Question #1: What further information would you require to make a treatment plan for this case?
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It doesn't look like the maxillary and mandibular midlines are lined up.
I'd want to measure the available space for the 4 maxillary anterior teeth, subtract the centrals and divide the result in half to estimate the available space for each lateral.
I would take a set of study models, cut off the centrals and move them to align with the lower midline and see if the available space coincided with the above calculation.
If yes, I would then wax up a veneer for the 1.2 and the implant crown for the 2.2 and look at the aesthetics.
This would give me the spacing needed and the guide for the orthodontist to create the needed space..
If a coincidental midline could not provide ideal space and aesthetics I would re-evaluate what was needed from an orthodontic standpoint to create it.
As long as the patient, the parents and I were happy with the diagnostic wax up as described above, I would have the orthodontist create the spacing, I would put the veneer on the 1.2 and have a retainer made with the 2.2 on it until she is 18 and can have the implant placed.
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There is a fair bit of information in these slides to give me a feeling for the major problems in this case. I would like to see pre-op study models and also a facial shot showing the teeth and facial midlines.
Background medical history would be interesting.
What length of time has the patient already been undergoing orthodontic treatment?
Occlusal radiograph or CT scan, if available, to show shape of bone in the area of tooth # 22
Mounted models showing occlusal relationship particularly in the anterior
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I would need a CT scan to assess available space in a 3D aspect prior to implant placement.
I would consider aligning midlines better,.....and placing a veneer/ crown on 1.2 for optimal symmetry with 2.2.
It would be great to have a diagnostic wax up to assess aesthetics
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What is the bone age of the young lady? I would like to see a wrist/hand x-ray analysis.
How much buccal bone is available for the implant alignment?
Is the midline of the maxillary dentition satisfactory? The mandibular midline is not the same.
Is the alveolar ridge height satisfactory?
What will be the gingival alignment on the implant crown?
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How long have the rectangular wires been in place?
What are the plans for the existing upper lateral incisor which is somewhat pegged?
How long has this person been in treatment?
Was the treatment plan discussed with whoever was to do the implant before orthodontic treatment was started?
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What is the labio-lingual width of bone in the 22 area? It looks thin and a bone graft may be required.
The mid-lines don't coincide so this may need to be corrected after the implant is placed.
The 12 is smaller mesio-distally than normal and may require a veneer for improved aesthetics.
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What is planned for the other lateral incisor?
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What is the thickness of the alveolar ridge labio-palatally at the 22 site?
Will she need bone grafting to allow an appropriate diameter of implant for maximal emergence profile and natural contours of the labial surface of the eventual crown in the arch?
I'd like to see a bigger smile. She's not showing any "gums" in the smile presented, so gingival contours may not be an issue (they will be if the gingival margins show in a big smile).
I would need the widths and lengths of all 6 anterior teeth to do a smile analysis, to determine ideal width requirement for the crown that will go on the implant for best appearance. While she is still bonded, it can be adjusted if necessary. Don't debond until this is done!
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1. Prior to surgery we need a medical history and current health status.
2. Has the patient stopped growing? (Unlikely at age 17)
3. What is the labiolingual dimension of the 22 site?
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In a case like this I would not be placing the implant; I would only be restoring it.
In terms of further information I would need to know from whoever is placing the implant, if the patient is ready? Is she ready psychologically, and have the pros and cons been discussed?
Has a CT been done to evaluate bone thickness? Is there adequate tissue?
One of the questions on the presentation is “Is the patient ready for debonding?” Again there would have to be an agreement with the orthodontist and patient.
I would need to see models to determine if the 1.2/2.2 spaces are equal and will the patient be happy with a bonded peg lateral? It would appear that the midlines are not coincidental at this time. Is that an issue?
I do not know how close the patient holds the mirror, so it is hard to know her aesthetic tolerance.
A major concern of mine, as it is with any anterior restoration, is "what about black triangles, interproximally?"
What is the probing depth to the bone and what, is the gingival height?
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What is the bone quality/quantity?
Information needed from specialist – what type of implant to be placed?
