case report orthodontic management of congenitally missing maxillary lateral incisors...

Case ReportOrthodontic Management of Congenitally Missing MaxillaryLateral Incisors A Case Report

Sergio Paduano1 Iacopo Cioffi2 Roberto Rongo2 Antonello Cupo3

Rosaria Bucci2 and Rosa Valletta2

1 Department of the Health University ldquoMagna Graeciardquo Catanzaro Viale Europa Localita Germaneto 88100 Catanzaro Italy2 Department of Neuroscience Section of Orthodontics University of Naples Federico II Via Pansini 5 80131 Naples Italy3 Private Practice Palomonte 84020 Salerno Italy

Correspondence should be addressed to Sergio Paduano paduanouniczit

Received 26 December 2013 Accepted 29 January 2014 Published 9 March 2014

Academic Editors P Lopez Jornet L J Oesterle and E F Wright

Copyright copy 2014 Sergio Paduano et alThis is an open access article distributed under the Creative CommonsAttribution Licensewhich permits unrestricted use distribution and reproduction in any medium provided the original work is properly cited

This case report describes the orthodontic treatment of a woman aged 15 years with permanent dentition brachyfacial typologywith congenitally missing maxillary lateral incisors Multibracket straightwire fixed appliance was used to open the space for dentalimplant placement and treat the impaired occlusion The missing lateral incisors were substituted with oral implants

1 Introduction

The management of missing lateral incisor requires an inte-grated multidisciplinary approach [1] Generally the choicebetween space opening with tooth replacement and spaceclosure with canine substitution relies on several parametersto be considered before treatment planning

Commonly the choice is related to occlusal relationship(ie overjet and overbite molar relationship) facial typologyand profile arch length and tooth size discrepancies Themorphology of the canine in terms of size and shape andits colour [2] also may address different treatment strategiesFinally patient expectation and compliance can influence thetreatment planning

In case of unilateral tooth agenesis space opening isoften recommended to improve the aesthetics of patients andpreserve smile symmetry On the contrary in case of bilateralagenesis space closure and space opening could be both per-formed with respect to the issues previously reported [3ndash6]

Space opening is advised in low-angle subjects whilst inhigh-angle individuals space closure should be preferred topreserve arch anchorage and avoid clock-wise rotation of thelower jaw Retruded profiles should be better treated withspace opening and tooth substitution in order to improvelabial sagittal relationships This treatment strategy should

be avoided in subjects with bimaxillary dental protrusion inwhich it could result in worsening of the profile

Molar relationship should be also considered Molarclass I or class III tendency should be better treated withspace opening to preserve ideal occlusal anterior andposterior relationship (ie canine and molar relationship)and establish a solid angle class I In case of full cusp orpartial molar class II space closure should be preferred tofacilitate orthodontic biomechanics and reduce treatmentduration A stable molar class II and canine class I are thenobtained However in case of arch length discrepanciesextractions in the lower arch should be considered thusobtaining a molar and canine class I

Anterior relationship that is overjet and overbite mustbe taken into account in terms of facilitation of biome-chanics Reduced overjet and increased overbite may easilybe improved by space opening mechanics whilst increasedoverjet and reduced overbite may benefit from space closure

Shape and size of canines affect the possible rehabilitationchoice Differently from cases with large canines in whichspace opening is advocated small canines can be easilytransformed in lateral incisors by using porcelain veneersor composite materials The original position of the canineshould be considered Teeth closer to the midline are bestcandidate for incisor substitution

Hindawi Publishing CorporationCase Reports in DentistryVolume 2014 Article ID 731074 7 pageshttpdxdoiorg1011552014731074

2 Case Reports in Dentistry

(a) (b) (c) (d)

Figure 1 Extraoral photographs before treatment

(a) (b) (c)

(d) (e) (f)

Figure 2 Intraoral photographs before treatment

The presence of third molars is an additional item sup-porting space closure mechanics Finally young individualsmay preferably be treatedwith space closure to avoid frequentprovisory prosthetic rehabilitation during adolescence

In this case report we describe the orthodontic treatmentof a girl aged fifteen years with permanent dentitionbrachyfacial typology with congenitally missing maxillarylateral incisors Multibracket straightwire fixed appliancealong with cantilever mechanics was used to open the

spaces for oral implant placement and treat the impairedocclusion according to the principles previously examinedThe missing lateral incisors were substituted with dentalimplants

