MANAGEMENT OF A PATIENT WITHCONGENITALLY MISSING LATERAL INCISOR:

a multidisciplinary team approachTÍTULO

Tratamento de um paciente com ausência congênita de um incisivo lateral:uma abordagem multidisciplinar

Bosco Thomas[a], Robin Mathai Joseph[b], Amar A. Sholapurkar[c]

[a]BDS, MDS, Senior Lecturer, Department of Orthodontics, People’s College of Dental Sciences, Bhopal. Madhya Pradesh, India[b]BDS, MDS, Senior Lecturer, Department of Prosthodontics, People´s College of Dental Sciences, Bhopal Madhya Pradesh, India[c]BDS, MDS, FAGE. Assistant Professor, Department of Oral Medicine and Radiology, Manipal College of Dental Sciences,

Manipal, Karnataka, India, e-mail: dr.amar1979@yahoo.co.in

Abstract

OBJECTIVE: The present paper highlights a case where the patients presented with spacing in theupper anterior region due to missing right lateral and peg shaped left lateral incisor. METHOD ANDRESULTS: The initial treatment was standard edgewise fixed orthodontic appliance to distalize thecanine, correct the bite and create space for the lateral incisors and correct the midline. CONCLUSION:After the active phase of fixed orthodontic treatment, an implant was placed and the peg shapedlateral incisor was built up with composite.

Keywords: Congenitally missing teeth. Orthodontics. Prothesis. Dental implant. Multidisciplinary team approach.

Resumo

OBJETIVOS: O presente artigo refere-se a um caso em que o paciente apresentava espaços naregião anterior da maxila devido à ausência de incisivo lateral direito e incisivo lateral esquerdocom coroa deformada. MÉTODO E RESULTADO: O tratamento inicial foi ortodontia fixa(edgewise) para distalizar o canino, corrigir a mordida e criar espaço para o incisivo lateral ecorrigir a linha média. CONCLUSÃO: Após a fase ativa da ortodontia, utilizou-se um implanteadequado na região do lateral direito e reconstruiu-se a coroa deformada do incisivo lateralesquerdo com compósito.

Palavras-chave: Ausência congênita de dente. Ortodontia. Prótese. Implante. Abordagem multidisciplinar.

ISSN 1807-5274Rev. Clín. Pesq. Odontol., Curitiba, v. 5, n. 3, p. 293-299, set./dez. 2009

Licenciado sob uma Licença Creative Commons

Rev Clín Pesq Odontol. 2009 set/dez;5(3):293-299

294 Bosco Thomas, Robin MJ, Sholapurkar AA.

Rev Clín Pesq Odontol. 2009 set/dez;5(3):293-299

INTRODUCTION

Permanent lateral incisors are the thirdmost common missing tooth in the mouth afterupper and lower second premolars (1). It is morecommon bilaterally and has a slightly higherfemale predilection. The prevalence ofcongenitally missing lateral incisors is between 1and 2 percent (1, 2). Congenitally missingmaxillary permanent lateral incisors often lead toan unattractive appearance and difficulty intreatment planning. Many factors must beconsidered before a decision is made both toclose spaces and modify the canines, or toredistribute the spaces and replace the missingteeth with prosthesis. Good communicationamong patients, dental specialists, and generalpractitioners is necessary (1).

When a maxillary lateral incisor ismissing, often the treatment options can be clearlydefined, that is, substitute an adjacent tooth forthe missing one; open the space for an implant, abonded bridge or fixed bridge. Three treatmentoptions exist for the replacement of congenitallymissing lateral incisors. They include caninesubstitution, a tooth-supported restoration, anda single-tooth implant. Selecting the appropriatetreatment option depends on the malocclusion,anterior relationship, specific space requirements,and condition of the adjacent teeth. The idealtreatment is the most conservative option thatsatisfies individual esthetics and functionalrequirements. Today, the single-tooth implanthas become one of the most common treatmentalternatives for the replacement of missing teeth(2). There must be coordination among therestorative dentist , the oral surgeon orimplantologist and the orthodontist to obtain theoptimum result (3).

CASE REPORT

A 22 year old male patient came to theorthodontic department of Manipal College ofDental Sciences, Manipal, India, with a chiefcomplaint of spacing in the upper front region(Figure 1).

On examination the following findingswere observed: maxillary anterior spacing withcongenitally missing right lateral incisor; pegshaped left lateral incisor; midline diastema of2mm. Shift in the dental midline to the right ofthe facial midline by 2mm (Figure 2).

