up
Mohadeb et al.

Author Rx plan decoro period Height Width RR Implant phase

Malmgren (19) (2015) # Decoronation 9–22 4.6 years Increase NS 6 Partial root resorption 18 implants (4/18)
required ridge augmentation
Mahak- unakorn (20) (2014) # Decoronation 13 3 month NS NS Evident at cervical area Planned later
# RPD
Tsuki-boshi (21) (2014) # Decoronation 10–18 1–2 years Increase Slight decrease Partial root resorption Planned later
# Simultaneous bone grafting with Bio-OSS
# RPD
Lin (22) (2013) # Decoronation 6–16 1–6 years Increase Decreased Partial root resorption Planned later
by 1.67 mm
Calasans Maia (23) (2013) # Orthodontic extrusion (fail) 13 5 years Increase NS Partial root resorption Xeno grafts were used
# Surgical replantation (fail)
# Decoronation
Sapir (13,14) (2009) # Decoronation 12 4 years Increase1 mm coronal bone formed NS Complete root resorption No grafts needed
# Resin tooth fixed by palatal wire
# Ortho Rx
Diaz (24) (2007) # Decoronation 10 3.5 years Coronal bone (after 2 yrs) NS Complete root resorption Planned later
# Splinting of natural tooth as pontic
Cohenca (25) (2007) # Decoronation 16 2.5 years Vertical bone growth NS Complete root resorption No grafts needed
# Simultaneous Bio-Oss graft
# Ortho Rx
# Acrylic pontic
Malmgren (15,16) (2006) # Decoronation 14 10 years Coronal bone growth Favorable Partial RR even after Implant placed.
# Resin pontic 10 yrs of decoronation No grafts needed
# Decoronation 13 1 years Coronal bone growth NS Complete root resorption NS
# Resin pontic
Filippi (26) (2001) # Decoronation 16 2–9 months 1 mm coronal bone Width preserved NS Planned later
Malmgren (17,18) (2000) # Decoronation 12 13 years Coronal bone growth Width preserved Complete root resorption Implant placed.
# Resin pontic No grafts needed
Malmgren (11) (1984) # Decoronation 13–19 18 months # 0.2–1.0 mm increase in 8 cases NS Both partial and complete NS
# Acrylic pontic and RPD # 0.3–1.3 mm decrease in 3 cases root resorption
# No change seen in 3 cases

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Fig. 1. PRISMA flowchart, illustrating
selection process of articles.
was preserved but also a mean of 1 mm coronal bone
increase was reported. Stated otherwise, decoronation can
preserve as well as augment vertical ridge height. In sup-
port of this favorable bone preservation, two mechanisms
have been proposed (11). In the first instance, as clot for-
mation occurs at the coronal portion of the ankylosed
root, bone forming cells are stimulated resulting in physio-
logical bone growth. In the second instance, by removing
the crown portion of the ankylosed tooth up to 1 mm
below the level of the osseous crest, circumferential, and
interdental gingival fibers are severed consequently allow-
ing the adjacent teeth to freely erupt without any restric-
tion. As eruption of adjacent teeth proceeds, bone
formation is also accompanied (16).
In contrast, the efficacy of ridge width preservation
has been underemphasized by most studies. Only five
studies reported the influence of decoronation on the
ridge width. In two cases, Malmgren (15–18) reported
favorable preservation of ridge width. Filippi (26)
reported a slight decrease in ridge width after 2 weeks
following decoronation, which remained constant even
after 9 months of follow up. Lin (22) pointed out that
preservation in ridge width following decoronation is
not 100% effective. By comparing the width at the
ankylosed area with that of the adjacent teeth, the
author noted a mean decrease of 1.67 mm in the trea-
ted area with a tendency of a further decrease as the
case was followed for a longer time. In the case series
(involving treatment of patients by surgical extraction,
decoronation, or auto-transplantation), Tsukiboshi (21)
documented that all techniques were associated with a
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Effectiveness of decoronation technique 259
lack of efficiency in bone volume preservation. While
the palatal side did not reduce over time, the buccal
cortical bone showed a greater tendency to resorption.
As a possible explanation, it was suggested that alveo-
lar bone loss should be viewed as TDBV (tooth depen-
dent bone volume) and TIDV (tooth independent bone
volume). TDBV represents the bone volume that is lost
after extraction of teeth or loss of vitality of periodon-
tal fibers. TIDV, in contrast, is genetically predeter-
mined and is unaffected by presence or absence of
teeth. To put it simply, decoronation preserves the
ankylosed root, thus as opposed to surgical extractions,
the loss in TDBV is minimized.
Factors influencing success rate
Timing of intervention
One of the prime determinants of successful treatment is
a timely and well-monitored intervention. Early studies
(31, 32) have confirmed a positive association among
tooth infra-position, age and skeletal growth pattern
(horizontal/vertical grower). In cases where ankylosis is
diagnosed before the growth spurt (10 years old), a
greater possibility of progressive tooth infra-position
exists, therefore a prompt intervention will be required
within 2–3 years. On the other hand, when ankylosis is
diagnosed during the growth spurt, the tooth should be
regularly monitored and decoronation can be initiated if
rate of infra-position becomes severe.
In most of the studies included in this review, decoro-
nation was initiated either before or during pubertal
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260 Mohadeb et al.

