Traumatic loss of a maxillary central incisor treated with nonextraction orthodontics Shiyou Huang, a Ting Kang, a and Yinzhong Duan b Xi'an, China This case report describes the orthodontic treatment of a girl who lost her maxillary left central incisor from trauma. The patient had a concave profile, a Class I molar relationship on the right side and a Class II molar re- lationship on the left side, with a slight maxillary retrusion, an anterior edge-to-edge bite, and a posterior cross- bite. Therefore, the treatment consisted of rapid palatal expansion to widen the maxilla in a transverse direction along with reverse headgear to improve the incisor relationship. The crown of the left canine was modified to re- semble the left lateral incisor, and a porcelain veneer was placed to make the left lateral incisor resemble the left central incisor. This case report illustrates how orthodontics alone can be used to treat a missing central incisor, without a bridge or an implant. (Am J Orthod Dentofacial Orthop 2013;143:246-53) T raumatic loss of maxillary incisors during the ac- tive teenage years is a serious and challenging clin- ical situation. 1 Because of the frequency of dental trauma in infancy and childhood, traumatized teeth with various long-term prognoses pose a problem when plan- ning orthodontic treatment. 2 An orthodontist often be- comes involved in managing these patients because of accompanying malocclusions such as midline shift, an- terior crossbite caused by space loss, or ectopic eruption of adjacent teeth. 1 The alternative approaches include reimplantation of the avulsed tooth, autotransplantation, placement of a bridge or an implant during adulthood, and sub- stitution of the ipsilateral lateral incisor for the central incisor after space closure. 3 The choice of the appropri- ate solution for the missing maxillary central incisor depends on the specific characteristics of each situa- tion. 4 However, the success of reimplantation depends on the status of the tooth's root, 5 the ability to perform endodontics, 3 and the length of time that the tooth has been out of the alveolar socket. 6 Some adolescents whose roots are not completely formed should not have restorations. This case report describes the orthodontic treatment of a patient who was missing a maxillary central incisor because of trauma; the treatment was completed with- out placing a bridge or an implant. DIAGNOSIS AND ETIOLOGY This girl had avulsed her maxillary left central incisor when she was 8 years old. Although the tooth was re- trieved at that time, the patient did not see a dentist to treat the trauma. At 14 years of age, she became con- cerned about the esthetic appearance of her teeth and facial profile and wanted orthodontic treatment. At that age, all permanent teeth had erupted, and the eden- tulous space had closed entirely. Viewed from the front, her face was well balanced and symmetric. Her facial profile was concave, with a slight maxillary retrusion and normal vertical propor- tions. No signs or symptoms of any temporomandibular joint disorder were noted. Intraorally, she had a mild Angle Class I molar and premolar relationship on the right side and an Angle Class II molar and premolar relationship on the left side. She had an anterior edge-to-edge bite and a poste- rior crossbite combined with palatal transversion and crossbite of the maxillary right lateral incisor. The maxillary dental midline deviated by 2.0 mm to the left with respect to the facial midline because of the missing central incisor. The mandibular dental midline was almost coincident with the facial midline. She had mild crowding of the maxillary and mandibular arches (Figs 1-3). From the Department of Orthodontics, School of Stomatology, Fourth Military Medical University, Xi'an, China. a Postgraduate student. b Professor. The authors report no commercial, proprietary, or financial interest in the prod- ucts or companies described in this article. Reprint requests to: Yinzhong Duan, Department of Orthodontics, School of Sto- matology, Fourth Military Medical University, No.145 West Changle Road, Xi'an, P.R. China, 710032; e-mail, [email protected]. Submitted, June 2011; revised and accepted, September 2011. 0889-5406/$36.00 Copyright Ó 2013 by the American Association of Orthodontists. http://dx.doi.org/10.1016/j.ajodo.2011.09.014 246 CASE REPORT
Transcript
CASE REPORT
Traumatic loss of a maxillary central incisortreated with nonextraction orthodontics
