Prosthodontic rehabilitation of a patient with missing teeth in the maxillary anterior aesthetic reg

TITLE OF CASE Do not include “a case report”

“Management of the patient with the partially edentulous maxillary anterior region having bilateral impacted supernumerary teeth associated with abutment teeth.”

SUMMARY Up to 150 words summarising the case presentation and outcome (this will be freely available online)

Background- A patient with missing teeth in maxillary anterior aesthetic region along with impacted supernumerary teeth associated with abutment teeth poses a greater challenge for prosthodontic rehabilitation. In such cases treatment using fixed partial denture (FPD) may not be feasible because of the possibility of damaging the vitality of the pulp of the abutment teeth and further complications associated with it. Objective- To present a case of multiple missing maxillary anterior teeth with impacted supernumerary teeth associated with abutment teeth rehabilitated using implant supported fixed prosthesis. Case report: A 26-year-old male patient was successfully rehabilitated using implant supported fixed prosthesis in the maxillary anterior region. Conclusion- Radiographic diagnosis of the bilateral impacted supernumerary teeth associated with the permanent abutment teeth was one of the important step, because of which abutment teeth cannot be used for tooth supported fixed partial denture. The successful management of such patient by implant supported fixed prosthesis can be one of the treatment modality when patient is not having any problem with the impacted supernumerary teeth.

BACKGROUND Why you think this case is important – why did you write it up?

Supernumerary teeth are those which are additional or more than normal number of the teeth. They can be either single or multiple, unilateral or bilateral with predilection for the premaxilla. Koch et al¹ stated that the prevalence of supernumerary teeth in the permanent dentition is 1-3% and the prevalence in primary dentition is 0.3-0.6% which is less as compared with the permanent dentition. The development of supernumerary teeth is not clear. It may be due to dichotomy of tooth bud or due to hyperactivity theory, suggestive of local independent, conditional hyperactivity of dental lamina.²

The surgical intervention of supernumerary teeth has been controversial with various authors having different opinions. The decision on proceeding with the supernumerary teeth should be based on the full clinical picture and interview. Early diagnosis and removal of supernumerary teeth is most preferred to reduce further complications. Erupted supernumerary teeth causing problems can be surgical removed to avoid the complications. Unerupted supernumerary teeth which are not causing any problem can be retained but patient should be made aware about future complications such as cystic changes, migration or damage to the permanent tooth roots.^{3, 4}

In the present case, supernumerary teeth were associated with roots of abutment teeth without any radiographic changes in the adjacent roots. Their close approximation with the roots made the abutments questionable for tooth supported fixed prosthesis. Patient was also not willing for the surgical removal of the supernumerary teeth by palatal approach. So to save the abutment teeth most conservative option was rehabilitating the patient without taking support of the abutment teeth.

The aim of the present article is to describe a case having multiple missing anterior teeth along with bilateral impacted supernumerary teeth in relation with abutment teeth, who was restored successfully by using implant supported fixed prosthesis.

CASE PRESENTATION Presenting features, medical/social/family history

Case history: A 26-year-old male patient reported to the department of prosthodontics with a complaint of missing anterior teeth and impaired aesthetic in relation with the maxillary arch. Patient gave history of trauma six months back. Trauma followed by extraction of root pieces with 12, 11, 21. Subsequently an interim removable prosthesis was fabricated to restore missing three anterior teeth which was loose and illfitting.

Treatment plan was formulated consisting fabrication of the interim removable prosthesis followed by complete clinical and radiographic examination of the edentulous region and abutment teeth.

INVESTIGATIONS If relevant

Clinical and radiographic identification of all the teeth is very important for a good treatment planning. The radiographic examination of the region reveled presence of the bilateral impacted supernumerary teeth in relation with maxillary left and right canine region. Supernumerary teeth were associated with the roots of permanent teeth without causing the root resorption or migration of the permanent teeth. Clinically there was no as such mal-alignment of the remaining permanent teeth. Palatal region associated with the impacted supernumerary teeth were without any abnormality like palatal bulge, history of pain or tenderness etc.

