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Table of Contents
CASE REPORT
Year : 2015  |  Volume : 5  |  Issue : 1  |  Page : 64-68

Emerging anterior esthetics: Multidisciplinary management of partial anodontia


Department of Prosthodontics, MGM Dental College and Hospital, Navi Mumbai, Maharashtra, India

Date of Web Publication2-Apr-2015

Correspondence Address:
Aditi Chintamani Sabnis
Department of Prosthodontics, 10, Shanti Kunj, B.J. Deorukhakar Road, Dadar (East), Mumbai - 400 014, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0974-6781.154446

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   Abstract 

Tooth agenesis is one of the common developmental dental anomalies in humans. Incidence of congenitally missing maxillary lateral incisors is approximately 1-2%. A multidisciplinary treatment plan needs to be executed for such cases. This article presents a case report of a young female with bilateral missing maxillary lateral incisors. The problems anticipated in this case were unequal space available for replacement of teeth, bony depression on the labial aspect of left maxillary lateral incisor, high labial frenal attachment causing a pull and lack of interproximal papillae with flat gingival architecture. Prosthodontically driven orthodontic treatment, followed by implant placement along with periodontal considerations was the chosen approach. Use of well contoured implant supported provisional restorations for creating the missing interproximal papillae and emergence profile is a simple, convenient and economical method making it a desirable treatment option to meet with the challenging esthetic demands in maxillary anterior region.

Keywords: Anterior esthetics, implant provisional restorations, multidisciplinary treatment, partial anodontia


How to cite this article:
Sabnis AC, Ram SM, Reshamvala AS, Shah N. Emerging anterior esthetics: Multidisciplinary management of partial anodontia. J Dent Implant 2015;5:64-8

How to cite this URL:
Sabnis AC, Ram SM, Reshamvala AS, Shah N. Emerging anterior esthetics: Multidisciplinary management of partial anodontia. J Dent Implant [serial online] 2015 [cited 2019 Sep 20];5:64-8. Available from: http://www.jdionline.org/text.asp?2015/5/1/64/154446


   Introduction Top


Tooth agenesis is one of the common developmental dental anomalies. Incidence of congenitally missing maxillary lateral incisors is approximately 1-2%. [1],[2] For restoring the missing tooth either by fixed or implant restoration adjunctive orthodontic correction may be needed for space management. [1],[3] Deficient soft tissue profile makes maxillary anterior single-tooth replacement a challenging task. [4] In such cases, a multidisciplinary treatment plan needs to be executed. This article presents a case report of a young female with bilateral congenitally missing maxillary lateral incisors treated with a multidisciplinary approach.


   Case report Top


A 35-year-old female had a chief complaint of missing teeth and spacing in upper anterior region. Patient had no similar family history; noncontributory past medical history; no associated syndromes and habits.

On extra oral examination, patient had thick competent lips of average length, adequate lip support and a medium smile line [Figure 1]. No positive findings with temporomandibular joint.
Figure 1: Preoperative extra oral

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On intraoral examination, a large midline diastema, missing maxillary right and left lateral incisors with uneven space distribution were noted. Thick fan shaped labial frenum with high attachment causing blanching on pull was observed. Bony depression was present on the labial aspect of left maxillary lateral incisor [Figure 2]. Healthy periodontium with thick gingival biotype was present.
Figure 2: Preoperative intra oral

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Treatment plan

Orthodontic treatment was planned for creation and distribution of space for missing teeth along with periodontal treatment for resection of the thick frenum. The final treatment planned for the patient was implant supported fixed restorations with well-formed provisional restoration for soft tissue contouring to achieve esthetics and good emergence profile.

Procedure

Two acrylic maxillary lateral incisor teeth were selected according to the golden proportion to assist the orthodontist for achieving the desired space. They were to be bonded with the archwire with brackets once the space was achieved [Figure 3] and [Figure 4]. Frenectomy of the maxillary labial frenum was carried out as it could have contributed to the midline diastema [Figure 5]. [5]
Figure 3: Diastema closure

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Figure 4: Space management for 12, 22 using acrylic teeth

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Figure 5: Frenectomy of maxillary labial frenum

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The orthodontic fixed appliance was maintained for another 6 weeks thereafter for stabilizing the teeth, maintaining the space and bone formation for implant placement. Archwire was removed just before making the diagnostic impression. 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 [Figure 6] and [Figure 7]. 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.
Figure 6: Preoperative orthopentamogram

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Figure 7: Preoperative intra oral periapical radiographs

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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 [Figure 8] and [Figure 9]. 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 [Figure 10]. Implant of the same size was placed on the other side as well [Figure 11] and [Figure 12]. 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 [Figure 13].

