Download Management of Congenitally Missing Lateral Incisor

JIOS
10.5005/jp-journals-10021-1016
CASE REPORT
Management of Congenitally Missing Lateral Incisor
Management of Congenitally Missing
Lateral Incisor
1
Nidhi Kedia, 2Ashima Valiathan
ABSTRACT
Multiple treatment options are available to patients who have congenitally missing teeth. Management options for the treatment of missing
teeth can include the following: (1) Orthodontic space closure and adjacent tooth substitution, (2) autotransplantation, (3) prosthetic replacement
with resin-bonded fixed partial dentures, conventional fixed partial dentures and single-tooth implants. In this case report, treatment of a
patient with congenitally missing maxillary right lateral incisor will be presented.
Keywords: Congenitally missing tooth, Lateral incisor, Midline shift, Oral rehabilitation, Interdisciplinary treatment.
How to cite this article: Kedia N, Valiathan A. Management of Congenitally Missing Lateral Incisor. J Ind Orthod Soc 2011;45(2):
93-97.
INTRODUCTION
Congenital tooth agenesis of one or more teeth also known as
selective tooth agenesis (STHAG) is the most common
abnormality of human dentition.1 In the permanent dentition,
the third molars are the most frequently congenitally missing
tooth (30%) followed by mandibular second premolars (3.4%)
and maxillary lateral incisors (2.2%).2
The oral rehabilitation of patients presenting with
congenitally missing dentition is challenging because of the need
for a multidisciplinary approach. 3 Different treatment
alternatives, such as canine substitution, resin-bonded fixed
partial dentures, conventional fixed partial dentures and singletooth implants are available for treatment of missing maxillary
lateral incisors in adults.
While formulating a treatment plan, several parameters need
to be considered, such as severity of hypodontia, underlying
skeletal and incisor relationship, facial profile, age, motivation,
tooth size, color and shape of adjacent teeth.
Orthodontic space closure is an alternative when there is a
concomitant malocclusion that has to be treated. A combination
1
Former Postgraduate Student, 2Professor, Director of PG Studies
1
Department of Orthodontics, Manipal College of Dental Sciences
Manipal, Karnataka, India
2
Department of Orthodontics, Manipal College of Dental Sciences
Manipal, Karnataka, India, Adjunct Professor, Case Western
Reserve University, Cleveland, Ohio, USA
Corresponding Author: Ashima Valiathan, Professor, Director
of PG Studies, Department of Orthodontics, Manipal College
of Dental Sciences, Manipal-576104, Karnataka, India
e-mail: [email protected]
Received on: 17/3/11
Accepted after Revision: 13/5/11
of factors representing a typical orthodontic indication may
include increased over-jet; marked crowding; poor
interdigitation of posterior teeth to name a few.4,5 In particular,
changing the axial inclination and crown torque of lateral
incisors and canines is a time-consuming and relatively difficult
orthodontic procedure. If the crown of a canine in lateral incisor
position has not been given the correct lateral incisor torque,
the result may appear unnatural.6,7
Few indications for prosthetic replacement include a stable
Angle’s Class I buccal segment relationship, a tendency towards
a Class III malocclusion, when there is a color incompatibility
between maxillary canines and central incisors, generalized
spacing of the teeth, additional congenitally missing teeth in
the quadrant which also have to be replaced.6,7
While attempting prosthetic replacement either by implants
or fixed bridges, space appropriation is a very critical factor.
The orthodontist should achieve the specific space requirements
by positioning the teeth in the ideal restorative position.5 The
correct amount of space is generally determined by the esthetic
placement of the central incisors and the functional positioning
of the canines.
In a patient with congenitally missing single maxillary lateral
incisor, the amount of space for the implant/pontic and crown
is determined by the contralateral lateral incisor. However, in
some patients, the existing lateral incisor may be peg-shaped.
In other situations, both lateral incisors are congenitally absent.
The amount of space is determined by two factors: Esthetics
and occlusion.
An esthetic relationship exists between the size of the
maxillary central and lateral incisor teeth. This size ratio has
been called the “golden proportion”. Ideally, the maxillary
lateral incisor should be about two-thirds width of the central
incisor.5 Most central incisors are between 8 and 10 mm wide.
