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D. Celli*, A. De Carlo**, E. Gasperoni**, R. Deli***
*Private practice of Orthodontics in Pescara, Italy
**Private Practictioner, Pescara, Italy
**Private Practictioner, Rimini, Italy
***Orthodontics Postgraduate Program,
Università Cattolica del Sacro Cuore, Rome, Italy
e-mail: [email protected]
Preprosthetic
interceptive
orthodontics for
missing lateral incisors
in late mixed dentition
abstract
Background Different treatment alternatives are
possible in the preprosthetic orthodontic management
of missing of lateral incisors. We describe an efficient
approach in a 12.11-year-old girl with incisors agenesis.
Case report Treatment started with repositioning
of the permanent canines in site 2 and the deciduous
canines in site 3. After growth completion the deciduous
canines will be extracted and replaced by dental implants.
Permanent canines will then undergo reshaping in
order to look like lateral incisors. The molar and cuspid
relationships were finalised in Class I, with correct
overjet and overbite. The mandibular and maxillary arch
forms were acceptable without crowding and rotations.
Opening the space offers different solutions for
maintaining the alveolar bone for a future implant, with
the advantage of a molar Class I relationship and a wider
arch. It would also be possible to achieve distalisation of
the permanent canine, following the Kokich’s principle
of alveolar development.
Conclusion The described treatment is a valid
alternative in the management of missing lateral incisors.
This solution can avoid an additional orthodontic
treatment in adulthood and allow easy management
of the retention phase prior to final rehabilitation with
single tooth implants.
Keywords Interceptive orthodontics; Lateral incisor
agenesis: Implants; Missing teeth; Space closure;
Space opening.
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Introduction
Maxillary lateral incisors are often subject to trauma
or agenesia. When one or both teeth are missing, the
clinician usually has two options: opening or closing the
space(s) of the missing tooth or teeth.
Space opening and subsequent implant placement is
considered a treatment to improve dental aesthetics with
low relapse tendency and maintenance of the canine
protected occlusion [Araújo et al., 2006]. Furthermore
implant treatment has some advantages such as tooth
structure preservation and alveolar bone maintenance
associated with adequate aesthetics and function
[Thilander et al., 2001]. However, some negative
observations on long-term aesthetic outcome have
been recently reported [Zachrisson and Stenvik, 2004].
Since a significant number of patients are adolescents,
a comprehensive treatment plan should be discussed,
taking into consideration a number of features such as
dental asymmetry, facial disharmony and tissue reaction
to orthodontic tooth movement.
Age is the main critical factor for timing, placement and
position of dental implants. Dentofacial development
and the continuous tooth eruption have been the focus
of a large number of studies on the infra-positioning
of dental implant [Thilander, 2008; Heij et al., 2006;
Rasner 2005].
The development of the implant site has to be wisely
managed until the adult age in order to warrant a
minimum amount of bone loss, the necessary space,
a comfortable dental condition, as well as adequate
aesthetic and occlusion outcomes [Vitályos, 2005;
Beyer, 2007].
An efficient approach was adopted in the preprosthetic
orthodontic management of a 12.11-year old female
patient showing lateral incisors agenesis.
Diagnosis
The patient had a pleasant facial profile with competent
lips. Cephalometric analysis showed a skeletal Class I
with Class III tendency. Intraoral examination indicated
a neutro-occlusion on the right, and a Class I on the left
side, deep bite during the late mixed dentition. Several
deciduous teeth were still in the arches (upper lateral
incisors, upper canines, left lower canine, second molars
and lower right lateral incisor). Radiographs revealed
the permanent second molars in course of eruption and
only the dental germs of the upper third molars.
In the lower anterior area crowding caused the
rotation of permanent canine and right lateral incisor
compared to their normal position with the deciduous
lateral incisor still in the arch.
The mandibular midline was shifted to the right. In
the upper anterior arch a median diastema was present
(Fig. 1).