DIFFERENTIAL DIAGNOSIS If relevant

TREATMENT If relevant

It may be difficult to formulate an ideal treatment with supernumerary teeth. Early diagnosis and removal of the supernumerary teeth is one of the advisable treatment modality. Whereas an unerupted supernumerary teeth which are not causing any problem can be retained.^3,4

The present clinical situation of the impacted supernumerary teeth was without any abnormal clinical or radiographic changes. Patient was informed about the presence of the impacted supernumerary teeth associated with the abutment teeth because of which their involvement in fixed partial denture treatment was questionable. Also the use of questionable abutment can lead to future complications leading to subsequent loss of the abutment teeth, increasing the length of edentulous span and further difficulty in rehabilitation.

Surgical removal of the impacted supernumerary teeth was another option to overcome the difficult clinical situation but patient was not willing to undergo surgical removal of teeth. So the option of fixed partial denture was completely taken off and another treatment option using implant supported fixed prosthesis was planed.

Complete diagnosis of the available bone was made using clinical, radiographic examination and bone mapping. According to the presence of available bone the implant placement in region 12 and 21 was planned. Two Zimmer tapered screw vent implants with diameter of 3.3 mm and length of 10 mm were selected. Stage one implant surgical implant placements were carried out and flaps were closed using surgical suture. After one week, re-evaluation of surgical site and suture removal was carried out. Patient’s interim removable partial denture was relined and inserted.

According to Breanmarks protocol second stage surgery was carried out after six months and healing collars were placed on the implants. Healing collars were selected according to the size of the implant platform (3.5 mm). After complete healing of soft tissues around the headlining collars i.e. after one week, abutments were tried.

Implant impression was made by closed tray technique using addition silicon impression material (Affinix). Impression was then evaluated and disinfected. Implant analogs and abutments were attached reinserted into impression. Components were evaluated in the impression for accurate positioning and stability. Impression was then poured with dental stone. Cast was retrieved from impression and abutments were modified accordingly.

Cast was used to fabricate wax pattern for three unit implant supported porcelain fused to metal fixed prosthesis. Wax pattern was then invested, casted and retrieved. Finishing of the framework and try-in was carried out. Ceramic built up was done and in next appointment is then evaluated and final adjustments were made before glazing. Prosthesis was completely made out off contact in both centric and eccentric mandibular movements. Cementation of prosthesis is carried out using zinc oxide-noneugenol cement (Relayx). Post-cementation instructions were given to the patient.

OUTCOME AND FOLLOW-UP

The Patient was recalled after the first day then after a week. The patient was happy with the aesthetics and functions of prosthesis and was advised for regular recall visits (Fig. )

DISCUSSION Include a very brief review of similar published cases

Rehabilitation of missing maxillary anterior teeth in aesthetic region along with impacted supernumerary teeth associated with abutment teeth was one of the difficult clinical situation to manage. The bilateral impacted supernumerary teeth associated with the permanent abutment teeth because of which abutment teeth cannot be used for tooth supported fixed partial denture. As the option of fixed partial denture will requires preparation of the abutment teeth which may lead to damage to pulpal vitality, periapical infection along with further complications leading to loss of abutment teeth or failure of fixed partial denture treatment.