2 Case Presentation

21 Diagnosis and Treatment Plan The extraoral and intrao-ral photographs of the patient are reported in Figures 1 and 2

Case Reports in Dentistry 3

SNA (∘)SNB (∘)A-N-Pg (∘)

SN^ANS-PNS ( ∘)SN^GoGn (∘)ANSPNS^GoGn (∘)

U1^ANS-PNS (∘)L1^GoGn (∘)L1 protrusion (L1-APo) (mm)

Overjet (mm)Overbite (mm)(U1^L1) (∘)

757

752

153

315

189

1167

934

15

37

30

1337

820

809

20

73

329

250

1100

900

10

25

30

1350

35

34

25

35

52

60

50

60

23

25

20

60

minus03

06

02

05

minus00

minus02

minus09

minus18lowast

minus17lowast

minus12lowast

minus10lowast

23lowastlowast

13lowast

Figure 3 Cephalometric values and panoramic radiograph at thestart of treatment From left to right value measured average valuefrom the population norm standard deviation of the average valuefrom the population norm and difference from the extreme valueof the population norm Blue values above the norm green valuesbelow the norm black values within the norm

The patient was 15 years old She presented this objectiveproblem list

(i) missing maxillary lateral incisors(ii) class I malocclusion(iii) presence of the deciduous maxillary right canine(iv) spacings in the left side(v) brachyfacial typology and retruded profile(vi) slight arch length discrepancies(vii) maxillary permanent canines close to midline(viii) slight deviation of the upper midline

She sustained a whiplash injury at the age of thirteendue to a car accident but she did not present signs orsymptoms of temporomandibular disorders according toResearch Diagnostic Criteria for Temporomandibular Disor-ders (RDCTMD) [7 8] Oral parafuctions such as clenchingwere present and taken into account because of a possiblerelation with muscle pain [9]

The cephalometric evaluation highlighted a brachifa-cial typology with a sagittal skeletal relationship of class I(Figure 3) The patient reported to have been treated at theage of 10 with a functional appliance (Sander Bite JumpingAppliance) to correct a skeletal class II malocclusion [10]

The treatment plan included the space opening ofmissinglateral incisors for implant placement and correcting herocclusion

A fixed multibracket appliance was placed to alignlevel and manage spacings of both upper and lowerdental arches Thermal Ni-Ti archwires were preferred toincrease patient compliance and reduce initial discomfort[11] The biomechanics and the progressive opening ofthe space for the maxillary lateral incisors are showed inFigure 4

Initially a 03610158401015840 stainless steel transpalatal arch wasmodelled to correct molar rotations and to obtain additionalanchorage Later compressed springs were applied to thisappliance to obtain further proclination of the upper incisors[12]

Alignment of both dental arches was achieved by usingmultibracket appliance (Roth prescription slot size 02210158401015840times02810158401015840 with heat activated Ni-Ti archwires (round 01410158401015840 andround 01610158401015840) Transbond XT (3M Unitek Monrovia US)adhesive primer was used for its strength [13] following theinstructions of the manufacturer

After aligning the cuspids distalization was obtained byusing interarches and intra-arch elastics on a round 01810158401015840AJ Wilcock Australian wire (regular + GampH OrthodonticsFranklin IN US) The anchorage was preserved by plac-ing the elastics between upper molars and canines duringdaytime and between lower molars and upper canines atnighttime This pattern was easily accepted by the patientsbecause during daytime the elastics were not visible Supere-lastic coil springs for gaining space for maxillary lateralincisors were avoided in order to preserve the initialoverjet

The distalization of the canines resulted in a slightdistopalatal rotation and a distal tip of the crowns Thedistopalatal rotations were corrected by using a 01910158401015840 times 02510158401015840TMA sectional determining Burstonersquos 6th Geometry [14] sothat an ideal rotational effect was obtainedwithout horizontalundesirable movements To further obtain root uprightingand achieve an ideal placement of the roots for a propersite for implant rehabilitation two cantilevers were used andapplied to the central incisors segment This allowed also fora better control of the overbite The correction of midlinediscrepancy was mainly obtained by using a stainless steel02110158401015840 times 02510158401015840 power arm positioned on the central incisorsand shaped so that the force was applied close to the centerof resistance of both teeth This was finally attached withan elastomeric ligature to a TMA 01910158401015840 times 02510158401015840 cantileverinserted in the auxiliary buccal gingival tube of the band ofthe first left maxillary molar