European Journal of Paediatric Dentistry vol. 15/1-2014
PREPROSTHETIC ORTHODONTICS for MISSING LATERAL INCISORS
fig. 1 12-year-old female presenting two lateral
maxillary incisors agenesis.
Treatment alternatives
Therapeutic options are mainly summarised in space
closure or space opening of the missing lateral incisors.
If space closure was chosen, treatment progress would
include the following steps: extraction of the deciduous
canines, shifting of the permanent canines in the space of
the lateral incisors, subsequent shaping and bleaching of
the canines in order to transform them into lateral incisors
and transformation of the first premolars into canines.
Other possibilities were space opening procedures.
A first space opening option included maintenance
of the deciduous lateral incisors for a dental implant to
place in adulthood. A retention plate or a Marylandlike template will be used until adult age if the lateral
deciduous would fall over the time. This solution could
be adopted if the permanent canines would erupt in a
distal, but normal position.
A second space opening option aimed at creating a
new implant site between teeth 4 and 5. For this option
the permanent canine has to be moved in the area of
the lateral incisor. At growth completion the deciduous
canine will be extracted and the space between teeth 4
and 5 will be created orthodontically. This solution aims
to place the implant far from the aesthetic zone.
A third space opening option was to move the
permanent canines in site 2 and the deciduous canines
in site 3. After growth completion the deciduous canines
will be extracted and replaced by dental implants.
Shaping of the permanent canines will be performed to
transform them in lateral incisors.
Treatment plan
After choosing the third space option, the following
objectives had to be pursued.
European Journal of Paediatric Dentistry vol. 15/1-2014
• Correction of the anterior deep bite and achievement
of ideal overbite and overjet.
• Achievement of a correct arch form.
• Space maintenance for the missing maxillary lateral
incisors.
• Bone preservation for a future implant and porcelain
crown.
The treatment plan also had to consider the upper
third molar, which should be extracted in adulthood
because the lower third molars were missing.
As regards the treatment time, it was decided to
begin the therapy before the loss of the lower second
deciduous molars in order to take advantage of the LeeWay space and to early derotate the lower right lateral
incisor. Orthodontic therapy established at an early
age, like in early or mid-mixed dentition, have proved
to be effective in correcting serious discrepancies with
good stability over time [Musich and Bush, 2007]. The
benefit of an early derotation is a reduced risk of relapse
[Vargo et al., 2007; Ferris et al., 2005;Musich and Bush,
2007]. Alternatively a lingual arch could be placed in
the mandibular arch to maintain the Lee-Way space,
postponing the orthodontic treatment until completion
of the permanent dentition, without the benefits of an
early derotation.
Treatment progress
The initial alignment started with bands on permanent
molars, and brackets bonded on the other permanent
teeth and on the upper deciduous canines using the
Step & Slide system (Leone, Firenze, Italy).
On the right lower permanent canine a bracket was
not positioned in order to ensure a better arch elasticity
and to avoid excessive bends in the wire which may
79
Celli D. et al.
result in an unintended resultant contrary force on the
other teeth. This would help primarily the alignment of
lower right lateral incisor.
On the upper arch a 014” Australian stainless steel
wire was used with omega loop bending against the
molar tubes to keep the arch form. On the lower arch
a 012” Australian stainless steel wire was inserted with
bend backs to avoid detachment of the arch from the
molar tubes. Non-conventional low friction ligatures
(Leone, Firenze, Italy) were used in order reduce friction.
During treatment, the archwires in the upper arch were
increased first to 018” and later to 020” Australian
stainless steel.
In the lower arch the archwires were increased to 016”
and 020” Australian stainless steel. After 6 months the
lower right permanent canine was bonded. Then it was
derotated with a tie-out tooth movement (named C-tie
technique by the author) and with an elastic chain from
the canine to the right lateral incisor. All the lower incisors
were tied together for anchorage purposes (Fig. 3).
