Q U I N T E S S E N C E I N T E R N AT I O N A L

RESTORATIVE DENTISTRY

Christian F. Selz

An interdisciplinary noninvasive all-ceramic treatment concept for nonsyndromic oligodontia in adolescence Christian F. Selz, DDS, Dr med dent1/Britta A. Jung, Prof Dr med dent, PhD2/Petra C. Guess, Prof Dr med dent, PhD3 Oligodontia has a substantial oral functional and psychosocial impact on the quality of life of children. The treatment of oligodontia in adolescence is an interdisciplinary approach which can include extraction of the primary teeth with orthodontic space closure, or prosthodontic rehabilitation. This case report describes a conservative approach for the rehabilitation of a 12-year-old patient with 19 ageneses (excluding third molars) of permanent teeth, infraocclusion of the persisting primary teeth, deep overbite, and reduced mesiodistal dimension of the maxillary incisors with a central diastema. The treatment

plan to restore esthetics and function included an initial noninvasive prosthetic rehabilitation for deep bite correction with additive leucite-reinforced glass-ceramic onlays/veneers until definitive orthodontic and implant therapy are reevaluated and determined in adulthood. Esthetics, functional occlusion, and crown-to-root ratio remained stable over a follow-up period of 3 years. No signs of fractures within the all-ceramic restorations or symptoms of a temporomandibular disorder were evident. (Quintessence Int 2015;46:111–118; doi: 10.3290/j.qi. a32635)

Key words: infraocclusion, leucite-reinforced glass-ceramic, nonsyndromic oligodontia

Agenesis of permanent teeth is one of the most common dental polymorphisms in humans.1-4 Dental agenesis is classified by its severity, whereas the congenital absence of six or more permanent teeth (excluding third molars) is referred to as oligodontia.1,5-7 Prevalence values of oligodontia mentioned in the literature range between 0.08% to 0.16%1,7-9 and 1.1%.1,10 Oligodontia may occur either solely (nonsyndromic oligodontia) or in association with syndromes (syndromic

1

Private Practice of Orthodontics, Freiburg, Germany; and Assistant Professor, Department of Prosthodontics, School of Dentistry, Albert Ludwigs University of Freiburg, Freiburg im Breisgau, Germany.

2

Professor and Chair, Department of Orthodontics, School of Dentistry, Albert Ludwigs University of Freiburg, Freiburg im Breisgau, Germany.

3

Associate Professor, Department of Prosthodontics, School of Dentistry, Albert Ludwigs University of Freiburg, Freiburg im Breisgau, Germany.

Correspondence: Christian F. Selz, Department of Prosthodontics, School of Dentistry, Albert Ludwigs University of Freiburg, Hugstetterstr.  55, 79106 Freiburg, Germany. Email: [email protected]

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oligodontia),11 such as ectodermal dysplasia,12 Down syndrome,13 or as a cleft lip and palate.14 It is a highly heritable condition and mainly associated with mutations in the PAX9 (paired box gene 9), MSX1 (muscle segment homeobox 1), EDA (ectodysplasin-A), and AXIN2 (axis inhibition protein 2) genes.1,7,15 The genetic transfer is characterized by an autosomal-dominant, autosomal-recessive, or x-linked condition,5,7,15 but may also be influenced by environmental factors.4,16 The prevalence of females to suffer from nonsyndromic dental agenesis is 1.4 times higher than in males.17 Oligodontia-affected patients often demonstrate significant variability in location, symmetry, and number of teeth involved. Their residual teeth show variation in size, shape, or in the rate of development,2,5,18-20 however their permanent dentition is more affected by agenesis.21 The treatment of oligodontia in adolescence often requires an interdisciplinary approach where the

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Fig 1 Lip line before prosthetic treatment showing a reduced vertical dimension of occlusion.

patient’s continuous skeletal growth needs to be considered. Removable prostheses and dental implants are common treatment concepts, but long-term data with respect to their influence on facial growth are still lacking.22,23 However, an ongoing subtle growth in adulthood accompanied by an unexpected functional and esthetic outcome of early placed implant restorations is described in the literature.24 Opening of interproximal contacts, changes in occlusion, and discrepancies of incisal edge lengths between implant restorations and adjacent natural teeth are possible long-term complications caused by continuous skeletal growth in adulthood.24 This case report demonstrates an alternative management of nonsyndromic oligodontia in a 12-year-old male patient with noninvasive all-ceramic onlays and veneers.