The anchorage for proper biomechanics was obtained byusing full size stainless steel wires and a passive transpalatalarch

The treatment lasted approximately thirtymonthsThere-after the patient was referred to the oral surgeon for the posit-ing of the implants The intraoral and extraoral photographsat the end of orthodontic treatment are presented in Figures5ndash7

Bone grafts from the extraction site of the lower leftwisdom tooth were inserted by piezoelectric surgery in themaxillary lateral incisors sites The grafts were fixed by usingosteosynthesis screws in the implant sites and covered byabsorbable membranes


(a) (b)

(c) (d)

(e) (f)

(g)

Figure 4 Progressive space opening for themaxillary lateral incisors ((a)ndash(f))The distopalatal rotations of the canines were further correctedby using a 01910158401015840 times 02510158401015840 TMA sectional determining Burstonersquos 6th Geometry (g)

Intralock (Boca Raton Fl US) implant 34mm diameter11mm length was used Provisory Maryland bridges wereapplied to preserve facial and smile aesthetics After 6months gold abutments were fixed with alumina-zirconiacrowns (Figure 6)

3 Discussion

The major objectives of the treatment were achieved Molarand canine class I relationship was achieved with overjetand overbite within the norms The panoramic radiograph


(a) (b) (c)

(d) (e) (f)

Figure 5 Intraoral photographs after treatment before implant positioning

(a) (b) (c)

(d) (e) (f)

Figure 6 Intraoral photographs after prosthetic rehabilitation


(a) (b) (c) (d)

Figure 7 Extraoral photographs after treatment




Overjet (mm)Overbite (mm)Angolo interincisivo (U1^L1) (∘)

794

763

13

145

320

201

1158

1069

32

09

minus01

1198

820

809

20

73

329

250

1100

900

10

25

30

1350

35

34

25

35

52

60

50

60

23

25

20

60

minus08

minus03

minus02

minus08

minus06

minus13lowast

21lowastlowast

12lowast

28lowastlowast

10lowast

minus15lowast

minus25lowastlowast

Figure 8 Cephalometric values just before the end of treatment and panoramic radiograph before final debonding and after implantplacement From left to right value measured average value from the population norm standard deviation of the average value from thepopulation norm and difference from the extreme value of the population norm Blue values above the norm green values below the normblack values within the norm


shows a good radicular parallelism and no signs of rootresorption (Figures 6 7 and 8) The clinical examination ofthe masticatory muscles and temporomandibular joints didnot show any pathological signs or symptoms at completionof treatment

The cantilever mechanics [15] allowed a correct reposi-tioning of the roots of the maxillary incisors

Conventional brackets were used because it has beensuggested that self-ligating brackets are critical for obtainingan adequate torque control [16] Also we used heat activatedNi-Ti archwires to reduce patient discomfort [11]

The results achieved were maintained during the reten-tion period by means of a fixed lingual 33ndash43 retainer Theresults achieved were substantially maintained at posttreat-ment control Occlusal relationship and dental alignmentwere stable

Conflict of Interests

The authors declare that there is no conflict of interestsregarding the publication of this paper

References

[1] L Savarrio and G T McIntyre ldquoTo open or to close spacemdashthat is the missing lateral incisor questionrdquo Dental Update vol32 no 1 pp 16ndash25 2005

[2] S Wriedt P Werner and H Wehrbein ldquoTooth shape and coloras criteria for or against orthodontic space closure in case of amissing lateral incisorrdquo Journal of Orofacial Orthopedics vol 68no 1 pp 47ndash55 2007

[3] MRosa andBU Zachrisson ldquoThe space-closure alternative formissingmaxillary lateral incisors an updaterdquo Journal of ClinicalOrthodontics vol 44 no 9 pp 540ndash561 2010

[4] G Richardson and K A Russell ldquoCongenitally missing maxil-lary lateral incisors and orthodontic treatment considerationsfor the single-tooth implantrdquo Journal of the Canadian DentalAssociation vol 67 no 1 pp 25ndash28 2001

