modern treatment for congenitally missing teeth : a multidisciplinary approach

INTERNATIONAL JOURNAL OF MAXILLOFACIAL RESEARCH VOLUME 1 ISSUE 2 2015

179

Modern Treatment for Congenitally

Missing Teeth : A Multidisciplinary

Approach

Muhamad Abu-Hussein1, Nezar Watted2, Azzaldeen Abdulgani3, Péter Borbély4

The maxillary lateral incisor is the second most common congenitally absent tooth. There are

several treatment options for replacing the missing maxillary lateral incisor, including canine

substitution, tooth-supported restoration, or single-tooth implant. Dental implants are an

appropriate treatment option for replacing missing maxillary lateral incisor teeth in

adolescents when their dental and skeletal development is complete. This case report presents

the treatment of a patient with congenitally missing maxillary lateral incisors using dental

implants. Finally, the importance of interdisciplinary team treatment planning is emphasized

as a requirement for achieving optimal final esthetics.

KEY WORDS: congenitally missing lateral incisors; orthodontic space opening,

hypodontia, treatment options.

INTRODUCTION

The lateral incisor is the most common

congenitally missing permanent tooth in

the maxillary anterior region with the

prevalence of 1 to 3%. This has been

associated with their anatomical position

in the fusion area of facial process.1

However, when maxillary lateral incisors

are missing, individuals are confronted

with functional problems and poor smile

esthetics at a young age.1, 2 The

management of maxillary lateral incisor

agenesis has gained of multiple dental

specialties (orthodontics, periodontics, oral

surgery, prosthodontics…).1

Congenitally missing maxillary permanent

lateral incisors often lead to an unattractive

appearance and difficulty in treatment

planning. Age, location, space limitations,

alveolar ridge deficiencies, uneven

gingival margins, occlusion, and

periodontal factors often necessitate an

interdisciplinary approach. 3,4

Several studies have shown that MSX1

and PAX9 genes play a role in early teeth

development. PAX 9 is a paired domain

transcription factor that plays a critical role

in odontogenesis. All identified mutations

of PAX 9 and MX1 have been associated

with nonsyndromic form of teeth agenesis.

O

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R

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1,2 Hypodontia creates significant

challenges to the clinicians in both

diagnosis and management.

Comprehensive management often

requires a multidisciplinary approach.

There are different treatment alternatives

for patients with a missing lateral incisor

because of congenital reasons 1-8. Esthetic

and functional problems can arise when an

orthodontic space closure is realized and

the canine is moved into the missing

lateral incisor’s space. 2-9

The two major alternative treatment

options are orthodontic space closure or

space opening for prosthetic replacements.

