Comprehensive Rehabilitation for a Permanent Tooth Anodontia Patient Using an Integrated Digital Approach

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Lauren H. Katz, DDS1 The absence of permanent denti- Lida Swann, DDS, MS1 tion, termed complete anodontia, Lee Culp, CDT2 is extremely rare. While the exact Lyndon F. Cooper, DDS, PhD3 prevalence of permanent tooth anodontia is unknown, the absence of more than six permanent teeth is re- Agenesis of the permanent dentition is rare. This report describes a 20-year- ported to be approximately 0.14%.1 old woman with 19 deciduous teeth, a single permanent mandibular premolar, Anodontia seldom presents as an and other physical traits associated with ectodermal dysplasia. The patient isolated anomaly and is usually as- demonstrated esthetic parameters associated with maxillomandibular alveolar sociated with a syndrome, the most insufficiency, and her chief complaints were directed toward esthetics and the potential impact of restorative choices on function. Three typical options common being ectodermal dyspla- for restoration include overdentures, removable partial dentures, or implant- sia (ED). Of the over 150 reported supported prostheses replacing her natural dentition. This report illustrates clinically distinct ectodermal dys- a fully integrated digital approach to treatment planning, the fabrication of a plasias, 120 have associated dental computer-aided design/computer-assisted manufacture surgical guide and defects,2 with hypohidrotic ED be- provisional restoration, guided implant placement, and definitive restoration ing one of the more common types. using monolithic zirconia implant-supported fixed dental prostheses. The lifelong management of this rehabilitation is an acknowledged challenge. Dental anomalies associated with Int J Periodontics Restorative Dent 2020;40:e111–e118. doi: 10.11607/prd.3924 anodontia or hypodontia include teeth that are reduced in size, malformed, and conical in shape. Ad- ditionally, alveolar bone hypoplasia3 with reduced occlusal vertical dimension (OVD) is observed. Patients with ED may also present with atypi- cal hair, nails, and sweat glands.4 Prosthetic treatment modalities for the ED patient include removable partial dentures, fixed partial dentures, complete dentures, and/ 1Division of Comprehensive Oral Health, Adams School of Dentistry, University of or implant-retained prostheses.5 Al- North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA. though placement of endosseous 2Sculpture Studios Dental Laboratory, Cary, North Carolina, USA. dental implants has been success- 3College of Dentistry, University of Illinois at Chicago, Chicago, Illinois, USA. 6–8 ful in ED patients, this treatment Correspondence to: Dr Lauren H. Katz, Division of Comprehensive Oral Health, is not routinely recommended Adams School of Dentistry, CB#7450, University of North Carolina at Chapel Hill, in growing children.9 Removable Chapel Hill, NC 27599-7450, USA. Fax: 919-537-3977. Email: [email protected] prostheses, which can be modified or remade as the child grows and Submitted May 8, 2018; accepted August 30, 2018. ©2020 by Quintessence Publishing Co Inc. develops, provide a satisfactory

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a b Fig 1 Preoperative extraoral (a) facial and (b) profile views of the patient, demonstrating maxillary and mandibular deficiency and insufficient maxillary incisor display.

method for the patient to function Case Report K, M through T (Universal system for until late adolescence is reached primary teeth), and permanent tooth and implants can be placed.5 Upon A 20-year-old female with physi- 34 (FDI system) (Fig 2). The maxillary reaching young adulthood, howev- cal traits associated with ED and and mandibular canines were coni- er, a fixed prosthesis may be more a dental diagnosis of permanent cal in shape, demonstrating typical psychosocially suitable than a re- tooth anodontia presented for a presentation in patients with ED. movable appliance.10 comprehensive evaluation with The lack of permanent teeth result- Comprehensive rehabilitation a chief complaint of esthetic and ed in a decreased occlusal vertical with implants is a complex, multistep functional dissatisfaction. A physi- dimension. There was an absence of process that requires integration of cian diagnosed the patient at age dental caries, periodontal disease, surgical and restorative procedures 2 with ED, but this finding has not and other intraoral pathology. in order to optimize the biologic, been confirmed by genetic testing. The diagnosis of permanent functional, and esthetic outcomes. In addition to anodontia, the patient tooth anodontia was confirmed ra- Recent advances to the digital work- had thin, sparse hair and dysplas- diographically (Fig 3). The retained flow have made it feasible to inte- tic fingernails. Other systemic, ra- deciduous teeth displayed only grate all phases of a treatment plan diation, or pharmacologic causes of modest root resorption. A large from implant placement with imme- tooth agenesis were ruled out. Prior marrow space apical to tooth A was diate provisionalization to design of dental history included composite evident radiographically. No other the definitive prosthesis. Digital plan- restorations and Smile Transitions odontogenic or osseous pathology ning and design allows for consis- prostheses (Glidewell Laboratories) was identified. tency across all stages of treatment for esthetic enhancement. that is more accurate and efficient Clinical examination revealed than with an analog workflow. The inadequate tooth display and a de- Treatment Planning aim of this case report is to illustrate crease in the lower third of the facial the steps used in an integrated digi- height with a short upper lip (Fig Diagnostic casts were mounted on tal approach to plan for treatment 1). Maximum opening height was a semi-adjustable articular using an and design and mill computer-aided recorded to be 40 mm with no de- arbitrary facebow and a centric re- design/computer-assisted manufac- viation upon opening. There was an lation record taken at an OVD that tured surgical guides, provisional absence of extraoral pathology in restored the patient’s lower face restorations, and definitive prosthe- the head and neck region. The intra- height. A cone-beam computed ses for a 20-year-old woman with oral examination revealed the pres- tomography (CBCT) scan of the permanent tooth anodontia. ence of deciduous teeth A through dentoalveolar region was captured

