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Missing Lateral
Missing Lateral
Missing Lateral
Agenesis of maxillary lateral incisors can be treated either by closing the space and substituting the canines for
the missing lateral incisors or, in adults, by replacing the missing teeth with fixed prosthetics or implants. This
article illustrates a method that can be used for a semipermanent implant replacement of the missing incisors
in adult patients. An Aarhus mini-implant was inserted perpendicular to the palatal mucosa of the alveolar pro-
cess of the edentulous area. A pontic was made at chair side of composite material around a stainless steel wire
extending from the mini-implant. This replacement approach allowed for the vertical development of the alveolar
process and maintained the bone density and morphology of the alveolar process. Five years after placement,
periapical radiographs showed that the alveolar process was following the vertical development related to the
eruption of the adjacent teeth, and that the morphology and the bone density were maintained, making the later
insertion of a dental implant possible without additional surgical buildup. (Am J Orthod Dentofacial Orthop
2017;151:989-94)
A
genesis of maxillary lateral incisors occurs with a ongoing growth-related development of the alveolar
variable prevalence in different ethnic groups. process.4,5 The effect of the vertical alveolar
According to Bozga et al,1 the range is 2.2% to development was at the beginning underestimated;
10.1%, whereas most analyses report a prevalence be- consequently, the recommended timing for insertion of
tween 6% and 8%. According to a PubMed advanced permanent replacements has repeatedly been postponed.
search, the first reports dealing with missing maxillary Although several attempts have been made, a
lateral incisors focused on their prevalence and etiol- consensus regarding space closure or space maintenance
ogy.2,3 The treatment options were limited to space with later replacement has not been reached.6,7 An
closure or fixed prosthodontic bridges involving explanation may be the interaction of many individual
invasive preparation of abutment teeth. With the factors such as facial morphology, tooth morphology,
introduction of bonding materials and later of lip length, and function, each of which has an
implants, replacements with less or no preparation of important impact on the decision. Although the trend
the neighboring teeth were possible. The introduction has been to recommend space closure, in patients
of temporary anchorage devices (TADs) also made where the replacement solution has been chosen, there
space closure easier, but in some patients the facial is a need for a temporary replacement until maturity
profile indicated that replacement would be the best has been reached.
treatment. Yet, a problem remained in relation to the The options frequently described have been a remov-
a
Private Practice, Recanati, Italy. able plate with a tooth replacing the missing tooth and a
b
Department of Orthodontics, Klinik f€ ur Kieferorthopedie Medizinische Hoch- bonded bridge with or without preparation of adjacent
shule, Hannover, Germany; Department of Orthodontics, University of Western teeth. The disadvantage of the removable plate is obvi-
Australia, Perth, Western Australia, Australia; Department of Orthodontics, Ken-
tucky University, Lexington, Ky. ously the required compliance in addition to the contin-
The first author has completed and submitted the ICMJE Form for Disclosure of uous coverage of the palatal mucosa. In relation to the
Potential Conflicts of Interest, and none were reported. The second author is a bonded bridge, occlusal contacts on the adjacent teeth
consultant for American Orthodontics, which sells the screws.
Address correspondence to: Birte Melsen, Holtevej 11, Aarhus C DK-8000, may have a negative influence, hampering the stability
Denmark; e-mail, birte@melsen.com. or making invasive preparation necessary. As an alterna-
Submitted, May 2016; revised and accepted, December 2016. tive, TADs have recently been suggested as temporary re-
0889-5406/$36.00
Ó 2017 by the American Association of Orthodontists. All rights reserved. placements. This may, on the other hand, lead to another
http://dx.doi.org/10.1016/j.ajodo.2016.12.012 problem because TADs, although not surface prepared as
989
990 Ciarlantini and Melsen
May 2017 Vol 151 Issue 5 American Journal of Orthodontics and Dentofacial Orthopedics
Ciarlantini and Melsen 991
Fig 1. Technique step by step: A, inserting the screw; B, bending the wire. Note that the wire must be
bent where it is inserted into the bracket head of the mini-implant because this bend reduces the forces
acting on the ligature; C and D, buildup of the pontic; E, polishing; F, ligating the sectional wire to the
screw.
Gingival impingement can occur when the adjacent head of the mini-implant. Without a bend in the wire al-
teeth erupt more than the distance between the pontic lowing for adjustment, a new pontic may be necessary.
and the mucosa; this was seen at visits of 2 patients. An example of gingival impingement is seen in
Moving the pontic more occlusally by straightening Figure 4, D, on the right side.
the wire connecting the pontic with the mini-implant
alleviated this impingement. A small V-bend on the DISCUSSION
wire when constructing the pontic allowed for the In patients with agenesis of maxillary incisors, 1 solu-
adjustment without removal of the wire from the bracket tion is to open space orthodontically for a later
American Journal of Orthodontics and Dentofacial Orthopedics May 2017 Vol 151 Issue 5
992 Ciarlantini and Melsen
Fig 3. Postorthodontic treatment intraoral radiographs: A, patient 1; B and C, patient 2, right and left
sides.
