Modern Treatment for Congenitally Missing Teeth : A Multidisciplinary Approach

INTERNATIONAL JOURNAL OF MAXILLOFACIAL RESEARCH VOLUME 1 ISSUE 2 2015 179
Modern Treatment for Congenitally
Missing Teeth : A Multidisciplinary
Approach
Muhamad Abu-Hussein1, Nezar Watted2, Azzaldeen Abdulgani3, Péter Borbély4
The maxillary lateral incisor is the second most common congenitally absent tooth. There are
several treatment options for replacing the missing maxillary lateral incisor, including canine
substitution, tooth-supported restoration, or single-tooth implant. Dental implants are an
appropriate treatment option for replacing missing maxillary lateral incisor teeth in
adolescents when their dental and skeletal development is complete. This case report presents
the treatment of a patient with congenitally missing maxillary lateral incisors using dental
implants. Finally, the importance of interdisciplinary team treatment planning is emphasized
as a requirement for achieving optimal final esthetics.
KEY WORDS: congenitally missing lateral incisors; orthodontic space opening,
hypodontia, treatment options.
INTRODUCTION
The lateral incisor is the most common
congenitally missing permanent tooth in
the maxillary anterior region with the
prevalence of 1 to 3%. This has been
associated with their anatomical position
in the fusion area of facial process.1
However, when maxillary lateral incisors
are missing, individuals are confronted
with functional problems and poor smile
esthetics at a young age.1, 2
The
management of maxillary lateral incisor
agenesis has gained of multiple dental
specialties (orthodontics, periodontics, oral
surgery, prosthodontics…).1
Congenitally missing maxillary permanent
lateral incisors often lead to an unattractive
appearance and difficulty in treatment
planning. Age, location, space limitations,
alveolar ridge deficiencies, uneven
gingival margins, occlusion, and
periodontal factors often necessitate an
interdisciplinary approach. 3,4
Several studies have shown that MSX1
and PAX9 genes play a role in early teeth
development. PAX 9 is a paired domain
transcription factor that plays a critical role
in odontogenesis. All identified mutations
of PAX 9 and MX1 have been associated
with nonsyndromic form of teeth agenesis.
O
R
I
G
I
N
A
L
R
E
S
E
A
R
C
H

1,2
Hypodontia creates significant
challenges to the clinicians in both
diagnosis and management.
Comprehensive management often
requires a multidisciplinary approach.
There are different treatment alternatives
for patients with a missing lateral incisor
because of congenital reasons 1-8.
Esthetic
and functional problems can arise when an
orthodontic space closure is realized and
the canine is moved into the missing
lateral incisor’s space. 2-9
The two major alternative treatment
options are orthodontic space closure or
space opening for prosthetic replacements.
But they both can compromise aesthetics,
periodontal health and function. Treatment
alternatives for restoring edentulous spaces
resulting from congenitally missing
permanent lateral incisors include
removable partial dentures, conventional
fixed bridges, resin-bonded bridges,
autotransplantation, orthodontic
repositioning of canines to close the
edentulous space and single-tooth
implant.5
The first step to the successful, long-term
management of a congenitally missing
lateral incisor case is early detection and
referral to the orthodontist. The role of the
orthodontist in the early mixed-dentition
stage of development is to monitor and
guide the eruption of the permanent
canine. If the crown of the permanent
canine is erupting apical to the primary
canine root as it normally does, it may be
necessary to selectively extract the primary
lateral incisor to encourage the permanent
canine to erupt adjacent to the central
incisor. The reason for this is twofold. A
mesially positioned canine not only
provides a natural means for augmenting
the supporting tissues, but it also allows
for greater flexibility in future treatment
planning.6,7,8
The single-tooth implant has become the
most popular treatment alternative for the
replacement of missing teeth. Various
studies have shown the successful
osseointegration and long-term function of
restorations supported by single-tooth
implants. In addition to the high success
rates, one main benefit of this type of
restoration is that it leaves the adjacent
teeth untouched. This is particularly
important in young patients and unrestored
dentitions. It is true that implant-supported
restorations are not without potential
problems. These problems range from
mechanical complications to biologic
changes thatcan impact their long-term
predictability.9,10
However, if the proper