After one year all permanent teeth were bonded, and
a 019” X 025” stainless steel arch wire was placed in
the lower arch with tie-backs. After the upper canines
eruption the final alignment of the upper arch was
achieved. Brackets were bonded to permanent canines
in the sites of teeth 12 and 22. Then, a 016” NiTi wire
was placed with lacebacks followed by a 016”, and a
020” Australian stainless steel wire. The last archwire
was a 019” X 025” stainless steel with tie-backs.
Results
After 18 months of active treatment, the brackets
fig. 2 After six months lower right permanent canine was derotated with a C-type technique and repositioned with an elastic chain.
were debonded, and a fixed retainer was placed in the
anterior area of the mandibular arch. The molar and
cuspid relationships were finalised in Class I, with correct
overjet and overbite. The mandibular and maxillary arch
forms were acceptable without crowding and rotations.
The periodontal health was maintained.
Contrary to what usually happens, the gingival margin
of the canines was too apical compared to the accepted
standards. A gingivectomy could improve this feature
and give a more easthetic gingival architecture.
The panoramic radiograph showed good roots
parallelism and the improved position of the lower
second molars. Post-treatment facial and intraoral
photographs showed good aesthetic, occlusion and
functional results (Fig. 3).
fig. 3 Patient at debonding after 18 months of
treatment.
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European Journal of Paediatric Dentistry vol. 15/1-2014
PREPROSTHETIC ORTHODONTICS for MISSING LATERAL INCISORS
Discussion
Congenital missing laterals are often combined with a
median diastema or general spacing, which makes space
closure problematic. The midline often shifts to the side
of the missing tooth, since the anterior segment does not
have the anchorage to oppose a canine and all posterior
teeth [Tabuchi et al., 2010]. The canine frequently
has a mesial eruption path, which favours its role as a
substitute for the missing incisor, after its angulation has
been corrected. The mesial position of the permanent
canine usually causes an irregular gingival architecture
that should be corrected by a slightly incisal reposition
of the gingival margin. The canine usually is larger than
the lateral incisor, even in its palatal-buccal dimension.
Moreover, it usually has a darker yellow colour than the
central incisors. The restorative dentist can solve this
problem by bleaching or by placing a porcelain veneer
or crown to re-create a normal lateral incisor shape and
colour [Kokich and Kinzer, 2005].
The recent literature provides several alternatives for
treatment of agenesis.
Kokich suggests to help the eruption of the permanent
canine to the place of the lateral incisor also extracting the
lateral deciduous. Otherwise the future implant site will
not be created. This way the bone loss after distalisation
of the canine is about 1% in 4 years compared to 34%
in 5 years after extraction of a maxillary tooth. The
Kokich protocol might avoid a regenerative procedure
for implant placement [Kinzer and Kokich, 2005].
Every treatment option has advantages and
disadvantages. Space closure could be a faster and safer
treatment with the exclusion of implant therapy. A Class
II molar relationship may arise, requiring a conservative
correction of the canine in an high aesthetic zone. When
closing spaces due to missing lateral incisors, improper
anchorage control can result in narrow dental arches
and over-retraction of the anterior teeth. Making already
narrow dental arches still narrower could impair facial and
dental aesthetics [Sarver, 2001; Sarver and Ackerman,
2003]. Opening the space instead offers different
solutions for maintaining the alveolar bone for a future
implant, with the advantage of a molar Class I relationship
and a wider arch. Placement of an implant (and crown)
has the highest success rate of any treatment option
and the adjacent teeth are usually unaffected. Implants
with smaller diameters have several limitations, since the
surface area for bone-implant contact is smaller, with
an increased risk of screw loosening, fatigue fracture,
and this could reduce the long-term life of the fixture
[Mish, 1995]. The one-piece design might reduce the
risk of screw loosening and crestal bone loss since there
are no abutment screws and no microgap. The primary
disadvantage is the requirement for an immediate
restoration [Degidi et al., 2009]. The problem about
implant placement is that it is not possible to predict
the amount of bone loss by the time the patient is fully
European Journal of Paediatric Dentistry vol. 15/1-2014
grown (First space opening option - zone 2), specially
in lateral incisor position. Lateral incisors usually have
a characteristic gingival contour, with a gingival zenith
that is not perpendicular but placed further distally than
in canines. Furthermore an implant can cause problems
over time such as discoloured labial gingiva, gingival
retraction and fixture exposure [Jemt et al., 2006;
Thilander, 2008; Heij, 2006; Rasner, 2005]. Posterior
site development may solve the aesthetic problems of an
implant treatment plan (second space opening option).
