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ePaper created 2017-03-17, 11:08:54 | version 1.38.0
I m p l a n t a n d o r t h o d o n t i c t r e a t m e n t Introduction Congenital tooth agenesis is a common dental anomaly, with reported incidences of 2.7% to 12.2%, excluding third molars. In the permanent dentition, maxillary lateral incisors are the most commonly afected,1 with a prevalence rate of between 1% and 4%2 and a female predomi- nance of approximately 2:1 compared with males.3 This anomaly is not usually an isolated phenomenon, but is associated with other den- tal anomalies, such as peg-shaped contralater- al incisors.1 Therefore, the concurrence of sev- eral dental anomalies in the same subject results in functional and esthetic problems, which may in turn afect the patient’s self-confidence and social relationships from a very young age. Treatment options for missing lateral incisors include space opening, followed by the place- ment of a conventional fixed bridge or a sin- gle-unit implant-supported crown, and ortho- dontic space closure with anatomical recontouring of the canines.4 Selecting the most appropriate therapy is still a challenge. Numer- ous clinical characteristics must be analyzed, such as the patient’s age, occlusal relationships, profile, smile line, presence or absence of third molars, and size, shape and color of the canines.5 In order to maximize the esthetic and func- tional results, an interdisciplinary approach in- volving an orthodontist, an oral surgeon and a restorative dentist has become essential. Com- prehensive rehabilitation and natural esthetics with implant and orthodontics (CRANIO) is a philosophy based on interdisciplinary treat- ments to achieve stable occlusion and healthy hard and soft tissue and to enhance the natural esthetic appearance and subsequent patient satisfaction. The aim of the present study was to describe an interdisciplinary approach to a clinical case presenting with a missing maxillary lateral inci- sor treated in two phases: orthodontic space opening, followed by placement of a narrow 3 mm diameter implant and restored with a screw-retained lithium disilicate crown ve- neered on a zirconia abutment. Case report A 24-year-old Caucasian female was referred to our private clinic to seek a second opinion for treatment, with the chief complaint of an unat- tractive smile and the mobility of the primary maxillary right canine. Clinical examination and radiographs confirmed the advanced root re- sorption of the primary maxillary right canine, the agenesis of the permanent maxillary right lateral incisor, with the presence of the perma- nent canine in place of the lateral incisor, and microdontia of the maxillary left lateral incisor (Figs. 1a–c). Intraoral observation revealed an Angle Class II relationship of the molars and ca- nine, an increased overjet, a normal overbite and a lower dental midline that was displaced 3 mm to the left compared with the upper midline. Cephalometric analysis (Dolphin Imaging 11.7, Dolphin Imaging and Management Solu- tions, Chatsworth, Calif., U.S.) highlighted a mesofacial facial pattern, with a Class II sagittal skeletal relationship (Fig. 2). The patient pre- sented with a symmetrical and proportional face and flat facial profile, with the upper lip posi- tioned 4 mm and the lower lip 2 mm behind the Ricketts E-line. The previously proposed treatment was ex- traction of the primary canine with space main- tenance for a future implant rehabilitation and canine substitution with a veneer restoration. In contrast to this, the alternative treatment pro- posed was extraction of the primary canine, followed by orthodontic space recovery for im- plant placement in the lateral incisal area, with alignment and leveling of the dental arches. The option of correcting the Class II relationship would have required orthognathic surgery, which was refused by the patient. The patient was initially very skeptical to- ward such a comprehensive treatment option. However, after discussion with both the ortho- dontist (CL) and implantologist (MT) of the ad- vantages and disadvantages of all of the avail- able treatment options, it became clear to the patient that the overall advantages of the pro- posed interdisciplinary treatment, involving or- thodontic treatment, implant placement and prosthetic rehabilitation, would provide im- proved esthetic and functional results. The dis- advantages of the proposed treatment were related to costs and a longer treatment time. The orthodontic treatment lasted 18 months. After the extraction of the primary canine, full- arch bonding with a fixed esthetic multibracket appliance was performed, and the maxillary right canine was strategically bonded with a mesial tip back to enhance root control. Skeletal anchorage by means of an orthodontic minis- crew (Aarhus System, American Orthodontics, Sheboygan, Wisconsin, U.S.; 1.5 mm diameter, Journal of Oral Science & Rehabilitation Volume 3 | Issue 1/2017 09