Latest orthodontic scientific evidence Esthetics · 14.03.2017 1 for congenitally missing maxillary lateral incisors: Space closure vs implant-borne crowns Ute Schneider-Moser, Italy

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for congenitally missing maxillary lateral incisors:

Space closure vs implant-borne crowns

Ute Schneider-Moser, Italy

With utmost appreciation and gratitude

dedicated to Dr. R. Vanasdall and Dr. D. Musich

Latest orthodontic scientific evidence…

De-Marchi LM et al. J Prosthet Dent 2014

Quadri 2 et al. J of Orthodontics 2016

No difference

OSC results are esthetic,if recontouring and bleaching is performed

Esthetics

Rosa M et al. Prog Orthod 2013

OSC preferred

AJODO Video of the monthSeptember 2016

2015

2005

photographs taken from Armbruster P.C., Gardiner D.M. et al World J Orthod 6, 2005

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Two-way ANOVA and Tukey post-hoc test

*p<0.05; **p<0.01; ***p<0.001; ****p<0.0001.

Clinically significant esthetic improvements for implant-borne crowns

were perceived by all 3 respondent groups

Andrade DC et al. Orthod Craniofac Res 2013;16:129-36.

I. Treatment for agenesis of maxillary lateral incisors: a systematic review evaluation all studies on the topic between 1965 and 2011

II. Prosthodontic replacement vs space closure for maxillary lateral incisor agenesis: a systematic review of all studies from 1975-2015

Santos Silveira G et al. Am J Orthod Dentofyc Orthop 2016; 150:228-37.

III. Treatment options for congenitally missing lateral incisors:a systematic review of all studies on the topic between 1975 and 2015

Kiliaridis S et al. Eur J Oral Implantology 2016;9(Suppl):S5-24.

Any new systematic reviews ?

Kiliaridis S et al. Eur J Oral Implantology 2016;9(Suppl):S5-24.

Up to date only 5 studies

directly comparing

the two therapeutic options

No implants

No implants

Very small sample size (7 OSC vs 4 implants)

“It is not possible to assert at this point in time that one treatment

approach is more advantageous than the other.”

III. A systematic review of all studies on the topic from 1975- 2015

Kiliaridis S et al. Eur J Oral Implantology 2016;9(Suppl):S5-24.

The absence of randomised controlled trials and the limited number of

prospective and retrospective studies comparing the two different therapeutic

options make it difficult to draw definitive conclusions about the superiority of one

treatment option over the other, regarding the biological, functional and

aesthetic outcomes.

III. Treatment options for congenitally missing lateral incisors.

A systematic review of all studies on the topic from 1975- 2015

According to this systematic review,

both therapeutic options are acceptable.

Latest orthodontic scientific evidence

is inconclusive

Scientific perio-implanto-prosthodontic evidence…

is there anything new?

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„Overall healthy and stable peri-implant tissue conditions,

a paramount criterion when it comes to esthetic implant crowns,

were consistently encountered and maintained longitudinally.“

Belser UC, Schmid B, Higginbottom F, Buser D. Outcome analysis of implant restorations located in the anterior maxilla: a review of the recent

literature. Int J Oral Maxillofac Implants 2004;19(Suppl): 30–42.

Chen ST, Buser D. Esthetic outcomes following immediate and early implant placement in the anterior maxilla – a systematic review.

Int J Oral Maxillofac Implants 2014;29(Suppl):186-215.

Giannopoulou C, Bernard JP, Buser D, Carrel A, Belser UC. Effect of intracrevicular restoration margins on peri-implant health: clinical, biochemical, and microbiologic findings around esthetic implants up to 9 years. Int J Oral Maxillofac Surg 2003;18(2):173-81

I.

„Contour augmentation with GBR was able to establish

and to maintain a facial bone wall in 95% of patients.“

Buser D, Chappuis V, Bornstein MM, Wittneben JG, Frei M, Belser UC. Long-term stability of contour augmentation with early implant placement following

single tooth extraction in the esthetic zone: a prospective, cross-sectional study in 41 patients with a 5- to 9-year follow-up. J Periodontol 2013;84:1517-27.

Jensen SS, Bosshardt DD, Gruber R., Buser D. Long-term stability of contour augmentation in the esthetic zone: histologic and histomorphometric evaluation

of 12 human biopsies 14 to 80 months after augmentation. J Periodontol 2014; 85(11):1549-56.

Weigl P, Strangio A. The impact of immediately placed and restored single-tooth implants on hard and soft tissues in the anterior maxilla.

