Our previous blog article discussed the timing of dental implants in the growing young patient. By understanding the complex interactions between the human dentition and its continued state of growth in the young patient, one can properly plan and place dental implants. This article will discuss the management of the congenitally (at birth) missing lateral incisor (front permanent tooth).
Most adults have thirty-two permanent teeth. However, about 20% of adults have hypodontia—the scientific term for congenitally missing teeth. Hypodontia occurs when a tooth fails to develop its normal tooth bud. The condition is often genetically linked and can be observed in several family members. According to epidemiological studies, one or both of the maxillary lateral incisors are congenitally missing in approximately 2% of the population.1 The congenitally missing lateral incisor is often recognized in the early mixed dentition.
The patient with a congenitally missing upper lateral incisors will present with a complex set of challenges. In order to achieve an optimal esthetic and functional result, it is often necessary to establish a coordinated, multi-disciplined approach involving an orthodontist, prosthodontist and periodontist. The first step is careful assessment and evaluation of the eruption pattern of the permanent canine. When a permanent tooth fails to erupt into the dental arch, it will result in narrower ridge width. It is ideal for the orthodontist to guide the eruption of the larger permanent canine tooth into the space of the missing permanent lateral incisor. Because of its larger root, it will naturally create a much thicker ridge dimension. Once the canine has erupted, the orthodontist has the option to move the tooth back to its natural position, leaving behind an augmented (thicker) ridge.2,3 Another critical aspect is to properly position the front teeth in a vertical manner and to allow adequate space for a bonded restoration 4 and possible future dental implant.
After the orthodontist has created space for the lateral incisor, there are several restorative options for the replacement of the missing lateral incisors. The 2 main options are the resin-bonded fixed partial denture (Maryland Bridge) and single-tooth dental implants (after growth is achieved). A conservative fixed treatment option for the growing, young patient is a MD bonded bridge (Pictures 1-3).
The dental implant option (Pictures 4,5) will serve as the gold standard to replace single missing teeth. However, they should be placed after facial growth has been determined to be completed. One method to evaluate the completion of facial growth is to take serial cephalometric radiographs 6 months to 1 year apart.5 The added benefit of using a bonded bridge approach first, is the fact that it can be removed and re-bonded during the implant healing process, so that the patient is never left without a missing front tooth.
By understanding the interactions between the human dentition and its continued state of dynamic change, one can appreciate the treatment challenges of managing missing teeth. Both Drs. Prestipino and Sfondouris routinely coordinate treatment with orthodontists and pediatric dentists at an early age, to ensure a long-term cosmetic and functional tooth replacement that is planned effectively.
1.Polder BJ. A meta-analysis of the prevalence of dental agenesis of permanent teeth. Community Dent Oral Epidemiol. 2004;32:217-226.
2.Kokich VG. Maxillary lateral incisor implants: planning with the aid of orthodontics. Int J Oral Maxillofac Surg. 2004;62:48-56.
3.Ostler MS, Kokich VG. Alveolar ridge changes in patients congenitally missing mandibular second premolars. J Prosthet Dent. 1994;71:144-149
4. Creugers NH, Kayser AF, Van’t Hof MA. A seven-and-a-half-year survival study of resin-bonded bridges. J Dent Res. 1992;71:1822-1825.
5. Fudalej P: Determining the cessation of facial growth to facilitate implant placement. Master’s Thesis. University of Washington, Department of Orthodontics. Seattle, WA 1998