If the central incisor is 8 mm in width, then the lateral incisor
should be 5.5 mm wide.
The Journal of Indian Orthodontic Society, April-June 2011;45(2):93-97
93
Nidhi Kedia, Ashima Valiathan
CASE REPORT
Treatment Plan
The patient was a 23-year-old girl. Her chief complaint was
spacing in upper teeth. She had a mild concave profile with
competent lips and shallow mentolabial sulcus (Fig. 1). She
had an Angle’s Class I molar relationship with missing right
lateral incisor, with an edge to edge bite. There was 1.5 mm
arch length discrepancy in the lower arch and mild rotations
present in the buccal segment. While in the upper arch 3.5 mm
spacing was present. The upper midline was shifted to the right
by 3 mm, while the lower midline was coincident with the facial
midline (Fig. 2). In the lower arch, Bolton discrepancy with
2 mm excess tooth material was present in the mandibular
anterior region. She had a dilaceration in the middle third of
the root 11 (Fig. 6).
Cephalometrically, she had a Class III skeletal base
malocclusion with congenitally missing 12, acceptable IMPA
angle, facial esthetics, acceptable axial inclination of the upper
and lower incisors with a normodivergent facial pattern
(Figs 3 and 4).
As she had a Class I molar relationship with acceptable profile,
prosthetic replacement of missing tooth was decided, since the
buccolingual ridge thickness was inadequate for an implant
placement. It was decided to open spaces for the replacement
of missing right lateral incisor with resin modified bridge as
this involved minimal tooth reduction.
Treatment Progress
0.022 inch edgewise brackets (Roth prescription) were bonded
and first molars were banded. Leveling and alignment were started
in both upper and lower arches with 0.016 inch Wilcock Premium
Plus wire. It was followed by 0.018 inch Wilcock Premium Plus
stainless steel wire and open coil was compressed between the
upper right central incisor and canine till the upper and lower
midline were coincident and 6.5 mm space had opened between
the right central incisor and right canine, this took 4 months.
Fig. 1: Pretreatment facial photographs
Fig. 2: Pretreatment intraoral photographs
94
JAYPEE
JIOS
Management of Congenitally Missing Lateral Incisor
Fig. 3: Pretreatment OPG
Fig. 5: Uprighting box loop in relation to 13
Fig. 4: Pretreatment lateral cephalogram
Fig. 6: Dilacerated root of 11
Fig. 7: Post-treatment facial photographs
In the lower arch, mild proximal stripping was done to
resolve the mild crowding. Wire was progressively changed to
0.019 × 0.025 inch stainless steel wire and the space closure
was done.
As tipping movements had occurred, uprighting movement
was started with a continuous archwire with a box loop
incorporated in the region of 13. Mild Class II elastics for
continuous wear were given for 3 months. In relation to 11,
The Journal of Indian Orthodontic Society, April-June 2011;45(2):93-97
95
Nidhi Kedia, Ashima Valiathan
step bends were placed in the 0.019 × 0.025 inch stainless steel
wire to upright the upper right central incisor, which was mildly
dilacerated (Fig. 6).
After desired amount of space was opened and uprighting
of teeth took place with midlines being coincident with facial
midline, settling elastics were given for 2 weeks. After which
debonding was done and upper (only in the second quadrant)
and lower fixed multi-stranded lingual retainers were bonded
(Figs 7 to 10).
The case was, here after referred to the prosthodontist for
placement of a resin modified bridge in relation to 11, 13. The
total treatment time was 13 months. Slight uprighting of 13
was still needed but the case had to be deboned prematurely, as
patient desired removal of the brackets.
The facial profile was better than the pretreatment even though
the teeth were flared. This is because of better lip support and
fullness of lips that was desireable (Figs 11 and 12, Table 1).