Eur J Oral Implantol 2016;9 Suppl 1(2):89-10.

Buser D, Bornstein MM, Weber HP, Grütter L, Schmid B, Belser UC. Early implant placement with simultaneous guided bone regeneration following single-

tooth extraction in the esthetic zone: A crossectional, retrospective study in 45 subjects with a 2- to 4-year follow-up J Periodont 2008; 79(9):1773-81.

II.

0,6-0,8mm of mean facial bone wall thickness

only in 10% a thick facial wall is present

GBR is nearly always mandatory in the esthetic zone

Anterior maxilla

Januario AL. et al. Clin Oral Implants Res 22, 2011

Vera C. et al. Int J Oral Maxillofac Implants 27, 2012

Huynh-Ba G. et al. Clin Oral Implants Res 21, 2010

Braut V.. et al. Int J Periodont Rest Dent 31, 2011

Ridge-volume deficiency increased 14 fold over 5.6 yrs 0.3mm² (T1), 1.9mm² (T2), 3.8mm² (T3)

Orthodontic site development is often insufficient

Beyer A. et al Angle Orthodontist 77/3, 2007

Ridge width decreased 13-15%, height decreased 6-12%, 2-fold increase of labial concavityUribe F. et al Eur J Orthod 35:87-92, 2013

Alveolar bone width decreased 17% -25%, labial concavity increased 0.8-2.3 foldUribe F. et al Am J Orthod Dentofacial Orthop 144/6, 2013

GBR should be more frequently performed for implants substituting congenitally mssing U2s

Kan JY, Rungcharassaeng K, Morimoto T, Lozada J. Facial gingival tissue stability after connective tissue graft with single immediate tooth

replacement in the esthetic zone: consecutive case reports. J Oral Maxillofac Surg 2009;67(11 Suppl):40-48.

Si M-S., Zhuang L-F., Gu Y-X., Chou C-H., Lai H-C.: Papillae alterations around single-implant restorations in the anterior maxillae: thick versus thin

mucosa. Int J Oral Science, 4:94-100, 2012.

Bruno, V.; O’Sullivan, D.; Badino, M.; Catapano, S. Preserving soft tissue after placing implants in fresh extraction sockets in the maxillary esthetic zone

and a prosthetic template for interim crown fabrication: A prospective study. J Prosthet Dent 2014; 111:195–202.

Lee, C.; Tao, C.; Stoupel, J. The effect of subepithelial connective tissue graft placement on esthetic outcomes following immediate implant

placement: systematic review. J. Periodontol. 2016;87:, 156–167.

“While the implant papilla may be maintained or re-established

to the normal level with the thick biotype, it can seldom be

recreated with the thin biotype.”

III.

Kinsel R.P., Lamb R.E. Int J Oral Maxillofac Implants 2/6, 2005

The preservation or augmentation of the soft tissue prior to implant placement

is of paramount importance in order to

obtain optimal gingival contours surrounding the definitive restorations.

Kan J.Y.K., Rungcharassaeng K. et al, J Periodontol 74/4, 2003

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PERI-IMPLANT MOULDING 12 & GINGIVAL MOULDING 22

Perio-implanto-prosthodontics by Dr. G. Pellitteri, Italy

Same patient 5 years after delivery of the implant-borne crown 12 & crown 22

Implant-prosthodontics by Dr. Giuseppe Pellitteri, Bolzano

Orthodontic space closure including first premolar intrusion and canine

extrusion in patients with missing lateral incisors does not incur risks for

periodontal tissue deterioration or TMD in the long term (10 years)

NO IMPLANTS EVALUATED

2016

compared with patients with no missing teeth.

Aim of the study

I. to evaluate if the implementation of correct 3D implant placement (eventually with hard and/or

soft tissue contour augmentation) can establish and maintain excellent esthetic and periodontal

conditions after a functional period of at least 5 years in patients with congenitally

missing maxillary lateral incisors

II. to compare these results to the outcomes of orthodontic space closure with canine

substitution and recontouring after a similar posttreatment time, and

III. to assess patients’ satisfaction with the final treatment outcomes in both groups.

Material & Methods

32 consecutively treated patients between Aug 2006 – Oct 2011

uni- or bilateral agenesis of U2

> 5 years post-treatment

16 (13f, 3m) treated with OSC

16 (10f, 6m) treated with implant-borne crowns (20 implants)

10 with hard tissue graft – 8 DBBM, 2 autologous bone

3 with hard & soft tissue graft

2 with soft-tissue graft

same orthodontist & implantologist/prosthodontist

facial and palatal plaque index (PI) according to Quigley and Hein

probing depth (PD) at 4 sites (mesial, distal, midfacial, palatal)

dichotomous score for bleeding on probing (BP) within 15 seconds

0=no bleeding , 1=bleeding

any gingival marginal recession

gingival biotype according to the TRAN method proposed by De Rouck et al. measured on the facial aspect of the upper right central incisor.