This case report describes the orthodontic treatment of a girl who lost her maxillary left central incisor fromtrauma. The patient had a concave profile, a Class I molar relationship on the right side and a Class II molar re-lationship on the left side, with a slight maxillary retrusion, an anterior edge-to-edge bite, and a posterior cross-bite. Therefore, the treatment consisted of rapid palatal expansion to widen the maxilla in a transverse directionalong with reverse headgear to improve the incisor relationship. The crown of the left canine was modified to re-semble the left lateral incisor, and a porcelain veneer was placed to make the left lateral incisor resemble the leftcentral incisor. This case report illustrates how orthodontics alone can be used to treat a missing central incisor,without a bridge or an implant. (Am J Orthod Dentofacial Orthop 2013;143:246-53)
Traumatic loss of maxillary incisors during the ac-tive teenage years is a serious and challenging clin-ical situation.1 Because of the frequency of dental
trauma in infancy and childhood, traumatized teeth withvarious long-term prognoses pose a problem when plan-ning orthodontic treatment.2 An orthodontist often be-comes involved in managing these patients because ofaccompanying malocclusions such as midline shift, an-terior crossbite caused by space loss, or ectopic eruptionof adjacent teeth.1
The alternative approaches include reimplantationof the avulsed tooth, autotransplantation, placementof a bridge or an implant during adulthood, and sub-stitution of the ipsilateral lateral incisor for the centralincisor after space closure.3 The choice of the appropri-ate solution for the missing maxillary central incisordepends on the specific characteristics of each situa-tion.4 However, the success of reimplantation dependson the status of the tooth's root,5 the ability to performendodontics,3 and the length of time that the tooth hasbeen out of the alveolar socket.6 Some adolescents
the Department of Orthodontics, School of Stomatology, Fourth Militaryal University, Xi'an, China.raduate student.ssor.uthors report no commercial, proprietary, or financial interest in the prod-r companies described in this article.t requests to: Yinzhong Duan, Department of Orthodontics, School of Sto-ogy, Fourth Military Medical University, No.145 West Changle Road, Xi'an,hina, 710032; e-mail, [email protected], June 2011; revised and accepted, September 2011.5406/$36.00ight � 2013 by the American Association of Orthodontists./dx.doi.org/10.1016/j.ajodo.2011.09.014
whose roots are not completely formed should nothave restorations.
This case report describes the orthodontic treatmentof a patient who was missing a maxillary central incisorbecause of trauma; the treatment was completed with-out placing a bridge or an implant.
DIAGNOSIS AND ETIOLOGY
This girl had avulsed her maxillary left central incisorwhen she was 8 years old. Although the tooth was re-trieved at that time, the patient did not see a dentistto treat the trauma. At 14 years of age, she became con-cerned about the esthetic appearance of her teeth andfacial profile and wanted orthodontic treatment. Atthat age, all permanent teeth had erupted, and the eden-tulous space had closed entirely.
Viewed from the front, her face was well balancedand symmetric. Her facial profile was concave, witha slight maxillary retrusion and normal vertical propor-tions. No signs or symptoms of any temporomandibularjoint disorder were noted.
Intraorally, she had a mild Angle Class I molar andpremolar relationship on the right side and an AngleClass II molar and premolar relationship on the leftside. She had an anterior edge-to-edge bite and a poste-rior crossbite combined with palatal transversion andcrossbite of the maxillary right lateral incisor.
The maxillary dental midline deviated by 2.0 mm to theleft with respect to the facialmidline because of themissingcentral incisor. The mandibular dental midline was almostcoincident with the facial midline. She had mild crowdingof the maxillary and mandibular arches (Figs 1-3).
Fig 1. Pretreatment facial and intraoral photographs.
Fig 2. Pretreatment dental casts.
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Fig 3. Pretreatment lateral cephalogram, tracing, and panoramic radiograph.
248 Huang, Kang, and Duan
TREATMENT OBJECTIVES
The primary treatment objectives were to restore thenormal appearance of the maxillary anterior teeth andestablish an acceptable occlusion despite the missing cen-tral incisor. The other essential objectives were to protractand expand the maxilla to correct the maxillary deficiencyand the posterior crossbite. Ideal overbite relationshipswere also desirable to establish immediate anterior guid-ance. Additional objectives were to eliminate the crowd-ing and correct the maxillary dental midline.