FIGURE 1 - Extraoral Frontal view showing spacing inthe upper front region

FIGURE 2 - Pretreatment photograph of the patientshowing Maxillary anterior spacing withcongenitally missing right lateral incisor,Peg shaped left lateral incisor, Midlinediastema of 2mm, Shift in the dental midlineto the right of the facial midline by 2mm

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The maxillary right canine had driftedmesially and was in an end-on relation with itsmandibular counterpart and the molar relationwas Class I (Figure 3).

active phase of orthodontic treatment took 11months. This was followed by a stabilization phasewith 0.019 x 0.025 rectangular wires (Figure 4).

Hence the aim of the treatment was toorthodontically open up space for the missing lateralincisor by bringing the upper right canine into classI relation and correcting the dental midline bymoving the central incisors. Secondly, prostheticreplacement of the missing right lateral incisor withoral root formed implants and finally aestheticrestoration of the peg shaped lateral incisor. Themultidisciplinary team included the role of anorthodontist, oral implantologist and prosthodontist.

Phase I - Orthodontic treatment

Fixed orthodontic treatment was initiatedwith standard edgewise appliance 0.022 X 0.028brackets (Dentauram TM). Leveling and alignmentwere achieved using sequential 0.016, 0.018 curve ofSpee round stainless steel wires in the upper archover a period of 3months. The distalization of canineinto Class I relation was done using a 0.019 X 0.025stainless steel rectangular wire with open coil NiTispring. Cervical pull head gear was used as an extraoral anchorage. Further space for the maxillary rightlateral incisor was created by moving the maxillaryincisors 2mm to the left. Doing so an 8mm space wasachieved for the missing lateral incisor and the uppermidline was simultaneously corrected. The total

FIGURE 3 - Drift in the maxillary right canine and anend-on relation with its mandibularcounterpart and Class I molar relation

Phase II - Implant placement

A preoperative orthopantomograph wastaken to ascertain the height of the availablebone for implant placement (Figure 5).

FIGURE 4 - Figure showing use of .019x0.025 stainlesssteel rectangular wire for canine distalization

Primary impressions were made fordiagnostic casts and fabrication of vacuum formedsurgical guide template using BiostarTM, for whichthe missing lateral was replaced with an acrylictooth and the template made over it (Figure 8).

Ridge mapping (Figure 6) was done toascertain bone width and was found to be adequateto accommodate a 3.8mm wide, 13 mm lengthFrialit 2TM hydroxyappatite coated implant fixture.

FIGURE 5 - A preoperative orthopantomograph takento ascertain the height of the availablebone for implant placement

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A mucoperiosteal flap was raised in the12 region and initial bone preparation done usinga pilot drill (Figure 7) with the surgical templateas guide for proper angulations.

After implant placement a cap screwwas put into place and the flap sutured back.(Figures 8, 9, 10).

FIGURE 6 - Figure showing Ridge mapping done toascertain bone width

FIGURE 7 - Figure showing initial bone preparationdone using a pilot drill with the surgicaltemplate as guide for proper angulations

FIGURE 8 - Figure showing diagnostic casts andfabrication of vacuum formed surgical guidetemplate using BiostarTM, for which themissing lateral was replaced with an acrylictooth and the template made over it

FIGURE 9 - Figure showing Frialit 2TM hydroxyappatitecoated implant fixture in place

FIGURE 10 - Cap screw in place after implant placement

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After 6 months the 2nd stage surgery wasdone using a tissue punch biopsy cutter so as tominimize bleeding and proper healing (i.e. flaplesstechnique) with healing abutment or gingivalformer in place (Figures 11, 12, 13).

The final impressions were made afterthe healing abutments were removed usingpolyether (Impregum TM) for laboratory fabricationof final restoration (Figure 14).

FIGURE 11 - Figure showing 2nd stage surgery doneusing a tissue punch biopsy cutter so asto minimize bleeding and proper healing

FIGURE 12 - Figure showing healing abutment in place

FIGURE 13 - Figure showing abutment in place

periodically radiographs were used totrack implant position and osseointegration(Figure 15).

Phase III - Prosthodontic treatment

After selection of a suitable abutment,the implant fixture was restored with porcelainfused to metal crown. The contra lateral pegshaped lateral was restored using composites ofappropriate shade (Figure 16).