Clinical assessments in both patient groups

De Rouck T, Eghbali R, Collys K, DeBruyn H, Cosyn J. The gingival biotype rev isited: transparency of the periodontal probe through the gingival margin as a method

to discriminate thin from thick gingiva. J Clin Periodontol 2009;36(5):428-433.

Quigley G A, Hein JW. Comparative cleansing of manual and power brushing. J Am Dent Assoc 1962. 65:26–29

Kornman KS, Loe H. The role of local factors in the etiology of periodontal diseases. Periodontol 2000 1993;2:83-97.

Joss A, Adler R, Lang NP. Bleeding on probing. A parameter for monitoring periodontal conditions in clinical practice. J Clin Periodontol 1994;6:402-8.

Lang NP, Adler R, Joss A, Nyman S. Absence of bleeding on probing—an indicator of periodontal stability. J Clin Periodontol 1990;17:714-21.

Miller PD Jr. A classification of marginal tissue recession. Int J Periodontics Restorative Dent 1985;5:8-13.

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Periapical radiographs at final crown delivery (T1) and at follow-up (T2)

Rx calibrated to actual implant size for evaluation of DIB (first bone-to-implant contact)

measured on the mesial & distal to calculate the change from baseline to follow-up. *

Radiograhic assessments in the Implant group

Weber HP, Buser D, Fiorellini JP, Williams RC. Radiographics evaluation of crestal bone levels adjacent to nonsubmerged titanium implants. Clin Oral Implants Res 1992;3:181-188.

Weber HP, Crohin CC, Fiorellini JP. A 5-year prospective clinical and radiographic study of non-submerged dental implants. Clin Oral Implants Res 2000;11:144-153.

*Dolphin 11.9 Annotations Software™ (Dolphin Imaging and Management Solutions, 9200 Oakdale Ave #500, Chatsworth, CA 91311, USA)

T1 T2

Professional esthetic assessments PES

PES SCORE

Variable 0 1 2

1. mesial papilla missing incomplete complete

2. distal papilla missing incomplete complete

3. soft tissue contour unnatural virtually natural natural

4. soft tissue level discrepancy>2mm discrepancy 1-2mm no difference

5. alveolar process,

soft tissue color & textureclear difference slight difference no difference

Pink esthetic score maximum = 10

Professional esthetic assessments WES

WES SCORE

Variable 0 1 2

1. tooth form major discrepancy minor discrepancy no difference

2. outline and volume “ “ “

3. color - hue and value “ “ “

4. surface texture “ “ “

5. translucency “ “ “

White esthetic score maximum = 10

Sum PES/WES maximum = 20

PES/WES evelaution performed by a calibrated external examiner (L.M.) and repeated after two weeks with inverted sequence of photographs

Patients‘esthetic assessment VAS

How satisfied are you with the appearance of your upper front teeth?

Completely satisfied Totally unsatisfied

100 mm

Statistics

Difference for age & observation time between groups - Mann Whitney U test.

Descriptive statistics including mean values, standard deviations and ranges

PI and Bleeding - Mann-Whitney U test

Frequency of recessions between groups - Chi Square test

PD and severity of recessions - MANOVA with dependent variables

Mesial-distal DIB differences at baseline and at follow-up - repeated measures ANOVA

Reproducibility for PES-WES variables - Wilcoxon test for paired data

Single PES & WES & Sum PES/WES between OSC- IMP group - MANOVA with dependent variables

Comparison of the VAS OSC-IMP - Mann-Whitney U test

Correlation PES/WES and VAS - One-tail Spearman test

All results with p<0.05 were considered significant.

All statistical analyses were performed with SPSS (22.0 version) and GraphPad Prism (6.0 version)

OSC IMP p

Age at end of tx 20 y ± 7y 6m 24y 6m ± 9y 1m 0,0037*

Age at follow-up 26y 4m ± 7y 7m 30y 1m ± 8y 9m 0,0098*

Observation time 5y 9m ± 1y 3m 6y 4m ± 1y 2m 0,1498

Age & observation time

IMP patients older, similar observation time

Means, SD and mean differences p for Age at end of tx, at follow-up and observation time in the OSC and IMP group; p*<0,05.

