Depending on the obstacles that may present, creating a beautiful smile can take on many different scenarios. Moreover, patient demands and the pseudo self-educated using the internet as a reference can add to the challenges of insuring a seamless treatment. However, if your patient is confident in the team that has been assembled and a disciplined sequence is followed from the planning stages to the conclusion, the result can be very satisfying for both the patient and the clinicians involved. In this specific case a general dentist with an interest in appearance related procedures, an orthodontist, and a periodontist came together as a cohesive unit to guide this patient from consultation to completion to deliver her vision into reality.
This very pleasant healthy 29-year-old female patient attended my office as a referral from another dental professional (Fig. 1). Her chief concerns were that she was very unhappy with her smile, specifically the position of the retained deciduous teeth. A brief clinical exam revealed retained 52, 53, 63, with 23 erupting into the 22 position (Figs. 2 & 3). When initially deciding on the pathway for clinical success, using the adage “begin with the end in mind” the intended result comes into focus and the steps to achieve the end become clear. As such my initial thoughts were:
1) Orthodontics to properly align the maxillary and mandibular arches by removing the deciduous teeth and placing the permanent dentition in the correct position.
2) Once tooth position is idealized, placement of implants to replace the missing permanent dentition.
The patient was invited to return for an appointment to gather information including a complete clinical exam, periodontal charting, and a full mouth series of X-rays. Subsequently the patient was referred to Dr. Bruno Vendittelli for orthodontic assessment/planning and Dr. Yair Lenga to assess the suitability of the ridges for implant placement once orthodontic treatment was complete.
Once the information was gathered and a joint review was done with all three providers, a comprehensive treatment plan was created, consisting of:
1) Refer to Dr. Vendettelli for orthodontics to idealize maxillary/mandibular arches allowing for prosthetic rehabilitation once complete.
2) Once orthodontic treatment is complete, a diagnostic wax-up is fabricated to replace missing teeth 12, 13, 22, and 36 (Note that this served as a visual example to the patient of the completed result and as a surgical template for placement of the implants.)
3) Dr. Lenga will place implant fixtures in the 12, 13, 22, and 36 positions.
4) Whiten the maxillary and mandibular arches.
5) Bonding (Bioclear method – Oral Health April 2017) to add to the distal of 11/21 to create the ideal proportions for 12, 13 and 22.
6) Placement of screw-retained implant crowns for 12, 13, 22, and 36.
Once the treatment plan was presented to the patient and reviewed, all questions and concerns were addressed, and the patient consented to move forward with orthodontic treatment.
After a comprehensive evaluation and consultation of the formalized treatment plan as described above, the patient consented to proceeding with orthodontic treatment. Orthodontic treatment consisted of the placement of maxillary and mandibular fixed appliances (Maxillary Clarity Advanced and Mandibular Speed) (Fig. 4). Once the appliances were placed, tooth 63 was extracted. Teeth 52 and 53 were kept in situ through the duration of orthodontic treatment to preserve alveolar bone. The goals of orthodontic treatment were as follows:
1) Distalize tooth 23 into an ideal position.
2) Move the maxillary midline to the left by approximately 2 mm to match the mandibular midline.
3) Create optimal space for implants at 12,13 and 23 (in essence, ensure the distance from 14 mesial to 11 distal equalled the distance from 21 distal to 24 mesial).
4) Create optimal space for an implant at 36.
5) Establish a Class I occlusion with cuspid rise on the left.
During orthodontic treatment and once adequate space was created at 22, a pontic was added for esthetics (Fig. 5).
Treatment lasted for 28 months. Once the above goals were accomplished, the patient was referred to both Dr. Soll and Dr. Lenga to deem the optimal set-up and to ensure adequate space existed for implant placement. Once confirmed, the fixed appliances were removed, and fixed lingual retainers were placed. Maxillary and mandibular Essix retainers were also fabricated. A pontic at 22 was placed in the maxillary Essix for esthetics.
Once the patient completed her orthodontic treatment and initial retention, study models were taken and duplicated to create a diagnostic wax up to serve as a visualization for the patient and surgical guide for the periodontist (Fig. 6). The patient was then referred to Dr. Lenga for placement of implants in the edentulous positions of 12, 13, 22, and 36 (space created by orthodontics). A maxillary Essix retainer with pontics at 13,12 and 22 was also created and Dr. Lenga was able to deliver this on the day that 52, and53 were extracted and implants were placed (Figs. 7A & B).