[5] B J Millar andN G Taylor ldquoLateral thinking themanagementofmissing upper lateral incisorsrdquoBritishDental Journal vol 179no 3 pp 99ndash106 1995

[6] E Argyropoulos and G Payne ldquoTechniques for improvingorthodontic results in the treatment of missingmaxillary lateralincisors A case report with literature reviewrdquo American Journalof Orthodontics and Dentofacial Orthopedics vol 94 no 2 pp150ndash165 1988

[7] S F Dworkin and L LeResche ldquoResearch diagnostic criteria fortemporomandibular disorders review criteria examinationsand specifications critiquerdquo Journal of Craniomandibular Dis-orders vol 6 no 4 pp 301ndash355 1992

[8] I Marini S Paduano M L Bartolucci F Bortolotti and GA Bonetti ldquoThe prevalence of temporomandibular disorders inpatients with late whiplash syndrome who experience orofacialpain a case-control series studyrdquo Journal of the AmericanDentalAssociation vol 144 no 5 pp 486ndash490 2013

[9] A Michelotti I Cioffi P Festa G Scala and M Farella ldquoOralparafunctions as risk factors for diagnostic TMD subgroupsrdquoJournal of Oral Rehabilitation vol 37 no 3 pp 157ndash162 2010

[10] R Martina I Cioffi A Galeotti et al ldquoEfficacy of the Sanderbite-jumping appliancein growing patients with mandibular

retrusion a randomized controlled trialrdquoOrthodontics amp Cran-iofacial Research vol 16 no 2 pp 116ndash126 2013

[11] I Cioffi A Piccolo R Tagliaferri S Paduano A Galeottiand R Martina ldquoPain perception following first orthodonticarchwire placementmdashthermoelastic vs superelastic alloys arandomized controlled trialrdquo Quintessence International vol43 no 1 pp 61ndash69 2012

[12] S Paduano G Spagnuolo G di Biase and I Cioffi ldquoTreatmentof a class II division 2 patient with severe skeletal discrepancyby using a custom made TPA proclination springrdquo The OpenDentistry Journal vol 20 no 7 pp 109ndash117 2013

[13] R Valletta D Prisco R De Santis L Ambrosio andRMartinaldquoEvaluation of the debonding strength of orthodontic bracketsusing three different bonding systemsrdquo European Journal ofOrthodontics vol 29 no 6 pp 571ndash577 2007

[14] C J Burstone and H A Koenig ldquoForce systems from an idealarchrdquo American Journal of Orthodontics vol 65 no 3 pp 270ndash289 1974

[15] S Paduano G Spagnuolo G Franzese G Pellegrino RValletta and I Cioffi ldquoUse of cantilevermechanics for impactedteeth case seriesrdquoTheOpenDentistry Journal vol 7 pp 186ndash1972013

[16] S Paduano I Cioffi G Iodice A Rapuano and R SilvaldquoTime efficiency of self-ligating vs conventional brackets inorthodontics effect of appliances and ligating systemsrdquo Progressin Orthodontics vol 9 no 2 pp 74ndash80 2008

Submit your manuscripts athttpwwwhindawicom

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Oral OncologyJournal of

DentistryInternational Journal of



International Journal of

Biomaterials


BioMed Research International


Case Reports in Dentistry


Oral ImplantsJournal of


Anesthesiology Research and Practice


Radiology Research and Practice

Environmental and Public Health

Journal of


The Scientific World JournalHindawi Publishing Corporation httpwwwhindawicom Volume 2014


Dental SurgeryJournal of

Drug DeliveryJournal of



Oral DiseasesJournal of


Computational and Mathematical Methods in Medicine

ScientificaHindawi Publishing Corporationhttpwwwhindawicom Volume 2014

PainResearch and TreatmentHindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Preventive MedicineAdvances in


EndocrinologyInternational Journal of



OrthopedicsAdvances in


(a) (b) (c) (d)

Figure 1 Extraoral photographs before treatment

(a) (b) (c)

(d) (e) (f)

Figure 2 Intraoral photographs before treatment

The presence of third molars is an additional item sup-porting space closure mechanics Finally young individualsmay preferably be treatedwith space closure to avoid frequentprovisory prosthetic rehabilitation during adolescence