Are there clenching or grinding habits, and is she active in sports? I need to have this information to know if there are needs in terms of a mouthguard and/or a nightguard.
I would need bitewings and a full exam for caries, in order to provide a comprehensive treatment plan.
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Several questions arise from the fact that the upper midline in this case is off to the right, and root alignment on the right side involving 1.2 and 1.3 could be improved.
I cannot accurately measure the space present for an implant, but surmise it will be less than what we see if and when midlines are corrected. I would anticipate a 3.3 mm implant would be required with at least 1.5 mm either side of the implant between 2.1 and 2.3.
I would also suspect this individual has not yet stopped growth and I would defer treatment until that has been confirmed.
Confirmation of bone volume in a bucco-palatal direction would be nice to visualize available bone.
It was nice to see roots of adjacent teeth are divergent rather than convergent.
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1. Is patient a grinder? 2. Are her aesthetic expectations reasonable? 3. I need models to assess the bite better. I am concerned about a deep bite giving minimal enough occlusal clearance. 4. Overall teeth look generally small. I would like to do a Bolton analysis (to assess tooth size discrepancy) 5. What is the quality of bone in the 2.2 area? 6. In 2.2 area, what is the depth of bone to the floor of the nose? I would like enough to at least insert a 10mm Straumann implant 7. In 2.2 area, what is the buccal - palatal thickness of the edentulous ridge? I would need at least 5.3 mm if using a narrow implant (3.3 mm), but I would prefer to fit a 4.1 mm wide implant ( would need min 6.1 mm bone thickness)
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Is the occlusion cuspid protected? Do we have immediate disclusion of all posterior teeth in protrusive excursions? In the presentation the patient and parents are described as eager to proceed with an implant: are they willing to invest a little more time in treatment? Is there a reason to explain the mis-alignment of the mid-line? Is the patient wearing a removable prosthesis at this time? How high are the aesthetic expectations of the patient and her parents?
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1- The medical and dental (including Oral Hygiene habits and score) patient's history 2- Socio-economic level of this patient (even if this patient is having orthodontic treatment, her treatment could be paid from an institutional source) 3- XRAY intra oral (PA) and digital scan of #2.2 area when she will get to 21 years of age 4- If the patient has active caries or any dental problems other than the actual gingivitis shown on the pictures submitted. Those data are necessary now and when she will come to the age of inserting the implant.
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1. What is the mesial-distal width allowed for #2.2? 2. How does this compare to the space for the peg lateral #1.2? 3. What is the buccal lingual bone width allowed for #22? Patient may need a CBCT. Does the patient need a graft? 4. The midlines look like they are off. Is the upper midline coincident with the facial midline? 5. Is the patient in group or cuspid guided occlusion. 6. Is it possible to lingualize the inclination of the implant so that it emerges from the cingulum of the proposed restoration for #2.2, so you can do a single piece screw down abutment crown?
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Though there appears to be enough bone mesial-distally, however, I wonder if there is enough bone buccally. There appears to be a concavity on the buccal midroot area of 22. Would a graft be necessary?
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- Periapical radiographs of #1.2, #1.1/2.1 areas. - Wrist radiograph to confirm completed skeletal growth. - Periodontal assessment in the maxillary anterior sextant. - Dimensional analysis of the anterior teeth with space available. We need to have a study model before debonding in order to take into account the peg lateral #1.2 dimensions and its impact in the overall esthetics of the case. - It also appears to me that the maxillary midline is about 2 mm to the right of the facial midline. This needs to be rectified before debonding. - Tthere is also marginal gingivitis present distal to #2.1 and mesial to #2.3. This needs to be addressed, and a perio consult will be helpful here. - The root alignment of #1.3 is also questionable on the panoramic radiograph, and this may need to be corrected prior to debonding.
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We do not have any data that would give us the buccal/ lingual thickness of bone. A scan may be requested. With a congenitally missing tooth, bone thickness is always a problem. Do we have minimum mesial/distal thickness at the root? I know they have the new smaller implants just for laterals but we would need at least 1.5 mm of bone on either side of the implant mesial and distal.