But they both can compromise aesthetics,

periodontal health and function. Treatment

alternatives for restoring edentulous spaces

resulting from congenitally missing

permanent lateral incisors include

removable partial dentures, conventional

fixed bridges, resin-bonded bridges,

autotransplantation, orthodontic

repositioning of canines to close the

edentulous space and single-tooth

implant.5

The first step to the successful, long-term

management of a congenitally missing

lateral incisor case is early detection and

referral to the orthodontist. The role of the

orthodontist in the early mixed-dentition

stage of development is to monitor and

guide the eruption of the permanent

canine. If the crown of the permanent

canine is erupting apical to the primary

canine root as it normally does, it may be

necessary to selectively extract the primary

lateral incisor to encourage the permanent

canine to erupt adjacent to the central

incisor. The reason for this is twofold. A

mesially positioned canine not only

provides a natural means for augmenting

the supporting tissues, but it also allows

for greater flexibility in future treatment

planning.6,7,8

The single-tooth implant has become the

most popular treatment alternative for the

replacement of missing teeth. Various

studies have shown the successful

osseointegration and long-term function of

restorations supported by single-tooth

implants. In addition to the high success

rates, one main benefit of this type of

restoration is that it leaves the adjacent

teeth untouched. This is particularly

important in young patients and unrestored

dentitions. It is true that implant-supported

restorations are not without potential

problems. These problems range from

mechanical complications to biologic

changes thatcan impact their long-term

predictability.9,10 However, if the proper


181

surgical and restorative protocols are

followed, potential complications or

esthetic compromises are minimal. To

achieve a stable esthetic and healthy

outcome with dental implants, it is

beneficial to understand their effects on the

surrounding hard and soft tissues.10,11

An interdisciplinary approach is necessary

to provide the most predictable treatment

results when single-tooth implants are

inserted to replace congenitally missing

lateral incisors. Osseintegration enables

long-term stability of a prosthesis

supported by a single-tooth implant.11,12 In

the past, however, neither approach

produced results that were entirely

satisfactory from an esthetic and functional

standpoint. Selecting the appropriate

treatment option depends on the

malocclusion, anterior relationship,

specific space requirements and condition

of the adjacent teeth. The ideal treatment is

the most conservative option that satisfies

individual esthetics and functional

requirements.13

The aim of this case report is to provide a

conservative multi-disciplinary approach

for the management of bilaterally missing

maxillary permanent lateral incisors.

CASE REPORT

A 17-year-old female patient reported to

my private clinic with the chief complaint

of spacing in the upper anterior region.

Angle's Class I molar relationship on both

sides and End on canine relationship on

both sides with an overbite of 3mm and

overjet of 3mm. Spacing in the maxillary

anterior region was attributed to the

absence of upper lateral insiors, with a

mild tongue thrust habit.

Panoramic radiograph examination reveals

no developmental disturbances except

congenitally missing maxillary lateral

incisors bilaterally. Cephalometric findings

report an orthognathic maxilla and

mandible; with mildly proclined upper and

lower incisors.

TREATMENT OBJECTIVES

1. To create optimal spaces for the

restoration of the missing lateral incisors.

2. To achieve class I canine relation

bilaterally and a canine-guided occlusion.

3. To replace the missing lateral incisors

with implant supported prosthesis.

4. To maintain the class I molar relation on

both sides.

5. Obtain a pleasing esthetic facial profile

TREATMENT PLAN

Treatment plan is divided in to two phases.

A) Orthodontic phase

B) Prosthodontic phase


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A. Orthodontic Phase:

Fig.1. Diastema closure

Fig.2. Space management for 12, 22 using

acrylic teeth

Fig.3a Preoperative orthopentamogram

Fig. 3b. Preoperative intra oral periapical

radiographs

The aim of the orthodontic phase is to

open the space by distalizing the canines

and closing the midline diastema. The

option of space closure by mesialising

canine was not preferred due to a

presenting Class I molar relationship with

well interdigitated posterior occlusion, and

also because recontouring of the canine

morphology to that of a lateral incisor

would be rather aggressive, which in turn

would necessitate the need for intentional

root canal treatment of sound natural teeth.

Orthodontic treatment was started with a

0.022” MBT Pre-adjusted Edgewise

appliance with upper fixed tongue crib.

The sequence of arch wires started initial

with 0.016” martensitic Nickel Titanium

arch wires which were sequentially

followed by 0.018” Stainless Steel, 0.016 x

0.022” Stainless Steel, 0.017x 0.025”

Stainless Steel and 0.019 x 0.025”

Stainless Steel arch wires. Upon leveling

with a 0.019 x 0.025” Stainless Steel arch

wire the maxillary canines were retracted

on both sides by Bennett's method of

canine retraction. Sufficient space was

gained for replacement of lateral incisors

by distalizing the cuspids to a Class I

relation and also by closing the mid line

space. Pre-prosthetic orthodontic treatment

period lasted for 18 months. After

retraction radiographs were taken to assess


183

the bone level and root parallelism for the

implant placement. After final finishing

and detailing of the occlusion the fixed

appliance were debonded and upper and

lower Essix retainers were placed.

B. Prosthodontic Phase:

On radiographic examination, the height

and width of the bone were 15 mm, 4.1

mm on right and 15 mm, 4 mm on the left

side respectively and . The thickness of

the soft tissue was approximately 2 mm all

over. Diagnostic wax-up was done. A stent

was made in clear acrylic resin.