DISCUSSION
The presented case report demonstrates that acceptable results
can be obtained with decision to replace missing tooth with
fixed prosthesis. The clinical situation associated with
congenitally missing teeth is often difficult, and a dilemma for
a clinician to select the best treatment plan. The common
alternatives may include single tooth implants,3 transplantation,
orthodontic space closure and conventional or resin-bonded
fixed partial dentures.8,9
By far, the most conservative tooth-supported restoration
is the resin-bonded fixed partial denture because it leaves the
adjacent teeth relatively untouched. As the patient had time
constraints along with decision not to disturb good buccal Class I
molar relationship, prosthetic replacement treatment plan was
prudent. Even though the upper teeth were proclined (from
Fig. 8: Post-treatment intraoral photographs
Fig. 9: Post-treatment OPG
96
Fig. 10: Post-treatment lateral cephalogram
JAYPEE
JIOS
Management of Congenitally Missing Lateral Incisor
Fig. 12: Profile tracings
Fig. 11: Superimposition
CONCLUSION
Table 1: Cephalometric values
Pretreatment
Post-treatment
Down’s analysis
Facial angle
Angle of convexity
AB-NPog
Y-axis
Mand plane angle
Cant occl plane
Interincisal angle
Lower incisor-MP
Lower incisor-occl plane
Upper incisor-APog
90°
10°
4°
54°
15°
5°
124°
6°
18°
4 mm
90°
11°
5°
54°
15°
4°
126°
2°
13°
6 mm
Tweed’s analysis
FMA
IMPA
FMIA
15°
96°
69°
15°
93°
72°
Steiner’s analysis
SNA
SNB
ANB
SND
Upper incisor-NA
Lower incisor-NB
NB-Pog
Interincisal angle
GoGn-SN
OP-SN
Wits appraisal
H-angle
77°
81°
–4°
79°
6 mm, 37°
4 mm, 20°
1.5 mm
124°
21°
11°
–4 mm
6°
76°
80°
–4°
79°
8 mm, 40°
3 mm, 15°
2 mm
126°
21°
10°
–3.5 mm
10°
6 mm, 37° to 8 mm, 40°), lips were better supported and a
more pleasing profile was achieved at the end of treatment.
Although single tooth implant prosthesis would have been
a good option, it was ruled out in this case as the ridge
requirements were not satisfactory. Treatment duration, buccal
corridor spaces along with type of malocclusion present are
some factors that need to be considered before contemplating
any type of tooth movement.
The oral rehabilitation of patients presenting with congenitally
missing dentition is challenging because of the need for a
multidisciplinary approach. Additional deficiencies present in
conjunction with the missing teeth, soft tissue defects, existence
of malformed dentition, severe diastemas, and psychological
status must be considered.
REFERENCES
1. Suresh M, Valiathan Ashima. Congenitally missing teeth. IJOG
1999;2(2):22-25.
2. Symons AL, Stritzel F, Stamatiou J. Anomalies associated with
hypodontia of the permanent lateral incisor and second premolar.
J Glin Pediat Dent 1993;17:109-11.
3. Ravinder V, James sunny, D’souza Mariette, Valiathan Ashima.
Osseo-integrated implants for maxillary lateral incisors
orthodontic considerations. Malaysian Dental Journal
2003;24(1):79-86.
4. Frank M Spear, David M Mathews, Vincent G Kokich.
Interdisciplinary management of single-tooth implants. Semin
Orthod 1997;3:45-72.
5. Vincent G Kokich, Frank M Spear. Guidelines for managing
the orthodontic-restorative patient. Semin Orthod 1997;3:
3-20.
6. Arvystas M. Orthodontic management of agenesis and other
complexities. Thomson Publishing Services 2003;109-10.
7. Stenvik A, Zachrisson BU. Single implants—optimal therapy
for missing lateral incisors: Letters to the editor. American
Journal of Orthodontics and Dentofacial Orthopedics
2004;126(6):13A-15A.
8. Zachrisson BU, Stenvik A. Management of missing maxillary
anterior teeth with emphasis on autotransplantation. American
Journal of Orthodontics and Dentofacial Orthopedics
2004;126(3):285-89.
9. Ewa M Czochrowska, Arild Stenvik, Björn Bjercke, Björn U
Zachrisson. Outcome of tooth transplantation: Survival and
success rates 17 to 41 years post-treatment. Am J Orthod
Dentofacial Orthop 2002;121:110-19.
The Journal of Indian Orthodontic Society, April-June 2011;45(2):93-97
97