Table 5. CARE checklist

Topic Item Checklist item description
Title 1 The words “case report” should be in the title along with the area of focus
Key Words 2 2–5 key words that identify areas covered in this case report
Abstract 3a Introduction—What is unique about this case? What does it add to the medical literature?
3b The main symptoms of the patient and the important clinical findings
3c The main diagnoses, therapeutics interventions, and outcomes
3d Conclusion—What are the main “take-away” lessons from this case?
Introduction 4 One or two paragraphs summarizing why this case is unique with references
Patient Information 5a De-identified demographic information and other patient specific information
5b Main concerns and symptoms of the patient
5c Medical, family, and psychosocial history including relevant genetic information (also see timeline)
5d Relevant past interventions and their outcomes
Clinical Findings 6 Describe the relevant physical examination (PE) and other significant clinical findings
Timeline 7 Important information from the patient’s history organized as a timeline
Diagnostic Assessment 8a Diagnostic methods (such as PE, laboratory testing, imaging, surveys)
8b Diagnostic challenges (such as access, financial, or cultural)
8c Diagnostic reasoning including other diagnoses considered
8d Prognostic characteristics (such as staging in oncology) where applicable
Therapeutic Intervention 9a Types of intervention (such as pharmacologic, surgical, preventive, self-care)
9b Administration of intervention (such as dosage, strength, duration)
9c Changes in intervention (with rationale)
Follow-up and Outcomes 10a Clinician and patient-assessed outcomes (when appropriate)
10b Important follow-up diagnostic and other test results
10c Intervention adherence and tolerability (How was this assessed?)
10d Adverse and unanticipated events
Discussion 11a Discussion of the strengths and limitations in your approach to this case
11b Discussion of the relevant medical literature
11c The rationale for conclusions (including assessment of possible causes)
11d The primary “take-away” lessons of this case report
Patient Perspective 12 When appropriate the patient should share their perspective on the treatments they received
Informed Consent 13 Did the patient give informed consent?

