Congenitally Missing Maxillary Lateral Incisor considerations…
This case involves a 20 y/o female with a congenitally missing #10 that I treated about 3 years ago. Orthodontic treatment had been completed approximately 1 year prior by a local orthodontist. I was referred the case via her general dentist for implant #10.
This case illustrates a common problem I see when treating these cases post ortho where the proper mesial/distal space exists along with adequate width but there is often “excess” vertical. I use this when I lecture to residents to illustrate the need to prepare a site even when “adequate bone” exists. Here a “saddle” was created to mimic natural architecture/ contour of the CEJ prior to implant placement.
Quite often we see the results of such simple cases where the fixture is simply placed crestal and the result is a short clinical crown resting on an implant. After implant placement I placed a buccal “contour” graft utilizing bovine particulate. I will search for post op photos, but as I came across this in preparation for a lecture I thought the concept was worth posting as it is extremely common and easy to over simplify with a well placed crestal implant placement that will result in aesthetic compromise.
18 Comments on Congenitally Missing Maxillary Lateral Incisor considerations…
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Sean Rayment
12/28/2018
Tim that is an interesting case and you bring up a good point about having too much bone resulting in a short crown. I would love to see a full smile photo as it looks like this patient has very short teeth, likely due to some variation of altered passive eruption. My concern about removing the crestal bone to allow for a longer abutment, you will have more running room to create a better emergence profile, but without altering the tissue height of the anterior segment in total, you will still end up with a short crown. Altering only the tissue height in the #10 position may create a bit of a black triangle on the distal of #9 if you also have to remove the interseptal bone. Thanks for sharing.
Richard Hughes, DDS
12/28/2018
I have removed bone by scalloping the crest to the level of the adjacent teeth.
This will yield a more esthetic restoration with proper crown height.
Carlos Boudet, DDS DICOI
12/28/2018
Sometimes these cases are best treated temporarily with acid etched bridges. The patient shows short crowns, maybe altered passive eruption, and would look much better if the crowns had the correct proportions (golden proportions) of crown height vs width.
Many times these patients request a smile makeover and an implant placed before healing from a crown lengthening procedure can be a problem if it is placed too coronally. Post restoration pictures would help.
Dennis Flanagan DDS MSc
12/28/2018
This case could have also been treated with a 2.5X15mm implant with less risk for root contact and more bone to encase the implant. Of course, there can be no occlusal contact.
Dorian Hatchuel
2/16/2019
Is the 2.5mm implant a one piece implant? If not, who makes such a small two piece implant?
Frank Celenza DDS
12/28/2018
That's an interesting thought, I treat a lot of these cases both as an orthodontist and periodontist, well done
Dok
12/28/2018
Crowns look short from two perspectives. 1) Cervical mismatch with scalloping against the adjacent teeth and 2) cervical to incisal edge inequality. If the scalloping looks uniform ( in similar proximity to the scalloping on the adjacent teeth ) then it is the buccal length that may need to be addressed. In this case ( from what I can see), enameloplasty on the centrals ( to shorten them a bit ) along with a veneer on the canine ( to lengthen it a bit ) may create better overall symmetry. Without surgical intervention, mismatches in scalloping ( assuming a high smile line ) can be address with some form of ceramic ridge lapping on the facial of the implant crown. Would only do this on a patient with impeccable home care and no history of periodontitis ( even no history of it in the immediate family ).
Doc
12/28/2018
Any concerns with placing an implant in a 17 year old female? I have seen a lot of these implants several years later when the patient is in their late 20s and early 30s where they are disappointed with the shorter crown due to continued jaw development. In hindsight, would you have waited a bit longer for this pt before placing this implant, ie. 21+?
Timothy C Carter
12/28/2018
This patient was 20 y/o at the time of treatment I suspect most of the disappointed patients had the implants placed at the crest without any scalloping.
Sergio
12/28/2018
This really is one of the cases for mini implant.