replacement with an implant. However, the maintenance development of the alveolar process. The idea was
of this space is not without problems, one being to allow born when a TAD that had served as anchorage for
for the vertical development of the alveolar process when mesialization of a molar in a patient with agenesis of
the adjacent teeth are erupting, and another to maintain all mandibular premolars was unintentionally left
the width necessary for the planned dental implant. behind on 1 side in the edentulous area corresponding
Several studies have demonstrated significant decreases to the first premolar.10 An additional observation was
in the width and height of the alveolar ridge in patients made in a patient with agenesis of both maxillary lateral
with congenitally missing maxillary lateral incisors who incisors, where a horizontally placed mini-implant had
had orthodontic treatment to create space for a dental served as anchorage only on 1 side. The hypothesis
implant.8,9 In this clinical report, a method for a was further supported by a dog experiment demon-
semipermanent replacement of a missing maxillary strating that a horizontally placed TAD could prevent
lateral incisor has been described. A TAD placed alveolar atrophy of an extraction space.10
parallel to the occlusal plane has been suggested. In The mini-implants inserted from the palatal side
contrast to TADs placed perpendicular to the occlusal serving as support for the pontics were not used as
plane, this position does not prevent the vertical anchorage for tooth movement but were loaded
May 2017 Vol 151 Issue 5 American Journal of Orthodontics and Dentofacial Orthopedics
Ciarlantini and Melsen 993
Fig 5. Intraoral radiographs at the 5-year follow-up: A, patient 1; B and C, patient 2, right and left sides.
American Journal of Orthodontics and Dentofacial Orthopedics May 2017 Vol 151 Issue 5
994 Ciarlantini and Melsen
dental implants.” Cope and McFadden12 supported the 3. Woolf CM. Missing maxillary lateral incisors: a genetic study. Am J
same statement when they presented 2 cases in which Hum Genet 1971;23:289-96.
4. Thilander B, Odman J, Jemt T. Single implants in the upper
they found no infraocclusion at the follow-up observation.
incisor region and their relationship to the adjacent teeth. An
However, in 1 case, in the follow-up x-rays, a minor lack of 8-year follow-up study. Clin Oral Implants Res 1999;10:
vertical development of the bone in the area where the 346-55.
screw was inserted can be noticed. 5. Thilander B, Odman J, Lekholm U. Orthodontic aspects of the use
The discrepancy between those who observe arrested of oral implants in adolescents: a 10-year follow-up study. Eur J
Orthod 2001;23:715-31.
vertical development and those who do not is explained
6. Kokich VO Jr, Kinzer GA, Janakievski J. Congenitally missing
by the difference in growth pattern and the short obser- maxillary lateral incisors: restorative replacement [Point/
vation period, since the rate of vertical development is Counterpoint]. Am J Orthod Dentofacial Orthop 2011;139:
both small and variable. 435-45.
Mini-implants with a small diameter may, on the 7. Zachrisson BU, Rosa M, Toreskog S. Congenitally missing maxillary
lateral incisors: canine substitution [Point/Counterpoint]. Am J
other hand, not be able to withstand occlusal forces,
Orthod Dentofacial Orthop 2011;139:434-44.
and the risk of miniscrew fracture can increase or 8. Uribe F, Chau V, Padala S, Neace WP, Cutrera A, Nanda R. Alveolar
decrease according to the diameter of the mini- ridge width and height changes after orthodontic space opening in
implants used. Ludwig19 reported recently on 2 patients patients congenitally missing maxillary lateral incisors. Eur J Or-
in whom there had been fracture of the mini-implants thod 2013;35:87-92.
9. Uribe F, Padala S, Allareddy V, Nanda R. Cone-beam computed to-
inserted on the top of the alveolar process; because of
mography evaluation of alveolar ridge width and height changes
this complication, he suggested not to use mini- after orthodontic space opening in patients with congenitally
implants inserted vertically. missing maxillary lateral incisors. Am J Orthod Dentofacial Orthop
2013;144:848-59.
CONCLUSIONS 10. Melsen B, Huja SS, Chien HH, Dalstra M. Alveolar bone preserva-
tion subsequent to miniscrew implant placement in a canine
A method for a semipermanent replacement of a
model. Orthod Craniofac Res 2015;18:77-85.
missing lateral incisor has been described, and mainte- 11. Hourfar J, Ludwig B, Bister D, Braun A, Kanavakis G. The most
nance over 5 years has been demonstrated. A composite distal palatal ruga for placement of orthodontic mini-implants.
pontic was placed on a stainless steel wire segment ex- Eur J Orthod 2015;37:373-8.
tending from a lingually placed TAD with a bracket- 12. Cope JB, McFadden D. Temporary replacement of missing maxil-
lary lateral incisors with orthodontic miniscrew implants in
like head (Aarhus mini-implant). The bicortically placed
growing patients: rationale, clinical technique, and long-term re-
TADs were able to preserve or even increase bone density sults. J Orthod 2014;41(Suppl 1):s62-74.
and morphology of the alveolar process, whereas the 13. Graham JW. Temporary replacement of maxillary lateral incisors
maintenance of distance between the pontic and the with miniscrews and bonded pontics. J Clin Orthod 2007;41:
alveolar mucosa allowed for continuous vertical devel- 321-5.
14. Jeong DM, Choi B, Choo H, Kim JH, Chung KR, Kim SH. Novel
opment.
application of the 2-piece orthodontic C-implant for temporary
crown restoration after orthodontic treatment. Am J Orthod Den-
ACKNOWLEDGMENT
tofacial Orthop 2011;140:569-79.
15. Paquette DE. Miniscrew-supported transitional tooth replace-
We thank Alberto Laino for collaboration in the treat- ment: an esthetic alternative. J Clin Orthod 2010;44:321-5.
ment of 1 patient. 16. Luzi C, Verna C, Melsen B. The Aarhus anchorage system. Histolog-
ical and clinical investigation [thesis]. Aarhus, Denmark: University
of Aarhus; 2005.
REFERENCES
17. Kokich VG, Swift EJ Jr. Temporary restoration of maxillary lateral
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Anthropol 1956;14:491-6. Congress; 2015 Sep 27-30; London, United Kingdom.
May 2017 Vol 151 Issue 5 American Journal of Orthodontics and Dentofacial Orthopedics