The treatment options for management of supernumerary teeth are mainly depends on whether they are erupted or unerupted and also on whether there is presence of any abnormality in the associated resion is present or not. Diagnosis and treatment planning depending on radiographic and clinical findings is the key for successful management. Erupted supernumerary teeth causing problems can be surgical removed to reduce the complications.⁴ Supernumerary teeth if they are associated with the roots of permanent teeth, it is advisable to await for complete root development before surgical extraction so that damage to permanent teeth is at lesser risk.⁵ Unerupted supernumerary teeth which are not causing any problem can be retained but patient should be made aware about future complications such as cystic changes, migration or damage to the permanent tooth roots.^3,4

In the present clinical situation, patient was informed about the presence of the impacted supernumerary teeth associated with the abutment teeth which were not causing any abnormality in relation with maxillary arch. The presence of bilateral impacted supernumerary teeth made permanent teeth questionable abutment for fixed partial denture treatment. Also the use of questionable abutment can lead to future complications leading to subsequent loss of the abutment teeth, increasing the length of edentulous span and further difficulty in rehabilitation.

Surgical removal of the supernumerary teeth was another option before proceeding to any other fixed treatment option for rehabilitation of missing teeth. As the teeth and associated area of the maxillary arch was without any abnormality patient was not ready to undergo for surgical removal of impacted supernumerary teeth. So the option of implant supported fixed prosthesis was thought for the rehabilitation.

The aesthetics and functional demands for replacement of missing teeth have been a major concern for the rehabilitation of the patient. The introduction of ossiointegrated implant increased the possibility of providing fixed prosthesis for rehabilitation of missing teeth in partially edentulous regions. Advantages of implant supported fixed prosthesis are mainly potential for stable and electively fixed prostheses, prevention the residual ridge resorption and minimal risk of preprosthetic surgical morbidity.

Belser UC et al presented protocol for prosthetic management of the partially dentate patient with fixed implant restorations and stated that multiple-unit restorations in sites of esthetic con­cern should be supported by a minimum of two im­plants. Also the placement of an implant for each missing tooth is not necessary. Modified ridge lap-design is labially adapted to the edentulous ridge and thus create the illusion of a scalloped gingival course with distinctly formed interproximal papillae. Similar protocols were followed during management of the present clinical situation.6

Zarb JP and Zarb GA presented report of prospective study on implant prosthodontic management of anterior partial edentulism. The results the study demonstrated a high survival rate for Branemark implants supporting tissue-integrated prostheses for the management of anterior partial edentulism.7

LEARNING POINTS/TAKE HOME MESSAGES 3 to 5 bullet points – this is a required field

• Supernumerary teeth can present in any region of the oral cavity. These may erupt or remain impacted and may lead to various complications.
• The clinician should recognize signs suggesting the presence of supernumerary teeth, particularly aberrations in the eruptive pattern, and perform the relevant investigations.

• Diagnosis and clinical, radiographic investigations is important step for formulating the predictable treatment plan.
• Timely management of supernumerary teeth and observation is important to prevent complications.

REFERENCES Vancouver style (Was the patient involved in a clinical trial? Please reference related articles)

1. Koch H, Schwartz O and Klausen B. Indications for surgical removal of supernumerary teeth in the premaxilla. Int J Oral Maxillofac Surg 1986;15:273-281.
2. Garvey MT, Barry HJ and Blake M. Supernumerary teeth: An overview of classification, diagnosis, and management. J Can Dent Assoc 1999;65:612‑616.
3. Hogstrum A and Andersson L. Complications related to surgical removal of anterior supernumerary teeth in children. ASDC J Dent Child1987;54:341‑343.
4. Amarlal D and Muthu MS. Supernumerary teeth: Review of literature and decision support system. Indian J Dent Res 2013;24:117-122.
5. Shah A, Gill DS, Tredwin C and Naini F.B. Diagnosis and management of supernumerary teeth. Dent Update 2008;35:510-520.
6. Belser UC, Mericske-Stern R, Bernard JP and Taylor TD. Prosthetic management of the partially dentate patient with fixed implant restorations. Clin Oral Impl Res 2000:11:126-145.
7. Zarb JP and Zarb GA. Implant prosthodontic management of anterior partial edentulism: long-term follow-up of a prospective study. J Can Dent Assoc 2002; 68(2):92-96.

FIGURE/VIDEO CAPTIONS figures should NOT be embedded in this document

Fig. 1.

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