Retained primary dentition is typically accompanied by a deficiency of the soft and hard tissues. The subsequent ridge deformity may cause severe functional and esthetic problems, especially in the anterior maxillary region. However, when mutilated occlusion and lateral deficiencies exist, as with missing lateral incisors and canines, a staged surgical approach is often necessary to first create suitable bone volume and esthetics prior to tooth extraction and permanent tooth replacement. 1
In the case of bilateral tooth agenesis, space opening is often recommended to improve the aesthetics of patients and preserve smile symmetry. 2-5 Orthodontic treatment is often necessary to align migrated permanent teeth while helping to develop the soft tissue emergence profile and papillae. 2
Anterior relationship, that is, overjet and overbite, must be taken into account when planning out tooth replacement in terms of facilitation of biomechanics. Reduced overjet and increased overbite may easily be improved by space opening mechanics, while increased overjet and reduced overbite may benefit from space closure. Placement of provisional restorations integrated into the orthodontic appliance can create soft tissue contours that resemble normal gingival topography before placement of the definitive prosthesis.
The clinical evaluation demonstrated that the primary teeth revealed grade II tooth mobility without percussion and palpation sensitivity. Bilateral labial depressions over the maxillary primary teeth were observed which created a functional and cosmetic defect requiring bone augmentation. Cross sectional radiographic examination confirmed buccal deficiencies (Figs. 8 & 9).
CT SC Upper Right before grafting.
CT SC Upper Left before grafting.
Treatment options and considerations for replacing the congenitally missing teeth were discussed. The patient elected to undergo pre-implant lateral bone augmentation followed by placement of four dental implants in each of the sites #13, 12, 22 and 36.
The first surgery was performed while the patient was in the final stages of completing orthodontic treatment. An IV was started and the patient was controlled with conscious sedation using benzodiazepines. After local anesthesia of the maxillary anterior sextant had been achieved, a full thickness mucoperiosteal flap was elevated over the buccal and palatal surfaces of the alveolar bone. Calipers were used to verify the integrity of the bony plates and confirm the 3 mm alveolar ridge dimension. The site was thoroughly debrided of any soft tissue tags and periosteum so as to leave fully exposed cortical bone. Bleeding points were created into the alveolar bone using the precision drill under copious sterile saline irrigation. The hard tissue depressions were augmented using allogenic cadaveric particulate bone (Creos, Nobel Biocare). The bone graft was rehydrated in sterile saline and then layered over the buccal plate in a scalloped architecture that mimicked the root prominences. The graft material was covered with a resorbable collagen membrane (Ossix plus, Datum Dental) and the soft tissue flaps were reapproximated and secured using 4-0 chromic gut interrupted sutures. The #22 pontic was reshaped and reattached to the orthodontic wire to serve as the fixed provisional prosthesis during the healing stage.
Four months after lateral bone augmentation the recipient sites were imaged again to confirm bone volume and plan out implant placement (Figs. 10 & 11). In determining appropriate implant placement, consideration was given to the angulation of the implants relative to the angulation of the roots of the adjacent teeth. The second surgery was performed while the patient was in orthodontic retention. An IV was started and the patient controlled with conscious sedation using benzodiazepines. Local anesthesia of the maxillary anterior sextant and the mandibular left quadrant was achieved, at which point full thickness mucoperiosteal flaps were raised.
Upper Right after grafting.
Upper Left after grafting.
Extraction of primary teeth #53 and #52 was performed with forceps alone. Ideal implant position involved placing the implants parallel to the roots of teeth #14/11, #21/23 and bisecting the root angulations of #35 and #37. A series of drills 11.5mm in length and of increasing width (2.0 mm, 3.5 mm, 4.3 mm and 5.0 mm) were used. At each incremental step, a “direction indicator” was placed in the prepared site and radiographed to determine proper angulation (Figs. 12-14). Correct placement was also confirmed by placing the plastic stent/surgical guide over the site after each drill sequence.
Upper Right Directional Indicator.
Upper Left Directional Indicator.
Lower Left Directional Indicator.
Four Nobel Biocare Replace Conical Connection tapered implants (#13 = 4.3×11.5 mm, #12 = 3.5×11.5 mm, #22 = 3.5×11.5 mm, #36 = 5.0×11.5 mm; Gothenburg, Sweden) were placed into the prepared sites with an insertion torque of 40 Ncm. Stock healing abutments (Nobel Biocare) were connected to the implants and adjusted intraorally to the desired emergence form. The removable orthodontic retainer was adjusted to fit over the healing abutments. The flaps were reapproximated and secured with 4-0 chromic gut interrupted sutures.