surgical and restorative protocols are
followed, potential complications or
esthetic compromises are minimal. To
achieve a stable esthetic and healthy
outcome with dental implants, it is
beneficial to understand their effects on the
surrounding hard and soft tissues.10,11
An interdisciplinary approach is necessary
to provide the most predictable treatment
results when single-tooth implants are
inserted to replace congenitally missing
lateral incisors. Osseintegration enables
long-term stability of a prosthesis
supported by a single-tooth implant.11,12
In
the past, however, neither approach
produced results that were entirely
satisfactory from an esthetic and functional
standpoint. Selecting the appropriate
treatment option depends on the
malocclusion, anterior relationship,
specific space requirements and condition
of the adjacent teeth. The ideal treatment is
the most conservative option that satisfies
individual esthetics and functional
requirements.13
The aim of this case report is to provide a
conservative multi-disciplinary approach
for the management of bilaterally missing
maxillary permanent lateral incisors.
CASE REPORT
A 17-year-old female patient reported to
my private clinic with the chief complaint
of spacing in the upper anterior region.
Angle's Class I molar relationship on both
sides and End on canine relationship on
both sides with an overbite of 3mm and
overjet of 3mm. Spacing in the maxillary
anterior region was attributed to the
absence of upper lateral insiors, with a
mild tongue thrust habit.
Panoramic radiograph examination reveals
no developmental disturbances except
congenitally missing maxillary lateral
incisors bilaterally. Cephalometric findings
report an orthognathic maxilla and
mandible; with mildly proclined upper and
lower incisors.
TREATMENT OBJECTIVES
1. To create optimal spaces for the
restoration of the missing lateral incisors.
2. To achieve class I canine relation
bilaterally and a canine-guided occlusion.
3. To replace the missing lateral incisors
with implant supported prosthesis.
4. To maintain the class I molar relation on
both sides.
5. Obtain a pleasing esthetic facial profile
TREATMENT PLAN
Treatment plan is divided in to two phases.
A) Orthodontic phase
B) Prosthodontic phase

A. Orthodontic Phase:
Fig.1. Diastema closure
Fig.2. Space management for 12, 22 using
acrylic teeth
Fig.3a Preoperative orthopentamogram
Fig. 3b. Preoperative intra oral periapical
radiographs
The aim of the orthodontic phase is to
open the space by distalizing the canines
and closing the midline diastema. The
option of space closure by mesialising
canine was not preferred due to a
presenting Class I molar relationship with
well interdigitated posterior occlusion, and
also because recontouring of the canine
morphology to that of a lateral incisor
would be rather aggressive, which in turn
would necessitate the need for intentional
root canal treatment of sound natural teeth.
Orthodontic treatment was started with a
0.022” MBT Pre-adjusted Edgewise
appliance with upper fixed tongue crib.
The sequence of arch wires started initial
with 0.016” martensitic Nickel Titanium
arch wires which were sequentially
followed by 0.018” Stainless Steel, 0.016 x
0.022” Stainless Steel, 0.017x 0.025”
Stainless Steel and 0.019 x 0.025”
Stainless Steel arch wires. Upon leveling
with a 0.019 x 0.025” Stainless Steel arch
wire the maxillary canines were retracted
on both sides by Bennett's method of
canine retraction. Sufficient space was
gained for replacement of lateral incisors
by distalizing the cuspids to a Class I
relation and also by closing the mid line
space. Pre-prosthetic orthodontic treatment
period lasted for 18 months. After
retraction radiographs were taken to assess

