INTERNATIONAL JOURNAL OF MAXILLOFACIAL RESEARCH VOLUME 1 ISSUE 2 2015 179 Modern Treatment for Congenitally Missing Teeth : A Multidisciplinary Approach Muhamad Abu-Hussein 1 , Nezar Watted 2 , Azzaldeen Abdulgani 3 , Péter Borbély 4 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 R I G I N A L R E S E A R C H
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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
R
I
G
I
N
A
L
R
E
S
E
A
R
C
H
INTERNATIONAL JOURNAL OF MAXILLOFACIAL RESEARCH VOLUME 1 ISSUE 2 2015
180
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
INTERNATIONAL JOURNAL OF MAXILLOFACIAL RESEARCH VOLUME 1 ISSUE 2 2015
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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
INTERNATIONAL JOURNAL OF MAXILLOFACIAL RESEARCH VOLUME 1 ISSUE 2 2015