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What is the measurement M-D of the space created for the 2.2? I would want a M-D measurement of 1.2. It appears to be a peg lateral and this would explain the non- coincident midlines. I would want to analyze space to be sure that we get much-needed symmetry.
I would want to evaluate the functional occlusion before I release this patient from orthodontic treatment for the restorative phase.
I always like to look at a set of mounted models. The stability of the occlusion is important. Does it have a good Class 1 molar and cuspid relationship. The midlines appeared to be off. Does an occlusal correction need to be completed for long term stability.
In the panorex the 1.3 root seemed to be tipped distally encroaching on the 1.4.
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1. A CT scan would be useful to assess the B-L dimension of bone in the #2.2 site (determine if block bone grafting or GBR is necessary).
2. Hand cephalometric radiograph to see that growth is complete.
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None
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A CT scan or to sound to the bone through the tissue is critical since the 3-dimensional aspect of the alveolus is unknown due to variations in tissue thickness
The desire of the parents and the patient to precisely balance the size discrepancy in the 12 peg lateral and the 22 edentulous site?
Overall contact of lower arch with the maxillary anterior arch: does the lower canine contact the upper canines?
Overall growth potential: is she still growing, how about siblings and history of growth pattern?
Does she play impact sports, and her desires and parents to long term perspective of replacement?
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I am concerned about #1.2, it appears to be a peg lateral with a periapical radiolucency?? What are the plans for this tooth?
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Can the orthodontist do a better job of correcting the midline, creating equal space for 1.2 and 2.2, correcting the axial angle of 13?
Is 1.2 vital? Is 1.2 a good candidate for a crown? Is the bone density sufficient?
Is the patient prepared for an implant at 2.2 and a crown at 1.2?
Do the patient and parents want a perfect job or, just fill the 2.2 space?
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Is she finished growing? How do we judge this? Age of first menses plus actual years? Radiographs of hand bones (metacarpals calcified)? Does she have stability of shoe size?
Study models and better view of midlines, OJ + OB.
Patient expectations with reagard to the peg lateral at 1.2?
What is the quantity of bone buccal to of 2.2? It is likely to be deficient because of congenitally missing tooth.
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Mounted diagnostic casts
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1. A 3-d scan of the 2.2 area
2. I would want to know the expectations of the patient with regard to esthetics
3. I would want to talk to the orthodontist. If I were doing the ortho, I would not consider this the time to debond the teeth. The midlines are off and the peg lateral (1.2) doesn't have the space to make it symmetrical with the 2.2.
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How much growth does the patient still need? Can the midlines be aligned? Can the space at tooth #1.2 be made similar to #2.2? Is there sufficient bone at #22, or do we need a bone graft? Can an implant be placed in a desirable position for both #2.2 and #1.2, resulting in an aesthetically pleasing outcome? Is there any drawback aesthetically from the gingival aspect?
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- I would like to know whether or not the patient is interested in "restoring" the peg-shaped lateral 1.2 to harmonize her smile. If 1.2 will be built-up in composite or veneered, it will determine the shape of 2.2 and hence the space required for implant placement.
- I would also like to know how urgent restoring the edentulous space is to the patient. I would like to ideally wait until patient has physically matured fully before implant placement to avoid further complications.
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1. Is there a plan to treat the contralateral lateral incisor (#12)? It appears to be a peg lateral. 2. Is the upper incisor midline consistent with the inter-pupillary midline? 3. Study models would be great to assess the overjet/overbite and protrusive tendency. 4. Photo of broadest smile.
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1. What is the pulpal and periapical status of the adjacent teeth, especially the contralateral tooth 1-2? 2. This peg lateral appears on the panoramic film to have a possible PA radiolucency. This may be an artefact, but this must be checked. 3. Is skeletal growth complete?
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1. Mounted study models and a diagnostic wax-up. 2. Some PA radiographs. 3. Perio charting.
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Periapical radiographs. Possibly, a CT scan to verify the bone in the implant site. I would also like to assess the peg lateral on the other side. There may be periapical pathology.