A non-steroidal anti-inflammatory drug (ketoralac; 0.5 mL of a 30 mg/mL solution) along with a steroidal anti-inflammatory drug (dexamethasone sodium phosphate; 1.5 mL of a 4 mg/mL solution) was injected by IV, and an ice pack was placed extraoral. A week-long course of antibiotics was prescribed along with anti-inflammatories and analgesics. A two-week postsurgical appointment revealed normal healing.
After a healing period of three months, when soft tissue shaping was achieved with the healing abutments and provisional retainer, implant Osseointegration was tested and confirmed at 35Ncm using a torque wrench in forward and reverse. The patient was then returned back into the care of her general dentist for completion of the restorative phase of treatment (Figs. 15-17).
Once Dr. Lenga confirmed integration of the implants, the patient had her teeth whitened with Zoom In-Office Whitening (Phillips Oral Care) and adhered to the prescribed protocol including the post treatment white diet to prevent premature staining as the enamel pores close.
The next step was to take impressions of the implant fixtures for the lab to create the crowns to integrate with them (Impergum–Medium Body – 3M Corp). Once the impressions were taken, they were sent to the lab along with the wax up so that the technician could create the ideal proportions knowing that the excess space would be attached to the distal of 11/21. When the crowns were returned they were tried in to their correct positions and seating was confirmed with periapical x-rays. The crowns were then torqued to 30Ncm and the access channels were sealed with cotton pellets and composite. The occlusion was adjusted and polished. Using the Bioclear matrices and protocol, 11/21 distal spaces were closed to 12/22 using Filtek Supreme – Shade A1 (3M Corp). All restorations and bonding were then polished to reveal a smile as nature intended (Figs. 18 & 19A-D).
As evidenced by the patient’s model shot, there has been a complete transformation in her outlook and confidence (Fig. 20). By simply thinking sequentially and drawing upon the expertise of others within your team, and remembering that “Jack of all trades, expert in none”, will result in an exceptionally rewarding outcome for both the patient and all clinicians involved. OH
Oral Health welcomes this original article.
The authors would like to thank Edwin Chung RDT, MDC, Bsc., at Krest Dental Studios, for his outstanding life like restorations.
- L. Savarrio and G.T. McIntyre, “To open or to close space – that is the missing lateral incisor question,” Dental Update, vol. 32, no. 1, pp. 16-25, 2005.
- M. Rosa and B. U. Zachrisson, “The space-closure alternative for missing maxillary lateral incisors: an update,” Journal of Clinical Orthodontics, vol. 44, no. 9, pp. 540–561, 2010.
- G. Richardson and K. A. Russell, “Congenitally missing maxillary lateral incisors and orthodontic treatment considerations for the single-tooth implant,” Journal of the Canadian Dental Association, vol. 67, no. 1, pp. 25–28, 2001.
- B. J. Millar and N. G. Taylor, “Lateral thinking: the management of missing upper lateral incisors,” British Dental Journal, vol. 179, no. 3, pp. 99–106, 1995.
- E. Argyropoulos and G. Payne, “Techniques for improving orthodontic results in the treatment of missing maxillary lateral incisors A case report with literature review,” American Journal of Orthodontics and Dentofacial Orthopedics, vol. 94, no. 2, pp. 150–165, 1988.
- J.Y. Kan, K. Rungcharassaeng, J. Lozada, “Immediate placement and provisionalization of maxillary anterior single implants: 1-year prospective study,” Int J Oral Maxillofac Implants, 18 (2003), pp. 31-39.
About the Authors
Dr. Jordan Soll is a Toronto based general practioner with special interest in appearance related procedures. He is principal of Central Dental Group, Co chairman of the editorial board of Oral Health Journal, and the dental expert for City Line with Tracy Moore.
Dr. Bruno L. Vendittelli is a Toronto based orthodontist whose practice is Forest Hill Orthodontics. He is a Staff Orthodontist at the Hosptial for Sick Children and an Associate at the University of Toronto, Faculty of Dentistry.
Dr. Lenga’s experience includes all periodontal and reconstructive procedures including bone regeneration and periodontal plastic surgery. He is skilled in a variety of dental implant devices and associated procedures. He has also completed a hospital- based fellowship in anaesthesia. Dr. Lenga currently works full-time in his private practice clinics in Ontario and Alberta.