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OSC group

8x second canine bleaching

2x devital canine

5x abfractions of canine composite, 4x abfractions of premolar composite

IMP group100% implant success no mobility, no suppuration, no signs of peri-implant tissue inflammation,

no radiological translucency

No prosthodontic failures no screw loosening, no decementation, no chipping

General clinical findings

13/192 sites (6,8%) of surfaces in OSC and 14/192 (7,3%) in the IMP group with PI 1

9/384 sites (2,5%) in OSC and 11 sites (2,9%) in the IMP group with BP

group sites (n) mean SD p

PI OSC 8 0,8125 0,8342

IMP 14 0,9375 0,9979 0,794

BP OSC 6 0,5625 0,6292

IMP 13 0,7500 0,7746 0,521

Means, SD and mean differences p for Plaque Index (PI) and Bleeding on Probing (BP) in the OSC and IMP group; p*<0,05.

Similar excellent level of OH in both groups

Neither intergroup nor tooth couple differences

Means, SD and mean differences p between OSC-IMP tooth couples for Pocket Depth (PD); p*<0,05.

OSC PD IMP PD

OSC tooth mean SD IMP tooth mean SD mean diff. p

14 2,25 0,24 13 2,42 0,08 0,69 0,059

13 2,3 0,4 12 2,5 0,25 0,81 0,127

11 2,23 0,23 11 2,28 0.07 0,25 0,481

21 2,22 0,24 21 2,28 0,12 0,31 0,369

23 2,23 0,15 22 2,36 0,04 0,56 0,155

24 2,23 0,24 23 2,38 0,09 0,56 0,079

Pocket Depth (PD) Gingival Recessions

In both groups gingival recessions

did not exceed 2mm

More frequent in OSC group*22 OSC vs 8 IMP

(χ2 = 6.501,1; p= 0.0108*)

Gingival Recessions

Significantly more severe recessions of OSC right first premolar & and left canine

No difference of overall severity between OSC and IMP

OSC Rec sites mean SDIMP

Recsites mean SD p

tooth n mm mm tooth n mm mm

14 9 0,63 0,62 13 2 0,13 0,34 0,008*

13 1 0,13 0,5 12 3 0,25 0,58 0,518

11 0 0 0 11 1 0,06 0,25 0,325

21 3 0,25 0,58 21 1 0,06 0,25 0,243

23 4 0,31 0,6 22 0 0 0 0,047*

24 5 0,56 0,96 23 2 0,13 0,34 0,34

Distance Implant-Bone (DIB)

At T2 a mean DIB of 0,33 mm increase was assessed.

No difference between the mesial and distal side.

DIB Pillai’s trace F p η squared

Time 0,924 459,800 0,000* 0,924

Time*Group 0,011 0,422 0,520 0,011

DIB Mean diff SE p Inf Limit Sup Limit

T1-T2 -0,330 0,015 0,000* -0,361 0,299

Mes-dist -0,035 0,175 0,842 -0,389 0,319

Repeated Measures ANOVA test for DIB, p*<0,05

Mean differences and SE for mesial and distal DIB and T1 and T2 mean differences; p*<0,05.

Buser D et al. J Periodontol 2011;82(3):342-9.

Berberi AN et al. Front Physiol 2014(5):1-7.

Mangano C et al J Esthet Restor Dent 2014;26(1):61–71.

Mangano A et al. J Oral Science Rehabilitation 2016;2(1):62–71.

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PES SD WES SD Sum PES/WES SD p

OSC 9,39 0,56 8,36 1,02 17,75 1,12

IMP 8,91 1,5 8,72 1,37 17,63 2,6 0,183

SUM PES/WES

Means, SD and mean differences p of PES, WES and Sum PES/WES in both patient groups; p*<0,05.

No differences PES

PES variable mean OSC SD mean IMP SD p

Mesial papilla 1,97 0,18 1,87 0,38 0,066

Distal papilla 1,98 0,18 1,94 0,27 0,458

Soft tissue curvature 1,75 0,51 1,76 0,54 0,916

Soft tissue level 1,72 0,50 1,69 0,62 0,935

Root convexity 1,97 0,18 1,65 0,66 0,013*

Total 9,39 0,56 8,91 1,50 0,183

Means, SD and mean differences p of the Pink Esthetic Scores (PES) in the OSC and IMP group; p*<0,05.