However in this case the treatment requires a second
orthodontic stage and two crown reshaping, increasing
the economical and biological expenditure.
The chosen treatment (third space opening option),
whose objective was to place the permanent canines in
site 2 and the deciduous canines and future implant in
site 3, has the advantage to avoid a further orthodontic
treatment in adulthood and to place the implant far
from the aesthetic risks posed by zone 2.
In the case of a single implant for canine replacement,
the literature suggests to avoid creation of excursive
contacts on single implant restorations, and it is
recommended to create a multiple contact distribution.
Decisions must be made about whether to distribute
lateral loads over all the working-side contact in group
function, how far distally the group function should
extend or where the traditional paradigm of anterior
guidance should be considered [Kim, 2005].
In this case, only single crowns of the permanent
canines could be useful to achieve a better aesthetic
result at growth completion.
It would also be possible distalisation of the
permanent canine, following the Kokich’s principle
of alveolar development. When compared to space
closure procedures, this solution has the advantage
to maintain the width and perimeter of the maxillary
arch. Unfortunately this procedure requires the use of
prosthetics crowns when canine colour and shape are
unfavourable.
Conclusion
Orthodontic therapy for patients with uni- or bilateral
congenitally missing lateral incisors is a challenge for the
clinician, who has to plan an effective treatment and
prepare the dental arches for the future prosthodontic
restoration. Furthermore a successful aesthetic and
functional result require a combined multidisciplinary
approach, which involves the orthodontist, the oral
surgeon, and the restorative dentist. Even if several
treatment options are available, the described therapy
could be a valid alternative in the management of
missing lateral incisors when possible. This solution can
avoid an additional orthodontic treatment in adulthood
and allow easy management of the retention phase
prior to final rehabilitation with single tooth implants.
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Celli D. et al.
References
› Araújo EA, Oliveira DD, Araújo MT. Diagnostic protocol in cases of congenitally
missing maxillary lateral incisors. World J Orthod 2006 Winter;7(4):376-88.
› Beyer A, Tausche E, Boening K, Harzer W. Orthodontic space opening in
patients with congenitally missing lateral incisors. Angle Orthod 2007
May;77(3):404-9.
› Chu SJ, Tan JH, Stappert CF, Tarnow DP. Gingival zenith positions and levels of
the maxillary anterior dentition. J Esthet Restor Dent 2009;21(2):113-20.
› Degidi M, Nardi D, Piattelli A. Immediate versus one-stage restoration of
small-diameter implants for a single missing maxillary lateral incisor: a 3-year
randomized clinical trial. J Periodontol 2009 Sep;80(9):1393-8.
› Ferris T, Alexander RG, Boley J, Buschang PH. Long-term stability of combined
rapid palatal expansion-lip bumper therapy followed by full fixed appliances.
Am J Orthod Dentofacial Orthop 2005 Sep;128(3):310-25.