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A 3D Tomogram required to determine the quality and quantity of bone in the 2.2 area.
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What are the patient's expectations? Consultation with oral surgeon or periodontist re: implant placement suitability. Future growth considerations of patient due to young age. Ortho retention phase options.
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At this stage of the case the patient is not ready for debonding. There is a lot of space for the placement of an implant at the 2.2 site, but most was gained by moving the other lateral and the centrals so that the patient’s midline is off.
I would have to see if, when midlines are corrected, there is equal space on both sides for implant placement, and possible aesthetic restoration of the 1.2 which, as a peg lateral, looks unattractive.
Not so sure 1.2 is actually a good candidate for anything other than composite build up – I would need PA to assess the periapical area of that tooth, which looks a little odd on the panoramic radiograph.
As the restorative dentist, I would not proceed with any treatment until the orthodontist fixes the problems and I would then see if there still enough space for implant placement. This is a very hard case to meet the expectations of this young lady and her parents.
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1. A parallel periapical view with a radiographic sphere/measurable marker. 2. +/- a CBCT scan of maxilla + radiographic Interpretation. 3. Feedback from patient and family on preparation to modify hypodontia (1.2) to achieve final symmetry of gingiva and clinical crown. 4. Does a broad smile show the gingival contours?
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Is this patient ready for debonding? At 17 she may be very young. Osseointegration at this time and possible further growth may produce future asymmetry.
What are the aesthetic considerations? Young lady seems to show low smile line but she possibly has a wider smile.
Is this patient ready to have a dental implant placed? The orthodontic root alignments seem to show favourable space considerations. The patient may experience further growth. The 3-D bone may show discrepancies. The papillae need to be trained for a favourable result on final crown.
What is the optimal timing for an implant in this case? Guided Bone Regeneration (GBR) - Wait 6-9 months - Implant 2.2 +/- CT graft - Wait 3 months - Provisionalize and monitor soft tissue conditioning - Wait 6 months - Final Abutment and Crown. (Total time approx 18 months).
What sizes of implants are used in the aesthetic zone? In this lateral region - 3.3 NC, 3.5 RN, 3.3 NC Roxolid?
Ideally how much bone should be on each side of an implant? Minimum 1.5 mm on M and D. Ideally 2 mm buccal. Minimum 1 mm palatal.
What is the optimal space for a lateral incisor implant? 7.3 mm or more
What is the minimal space for a lateral incisor implant? 6.3 mm
Are there any grafting considerations? Most likely, one hasto be prepared for deficiency of bone requirements in apical third. Very likely to have to consider and prepare for possible dehiscence at the gingival level. Guided bone regeneration +/- Connective tissue grafting need to be considered.
What are the alternatives? Bridge, Denture, Temporary Acrylic Denture, Missing Tooth.
How would you sequence treatment for this patient from this point forwards?
1. Communicate with Orthodontist.
2. Communicate with Oral Surgeon.
3. Wax up case and communicate with patient + family and Lab Technician. Communicate time, outcome and financial expectations with patient.
4. Ongoing teamwork with Oral Surgeon, Patient and Lab Technician.
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What is the plan for the microdont (1.2)? This tooth should be restored at the same time as the final implant restoration?
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What is the bone width in the area of implant placement? Given the fact the tooth is congenitally missing and the occlusal photograph suggests bone width deficiency, it would be helpful to know the amount of bone width to better prepare for implant placement (there is possibly a need for grafting).
I would want to measure the space for each lateral incisor – to make sure that they are the same and that they are in aesthetic proportion to the centrals before debonding
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What was the initial orthodontic presentation, including the maxillary/mandibular unit difference? What do the parents look like (i.e. are they class III?)? What has been the patient's compliance with treatment (OHI, retainers, etc.)? I would want a CT scan of the alveolar bone at implant site and, in the 12 site, study models and profile photographs. Who is paying for the treatment and who is paying for the ongoing maintenance?
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Any treatment plan options discussed with patient for restoring 1.2? It appears that the space available for restoring 1.2 is much less than 2.2.
Any x-ray investigations done to check whether skeletal growth for the patient is completed?