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b c Fig 2 Preoperative intraoral (a) facial, (b) maxillary occlusal, and (c) mandibular occlusal views. Note that teeth C, H, M, and R (Universal system for primary teeth) are malformed and conical in shape.

using a Galileos imaging system that proper oral hygiene and pros- (Dentsply Sirona) to complement thetic and implant maintenance is the diagnostic information. Informa- essential to the lifelong success of tion gathered from the comprehen- this treatment. sive exam, CBCT, and patient history was used to generate a treatment plan involving six maxillary and six Treatment mandibular implants supporting op- posing screw-retained monolithic A D900L scanner (3Shape) was used Fig 3 Preoperative panoramic radiograph. zirconia prostheses. The benefits, to scan the maxillary and mandibular No permanent teeth are present except for risks, and alternatives to this type casts individually and then together tooth 34 (FDI system). of treatment were thoroughly dis- to record the maxillomandibular re- cussed with the patient. Other pro- lationship. Additionally, a cast of the posed treatment options included: patient’s Smile Transitions prosthesis (1) tooth-supported overdentures, was scanned to transfer the desired Implants were planned based on (2) composite restorations and re- incisor position. Both a digital wax- appropriate prosthetic parame- movable partial dentures, and (3) no up of the desired tooth arrange- ters, adequate height and width of treatment. The patient’s consent to ment and the DICOM files from the bone, avoidance of vital structures, treatment was obtained, and she patient’s CBCT were imported into and ideal anterior-posterior spread demonstrated an understanding 3Shape Implant Studio software. (Fig 4). Superimposition of the

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Fig 4 3Shape Implant Studio software was used to plan the implant placement for Fig 5 Superimposition of the maxillary diagnostic the maxilla and mandible (not pictured). The reconstructed panoramic, axial, sagittal tooth set-up and implant placement from the and coronal views are shown. occlusal view. Note the ideal placement of the implants with the restorative platforms at the center of the occlusal surfaces. The mandible was planned using the same manner (not pictured).

Fig 6 Pilot surgical guides were designed for both the maxilla and mandible (not pictured) using (a) 3Shape and then (b) milled out of PMMA. The guide was milled with windows on teeth B and I to visually assess seating of the a b guide.

CBCT with the three-dimensional permit the use of a fully guided surgi- made through the guide at implant (3D) virtual tooth set-up allowed for cal protocol. The last step was to use sites 11, 13, 16, 21, 23, and 26. The the planned implant placement to the diagnostic set-up to design and guide was removed and implant be prosthetically driven (Fig 5). mill a double–cross-linked PMMA sites were prepared using stan- In order to accurately execute provisional. The Zenotec Select Hy- dard Astra Tech Implant System EV the desired implant placement, the brid mill and Temp Esthetic PMMA (Dentsply Sirona) drilling sequence surgical plan was used to mill a pilot material (Harvest Dental) were used and manufacturer-recommended guide from single cross-linked clear to create the prosthesis, which was speeds. 4.2-mm–diameter Astra polymethyl methacrylate (PMMA) made for initial intraoral placement OsseoSpeed EV implants (Dentsply material (Wieland Dental) using a and pick-up on the day of surgery. Sirona) were placed in sites 16 and Zenotec Select Hybrid mill (Wieland For the maxilla, the surgical 26, and 3.6-mm–diameter Astra Dental). The guide was designed to procedure consisted of extract- OsseoSpeed EV implants were be supported by the teeth not locat- ing teeth A, C, E, F, H, J and seat- placed in sites 11, 13, 21, and 23. Ex- ed in a planned implant location (Fig ing the pilot guide on teeth B, D, G, cellent primary implant stability was 6). Lack of interdental space did not and I (Fig 7). Pilot osteotomies were achieved for all implants. Remaining