FIGURE 14 - Figure showing final impression with labanalog

FIGURE 15 - Figure showing post-operative OPG

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DISCUSSION AND CONCLUSION

Missing lateral incisor leads to an obviousasymmetry in the patients smile, shift in the dentalmidline. In addition the peg shaped lateral incisorfurther adds to the unsightliness of the smile. Thereseems to be an association between hypodontia andmalformation of the maxillary laterals which may bereduced in size or simplified in shape, often becomingpeg-shaped. It may even provoke an unfavorableresponse from others in society. The canine candrift mesially into an end-on or Class II relationwhich is functionally undesirable.

The early loss of permanent teeth followingtrauma or congenital aplasia and agenesia need tobe corrected by orthodontic or prosthetic means,sometimes combined with implant therapy.Preprosthetic orthodontic measures (4) are often anintegral part of comprehensive oral rehabilitation.The individual aspects of treatment are aimed atoptimizing dentofacial esthetics and at improvingmasticatory function and hygiene potential ofprosthetic restorations. The orthodontic solutionresults usually in different anatomic, functional,and esthetic problems. Prosthetic and implantprocedures are very demanding and require long-term maintenance (4).

Absence of the maxillary lateral incisor

creates an aesthetic problem which can be managedin various ways. The condition requires carefultreatment planning and a consideration of the optionsand outcomes following either space closure orprosthetic replacement. Recent developments inrestorative dentistry have warranted a re-evaluationof the approach to this clinical situation. Factorsrelating both to the patient and to the teeth, includingthe presenting malocclusion and the effect on theocclusion, are considered (5).

Implants are commonly used to replacecongenitally missing lateral incisors in adolescentorthodontic patients. However, these restorationsare often challenging for the orthodontist, surgeon,and restorative dentist. In some patients the spaceacross the alveolar crest is too narrow to permitthe surgeon to place the implant. Occasionally theroot apices of the adjacent central incisor andcanine are in close proximity. In other cases theridge thickness could be inadequate and requireaugmentation. When the orthodontist opens thespace, the papilla heights are adversely affected.Some adolescent patients have altered passiveeruption after orthodontic treatment, which affectsthe level of the gingival margins.

Finally, questions commonly arise regardingthe appropriate age for implant placement in theseyoung patients. If not addressed, these issues couldcompromise the aesthetics of the implant restoration(6). From an aesthetic and functional point of viewsuch patients need a combination of orthodontic,prosthetic and restorative care.

In this case, the use of a simple vacuumformed surgical guide template was found to be verycost effective and accurate for the implant placement.

Congenitally missing lateral incisorpresents challenging treatment planning for thedentist as they are usually associated with othermalocclusions and abnormalities. Selecting theappropriate treatment option depends on themalocclusion, the anterior relationship, specificspace requirements and the conditions of theadjacent teeth. In order to obtain the best aestheticand functional result, a multidisciplinary teamapproach involving the orthodontist ,implantologist and prosthodontist is required.

FIGURE 16 - Figure showing restorations and finalaspect anterior region of the maxilla

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REFERENCES

1. Chu CS, Cheung SL, Smales RJ. Managementof congenitally missing maxillary lateralincisors. Gen Dent. 1998;46(3):268-74.

2. Kinzer GA, Kokich VO Jr. Managingcongenitally missing lateral incisors. Part III:single-tooth implants J Esthet Restor Dent.2005;17(4):202-10.

3. Tichler HM, Abraham JE. Management of acongenitally missing maxillary central incisor.A case study. NY State Dent J. 2007;73(2):20-2.

4. Vitályos G, Török J, Hegedus C The role ofpreprosthetic orthodontics in the interdisci-plinary management of congenitally missingmaxillary lateral incisors: case report. FogorvSz. 2005;98(6):223-8.

5. Millar BJ, Taylor NG. Lateral thinking: themanagement of missing upper lateral incisors.Br Dent J. 1995;179(3):99-106.

6. Kokich VG. Maxil lary lateral incisorimplants: planning with the aid ofor thodontics. J Oral Maxil lofac Surg.2004;62(9 Suppl 2):48-56.

Received: 01/15/2009Recebido: 15/01/2009

Accepted: 03/11/2009Aceito: 11/03/2009

Reviewed: 26/11/2009Revisado: 11/26/2009

Management of a patient with congenitally missing lateral incisor

Rev Clín Pesq Odontol. 2009 set/dez;5(3):293-299