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I see stain on the lingual of the maxillary incisors. Does this patient smoke - perhaps covertly? This would be a contraindication for an implant at this time.
The midlines appear to be off in the photos but better in the panoramic x-ray. I would prefer to have the 1.1 & 2.1 moved to the left and enlarge the space around the #1.2 to allow for a resin and/or a veneer so that the width of #1.2 and #2.2 would be equal.
I don't personally place implants so I don't know the minimum space required for an implant, but there appears to be more than adequate bone and good root separation for the #2.2 implant. A CT scan would also reveal the angle of the pre-maxilla and indicate whether a custom abutment would be required.
Smile line does not appear to be a concern in either case. I would also enquire if the patient is active in any contact sports. This could also be a contraindication for an implant at this time.
Oral hygiene doesn't appear to be great although there are no restorations or obvious caries. Implant surgery or pre-emptive periodontal surgery to enlarge the papillae should be delayed until the OH improves - hopefully through the retention phase.
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I would ask the orthodontist if he feels s/he could achieve better symmetry. When I look at the case, I note a congenitally missing 2.2 and a peg 1.2. There is more space in the 2.2 position than in the 1.2 position. Is it possible to balance that space?
What are the patient's and parents’ goals with respect to tooth size and spacing? Is their ultimate goal an aesthetically balanced smile, or would they be content with residual spaces or tooth size discrepancy?
If the patient does not want treatment for 1.2, do we leave residual space on the left side to balance her smile or do we accept a wider 22?
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Confirm skeletal growth is complete. Confirm adequate bone for an implant (in facio-palatal dimension). Sound (i.e. measure) bone heights interproximally on adjacent teeth. Aesthetic diagnostic wax-up. Intra-oral mock-up. Determine level of para-functional habit.
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- Discussion with the orthodontist regarding the position of the 1.2 and the alignment of the 1.1 and 2.1 (it appears they are not at the midline leaving too much space for the 2.2, which will compromise the final aesthetics).
- 1.2 will likely require crowning to optimize aesthetics, therefore models and a wax-up of the final aesthetics with present tooth and spacing considerations could be done to translate the aesthetic concerns to the orthodontist; a second set of models and wax-up could be done to translate as to where better 1.2 position and 2.2 spacing would be for optimal aesthetics.
- Discussion with the surgeon or the periodontist as to the size and type of implant proposed (I do not place implants myself).
- Relay this information to the laboratory to determine if optimal aesthetics can be achieved with the proposed size and placement of the implant (once ideal spacing has been achieved).
- A CT, ideally with a computer-generated scanning appliance, to determine not only if there is adequate mesial/distal bone width, but if there is adequate buccal and lingual bone thickness to accommodate the proposed implant size and placement.
- Discuss with the surgeon/periodontist if a buccal bone graft is required.
- Once the 1.2 position and the 2.2 spacing have been optimally achieved, placement of the implant can be performed (based on the appropriate size and placement of the implant which has already been pre- determined), using a surgical guide based on the scanning appliance.
- The patient would be left in fixed orthodontics (perhaps placing a pontic on the wire at this stage to improve aesthetics), until healing of the implant site has occurred.
- Once healing has occurred (approximately 6 weeks after placement of the healing cap), the patients can be debonded and the abutment and provisional crown can be placed on the 2.2 implant.
- 1.2 crown prep and provisional could then the performed so optimal aesthetics could be created between the 1.2 and 2.2 before final crown fabrications.
- Cementation of 1.2 and 2.2 crowns
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Consideration should be given to a veneer on tooth #. 1.2, a peg lateral.
1] Although there has been discussion about the missing tooth, nothing has been said about the peg lateral and the patient's happiness or not with this tooth. [I do note that there is a distinct lack of root parallelism with the centrals and this tooth and would wonder about long term stability of the case.] There is a midline discrepancy between the upper and lower which I would ascribe to different size spaces for the laterals. Essentially if we want to make full size laterals the case does not appear to be complete orthodontically.
2] Is growth and development complete in this case?