With very light to no occlusion, a mini wouldve decreased any potential damages to adjacent roots and surgical complexity quite a bit. OPs treatment works, of course, but a result with good long term prognosis could ve been reached with a simple surgery with a mini.
HASAN BASHIR
12/28/2018
Roots of # 9 and # 11 are converging, things will be lot better if orthodontist might have observed root parallelism and tipped the roots of above said teeth to their right place . I have seen confirmed relapse in these conditions as crowns always postorthodontic treatment teeth will try to follow root tips . This situation might be more clear in OPG. If this is not a case of immediate loading , space maintainer is must in this case .
Paul
12/28/2018
The proximity to adjacent teeth may end up a problem in near future. Natural teeth do not like to be that close (not because they get along with their neighbor) but because of bone physiology. If 9 and 11 were somewhat moved a relapse can potentially bring the implant even closer to the adjacent roots. In the end one ends up with a lot of space because of loss of 9 and 11.
dr.tawfik
12/29/2018
Interesting case! You did not show us how was it after final restoration nor how does it look now (after 3 years). what size implants did you place? I agree with others that they are too close to adjacent teeth, although no measurements have been mentioned here. did you discuss alternative treatment options?
In my opinion, it does carry a risk. however, as long as the patient is informed about the potential risks and all the +ve & -ve effects, I guess is Ok.
good luck
Frank Celenza DDS
12/29/2018
My experience with retaining orthodontically positioned teeth., over a few years, as in waiting for maturation, is that it had better be fixed retention. Removable retainers with pontic teeth work fine for holding intercoronal distance, and although compliance is high (owing to pontics), but the roots relapse and will encroach on the implant site, usually requiring ortho retreat.
CRS
12/29/2018
Hard to say without final restoration but patient seems to have delayed passive eruption of the maxillary adjacent teeth. Scalloping just the implant doesn’t do much if the adjacent teeth crown lengths are not addressed the tissue just reattaches. An implant is not a tooth. Sequencing is tricky. So the implant crown matches the adjacent teeth which is probably better than a long implant crown. Perhaps addresses the ideal final gingival heights with esthetic crown lengthening prior to final implant restoration, A provisional implant crown can be used to guide soft tissue . I don’t bother scalloping the interproximal bone height is determined by the adjacent teeth and the labial bone will resort.This problem could have been addressed with a diagnostic wax up and serial cephs or wrists films to determine if growth is complete. Hopefully it was. I don’t recommend placing any implants until growth is complete. The tip off is the gingival margins on the canine “short “ crown. Interesting case please post photo of current crowns. Thanks
Dennis Flanagan DDS MSc
12/29/2018
There is some evidence that in a minority of females there can be continued maxillary growth to age 25. I may have been better to wait the 4 years and use bonded temporary with subsequent 2.5X15 implant.
Paul Ouellette aka Dr O
12/30/2018
Thank you for posting your case! For the last 10 years as an AAID implant trained orthodontist, I have been working on a better solution for lateral genesis cases. There does not seem to be an ideal way of maintaining lateral implant sites without placing some sort of mini implant or bucortical bone screws to maintain bone. Often the patient requires repeat of their orthodontic treatment as adjacent roots relax and patients do not comply wearing removal retainers. There are also problems with resin bonded bridges. If a fixture is not placed the bone will continue to resorb and bone grafting will be required prior to placing implants at a later age. Refer to my website www.tadplant.com for more information and research articles that support a new concept using hybrid provisional dental implants that are easily removed and replaced 4 or more years later. The maxilla is a moving target.!! Patients continue to grow into their 30s. Ref: Behrents.....I look forward to group comments and your suggestions for treating these cases.
Greg Kammeyer, DDS, MS, D
1/2/2019
Altered passive eruption in that whole quad....likely generalized. The central looks like a butter paddle. You have the right idea yet about the one site yet need to address the overall problem if aesthetics is a factor.