No differences except for root convexity < IMP

WES variable Mean OSC SDMean

ImplantsSD p

Tooth form 1,81 0,39 1,50 0,64 0,029*

Hue & value 1,60 0,50 1,83 0,38 0,050*

Surface texture 1,60 0,50 1,89 0,22 0,001*

Translucency 1,69 0,47 1,90 0,22 0,020*

Tooth proportion 1,66 0,47 1,60 0,59 0,746

Total 8,36 1,02 8,72 1,37 0,183

WES

Means, SD and mean differences p of the White Esthetic Scores (WES) in the OSC and IMP group; p*<0,05.

IMP > OSC except for tooth form & proportion*

Esthetics VAS SD Sum WES/PES SD p

OSC 97,50 4,58 17,75 1,12 ns

IMP 96,25 6,19 17,63 2,6 ns

Means, SD and mean differences p for Sum PES/WES and VAS in the OSC and IMP group; p*<0,05.

High patients`s satisfaction VAS

No correlation between Sum PES/WES and VAS

Committee on Strategies for Small-Number-Participant Clinical Research TrialsBoard on Health Sciences Policy

Small Clinical Trials: Issues and Challenges

The National Academies of Science, Engineering and Medicine, Washington D.C. 2001

1. Whenever feasible, clinical trials should be designed and performed so that they have adequate statistical power.

2. However, when the clinical context does not provide a sufficient number

of research participants for a trial with adequate statistical power, but the research question has great clinical significance, research can still proceed under certain conditions.

3. Small clinical trials might be warranted for the study of rare diseases,

unique study populations (e.g., astronauts), individually tailored therapies,in environments that are isolated, in emergency situations, and in instances of public health urgency.

4. However, the conclusions derived from such studies may require careful

consideration of the assumptions and inferences, given the small numberof participants.

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PES of 7.8 (SD 0.88) and WES of 6.9 (SD 1.47) after 3-4 years Belser UC et al. J Periodontol 2009

21% PES/WES=20, 58% PES/WES14-20, 21% PES/WES <14 after 3 years Cosyn J et al. L Clin Periodontol 2011

PES 7.9 ±1.7, WES 7.0±1.5 after 1 year Furze D et al. Quintessence Int 2012

Mean Sum PES/WES 14.4, PES 7.2, WES 7.3 after 6 years Eccellente T et al Clin Oral Impl Res 2014

Mean Sum PES/WES of 14.44; SD 2.34 (range:9-20) after 4 years Kolerman R et al Clin Oral Implants Res 2016

Superior results compared to most existing studiesevaluating post-extraction implants in the esthetic zone

Slightly superior results compared to two studies reporting on 20 implants for congenitally missing maxillary lateral incisors

Mangano C et al. J Esthet Restor Dent 2014;26(1):61–71.

Mangano A et al. J Oral Science Rehabilitation 2016;2(1):62–71.

PES 8,72 vs 8,35

WES 8,91 vs 8,80

SUM PES/WES 17,63 vs 17,15

without any grafting

No matter which treatment approach is chosen,

both require a highly skilled and perfectly orchestrated team

and excellent long-term patient compliance

for excellent and stable results.

And even then

implant/prosthodontic or orthodontic failures can occur,

which might be very cumbersome to recuperate

2010 2016

Restoration/orthodontics related issues

Forsberg C.M. Eur J Orthod 1, 1979

Iseri H, Solow B. Eur J Orthod 18, 1996Bondevik O. Angle Orthodontist 68/1, 1998

Bishara S.E., Jakobsen J.R. et al. Am J Orthod Dentofacial Orthop 114, 1998Thilander B., Oedman J. et al. Eur J Orthod 23, 2001

Pecora N.G., Baccetti T., Mc Namara J.A. Am J Orthod Dentofacial Orthop 134/4, 2008

Jemt T., Ahlberg G. et al Int J Prosthodont 19/5, 2006Jemt T., Ahlberg G. et al Int J Prosthodont 20/6, 2007

Thilander B., Eur J Orthod 31, 2009

infraocclusion ? Is this

2010

2016

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Wrong crown design

Infraocclusion … or?

Loss of torque

Prosthodontic failure & orthodontic relapse

Although single-tooth implants in the esthetic zone can deliver

comparable results to space closure in the middle term,

if executed by a well-orchestrated and highly skilled team,

for situations where both approaches are applicable,

orthodontic space closure is advantageous over implant-borne crowns,

regarding the potential risk of infraocclusion over time.

Dr. David Musich

for congenitally missing maxillary lateral incisors:

Space closure vs implant-borne crowns

Ute Schneider-Moser, Italy