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a b Fig 7 (a) Extraction of teeth A, C, E, F, H, and J and (b) seating of pilot guide on teeth B, D, G, and I the day of maxillary implant surgery. The same procedure was repeated for the mandible (not pictured).

a b Fig 8 (a) Occlusal view of the maxillary provisional shell seated on the palate prior to pick-up of the temporary cylinders. (b) Facial view of maxillary provisional shell and PMMA overlay of planned mandibular restorations used to establish occlusal relationship. The same procedure was repeated for the mandible (not pictured).

teeth B, D, G and I were then ex- ite (3M). Further guidance for po- were hand-tightened to secure the tracted. Postoperative periapical sitioning the maxillary prostheses prosthesis in place. radiographs were taken to confirm was provided by use of an overlay The patient was dismissed from proper implant placement. prosthesis representing the planned the clinic in stable condition and Immediately after surgery, Uni restorations for the mandible. The returned 2 weeks later to receive Abutment EVs (Dentsply Sirona) overlay prosthesis was placed on mandibular treatment. Decidu- were torqued to 35 Ncm in each the mandibular deciduous teeth to ous teeth K, M, N, Q, R, S, and T implant and Temp Abutment EVs position the maxillary prosthesis in and permanent tooth 34 were ex- (Dentsply Sirona) were hand-tight- the planned occlusal relationship tracted, and the pilot guide was ened onto the abutments. The at the time of temporary abutment seated on teeth O and P. Pilot os- milled PMMA provisional was seat- attachment (Fig 8). The provisional teotomies were made through the ed using a palatal strap index, and restoration was finished and pol- guide at implant sites 32, 34, 36, intraoral pick-up of the temporary ished in the laboratory prior to plac- 42, 44, and 46. Astra OsseoSpeed abutments were made using Filtek ing it back in the patient’s mouth. EV implants with a 4.2-mm diameter Supreme Ultra flowable compos- Bridge Screw EVs (Dentsply Sirona) were placed in sites 34, 36, 44, and

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lar relationship was recorded using Insertion and Follow-Up Care acrylic duplicates of the patient’s in- terim restorations. The D900L Scan- The screw-retained zirconia implant- ner imported the master cast data supported fixed dental prostheses into the 3Shape software. Based were inserted on Astra EV Uni Abut- on the provisional restorations, a ments using Astra EV bridge screws longer maxillary incisor length was torqued to 15 Ncm. Esthetics, pho- requested, and the design was re- netics, and fit were determined to vised. To achieve this, the Dynamic be appropriate by both the patient Abutment System (PREAT) was uti- and clinician. A mutually protected lized for the implant in tooth posi- occlusal scheme was established. tion 11; the incisal length increase Screw access holes were covered Fig 9 Milled PMMA prototype prostheses. resulted in the screw access channel with PTFE tape and Filtek Supreme emerging through the incisal edge. Ultra flowable composite. The occlu- Prototype prostheses were sal guard was adjusted so that even milled from Temp Esthetic PMMA posterior centric contacts and ante- 46, and 3.6-mm–diameter implants (Fig 9). The patient wore the try- rior guidance were established. were placed in sites 32 and 42. Ex- in prostheses for approximately 1 Oral hygiene instructions were cellent primary implant stability was month to evaluate esthetics, pho- given to the patient. The impor- achieved for all implants. Lastly, netics, function, and passive fit of tance of cleaning around the im- teeth O and P were extracted. Post- the proposed definitive restora- plants, wearing the occlusal guard, operative periapical radiographs tions. Alginate impressions were and returning for professional main- were taken to confirm proper im- made of the prosthetics, and the tenance were emphasized. The pa- plant placement. The implants were casts were scanned to evaluate oc- tient was satisfied with the esthetic immediately loaded in the same clusal wear patterns over this time and functional outcome of her reha- manner as the maxilla. Occlusion period. Changes were made to the bilitation (Fig 10). A postoperative was checked and adjusted so that it proposed definitive restorations panoramic radiograph demonstrat- was mutually protected. based on occlusion and esthetic pa- ed complete seating of the prosthe- The patient returned 2 weeks rameters evaluated by both the pa- ses and stable bone levels (Fig 11). later for a postoperative visit and tient and the clinician. The definitive The patient returned for post- was determined to be healing ap- prostheses were milled using Zeno- operative evaluations at 1 week, 1 propriately without complications. star MO zirconia (Ivoclar Vivadent) and 6 months, and 1 year. Assess- Final impressions would have been using a Zenotec Select Hybrid mill. ments were positive, with minor made at approximately 3 months IPS e.max Ceram (Ivoclar Vivadent) esthetic and occlusal adjustments postoperative per standard pro- was used to veneer only the facial made at these appointments. At the tocol, but the patient selected an surfaces of the prostheses’ anterior 6-month visit, the patient had pro- 8-month academic travel course, teeth. Titanium cylinders (PREAT) fessional maintenance performed. delaying treatment. were luted to the prostheses using Peri-implant health was determined Upon the patient’s return, os- Multilink Hybrid Abutment cement to be excellent with absence of in- seointegration of all implants was (Ivoclar Vivadent). Lastly, an occlusal flammation, plaque, and bleeding manually confirmed and final im- guard was designed on the defini- on probing. The patient will con- pressions were made using Uni- tive maxillary prosthesis on 3Shape tinue professional maintenance in Abutment EV Pick-Ups (Dentsply and printed from a Form 2 3D print- 6-month intervals, with the prosthe- Sirona) for an open-tray impression er (Formlabs) using clear photopoly- ses being removed once a year. technique. The maxillomandibu- mer resin (Formlabs).