growth period, as per the guidelines set by Malmgren
(17). On the contrary, in two studies (25, 26), decorona-
tion was carried out at a later date (around 16 years old)
wherein the patient surpassed the peak time of pubertal
growth. While both authors reported a coronal bone
increase following treatment, we believed that the prog-
nosis of the technique, in such cases, is questionable. The
reported bone increase in Cohenca’s study (25) could
actually be extrapolated to the synergistic influence of
bone grafts that were placed simultaneously at the time
of decoronation. On the other hand, success of treatment
in Filippi’s study (26) could well be attributed to the mild
severity of the case (Index 1).
Stated otherwise, in patients who have surpassed the
pubertal growth peak (age 16), benefits of treating anky-
losed teeth by decoronation cannot be fully exploited. In
such age groups (nearing the end of growth spurt), rate
of infra-position, alveolar ridge deformity or tilting of
adjacent teeth, is already well-established. Therefore
even though bone increase can be satisfactory, decorona-
tion can do little to correct the persistent alveolar ridge
deformity and tooth infra-position.
Possible adverse events associated with decoronation
placement included removable appliances, acrylic resin
teeth or natural crowns of the offending teeth (shaped
as natural pontics) fixed by splinted palatal wire. In a
strict sense, it should be remembered that irrespective
of the choice of appliance, they all can interfere with
normal eruption of adjacent teeth or normal inter-arch
width development. Clasp assembly in removable par-
tial dentures should be regularly monitored so as to
eliminate any premature dental contacts or dental
interference. Rigid fixation of pontic to adjacent teeth
should be avoided where maxillary canines are still in
the process of eruption, since they can interfere with
lateral arch development (17). Last but not the least; a
minimum clearance space should be respected between
edge of pontic and ankylosed root surface, so as to
accommodate coronal bone growth.
Additional grafts are needed
Use of decoronation technique to preserve the implant
site, does not exclude the possibilities of bone grafting.
As confirmed by Calasans-Maia (23), decoronation can
help to preserve initial bone required for primary bone
stability, while additional grafts are relied on for sec-
ondary stability and implant coverage.

Retention of temporary restoration Progression of root resorption

Although not reported in most studies, the risk of
recurrent failures of temporary restorations or break-
age of removable appliances placed over long periods
of time cannot be overlooked. From the results of this
review, temporary restorations used until implant
As shown in Table 4, the rate of progression of root
replacement resorption differed across studies. How-
ever, it is equally true that age and individual variation
can influence progression of root resorption (33). In
support of such observation, we were able to identify

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Effectiveness of decoronation technique 261

Table 6. Quality assessment of case report

Study/Item Calasans Malmgren Malmgren
Number Mahak-unakorn Tsukiboshi Lin Maia Sapir Diaz Cohenca (15, 16) Filippi (17, 18) Malmgren (11)
1 √ √ X X X √ √ X X X X
2 X X √ X X X X √ X X √
3a √ √ √ √ √ √ √ √ √ √ √
3b √ √ √ √ √ √ √ √ √ √ √
3c √ √ √ √ √ √ √ √ √ √ √
3d √ √ √ √ √ √ √ √ √ √ √
4 √ √ √ √ √ √ √ √ √ √ √
5a √ √ √ √ √ √ √ √ √ √ √
5b √ √ √ √ √ √ √ √ √ √ √
5c √ √ X √ √ √ √ √ √ √ √
5d √ √ X √ √ √ √ √ √ √ √
6 √ √ √ √ √ √ √ √ √ √ √
7 √ √ √ √ √ √ √ √ √ √ √
8a √ √ √ √ √ √ √ √ √ √ √
8b X X X X X X X X X X X
8c √ √ √ √ √ √ √ √ √ √ √
8d √ √ √ √ √ √ √ √ √ √ √
9a √ √ √ √ √ √ √ √ √ √ √
9b √ √ √ √ √ √ √ √ √ √ √
9c √ √ √ √ √ √ √ √ √ √ √
10a √ √ √ √ √ √ √ √ √ √ √
10b √ √ √ √ √ √ √ √ √ √ √
10c √ √ X √ √ √ √ √ √ √ √
10d √ √ √ √ √ √ √ √ √ √ √
11a X √ √ √ √ √ √ √ √ √ √
11b √ √ √ √ √ √ √ √ √ √ √
11c √ √ √ √ √ √ √ √ √ √ √
11d X √ √ √ √ √ √ √ √ √ √
12 X X X X X X X X X X X
13 X X X X X X X X X X X
Score Moderate High Moderate Moderate High High High High High High High