At the time of surgery, depression was

seen on the labial aspect of left maxillary

lateral incisor as expected. The osteotomy

site was made and further enlarged to a

diameter 3.8 mm and length 15 mm.

Implant of diameter 3.8 mm and 13 mm

length was placed. Autogenous bone

particles collected in the osteotomy drills

were mixed with patient's blood and saline

and placed in the area of fenestration.

Progide resorbable barrier membrane of

approximately the size of the defect was

tucked in over the bone graft . Implant of

the same size was placed on the other side

as well . Archwire was placed back

immediately. Previously used acrylic

lateral incisor teeth were hollowed on the

palatal aspect. On suture removal, they

were bonded with archwire with no contact

to the ridge to occupy and maintain the

space created orthodontically .

Fig.4. Fenestration on the labial aspect of

22

Fig.5. Placement of implant with 22

Fig. 6. Placement of bone graft and barrier

membrane

http://www.jdionline.org/viewimage.asp?img=JDentImplant_2015_5_1_64_154446_f6.jpg


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Fig.7. Postoperative orthopentamogram

At the time of second stage surgery, an

implant level impression was made using

impression material for fabrication of the

provisional restorations. Provisional

restorations were contoured using

composite resin on 3.8 mm diameter

provisional abutments (Biotemp, Myriad

Equinox) in such a way that the contact

area was 5 mm above the crestal bone and

no occlusal contact.

Fig. 8. Postoperative healing and

provisionalization with acylic teeth bonded

to arch wire

Fig.9. Soft tissue profile and

interproximal papillae prior to final

restoration

After 1-month, growth of the interproximal

papillae with a well-formed gingival cuff

was seen around both the implants .

Implant level final impression was made

with impression material. Final

restorations were fabricated . Patient was

satisfied with the final outcome of the

treatment . Fig.10a-b

Fig. 10a. Final restoration


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Fig. 10.b. Postrestoration radiograph

DISCUSSION

However orthodontic space closure

procedure has been reported as

encouraging for periodontal health

preservation compared with prosthetic

replacements, the presence of undesirable

buccal corridors may be a drawback for

smile esthetics, as well as the inherent size,

shape, and shade of canines if

orthodontically moved.1, 4 In the opposite,

the choice of orthodontic space opening

facilitates the maintenance of the canines

of their natural position within the dental

arch having the ideal intercuspation

through first premolars, and provision of

canine-protected occlusion.1 However, a

prosthetic restoration should replace the

missing lateral.

The term “team approach” has been used

throughout the health care industry, and as

technologies continue to advance, this term

has evolved from simply referring a patient

back and forth to detailed treatment

planning and case selection. In this case

report, the restorative dentist presence and

participation at stage I surgery was a

valuable asset to achieving the ideal

esthetic and functional result for this

patient. Patients with congenitally missing

maxillary lateral incisors may seek

orthodontic therapy as part of a restorative

plan.

Since Branemark et al. [34] introduced the

possi-bility of direct alveolar anchorage

for the replacement of missing teeth,

ossteointegrated implants have been used

successfully in dentistry for more than 30

years. Implants are predictable and

successful means of replacing missing

teeth by supporting crowns, bridges,

overdentures and other maxillofacial

prostheses. In longitudinal studies,

conventional implant treatment has a

success rate of 91 to 99% in the mandible

and 84 to 92% in the maxilla 3,4. Patients

with congenitally missing teeth usually

present in childhood, but implant

placement usually has to be postponed

until the completion of skeletal growth.

While the orthodontist is responsible for

satisfactory mesiodistal and parallel space-

opening, the implantologist must create a

favorable thick vestibulopalatal hard- and

soft-tissue framework which may require

not only bone, but also connective tissue

grafting. If these tasks are carefully

performed, we will very likely find a much

higher percentage of successful long-term

outcomes of implant-born restorations for

congenitally missing laterals in the future

orthodontic literature.