3] There is adequate space between the teeth, good bone height and a smile line suited to implant therapy. However, I wonder about the ridge width buccally and lingually and whether this could be expanded during implant placement or whether there would be bone grafting needed.
4] I would need to know that the patient's hygiene met the needs of the case though this seems likely from the photos.
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When is skeletal growth complete for her? Can midline relationship be improved and, at the same time, can more space be created to increase the size of the 1.2? What is the anticipated quality of bone in the area for the 2.2? Should a periodontal procedure be considered to improve the aesthetics in the 1.3 to 2.3 area? What occlusion is likely after orthodontics? What finances are available for this case?
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A cone beam or CT scan would be helpful to know how much bone volume is present for the implant. It would be helpful to know if the patient is open to ideal treatment or just having debanding and an implant placed. Would she consider having more orthodontic treatment to create an ideal space for the implant and to address the 1.2 peg later, would she consider periodontal surgery to create ideal gingival contours?
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Is the patient willing to undergo implant surgery? How much is this patient willing to invest financially?
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1) To ensure that the current maximum intercuspation (MIP) evident on the images is also in centric relation (CRO) in the temporo-mandibular joints, face bow mounted centric relation mounted casts are required prior to debanding.
2) Additional clinical photographs are required to assess the high lip line, the inter-arch relationships in CRO and the patient's profile
3) A consultation will be required with the orthodontist regarding the following concerns: a) Any positional shift between CRO and MIP b) The possibility of #1.2 requiring endodontic treatment or extraction c) The position of the upper lip with a broad smile (high lip line) d) The initial treatment plan for the restoration of tooth 1.2 before orthodontics was initiated e) The possibility of providing proportionately ideal mesio-distal space for the restoration of symmetrical teeth 1.2 and 2.2. f) The lingual angulation of teeth 1.3, 2.3, 3.3 and 4.3 and providing adequate coupling for cuspid guided occlusion protective of teeth 1.2 and 2.2 g) The maxillary midline shift to the right h) The possibility that cone beam computerized tomography (CBCT) will be required prior to placing implant (s?)
4) A consultation with an endodontist regarding the prognosis for tooth 1.2: a) Is it devitalized? b) Can a peg lateral be treated and have a good prognosis endodontically due to the aberrant anatomy. c) If endodontically treated, can a post be placed which will not further weaken the already thin root? d) Is extraction and implant placement a better long-term treatment option?
5) Referral to a radiologist for CBCT imaging regarding the 1.2 and 2.2 sites to assess whether or not bone grafting will be required.
6) A consultation between the orthodontist, endondontist (if necessary), oral surgeon (or periodontist) and restorative dentist to review the findings and plan an appropriate treatment to be presented to the patient and her parents or guardians.
7) A consultation between the patient, her parents or guardians, the orthodontist and the restorative dentist.
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Any cost considerations?
CT scan information with regard to positioning of implant or need for graft.
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- When are the braces scheduled to come off? - Would taking them off prior to implant placement and restoration cause loss of space due to tipping of the central and/or the canine? - The midlines are off, couldn't this be corrected? - If the midline was corrected would this leave enough space to restore the 1.2 with a veneer or crown and still leave enough room for the implant?
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Has the patient completed her skeletal growth?
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Study models to assess for bone width, interocclasal space, interdental space, Periapical radiographs, Laboratory wax up.
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A better picture to assess dental midlines. Overjet and Overbite. Confirmation of adequate attached gingiva. Measurement of soft tissue volume and distance to bone in 2.2 position. Assessment of bone volume, especially the buccal plate. A radiograph of the hand to assess if the patient has finished growing. A measurement of the width of the 1.2 and current space present.
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Consult with a surgeon to determine if enough bone is available for implant placement and would grafting be necessary. Does patient want an implant? She is a little young for an implant presently so some sort of provisional replacement would be needed. This could be a PUD, retainer with a tooth, or resin bonded restoration. Is she interested in treating the 1.2 peg lateral also? Para functional habits? Playing contact sports? Diagnostic wax up of 1-2 and 2-2 to check for symmetry before debanding.
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