seven studies (11, 13–19, 24, 25) in which complete root

resorption was reported after an average of 1–10 years
of follow up. In those cases where root remnants were
still present at the time of implant placement, the case
was managed by drilling root dentine and placing the
implant in contact with tooth root and bone. Arguably
enough, Szmukler-Moncler S et al. (34) showed success
of implants placed in those affected areas, even when
remnant root material was in contact with the implant.
Overall success rate
In all the studies analyzed in this review, no implant
failures in augmented sites were reported. Complica-
tions occurring either during or after decoronation,
was reported as being non-existent, hence confirming
its success rate. Not to be ignored is the patient’s per-
ception of treatment, which unfortunately, has been
underemphasized by all studies.

Strength and limitation

Table 7. Newcastle – Ottawa quality assessment scale
Item
Representativeness of the exposed cohort
Selection of the non-exposed cohort
Ascertainment of exposure
Demonstration that outcome of interest was not
present at start of study
Comparability of cohorts on the basis of the design
or analysis (2 stars allowed)
Ascertainment of outcome (1 star allowed)
Was follow-up long enough for outcomes to occur
Adequacy of follow up of cohorts
Overall quality rating
*A maximum of 1 star for each item within selection and exposure/outcome
categories
**Maximum of 2 stars for comparability.
Ideally, studies included for a systematic review should
be based on reporting of high-level evidence (RCT,
Malmgren 2015 prospective case studies). Questionable as it may seem
* to be, to fulfill the objectives of our study, data were
* extracted mostly from case series/reports. On one hand,
* it is logical to assume that such type of data sources
* can be prone to bias (low level evidence in evidence
pyramid) (35) and therefore should be omitted from
** systematic review. On the other hand, rejecting such
huge amount of literature under the claim of being of
*
* poor quality evidence is equally un-founded, especially
* in cases where controlled trials are unavailable (36).
High quality Until recently, the strongest level of evidence about
decoronation technique has been presented as a retro-
spective cohort study. In support of the definite lack of
well-controlled trials (Level I, II evidence), it should be
remembered that dental ankylosis in human subjects is

© 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd

262 Mohadeb et al.
of rare occurrence. Moreover, due to the inherent nat-
ure of the study field (intervention type), conducting
controlled trials would encroach on the intention to
treat basis, thus would be unethical in human subjects.
Therefore, in this aspect, it appears that cohort studies
are valid alternatives to randomized clinical trial.
Conclusion
In summary, the following points were highlighted in
this review article:
• While decoronation can effectively preserve ridge
height around ankylosed teeth, its success in main-
taining ridge width is slightly compromised. A slight
reduction in ridge width (1.67 mm) following deco-
ronation is inevitable.
• For patients who have surpassed the pubertal
growth peak (which is individual and is earlier in
girls), decoronation can do little to correct the per-
sistent alveolar ridge deformity and tooth infra-
position. Since in those age groups, rate of infra-
position, alveolar ridge deformity or tilting of
adjacent teeth is already well-established, decorona-
tion can only preserve remaining bone.
• Decoronation does not exclude possibilities of addi-
tional grafts at the time of implant placement
• Following decoronation, fixed or removable appli-
ances used as temporary restorations should be regu-
larly checked so as to eliminate dental interferences.
•
Rate of replacement of root substance by bone
deposition, differed across studies. Even after 1–
10 years following decoronation, some studies
reported incomplete root resorption at the time of
implant placement. However, insertion of implants
in contact to root substance did not hamper success
of treatment.
• In the overall scheme, decoronation technique to treat
ankylosed teeth is associated with a favorable progno-
sis. None of the studies reported any adverse events.
Acknowledgement
Authors deny any conflict of interests related to this
study.
The authors wish to thank Mr Mohadeb Praveen
Shivchandra from Southern Medical University,
Guangzhou, China, for his assistance in this work.
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