TIME OF IMPLANT PLACEMENT


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Generally, implants must not be placed

until the patients have completed their

facial growth and the majority of their

tooth eruption As the face grows and the

mandibular rami lengthen, teeth must erupt

to remain in occlusion. However, the

implant behaves like an ankylosed tooth

and will not follow the changes of the

alveolar processes due to the eruption of

adjacent teeth.

Williams et al. showed a relatively high

risk of debonding. Finally, treatment with

the single implants – a frequently

described method of one-tooth

replacement should be mentioned 18.Many

investigations showed that more than

90%of the patients are satisfied with the

effects of implant supported single tooth

restoration in the aesthetic zone19,20.

Nonetheless, the longterm observations

proved many negative alterations. The

periodontal problems such as marginal

bone loss around the adjacent teeth,

connected with a larger loss and reduction

of the distance between the implant and

the tooth were mentioned in contemporary

literature 20.

A Swedish article regarding implant

insertion in the aesthetic zone showed

other unfavorable aspects: atrophy of the

distal papillas, increased frequency of

bleeding or mucositis when compared to

the contralateral natural teeth 20.

Iseri and Solow examined radiograms of

the patients aged 9–25 years and proved

continuous eruption of the natural teeth,

which allowed the conclusion that dental

implants should not be used in childhood,

adolescence or young adulthood. This

observation showed the need for

temporary reconstruction of the spaces

opened for the prosthodontic restorations

in the young patients. Some of the

disadvantages of single-tooth replacements

with the dental implants may be reduced

by proper orthodontic treatment with the

gaining of adequate space for the screws.

Also, the correct timing of implant

insertion after completed dental and

skeletal development may lead to an

improvement of the results. 21

.

Czochrowska et al. highlighted that canine

substitution is a valid therapeutic option,

giving satisfying aesthetics. Morphology,

width and color of the upper canines

serving as the “new lateral incisors”, are

the major factors influencing good

treatment effects. Brighter than normal and

rather small canines are favorable in

achieving an attractive smile after closure

of the spaces 22. The substituted canines

often need recontouring. Thordarson et al.


187

showed that this procedure is safe and

painless to the patient.23,4

The choice of an ideal orthodontic

treatment for young patients with missing

permanent teeth should be based on a

careful evaluation of all factors involved in

diagnosis, as well as on the characteristics

of each patient.12 In this clinical case

report, we considered individual

characteristics and needs and chose a

multidisciplinary approach to ensure that

the wanted esthetic and functional

objectives were achieved.

CONCLUSIONS

Orthodontic space closure and implant

substitution of missing maxillary incisors

produced similar satisfactory esthetic

results. Neither of the treatments impaired

temporomandibular joint function.

However, orthodontic space closure

patients had better periodontal health in

comparison with implant substitution

patients. Furthermore, infraocclusion more

than 1 mm was noticed in all the implant

patients.

It is important that the orthodontist

together with the other specialists frame a

treatment objectives which are realistic

and meet the needs of the patient. Constant

interaction and communication among the

team members and the patient at all level

of treatment are the keys to the success of

the interdisciplinary treatment.

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1. Muhamad Abu-Hussein*

Center for Dentistry research and Aesthetics,

Jatt/Israel

2. Nezar Watted

Center for Dentistry research and Aesthetics,

Jatt/Israel

3. Viktória Hegedűs

Department of Pediatric Dentistry and Orthodontics,

University of Debrecen,

Debrecen,

Hungary

4. Borbély Péter

Fogszabályozási Stúdió,

Budapest,

Hungary

5. Abdulgani Azzaldeen

Department of Conservative Dentistry,

Al-Quds University,

Jerusalem,

Palestine

*Corresponding Author

Address:

Abu-Hussein Muhamad

DDS,MSCD,MSC,PEDO CERT.,FICD

123 Argus Street

10441 Athens

Greece

[email protected]

mailto:[email protected]

modern treatment for congenitally missing teeth : a multidisciplinary approach

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