CASE REPORT A healthy male patient, aged 12 years, with numerous persisting primary teeth was referred to the Department of Orthodontics and Prosthodontics for interdisciplinary treatment. He previously received a functional orthodontic treatment at a private orthodontic practice. A removable activator appliance, which included an expansion screw (tooth-borne active appliance) was inserted for growth modification. Anterior bite blocks were used to prevent the maxillary incisors from erupting. The mandibular first permanent molars were free to erupt while the eruption of the maxillary first molars was impeded by an acrylic shield. The treatment was discontinued because of progressive infraocclusion of the primary teeth. Extraoral examination showed facial asymmetry,

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a convex soft-tissue profile, and a reduced lower face height as well as competent lips. The intraoral photographs and dental casts revealed 17 persisting primary teeth (the mandibular left incisor, and maxillary and mandibular lateral incisors, canines, and molars), malformed primary teeth (maxillary and mandibular lateral incisors and canines), a deep bite of 5 mm, a central diastema of 2 mm, and a physiologic Class II molar relationship on both sides (Figs 1 and 2). First and second primary molars were checked with double-layered articulating paper (Hanel Articulating foil, 12 μm, Coltène/Whaledent) and showed nonocclusion. The panoramic radiograph (Fig 3) showed 19 ageneses of permanent teeth (mandibular left central incisor, maxillary and mandibular lateral incisors, maxillary and mandibular canines, maxillary and mandibular first and second premolars, mandibular second molars) and a moderate infraocclusion of all retained primary teeth. The cephalometric analysis showed a Class I jaw-base relationship with vertical growth. The treatment objectives were to: • preserve all primary teeth and the leeway-space (physiologic Class II molar relationship) through adolescence for potential implant placement • facilitate eruption of the permanent first molars • correct the infraocclusion of the primary molars with adhesively cemented nonpreparation allceramic onlays and veneers. Further aims were to: • improve function • improve facial and dental esthetics • preserve the crown-to-root ratio of the primary teeth.

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Q U I N T E S S E N C E I N T E R N AT I O N A L Selz et al

c

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d

b

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Figs 2a to 2e Initial intraoral photographs showing 17 persisting primary teeth, infraoccluded primary teeth, a deep bite, reduced mesiodistal dimension of the maxillary incisors with a central diastema of 2 mm, and a physiologic Class II molar relationship on both sides.

Fig 3 Initial panoramic radiograph showing 19 ageneses (mandibular left central incisor, maxillary and mandibular lateral incisors, maxillary and mandibular canines, maxillary and mandibular first and second premolars, mandibular second molars) of permanent successors.

Phonetic aspects related to the multiple diastemata were also considered during the treatment planning process. Hence prosthetic and orthodontic diastema closure and their potential risks were discussed with the parents. Both treatment options were rejected because of an insufficient length/width ratio of the maxillary anterior teeth resulting in poor esthetics and a disproportion between jaw and tooth size. Moreover, the patient was used to the central diastema.

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The extraction of all primary teeth and gap closure by implant placement was considered obsolete as it would impair the vertical development of the maxilla and mandible.25,26 Hence a conservative treatment approach with noninvasive all-ceramic restorations was selected for the present case as an intermediate solution that allows the completion of skeletal development. Common therapy concepts for selective hypodontia are fixed dental prostheses,27 direct com-

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a

b

Figs 4a and 4b Leucite-reinforced glass-ceramic onlays/veneers (IPS Empress, Ivoclar Vivadent) on the master model after surface characterization with stains.

posite resin restorations,28 or removable partial dentures25 and implant placement23 for oligodontia. In this case all remaining primary teeth revealed only minor malformation and the enamel as well as dentin structure were intact and free of caries (Fig 2). All teeth showed no clinical mobility or percussion sensitivity and revealed a preserved root length of at least ½ to ¾ of the original size. Thus, extraction of the primary teeth due to a poor crown-to-root ratio with subsequent removable partial denture therapy was not a treatment option. Hence all primary teeth were preserved and the major treatment aims were to improve functional occlusion and esthetics with adhesively cemented non-prep all-ceramic onlays and veneers.