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a b

c d Fig 10 Postoperatove intraoral (a) maxillary and (b) mandibular occlusal views and extraoral (c) facial and (d) lateral views demonstrating restored OVD and enhanced esthetics from initial presentation.

Discussion

Rehabilitation of a 20-year-old female patient with permanent tooth anodontia was achieved using endosseous dental implants and implant-supported prostheses. The 12 implants integrated successfully and have been in the mouth for over

4 years with no signs of biologic or Fig 11 Postoperative panoramic radiograph. technical complications. Bone levels have remained stable during this period. Implants have been placed, loaded, and restored successfully in children or adolescents; it is neces- The patient’s full-arch implant- patients with ED, yielding survival sary to follow these patients long- supported prostheses have suc- rates between 88.5% and 97.6%.6–8 term to better understand implant cessfully been in function for The majority of studies assessing performance over an extended pe- approximately 3 years with no bio- implant survival in ED patients are in riod of time. logic or technical complications.

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Abdulmajeed et al11 reports a cu- prostheses for a patient lacking per- 8. Sweeney IP, Ferguson JW, Heggie AA, mulative prosthetic survival rate of manent teeth. The patient will con- Lucas JO. Treatment outcomes for ado- lescent ectodermal dysplasia patients 96.8%12–16 for complete-arch implant- tinue to be monitored and assessed treated with dental implants. Int J Pae- supported monolithic zirconia fixed in order to understand long-term diatr Dent 2005;15:241–248. 9. Op Heij DG, Opdebeeck H, van Steen- dental prostheses for up to 5 years. outcomes of this type of treatment. berghe D, Quirynen M. Age as com- Prosthetic complications include promising factor for implant insertion. Periodontol 2000 2003;33:172–184. porcelain chipping,12,14 fractured or 10. Brennan M, Houston F, O’Sullivan M, loose abutments, debonded com- Acknowledgments O’Connell B. Patient satisfaction and oral health-related quality of life out- ponents, and fracture of the prosthe- comes of implant overdentures and sis.13 While the reported short-term Implants were generously provided by fixed complete dentures. Int J Oral Maxillofac Implants 2010;25:791–800. Dentsply Sirona. Mr Culp receives honoraria performance rates of monolithic zir- 11. Abdulmajeed AA, Lim KG, Närhi TO, conia prostheses appear promising, from Ivoclar Vivadent. Dr Cooper receives Cooper LF. Complete-arch implant-sup- honoraria from Dentsply Sirona. Drs Katz ported monolithic zirconia fixed dental long-term success is unknown and and Swann declare no conflicts of interest. prostheses: A systematic review. J Pros- will require longer follow-up times to thet Dent 2016;115:672–677.e671. 12. Oliva J, Oliva X, Oliva JD. 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