the bone level and root parallelism for the
implant placement. After final finishing
and detailing of the occlusion the fixed
appliance were debonded and upper and
lower Essix retainers were placed.
B. Prosthodontic Phase:
On radiographic examination, the height
and width of the bone were 15 mm, 4.1
mm on right and 15 mm, 4 mm on the left
side respectively and . The thickness of
the soft tissue was approximately 2 mm all
over. Diagnostic wax-up was done. A stent
was made in clear acrylic resin.
At the time of surgery, depression was
seen on the labial aspect of left maxillary
lateral incisor as expected. The osteotomy
site was made and further enlarged to a
diameter 3.8 mm and length 15 mm.
Implant of diameter 3.8 mm and 13 mm
length was placed. Autogenous bone
particles collected in the osteotomy drills
were mixed with patient's blood and saline
and placed in the area of fenestration.
Progide resorbable barrier membrane of
approximately the size of the defect was
tucked in over the bone graft . Implant of
the same size was placed on the other side
as well . Archwire was placed back
immediately. Previously used acrylic
lateral incisor teeth were hollowed on the
palatal aspect. On suture removal, they
were bonded with archwire with no contact
to the ridge to occupy and maintain the
space created orthodontically .
Fig.4. Fenestration on the labial aspect of
22
Fig.5. Placement of implant with 22
Fig. 6. Placement of bone graft and barrier
membrane

Fig.7. Postoperative orthopentamogram
At the time of second stage surgery, an
implant level impression was made using
impression material for fabrication of the
provisional restorations. Provisional
restorations were contoured using
composite resin on 3.8 mm diameter
provisional abutments (Biotemp, Myriad
Equinox) in such a way that the contact
area was 5 mm above the crestal bone and
no occlusal contact.
Fig. 8. Postoperative healing and
provisionalization with acylic teeth bonded
to arch wire
Fig.9. Soft tissue profile and
interproximal papillae prior to final
restoration
After 1-month, growth of the interproximal
papillae with a well-formed gingival cuff
was seen around both the implants .
Implant level final impression was made
with impression material. Final
restorations were fabricated . Patient was
satisfied with the final outcome of the
treatment . Fig.10a-b
Fig. 10a. Final restoration

Fig. 10.b. Postrestoration radiograph
DISCUSSION
However orthodontic space closure
procedure has been reported as
encouraging for periodontal health
preservation compared with prosthetic
replacements, the presence of undesirable
buccal corridors may be a drawback for
smile esthetics, as well as the inherent size,
shape, and shade of canines if
orthodontically moved.1, 4
In the opposite,
the choice of orthodontic space opening
facilitates the maintenance of the canines
of their natural position within the dental
arch having the ideal intercuspation
through first premolars, and provision of
canine-protected occlusion.1
However, a
prosthetic restoration should replace the
missing lateral.
The term “team approach” has been used
throughout the health care industry, and as
technologies continue to advance, this term
has evolved from simply referring a patient
back and forth to detailed treatment
planning and case selection. In this case
report, the restorative dentist presence and
participation at stage I surgery was a
valuable asset to achieving the ideal
esthetic and functional result for this
patient. Patients with congenitally missing
maxillary lateral incisors may seek
orthodontic therapy as part of a restorative
plan.
Since Branemark et al. [34] introduced the
possi-bility of direct alveolar anchorage
for the replacement of missing teeth,
ossteointegrated implants have been used
successfully in dentistry for more than 30
years. Implants are predictable and
successful means of replacing missing
teeth by supporting crowns, bridges,
overdentures and other maxillofacial
prostheses. In longitudinal studies,
conventional implant treatment has a
success rate of 91 to 99% in the mandible
and 84 to 92% in the maxilla 3,4
. Patients
with congenitally missing teeth usually
present in childhood, but implant
placement usually has to be postponed
until the completion of skeletal growth.
While the orthodontist is responsible for
satisfactory mesiodistal and parallel space-
opening, the implantologist must create a
favorable thick vestibulopalatal hard- and
soft-tissue framework which may require
not only bone, but also connective tissue
grafting. If these tasks are carefully
performed, we will very likely find a much
higher percentage of successful long-term
outcomes of implant-born restorations for
congenitally missing laterals in the future
orthodontic literature.
TIME OF IMPLANT PLACEMENT