In this case report we describe the orthodontic treatmentof a girl aged fifteen years with permanent dentitionbrachyfacial typology with congenitally missing maxillarylateral incisors Multibracket straightwire fixed appliancealong with cantilever mechanics was used to open the

spaces for oral implant placement and treat the impairedocclusion according to the principles previously examinedThe missing lateral incisors were substituted with dentalimplants

2 Case Presentation

21 Diagnosis and Treatment Plan The extraoral and intrao-ral photographs of the patient are reported in Figures 1 and 2






757

752

153

315

189

1167

934

15

37

30

1337

820

809

20

73

329

250

1100

900

10

25

30

1350

35

34

25

35

52

60

50

60

23

25

20

60

minus03

06

02

05

minus00

minus02

minus09

minus18lowast

minus17lowast

minus12lowast

minus10lowast

23lowastlowast

13lowast
















(a) (b)

(c) (d)

(e) (f)

(g)



3 Discussion



(a) (b) (c)

(d) (e) (f)


(a) (b) (c)

(d) (e) (f)



(a) (b) (c) (d)






794

763

13

145

320

201

1158

1069

32

09

minus01

1198

820

809

20

73

329

250

1100

900

10

25

30

1350

35

34

25

35

52

60

50

60

23

25

20

60

minus08

minus03

minus02

minus08

minus06

minus13lowast

21lowastlowast

12lowast

28lowastlowast

10lowast

minus15lowast

minus25lowastlowast









References

























Biomaterials












Journal of
























757

752

153

315

189

1167

934

15

37

30

1337

820

809

20

73

329

250

1100

900

10

25

30

1350

35

34

25

35

52

60

50

60

23

25

20

60

minus03

06

02

05

minus00

minus02

minus09

minus18lowast

minus17lowast

minus12lowast

minus10lowast

23lowastlowast

13lowast
















(a) (b)

(c) (d)

(e) (f)

(g)



3 Discussion



(a) (b) (c)

(d) (e) (f)


(a) (b) (c)

(d) (e) (f)



(a) (b) (c) (d)






794

763

13

145

320

201

1158

1069

32

09

minus01

1198

820

809

20

73

329

250

1100

900

10

25

30

1350

35

34

25

35

52

60

50

60

23

25

20

60

minus08

minus03

minus02

minus08

minus06

minus13lowast

21lowastlowast

12lowast

28lowastlowast

10lowast

minus15lowast

minus25lowastlowast









References

























Biomaterials












Journal of




















(a) (b)

(c) (d)

(e) (f)

(g)



3 Discussion



(a) (b) (c)

(d) (e) (f)


(a) (b) (c)

(d) (e) (f)



(a) (b) (c) (d)






794

763

13

145

320

201

1158

1069

32

09

minus01

1198

820

809

20

73

329

250

1100

900

10

25

30

1350

35

34

25

35

52

60

50

60

23

25

20

60

minus08

minus03

minus02

minus08

minus06

minus13lowast

21lowastlowast

12lowast

28lowastlowast

10lowast

minus15lowast

minus25lowastlowast









References

























Biomaterials












Journal of




















(a) (b) (c)

(d) (e) (f)


(a) (b) (c)

(d) (e) (f)



(a) (b) (c) (d)






794

763

13

145

320

201

1158

1069

32

09

minus01

1198

820

809

20

73

329

250

1100

900

10

25

30

1350

35

34

25

35

52

60

50

60

23

25

20

60

minus08

minus03

minus02

minus08

minus06

minus13lowast

21lowastlowast

12lowast

28lowastlowast

10lowast

minus15lowast

minus25lowastlowast









References

























Biomaterials












Journal of




















(a) (b) (c) (d)






794

763

13

145

320

201

1158

1069

32

09

minus01

1198

820

809

20

73

329

250

1100

900

10

25

30

1350

35

34

25

35

52

60

50

60

23

25

20

60

minus08

minus03

minus02

minus08

minus06

minus13lowast

21lowastlowast

12lowast

28lowastlowast

10lowast

minus15lowast

minus25lowastlowast









References

























Biomaterials












Journal of


























References

























Biomaterials












Journal of


























Biomaterials












Journal of



















case report orthodontic management of congenitally missing maxillary lateral incisors...

Documents