› Heij DG, Opdebeeck H, van Steenberghe D, Kokich VG, Belser U, Quirynen
M. Facial development, continuous tooth eruption, and mesial drift as
compromising factors for implant placement. Int J Oral Maxillofac Implants
2006 Nov-Dec;21(6):867-78. Review.
› Heij DG, Opdebeeck H, van Steenberghe D, Kokich VG, Belser U, Quirynen
M. Facial development, continuous tooth eruption, and mesial drift as
compromising factors for implant placement. Int J Oral Maxillofac Implants
2006 Nov-Dec;21(6):867-78. Review.
› Holt LR, Drake B. The Procera Maryland Bridge: a case report. J Esthet Restor
Dent 2008;20(3):165-71.
› Jemt T, Ahlberg G, Henriksson K, Bondevik O. Changes of anterior clinical
crown height in patients provided with single-implant restorations after more
than 15 years follow-up. Int J Prosthodont 2006;19:151–157.
› Kim Y, Oh TJ, Misch CE, Wang HL. Occlusal considerations in implant therapy:
clinical guidelines with biomechanical rationale. Clin Oral Implants Res 2005
Feb;16(1):26-35. Review.
› Kinzer GA, Kokich VO Jr. Managing congenitally missing lateral incisors. Part
III: single-tooth implants. J Esthet Restor Dent. 2005;17(4):202-10
› Kokich VO Jr, Kinzer GA. Managing congenitally missing lateral incisors. Part
I: Canine substitution. J Esthet Restor Dent 2005;17(1):5-10.
› Misch CE. Treatment options for a congenitally missing lateral incisor: a case
report. Dent Today 2004 Aug;23(8):90, 92, 94-5; quiz 95.
› Musich D, Busch MJ. Early orthodontic treatment: current clinical perspectives.
Alpha Omega 2007;100(1):17-24.
› Rasner SL. Replacing congenitally missing maxillary lateral incisors: assessing
treatment options and case report. Dent Today 2005 May;24(5):66, 68, 70
passim; quiz 73, 65.
› Rasner SL. Replacing congenitally missing maxillary lateral incisors: assessing
treatment options and case report. Dent Today 2005 May;24(5):66, 68, 70
passim; quiz 73, 65.
› Sarver DM. The importance of incisor positioning in the esthetic smile: The
smile arc, Am J Orthod 2001;120:98-111.
› Sarver DM, Ackerman MB. Dynamic smile visualization and quantification: Part
2. Smile analysis and treatment strategies. Am J Orthod 2003;124:116-127.
› Tabuchi M, Fukuoka H, Miyazawa K, Goto S. Skeletal Class III malocclusion
with unilateral congenitally missing maxillary incisor treated by maxillary
protractor and edgewise appliances. Angle Orthod 2010 Mar;80(2):405-18.
› Thilander B. Orthodontic space closure versus implant placement in subjects
with missing teeth. J Oral Rehabil 2008 Jan;35 Suppl 1:64-71. Review.
› Thilander B, Odman J, Lekholm U. Orthodontic aspects of the use of oral
implants in adolescents: a 10-year follow-up study. Eur J Orthod 2001
Dec;23(6):715-31.
› Thilander B. Orthodontic space closure versus implant placement in subjects
with missing teeth. J Oral Rehabil 2008 Jan;35 Suppl 1:64-71. Review.
› Vargo J, Buschang PH, Boley JC, English JD, Behrents RG, Owen AH 3rd.
Treatment effects and short-term relapse of maxillomandibular expansion
during the early to mid mixed dentition. Am J Orthod Dentofacial Orthop
2007 Apr;131(4):456-63.
› Vitályos G, Török J, Hegedus C.The role of preprosthetic orthodontics in
the interdisciplinary management of congenitally missing maxillary lateral
incisors: case report Fogorv Sz 2005 Dec;98(6):223-8 (Hungarian).
› Zachrisson BU, Stenvik A. Single implants-optimal therapy for missing lateral
incisors? Am J Orthod Dentofacial Orthop 2004 Dec;126(6):A13-5.
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Poland
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It’s been already 24 years since the European
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European Journal of Paediatric Dentistry vol. 15/1-2014