Download the posterior space opening - European Journal of Paediatric Dentistry

L. Favero1, C. Pizzo2, D. Farronato3, A. Balercia4,
V. Favero5
Professor and Chair, Department of Neuroscience, Institute of
Clinical Dentistry, University of Padua, Italy
2
Department of Neuroscience, Institute of Clinical Dentistry,
University of Padua, Italy.
3
Private Practice in Milan, Italy.
4
Department of Surgical, Reconstructive and Diagnostic
Sciences, Fondazione IRCSS Cà Granda, University of Milan, Italy
5
Department of Surgery and Dentistry, Oral and Maxillofacial
Surgery Unit Resident, University of Verona, Italy
Keywords Canine camouflage; Endosseous
implants; Miniscrews; Space-closure; Tooth agenesis.
1
e-mail: [email protected]
A new methodological
and clinical approach
for the treatment
of upper lateral
incisors agenesis:
the posterior space
opening
Introduction
Excluding the third molars, the agenesis of the upper
lateral incisors is unfortunately second only to the
agenesis of the second bicuspids, with a prevalence of
about 1-1.5% [Mattheeuws et al., 2004; Polder, 2004;
Celikoglu, 2011]. The development of permanent
teeth in children with dental agenesis is delayed when
compared with normal patients. The current treatments
found in the scientific literature, such as anterior space
closure with canine replacement [Kokich Jr, 2005;
Brough, 2010; Rosa, 2010] or anterior space opening
with implant placement [Krassnig, 2011], have their
own peculiar advantages and disadvantages [Kavadia,
2011; Uribe, 2011; Park, 2011].
The purpose of this study is to apply a new
methodological and clinical approach for the treatment
of upper lateral incisors agenesis, a new “Third Way”
able to safaguarding the occlusal integrity and the
dental and periodontal aesthetics of the front teeth,
with the advantages [Mirabella, 2011] of previous
techniques and without their drawbacks.
Material and methods
abstract
Aim The purpose of this study is to present a new
clinical approach for the treatment of upper lateral
incisor agenesis.
Materials and methods A new treatment option
was conceived and applied: posterior space opening
as a safeguard of occlusal integrity and dental and
periodontal aesthetics of the front teeth. This is
acheved by means of the anterior space closure, with
the mesialisation of the canines and the bicuspids,
combined with a posterior space opening to create
adequate room for the placement of an implant in
the second premolar area. The obtained space should
be maintained with a space retainer or a provisional
Maryland bridge until the patient is old enough to
undergo implant rehabilitation and the canines must
be reshaped into a lateral incisor.
Conclusion The results of this treatment are a correct
teeth alignment, without diastema, Class I occlusion,
and occlusal integrity with all natural teeth in the
anterior area. In this way there are many advantages
for the patient; so it is an effective approach.
European Journal of Paediatric Dentistry vol. 13/2-2012
This new approach was conceived by means of the
anterior space closure, with mesialisation of the canine
and the bicuspids, if necessary aided by mini-implants,
combined with posterior space opening to create
adequate room for the placement of an implant in the
second premolar area.
Usually the patient presents the following conditions
at baseline (Fig. 1, 2, 3).
Mono- or bilateral agenesis of maxillary lateral
incisors.
Class I molar relationship with tendency toward
Class II.
Skeletal Class I, normodivergent.
Normal overjet.
Increased overbite.
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Treatment
The first phase of the treatment consists in applying
a fixed orthodontic appliance in order to obtain the
mesialisation of the canines and the bicuspids, along
with the distalisation of the molars if necessary. This
objective can be obtained by means of an elastic chain,
compressed springs between molars and premolars,
and springs between miniscrews and Power Arm
151
FAVERO L. et al.
fig. 1 Starting point of the
treatment: radiographic and
clinical frontal view.
fig. 2 Starting point: lateral clinical view.
fig. 3 Starting point: face of the patient.
fig. 4 Mesialization of canines and bicuspids.
fig. 5 Derotation and mesialization of the second premolar.
fig. 6 Final result of the orthodontic phase: frontal intraoral view.
[Kravitz ND, 2007; Wehrbein H, 2008 ] [Fig. 4].
In case of upper lateral incisors agenesis, second
bicuspids are often rotated [Arte, 2001]: this condition
can be corrected using an elastic chain between
a palatal button on the second premolar and the
bracket on the first premolar, or between the bracket
on the second premolar and a miniscrew placed
buccally [Favero, 2010; Favero, 2009; Favero, 2002;
Antoszewska, 2010] (Fig. 5).
At the end of the orthodontic phase [Garino, 2003],
anterior space closure and posterior space opening are
obtained. The space is opened in the second premolar
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European Journal of Paediatric Dentistry vol. 13/2-2012
lateral incisor agenesis: a new treatment option
fig. 7 Final
result of the
orthodontic
phase:
occlusal view.
figg. 8
Final result:
occlusal
view
for the patient:
Preservation of all natural teeth in the aesthetically
relevant anterior area: implant rehabilitation is not
performed at the lateral incisor area, since canines
and premolars are mesialised and reshaped.
Highly aesthetic and stable dental and periodontal
results, which are obtained at the right moment of
the orthodontic treatment, with: presence of natural
teeth in the front area, orthodontic correction of
the gingival pattern and reshaping of canines and
bicuspids warrant a very good aesthetic result.
The implant and crown are placed in the posterior
area, which is less aesthetically relevant, therefore
the possible consequences of the implant therapy
(bone resorption, gingival recession, perimplantitis,
implant loss) have a lower impact.
Occlusal integrity and simmetry are maintained,
which cannot be achieved with the sole anterior
space closure technique.
In the posterior area the interradicular space is
usually sufficient for implant surgery. Instead
with the anterior space-opening techniques, the
proinclination of the frontal teeth to open the
space for the implant and the crown causes loss of
the interradicular space. As a consequence, if the
maxillary basal bone is not sufficient, it is sometime
impossible to place an implant in such position.
Bone volume is maintained by the presence of natural
teeth and implant all around the arch perimeter.
Low biological costs: permanent damage to the
hard structures of the teeth are limited to minor
reshaping of the canine and the first premolar.
This new method can be considered an effective
approach [Favero, 2009] for the treatment of
congenitally missing upper lateral incisors.
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figg. 9 Final result: face
view of the patient
area and it is sufficient for implant rehabilitation (Fig.
6, 7).
After this, the space obtained must be maintained
with a space retainer or a provisional Maryland bridge,
until the patient is old enough to undergo implant
therapy, and the canines must be reshaped into lateral
incisors.
Finally, when the patient is old enough, an implant
can be placed in the second premolar area and the final
prosthetic crown can be made.
Results
The results of this new approach are a correct
teeth alignment without diastema, Class I occlusion,
and occlusal integrity with all natural teeth in the
anterior area, with lower risk of aesthetic periodontal
consequences compared to implant therapy in the
maxillary lateral incisor area [Furze, 2012; Belser, 2004]
(Fig. 8, 9, 10), with better long-term outcomes and
stability.
Conclusion
The advantages of this new methodological and
clinical approach can be found in the synergic use
of the two main treatments for congenitally missing
upper lateral incisors, that have always been used
antithetically. The new approach has many advantages
European Journal of Paediatric Dentistry vol. 13/2-2012
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European Journal of Paediatric Dentistry vol. 13/2-2012