Conservative interdisciplinary management for a congenitally missing maxillary lateral incisor in an adolescent patient

Abstract

A congenitally missing lateral incisor tooth is commonly associated with both short and long-term clinical dilemmas, particularly for a growing patient. A unilaterally missing maxillary lateral incisor tooth creates a significant dental asymmetry in the critical aesthetic zone of the smile and potentially increases the difficulty of any subsequent orthodontic and restorative treatment. Carefully planned interdisciplinary management is required to address the challenges of anterior dental asymmetry, unilateral orthodontic space closure and to alleviate the concerns that accompany restorative implant placement in the anterior maxilla. The use of skeletal temporary anchorage devices has increased the predictability of orthodontic space closure, particularly for missing maxillary lateral incisor cases which were previously considered to be unsuitable.

Keywords: Interdisciplinary management; adolescent patient; congenitally missing maxillary lateral incisor; critical aesthetic zone; temporary anchorage devices.

Fig. 1

(a–f) Pre‐treatment photographs of a 15‐year‐old patient with a presenting concern regarding the appearance of the maxillary anterior teeth, particularly the intra‐arch spacing. The 12 was diminutive in size, and the 22 appeared to be congenitally absent. The maxillary dental midline was located 3 mm to the left side of the facial midline and the mandibular dental midline.

Fig. 2

(a) The panoramic radiograph revealed that the root morphology of the 12 was satisfactory and confirmed that the 22 was congenitally missing. The maxillary and mandibular third molars were present and in the crown stage of development. (b) The lateral cephalograph revealed a mild Class II skeletal base relationship with mesofacial vertical facial proportions.

Fig. 3

(a) A 2.3 mm (diameter) × 11.0 mm (length) non‐osseointegrating palatal TAD (PSM Medical Solutions, Tuttlingen, Germany) in the slow‐speed handpiece prior to placement in the mesial aspect of the palate (b) The 2 palatal TADs were placed slightly lateral to mid‐palatal suture in a mesial and distal orientation. The distal TAD dimensions were 2.3 mm (diameter) × 9.0 mm (length). (c) Nickel–titanium superelastic closed coil spring was placed on the Mesial‐slider® to commence orthodontic space closure in the maxillary arch (d) At 11 months into active treatment, a distalizing component utilizing a compressed push coil spring was placed on the right‐side of the TAD appliance to facilitate correction of the maxillary dental midline position and improve the posterior occlusion on the right‐side. (e) At 18 months into treatment, additional space had been opened in the first quadrant to improve the position of the maxillary dental midline. (f) At 22 months into treatment, the residual space had been closed in the first quadrant and the Mesial‐slider® appliance was removed. The composite resin restorations were then performed for the maxillary anterior teeth. (g) After 26 months, the orthodontic appliances were removed. The mesial and distal TADs were also removed at this time under a local anaesthetic.

Fig. 4

(a–i) This series of progress maxillary arch occlusal photographs demonstrate the alignment and relocation of the maxillary anterior teeth (a) 1 month (b) 11 months (c) 18 months (d) 22 months – the maxillary anterior brackets and maxillary archwire were removed immediately prior to the composite resin restorations being performed (e,f) 22 months – immediately after the composite resin restorations were performed (g) 22 months – immediately after replacing the maxillary anterior brackets and maxillary archwire (h) 24 months (i) 26 months, following removal of the orthodontic appliances.

Fig. 5

(a) A progress panoramic radiograph taken at 19 months demonstrated pleasing root parallelism of the maxillary anterior teeth, which confirmed that the composite restorations could be performed. (b) The lateral cephalograph taken at 19 months revealed acceptable incisor angulations and a positive anterior overjet despite the significant orthodontic space closure in the maxillary arch.

Fig. 6

The patient was reviewed 15 months after the completion of active orthodontic treatment. A small space had re‐opened between the 23 and 24, however, this could be potentially remedied with a slightly wider restoration for the 24. The maxillary midline had relapsed 1 mm to the left‐side, however, this minor movement is not expected to not result in any significant aesthetic or functional compromise. The 28 had erupted clinically into functional contact with the opposing arch.

Fig. 7

A panoramic radiograph taken 15 months after the completion of active orthodontic revealed the dimensions of the composite restorations placed on the 12, 23 and 24. The 28 had erupted clinically, which is a favourable result following the significant mesial movement of the maxillary posterior teeth in the second quadrant. In contrast, the 18, 38 and 48 appear unlikely to erupt and may require future removal.