A clinical case by our Community member Dr. Mohammed Shaga
This article and its content are published under the Author’s responsibility as an expression of the Author’s own ideas and practice. Styleitaliano denies any responsibility about the visual and written content of this work.
Aesthetic dilemmas created by congenitally missing teeth in the maxillary anterior segment constitute a challenge for dentists, not only in achieving harmony between hard and soft tissues, but also in producing a conservative, cosmetic and functional result. Maxillary lateral incisors and first premolars are among the most common congenitally missing teeth. The first step in selecting a suitable treatment option is the correct diagnosis of congenitally missing lateral incisors. This is usually made in childhood by the general dentist, who will coordinate initial treatment options with an orthodontist. As the case progresses, other specialists including periodontists, oral surgeons and prosthodontists may be involved in producing an optimal treatment outcome. Selecting a path of treatment depends on the age of the patient, presenting malocclusion, space requirements, the size and shape of neighboring teeth and patient preference.
There are three accepted options for treating maxillary lateral incisor missing that each rely on careful case selection and coordinated interdisciplinary management. The first treatment option is canine substitution, whereby space closure is obtained by orthodontic mesialization of the canines and premolars that would allow for restorative treatment “as this case” . The second and third treatment options, prosthodontic and implant, involve space opening by orthodontic distalization of the canines and premolars to create an ideal space for prosthetic tooth addition at the lateral incisor position.
In this article, I will discussion the first treatment option of congenitally missing maxillary lateral incisor due to the patient undergo to previous orthodontic treatment and come to my clinic to change her smile in shape and color.
Fig.1
A 36-year-old female patient presented to our clinic wishing to improve her smile. She was mostly concerned about her missing lateral incisors and the color of her teeth. She asked to get straighter, whiter teeth with no gaps and without the need for further orthodontic repositioning.
Fig.2
Lateral view of the extra-oral pre-operative situation.
Fig.3
Intra-oral pre-operative situation.
Fig.4
One of the important and critical tasks in esthetic dentistry is creating a harmonious proportion when restoring teeth. For a smile to be considered perfect, the upper anterior teeth should follow the golden ratio. When viewed from the facial, the lateral incisors should be 60% the width of the central incisors, and the canines 60% that of the lateral incisors.
Fig.5
A 3D digital wax up can give an idea of how the final result will look before starting the treatment. The tooth shape is selected according to the Visagism interview with the patient.
Fig.6
It is also important to check the design from the occlusal point of view, to check if adequate thickness is available and if preparation of teeth is needed.
Fig.7
The virtual 3D diagnostic wax up analysis of a dentition before treatment allows for minimally invasive treatment planning.
After the model is 3D-printed (Anycubic 3D printer). For an optimum result, tooth 13 had to be prepared. To transfer this design to the patient’s teeth, a guide was created to highlight this exact area on the actual tooth.
Fig.8
Vacuum-formed template generated on the 3D model with a perforation of the area that needs more preparation to be aligned with the adjacent teeth.
Fig.9
Vacuum-formed guide try-in.
Fig.10
The area to be prepared was highlighted for precise preparation.
Fig.11
After preparation, teeth were isolated with the rubber dam. Inversion was achieved and ligatures were knotted to push the rubber deep in the sulcus and hold itin place during the restorative procedure.
Fig.12
After etching the enamel, multiple coats of bonding agent were applied, and after 20 seconds air was blown using oil-free syringe to let the solvent evaporate. Light curing was carried out for 20 seconds.
Fig.13
A silicone index was fabricated to place the palatal composite shells according 3D printing model.
Fig.14
The palatal shells were built using W2 Zenit composite (President Dental).
Fig.15
Proximal walls were built using metallic sectional matrices with A1 shade from Zenit composite system.
Fig.16
For better control of the labial contour, the cervical outline was created before layering the buccal composite.
Fig.17
Right after layering the final enamel layer (W2 shade, Zenit composite by President Dental), finishing procedures could start.
Fig.18
Two-months follow-up, after finishing and polishing.
Fig.19
The patient’s satisfied smile after 2 months.
Fig.20
Lateral view of the new smile after 2 months.
Fig.21
Surface texture and gingival healing.
Conclusions
The treatment of congenitally missing maxillary lateral incisors is challenging and complex, requiring very careful treatment planning, communication with the patient, and, sometimes, an interdisciplinary approach. Therefore, there is no one best treatment option for this particular clinical situation. It is only after evaluating all of the options available, analyzing existing conditions, and consulting with the patient and other specialists that a method of treatment should be chosen.
Bibliography
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2. Janmohamed N. Restorative Treatment Following Canine Substitution for Maxillary Lateral Incisor Agenesis: A Case Report. November 10, 2020.
3. Papaspyridakos P, Lal K. Use of vacuum-formed templates to guide tooth preparation and insertion of interim restorations. J Prosthodont. 2010 Jun;19(4):303-6.
4. Gürel, G., Shayder, M. A., & Hallawell, C. P. Visagism: The Art of Dental Composition.
5. Manauta J, Salat A. Layers, An atlas of composite resin stratification.Quintessence Books, 2012.
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