Esthetic and Palliative Management of Congenitally Missing Anterior Teeth using All Ceramic Fixed Prosthesis: A Clinical Case Report.

Congenitally missing anterior teeth alters the patient's physiognomy and diction in a big way. Maxillary incisor agenesis, prominently the lateral incisor is the most common congenitally missing permanent tooth, in the anterior maxillary region, which is the esthetic zone, representing approximately 20% of all dental anomalies. Treatment planning is inclusive of; smile design, preparation, perception of the patients, and their expectations in relation to esthetics, interdisciplinary alliance that meets the functional, health, and esthetic needs. A critical factor for the overall success is that of choosing a suitable restorative recourse. The case report describes the esthetic rehabilitation for congenitally missing maxillary lateral incisor and early traumatic loss of central incisor using an all ceramic-fixed prosthesis. Copyright:

INTRODUCTION

As Frush observes, “A smile can be attractive, a prime asset to a person's appearance, and it can be a powerful factor in the ego and desirable life experiences of a human being. It cannot be treated with indifference because of its deep emotional significance” (Goldstein, 2006). Hypodontia is a term used for defining the developmental absence of one or more teeth except third molars in both dentitions.[1] It is relatively common ranging from 4.5% to 7.4% of the population. The prevalence of dental agenesis is 1.37 times higher in women than that in men.[23] Missing maxillary incisors compromise dental esthetics due to their eminent position in the smile.[4]

Patients with missing anterior teeth usually present with deviated midline, abnormal overlap, and overbite, reduced masticatory ability, and other functional problems.[5] The vulnerability of maxillary lateral incisors to dental agenesis has been correlated with their anatomical position in the maxillary arch and also the fact that they are the last teeth to evolve in their corresponding classes.[6] Traumatic loss of anterior teeth is also very prevalent among youngsters as the antecedent teeth take the brunt of all mishaps.

Various dental treatment protocols are available for conditions involving the anterior sextant where the esthetics is involved. Common treatment modalities for restoring anterior edentulous spaces include removable partial dentures, resin-bonded bridges, auto transplantation, and single-tooth implant. The clinical situation becomes dicey when rehabilitation has to be accomplished for more than one missing teeth with inadequate spacing. The treatment plan here would entail orthodontic intervention, followed by space maintenance with subsequent masking of the canine to resemble the congenitally missing lateral incisor. The case report describes the esthetic rehabilitation for congenitally missing maxillary lateral incisor and early traumatic loss of central incisor using all ceramic-fixed prosthesis.

CASE REPORT

A 21-year-old female patient reported to the Department of Prosthodontics, Sri Rajiv Gandhi College of Dental Sciences, Bangalore, India with a chief complaint of unattractive smile owing to missing teeth in the upper front teeth region. The patient had no relevant medical history. The patient had a history of an accidental fall 2 years back with loss of central incisor and also a congenitally missing lateral incisor.

Intraoral examination revealed Angle's class 1 malocclusion, with an insufficient mesiodistal width to replace 21 and 22. Endodontic treatment had been done in relation to 11 with noticeable discoloration. Due to the mesial migration of 11 and 23, the midline relationship was unsatisfactory and unesthetic. Orthodontic intervention was planned for space rectification in relation to 21 with subsequent use of interim prosthesis for space maintenance. Postorthodontic treatment, sufficient space was gained [Figure 1]. To harmonize the midline relationship and to conform with the issue of adequate space maintenance, an interim prosthesis was fabricated in relation to 21 [Figure 2].

Figure 1

Preoperative view after post orthodontic treatment missing teeth IRT 21, 22

Figure 2

Midline assessment

Alginate impressions were made with respect to upper and lower arches and poured with Dental stone. A temporary Maryland bridge was fabricated [Figure 3] in relation to 21 and cemented [Figure 4]. Although the initial treatment plan entailed the placement of an implant supported prosthesis in relation to 21, with subsequent crown on 11, the patient was hesitant in regard to the implant surgery. To subsist with the situation, an all-ceramic fixed prosthesis was planned in relation to 11, 21, and 23. To ameliorate with the absence of the lateral incisor, it was planned to mask the canine in the fixed prosthesis to propound as the lateral incisor and a minor amount of enameloplasty on the first premolar to impersonate the canine.

Figure 3

Interim prosthesis fabricated

Figure 4

Temporary Maryland bridge cemented post orthodontic treatment

Tooth preparation was carried out in relation to 11 and 23 [Figure 5]. Impressions were made with a two-step poly vinyl siloxane rubber base impression material [Figure 6] and poured with die stone. All ceramic prosthesis was fabricated in relation to 11, 21, and 23 with 23 made to conform with the shape of 22 [Figure 7]. The prosthesis was cemented with type 1 glass ionomer cement [Figure 8]. Enameloplasty was carried out in relation to 24 to create a semblance to canine. A perfect harmony was achieved, highlighting the naturalness and biomimetics of the restoration, while also achieving the expectations and wishes of the patient for a more esthetic smile [Figures 9 and 10].

Figure 5

All-ceramic tooth preparation done IRT 11, 23

Figure 6

Impression made

Figure 7

All ceramic FPD IRT 11, 21 and 23, for esthetic reasons was shaped into 22

Figure 8

All ceramic Fpd cementation done

Figure 9

Pre – Operative View

Figure 10

Postoperative View

DISCUSSION

Hypodontia is a typical dental anomaly amid Indian population, pursued closely by impacted teeth. Missing teeth in the anterior teeth region has a major repercussion on attitudinal well-being of patients affecting their self-respect and social credence.[7] Rehabilitation in such cases would depend on the factors such as measure of the edentulous span, calibration of the teeth in the arch, the scope of space present, the category of occlusion present, the skeletal correspondence, and if any shift in the midline. The other factors include the gradient of teeth present, the accessibility of primary abutments, the standard and total sum of the cardinal osseous topography; the outlook, affirmation and consent of the patient and the available proficiency and resources all play a deciding factor.[8]

The varying modalities of prosthetic rehabilitation spans from restoring esthetics with a transitional or interim removable partial denture, using a resin-bonded fixed dental prosthesis or rehabilitating with an implant supported prosthesis. In case where implant treatment is not a possibility then to ensure a plausible esthetic result orthodontic techniques like distalisation of the canine which helps retrieve adequate space in case of missing maxillary lateral incisors have been customarily recommended by various authors. This provides leeway for rectification and restoration of balance esthetically.[910]

CONCLUSION

Loss of anterior teeth accompanied by congenitally missing anterior teeth presents a challenging conquest in terms of prosthodontic rehabilitation. The solution for such a clinical situation depends on factors such as the malocclusion, the anterior relationship, specific space requirements, and the conditions of the adjacent teeth. A synchronized and unified effort to build optimum esthetics in the anterior section with prominence on reaching an equilibrium on satisfying the patients concerns, using the best treatment methods available and using the adroitness of the dentist to bring about a ternion of successful results is the need of the hour.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms.

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understand that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.