Generally, implants must not be placed
until the patients have completed their
facial growth and the majority of their
tooth eruption As the face grows and the
mandibular rami lengthen, teeth must erupt
to remain in occlusion. However, the
implant behaves like an ankylosed tooth
and will not follow the changes of the
alveolar processes due to the eruption of
adjacent teeth.
Williams et al. showed a relatively high
risk of debonding. Finally, treatment with
the single implants – a frequently
described method of one-tooth
replacement should be mentioned 18
.Many
investigations showed that more than
90%of the patients are satisfied with the
effects of implant supported single tooth
restoration in the aesthetic zone19,20
.
Nonetheless, the longterm observations
proved many negative alterations. The
periodontal problems such as marginal
bone loss around the adjacent teeth,
connected with a larger loss and reduction
of the distance between the implant and
the tooth were mentioned in contemporary
literature 20
.
A Swedish article regarding implant
insertion in the aesthetic zone showed
other unfavorable aspects: atrophy of the
distal papillas, increased frequency of
bleeding or mucositis when compared to
the contralateral natural teeth 20
.
Iseri and Solow examined radiograms of
the patients aged 9–25 years and proved
continuous eruption of the natural teeth,
which allowed the conclusion that dental
implants should not be used in childhood,
adolescence or young adulthood. This
observation showed the need for
temporary reconstruction of the spaces
opened for the prosthodontic restorations
in the young patients. Some of the
disadvantages of single-tooth replacements
with the dental implants may be reduced
by proper orthodontic treatment with the
gaining of adequate space for the screws.
Also, the correct timing of implant
insertion after completed dental and
skeletal development may lead to an
improvement of the results. 21
.
Czochrowska et al. highlighted that canine
substitution is a valid therapeutic option,
giving satisfying aesthetics. Morphology,
width and color of the upper canines
serving as the “new lateral incisors”, are
the major factors influencing good
treatment effects. Brighter than normal and
rather small canines are favorable in
achieving an attractive smile after closure
of the spaces 22
. The substituted canines
often need recontouring. Thordarson et al.

showed that this procedure is safe and
painless to the patient.23,4
The choice of an ideal orthodontic
treatment for young patients with missing
permanent teeth should be based on a
careful evaluation of all factors involved in
diagnosis, as well as on the characteristics
of each patient.12
In this clinical case
report, we considered individual
characteristics and needs and chose a
multidisciplinary approach to ensure that
the wanted esthetic and functional
objectives were achieved.
CONCLUSIONS
Orthodontic space closure and implant
substitution of missing maxillary incisors
produced similar satisfactory esthetic
results. Neither of the treatments impaired
temporomandibular joint function.
However, orthodontic space closure
patients had better periodontal health in
comparison with implant substitution
patients. Furthermore, infraocclusion more
than 1 mm was noticed in all the implant
patients.
It is important that the orthodontist
together with the other specialists frame a
treatment objectives which are realistic
and meet the needs of the patient. Constant
interaction and communication among the
team members and the patient at all level
of treatment are the keys to the success of
the interdisciplinary treatment.
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1. Muhamad Abu-Hussein*
Center for Dentistry research and Aesthetics,
Jatt/Israel
2. Nezar Watted
Center for Dentistry research and Aesthetics,
Jatt/Israel
3. Viktória Hegedűs
Department of Pediatric Dentistry and Orthodontics,
University of Debrecen,
Debrecen,
Hungary
4. Borbély Péter
Fogszabályozási Stúdió,
Budapest,
Hungary
5. Abdulgani Azzaldeen
Department of Conservative Dentistry,
Al-Quds University,
Jerusalem,
Palestine
*Corresponding Author
Address:
Abu-Hussein Muhamad
DDS,MSCD,MSC,PEDO CERT.,FICD
123 Argus Street
10441 Athens
Greece
abuhusseinmuhamad@gmail.com

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