Treating congenitally missing teeth with an interdisciplinary approach.

Congenitally missing teeth are frequently presented to the dentist. Interdisciplinary approach may be needed for the proper treatment plan. The available treatment modalities to replace congenitally missing teeth include prosthodontic fixed and removable prostheses, resin bonded retainers, orthodontic movement of maxillary canine to the lateral incisor site and single tooth implants. Dental implants offer a promising treatment option for placement of congenitally missing teeth. Interdisciplinary approach may be needed in these cases. This article aims to present a case report of replacement of bilaterally congenitally missing maxillary lateral incisors and right mandibular second premolar with dental implants.

INTRODUCTION

The therapeutic goal of dentistry is to provide patients with a dentition that is in harmony with the patients’ musculature and temporomandibular joint. Close relationship exist between teeth, musculature and temporomandibular joint. Congenitally missing teeth adversely affects this relationship. Congenitally missing teeth present a great difficulty to the treatment planning of the dentist, incidence being as high as 5%.

The available treatment modalities to replace congenitally missing teeth include prosthodontic fixed and removable prostheses, resin bonded retainers, orthodontic movement of maxillary canine to the lateral incisor site and single tooth implants.

Implants provide the advantage of conservation of adjacent natural teeth upon the fixed partial restoration provided the available space is enough for implant placement. But if the provided space is not adequate, it can be gained orthodontically. This article aims to present a case report of replacement of bilaterally congenitally missing maxillary lateral incisors and right mandibular second premolar with dental implants.

CASE REPORT

A 23-year-old female patient reported to the Department of Periodontology and Oral Implantology, Luxmi Bai Institute of Dental Sciences and Hospital, Patiala to get a better tooth and gum esthetics. No specific past dental, family and medical history was elicited. No relevant findings were observed on extra-oral examination. Intra-oral examination revealed retained primary maxillary right and left canines. Diastema was present between maxillary central incisors and between right central incisor and primary maxillary canine. Distally tilted right maxillary second molar was present. Gingival and periodontal examination revealed healthy periodontium. Radiographic examination was done to evaluate the proposed site for implant placement, which included intra-oral periapical radiograph and orthopantomogram [Figure 1]. Based on the above findings, patient was diagnosed congenitally lateral missing lateral incisors and right mandibular second premolar.

Figure 1

Pre-operative radiographic examination

The case was discussed with the Department of Orthodontics and treatment to be done was planned. Informed consent was obtained from the patient. Extraction of retained deciduous maxillary right and left canine was done. Simultaneous closure of midline diastema and bilateral distalization of maxillary canine was done to gain space between central incisor and canines bilaterally.

When the sufficient interdental area between two teeth was gained [Figure 2], the implant placement surgery was planned. Under local anesthesia, the crestal incision was given and mucoperiosteal flap was elevated. The site was initially with 2 mm pilot drill. The site was then gradually enlarged with standard color coded drills to the desired lengths at the osteotomy sites. The implant was delivered at the prepared osteotomy sites [Figure 3]. Primary closure of the flap was obtained with interrupted type resorbable sutures. Radiographic examination was done post-operatively [Figure 4]. Patient was prescribed non-steroidal anti-inflammatory drug ibuprofen 600 mg thrice a day for 5 days. Chlorhexidine gluconate 0.2% was prescribed for 2 weeks, soft diet instructions were given. After 5 months under sterile conditions, 2nd stage surgery was done using crestal exposure of implant cover screw. A healing abutment was placed with hex screw driver on each implant. At 2 weeks later impressions were made with open tray technique with impression copings placed into the implants. Shade selection was done. Healing abutments were replaced until prosthesis was manufactured. After a week, the healing abutments were removed and replaced by final abutments onto which final prosthesis was given [Figure 5]. Patient was happy with her new smile.

Figure 2

Space gained between teeth for implant placement

Figure 3

Implant delivered at prepared osteotomy site

Figure 4

Post-surgical radiograph orthopantomogram

Figure 5

Final prostheses delivered

DISCUSSION

Patients afflicted with congenital absence of either single or multiple teeth are unique and appropriate candidates for tooth replacement using osseointegrated implants. However, adjunctive procedures to optimize esthetics and longevity are frequently needed for replacement of missing tissues consistently found in these patients.[1] Preservation of remaining tooth structure and underlying bone are universal goals in prostheses fabrication.

Frequently, these patients have differences in spatial position relative to the opposing arch, which places emphasis on ancillary treatment with orthodontics and oral surgery.[2] A thorough diagnostic work-up should include an interdisciplinary approach to ensure optimal treatment and timing of treatment in those who are developing.[1]

Congenital absence of a single mandibular second premolar was the most prevalent, incidence being 3.4%. The maxillary lateral incisors are missing with incidence being 2.2%.[34]

Dental implants provide a promising treatment options for treatment options for the replacement of congenitally missing teeth. They provide the advantages of preservation of adjacent natural tooth structure, preservation of the alveolar ridge and achievement of optimal esthetic and restorative results.[5] The limitations faced for the implant patient includes inadequate available space, inadequate alveolar ridge thickness and inadequate alveolar bone support for gingival papilla.[67]

Another factor that plays an important role is completed skeletal growth or the age of the patient at the time of implant placement. If the implant is placed before the cessation of the peak growth periods, it can cause various esthetic and functional problems. Orthodontic treatment is required when the space available between the adjacent roots and the adjacent crowns is inadequate.[8] In this case the space available for implant placement was inadequate after extraction of right and left primary maxillary canines. To gain the space for implant placement, simultaneous closure of midline diastema and distalization of canine was done.

Osseointegrated implants have been used predictably for many years in the prosthetic rehabilitation of edentulous patients.[9] As this predictability became recognized, extended applications to the partially dentate patient became apparent and comparable success was seen. Microbiological and clinical follow-up in those who are partially dentate have been surveyed as well to indicate favorable outcomes. No significant differences in bone loss have been found as compared with edentulous patients treated with osseointegrated implants.[910] Excessive interfacial micromotion early after implantation interferes with local bone healing and predisposes to a fibrous tissue interface instead of osseointegration.[11] The level of the interproximal papilla of the implant is independent of the proximal bone level next to the implant, but is related to the interproximal bone level next to the adjacent teeth.[12] Treatment using implants in missing lateral incisors cases are satisfactory for the patient's esthetic expectations.[13] Interdental papilla levels were increased gradually and improved natural appearance.[14]

CONCLUSION

Congenitally missing teeth is a rather common complaint in the patients attending to the clinics for the replacement of the teeth. Interdisciplinary approach should be followed to treat such patients to achieve esthetics and function. Dental implants offer a predictable solution to replace the congenitally missing teeth, provided the bone quality is good enough and skeletal age is completed.