TREATMENT ALTERNATIVES
Based on the objectives, 2 treatment options were pro-posed. The first option consisted of increasing the archlength and opening a space for the missing central incisoralong with restoration of the space with a bridge or animplant. The second option consisted of orthopedic andorthodontic treatment, including rapid palatal expansionto expand the maxilla in a transverse direction withreverse headgear to correct the maxillary retrognathia
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and anterior crossbite. The left lateral incisor could besubstituted for the central incisor, and the left caninecould be substituted for the lateral incisor; no bridge orimplant would be necessary. This option seemed to bethe most plausible.
The option of opening an edentulous space fora bridge would be difficult because of the inclinationof the anterior teeth and the patient's vertical skeletalpattern. Furthermore, it would most likely extend thetreatment time. Considering all of these factors, we dis-cussed the treatment options with the patient's parentsand then decided on the second option.
TREATMENT PROGRESS
Treatment began with rapid palatal expansion andreverse headgear to protract the maxilla downward andforward and to expand the maxilla transversely. Mean-while, fixed 0.022 3 0.028-in preadjusted bracketswere placed on the mandibular teeth (Fig 4). Reverseheadgear was worn 12 to 14 hours at night, with 1 kg
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Fig 4. Expansion and facemask protraction in progress intraoral photographs.
Fig 5. Posttreatment facial and intraoral photographs.
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Fig 6. Posttreatment dental casts.
250 Huang, Kang, and Duan
of force, and Class III elastics was used during the day-time.
After 5 mouths, the maxillary teeth were bracketedbecause sufficient overjet had been achieved. The initialalignment was performed with nickel-titanium arch-wires, followed by space creation to obtain room forthe midline correction and restoration of the maxillaryleft lateral incisor that would be substituted for thecentral incisor. The crown of the maxillary left caninewas modified to resemble a lateral incisor by carefulreshaping. Vertical intermaxillary elastics were used forabout 8 weeks to obtain satisfactory tooth interdigita-tion. Active treatment was completed in 23 months;the appliances were removed, and Hawley retainerswere placed for retention.
TREATMENT RESULTS
Upon smiling, an ideal amount of tooth display wasachieved. The anterior gingival margins were leveled,and a porcelain veneer was used to build up the maxillaryleft lateral incisor and transform it into a central incisor.The maxillary left canine was reshaped and transformedinto the ipsilateral maxillary lateral incisor (Figs 5-8).
Intraorally, the arch length and width deficiencieswere eliminated in the maxillary arch, satisfactory toothalignment was obtained, and overbite and overjet wereimproved. The Class I molar relationship on the rightside was maintained, and a Class II canine relationship
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was obtained on the left side. The patient's upper lipprominence was dramatically increased. The patientand her parents were pleased with the final results.
DISCUSSION
This article describes a strategy for orthodontic treat-ment without a bridge or an implant for a patient whohad avulsed a maxillary central incisor. The patient wasa child when the tooth was avulsed and did not see a den-tist at the time. A few years later, when she wanted to be-gin orthodontic therapy, the edentulous space hadclosed almost entirely. It can be advantageous to placenothing in an edentulous space. This choice allows theadjacent lateral incisor and contralateral central incisorto drift and erupt bodily toward each other and closethe space. A distinct advantage is that the erupting teethwill drift bodily in a growing child and bring the alveolarbone as well. The edentulous space will completely closeby the time the remaining teeth have erupted. In this sit-uation, the better option for overcoming a missing max-illary central incisor was to substitute the lateral incisorfor the central incisor in the final occlusal scheme.7
When a lateral incisor is substituted for a missingmaxillary central incisor, several important steps will en-sure an esthetic result. First, the gingival margins of themaxillary anterior teeth must be positioned properly.7
When the lateral incisor is substituted for the central in-cisor, the canines are substituted for the lateral incisors.
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Fig 7. Posttreatment lateral cephalogram, tracing, and panoramic radiograph.
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In this situation, the orthodontist must disregard the in-cisal edges of these teeth as guides for final tooth posi-tioning. During orthodontic treatment, the maxillarycanines must be extruded to move their gingival marginsincisally to resemble the usual gingival margin positionof lateral incisors. The lateral incisor must be intrudedsignificantly so that its gingival margin matches the ad-jacent central incisor and creates the illusion of a normalanterior gingival level.