At the time of second stage surgery, an implant level impression was made using polyvinyl siloxane 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) [Figure 14] in such a way that the contact area was 5 mm above the crestal bone [Figure 15] and no occlusal contact. They were placed in patient's mouth for a month to contour the peri-implant soft tissue and achieve interproximal papillae. Recall was done every week.
Figure 8: Fenestration on the labial aspect of 22

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Figure 9: Placement of implant with 22

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Figure 10: Placement of bone graft and barrier membrane

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Figure 11: Placement of implant with 12

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Figure 12: Postoperative orthopentamogram

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Figure 13: Postoperative healing and provisionalization with acylic teeth bonded to arch wire

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Figure 14: Bio-temp temporary abutment

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Figure 15: Provisional prosthesis intra orally

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After 1-month, growth of the interproximal papillae with a well-formed gingival cuff was seen around both the implants [Figure 16]. Implant level final impression was made with polyvinyl siloxane impression material. Final restorations were fabricated [Figure 17] and [Figure 18]. Patient was satisfied with the final outcome of the treatment [Figure 19].
Figure 16: Soft tissue profile and interproximal papillae prior to final restoration

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Figure 17: Final restoration

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Figure 18: Postrestoration radiograph

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Figure 19: Post-operative extra oral

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   Discussion Top


Among the given prosthetic treatment options, patient rejected the removable prosthesis. Adhesive fixed partial denture is not a dependable line of treatment. Single-tooth implant supported fixed restoration has advantages of bone maintenance, no reduction of abutment teeth unlike fixed partial dentures, reduced abutment teeth complications, increased survival of adjacent teeth and longevity. [4] So implant supported fixed prosthesis with the growth of interproximal papillae by means of well contoured provisional restorations was planned.

The lost interproximal papillae are not capable of self-regeneration. Their reconstruction poses a greater challenge. Slight change in their level could lead to great problems in esthetics and phonetics. Depending upon the measurement from the contact point to the crest of the bone, Tarnow et al. developed a classification for the predictability of interproximal papillae. The predictability is almost 98-100% for 5 mm or less, 56% for 6 mm and 27% for 7 mm or more. [6],[7]

Prosthetic solutions for missing interproximal papilla include creation of papillary illusions by moving the contact area in an apical direction, use of pink porcelain in the area of missing papillae and use of provisional prosthesis to contour the peri-implant soft tissue. [6]

The rationale suggested behind the use of implant provisional restoration is that the restoration exerts lateral pressure on the soft tissues in the interproximal zone and forms gingival peaks. Emergence profile is an important factor to provide support and contralateral pressure for the papillae and gingival wall. Third important factor is the vertical proximal surface close to the gingival embrasure with its apical limit <5 mm from the osseous crest. [7]


   Conclusion Top


In the described case report, prosthodontically driven orthodontic treatment was followed by implant placement. Use of implant supported provisional restorations to re-contour the soft tissue is a simple, convenient and economical method making it a desirable treatment option to meet with the challenging esthetics demands in maxillary anterior region.

 
   References Top

1.
Krassnig M, Fickl S. Congenitally missing lateral incisors - A comparison between restorative, implant, and orthodontic approaches. Dent Clin North Am 2011;55:283-99, viii.  Back to cited text no. 1
    
2.
Rajendran R. Developmental disturbances of oral and paraoral structures. In: Rajendran R, Sivapathasundharam B, editors. Shafer′s Textbook of Oral Pathology. 5 th ed. New Delhi: Reed Elsevier India Private Limited; 2007. p. 62-4.  Back to cited text no. 2
    
3.
Kokich VG. Maxillary lateral incisor implants: Planning with the aid of orthodontics. J Oral Maxillofac Surg 2004;62:48-56.  Back to cited text no. 3
    
4.
Misch CE. Anterior single-tooth replacement: Surgical considerations. In: Misch CE, editor. Contemporary Implant Dentistry. 3 rd ed. Missouri: Mosby Elsevier; 2008. p. 739.  Back to cited text no. 4
    
5.
Suter VG, Heinzmann AE, Grossen J, Sculean A, Bornstein MM. Does the maxillary midline diastema close after frenectomy? Quintessence Int 2014;45:57-66.  Back to cited text no. 5
[PUBMED]    
6.
Askary AE, editor. Soft tissue management. In: Reconstructive Aesthetic Implant Surgery. 1 st ed. Iowa: Blackwell Publishing Company; 2003. p. 100-14.  Back to cited text no. 6
    
7.
Saadoun AP. Single tooth peri-implant: Hard and soft tissue management for esthetic results. In: Babbush CA, editor. Dental Implants the Art and Science. 1 st ed. Philadelphia: W.B. Saunder′s Company; 2001. p. 335-50.  Back to cited text no. 7
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13], [Figure 14], [Figure 15], [Figure 16], [Figure 17], [Figure 18], [Figure 19]



 

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