An additional benefit of intruding the lateral incisoris to facilitate restoration of this tooth into the shapeof the central incisor. Because the lateral incisor mustbe grossly overcontoured, this type of restoration is eas-ier when the clinician has a longer rather than a shortertooth to restore.3 Additionally, when a lateral incisor issubstituted for a central incisor, the provisional restora-tion should have a mesial surface shape that matches theadjacent central incisor. The emergence profile of a max-illary central incisor is generally flat on the mesial sur-face. The orthodontist must move the lateral incisor
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close enough to the central incisor to allow the restor-ative dentist to contour the restoration properly.
When clinicians must make a decision about a patientwith a traumatically avulsed maxillary central incisor,several options exist for replacing the missing tooth.The options that have been commonly used have advan-tages and disadvantages. The most conservative ap-proach for managing an avulsed central incisor is toreimplant it as soon as possible.7 The greatest benefitof successful reimplantation is preservation of the alve-olar bone. However, if the implanted tooth becomes an-kylosed, it obviously will not erupt and could createa significant alveolar defect. The vertical discrepancywould even be magnified if the patient has significantgrowth remaining.
Second, if an avulsed tooth is not a good candidatefor reimplantation, autotransplantation might be an op-tion.7 However, the patient should have an arch-lengthdeficiency, and the root formation of the premolarsshould be between one half and two thirds developed.
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Fig 8. Superimposed tracings.
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The technique for extracting and reimplanting a rootand crown without damaging the tissues surroundingthe root is difficult and requires experience, with a deli-cate approach.
Third, if reimplantation and autotransplantationare not possible, a typical solution for maintainingthe edentulous space is to construct a temporary re-movable prosthesis with a plastic tooth during child-hood and adolescence, and to place a bridge or animplant during adulthood. This will improve esthetics,speech, and function. However, placing a temporaryremovable prosthesis in the edentulous space duringthe transition from the mixed to the permanent den-tition seems to be unadvisable because without a toothdeveloping in this site, the alveolar ridge would benarrow and difficult to restore in the future with ei-ther a bridge or an implant. Furthermore, either reim-plantation or autotransplantation is unpredictable,and replanted teeth have variable long-term progno-ses and can present a problem when it is time to beginorthodontic therapy.
In a young patient, if nothing were placed in theedentulous space, what would occur? In this report,we obtained a satisfactory result in a patient who hadan avulsed maxillary central incisor but did not seektreatment until after the edentulous space had closed.
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Based upon this evidence, we propose that 1 strategyis no treatment after the trauma, wait for spontaneousclosure of the edentulous space, and then use orthodon-tic therapy to create the appropriate tooth position forrestoration during adulthood.
CONCLUSIONS
The clinical result of restoring a lateral incisor asa central incisor in our patient was satisfactory. Shewas pleased with the treatment result, even though thecrown morphology of the recontoured lateral incisordid not ideally match that of the contralateral lateral in-cisor. The appearance of the gingival margins was nearlyideal. This report presents a method of treating a missingmaxillary central incisor without replacing the toothwith a bridge or an implant.
REFERENCES
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2. Bauss O, R€ohling J, Schwestka-Polly R. Prevalence of traumaticinjuries to the permanent incisors in candidates for orthodontictreatment. Dent Traumatol 2004;20:61-6.
3. Kokich VG, Nappen DL, Shapiro PA. Gingival contour and clinicalcrown length: their effects on the esthetic appearance of maxillaryanterior teeth. Am J Orthod 1984;86:89-94.
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4. Kokich VG, Crabill KE. Managing the patient with missing or mal-formed maxillary central incisors. Am J Orthod Dentofacial Orthop2006;129(Supp):S55-63.
5. Ongkorahadjo A, Kusnoto B. The use of pre-implantation toothlengths in the treatment of avulsed teeth. J Clin Pediatr Dent2000;24:91-5.
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6. Kandemir S, Alpoz E, CaliskanMK, Alpoz AR. Complete replacementresorption after replantation of maxillary incisors: report of a case. JClin Pediatr Dent 1999;23:343-6.
7. Bowden DE, Patel HA. Autotransplantation of premolar teeth toreplace missing maxillary central incisors. Br J Orthod 1990;17:21-8.