RESTORATIVE PROCEDURES The all-ceramic rehabilitation with noninvasive veneers and onlays was conducted when the patient was 12 years old. To avoid any kind of trauma and pathologic root resorption of the primary teeth, no preparation at all was performed.29 Full-arch impressions were taken with individual trays and a polyether impression material (Permadyne, 3M ESPE). After fabrication of the master models (GC FujiRock EP, GC Europe), a shade selection was carried out (Chromascop, Ivoclar Vivadent). A diagnostic wax-up (1 mm interocclusal distance at the first permanent molars) was completed and transferred into the definitive all-ceramic restor-

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ations. The vertical dimension of occlusion (VDO) was increased by 3 mm to achieve a normal overbite. The non-prep restorations were fabricated out of a leucitereinforced glass-ceramic (IPS Empress, Ivoclar Vivadent) using the press technique according to the manufacturer’s instructions. The monolithic IPS Empress onlays and veneers were individualized (Fig 4) with the surface staining technique (IPS Empress Universal Stains, Ivoclar Vivadent). No veneering ceramic application was performed. All non-prep restorations were adhesively luted under rubber dam. After cleaning and etching of the primary teeth with 37% phosphoric acid (enamel, 40 seconds; dentin, 15 seconds; Total-Etch, Ivoclar Vivadent), Syntac Primer (15 seconds; Ivoclar Vivadent) followed by Syntac Adhesive (10 seconds; Ivoclar Vivadent) and Heliobond (Ivoclar Vivadent) were applied. At the same time, the all-ceramic restorations were cleaned with 99% isopropanol and etched for 60 seconds with 4.9% hydrofluoric acid (IPS Ceramic Etching Gel, Ivoclar Vivadent). After ceramic surface silanization for 60 seconds, a dual-polymerizing composite cement (Monobond-S and Variolink II high viscosity, Ivoclar Vivadent) was used for adhesive luting. A glycerin gel (Liquid-Strip, Ivoclar Vivadent) was applied to prevent an oxygen inhibition layer at the preparation margin. Light curing was performed from different directions for 40 seconds (Elipar Free Light 2, 3M ESPE). Residual excess cement was removed with a finishing diamond (#852EF.314.014, Gebr. Brasseler) and flexible polishing

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Fig 5 Anterior view after prosthetic treatment showing a deep bite correction of 3 mm.

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Figs 6a to 6e Intraoral photographs at 3-year follow-up. Esthetics and functional occlusion remained stable. No signs of fractures within the ceramic were evident.

disks (Sof-Lex Pop-On, 3M ESPE). Minor occlusal adjustments were made chairside and repolished with ceramic silicone polishers (OptraFine Polishing Set, Ivoclar Vivadent). A stable static occlusion (physiologic Class II molar relationship by Class I jaw-base relationship), and a dynamic occlusion with incisal/canine guidance were obtained. Moreover, the VDO was increased by 3 mm (Fig 5). The first permanent maxillary and mandibular

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molars, which were in nonocclusion due to the increase of the VDO, erupted 1 mm into antagonistic occlusion after 8 weeks. All persisting primary teeth were in-situ and stabilized through the adhesively cemented allceramic onlay and veneer restorations at the 3-year recall. The intraoral photographs confirmed a stable occlusion, a healthy periodontal situation, and no marginal staining or plaque accumulation (Fig 6). No caries at the restoration margins or signs of fractures within

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the all-ceramic restorations were observed. Moreover, no symptoms of a temporomandibular disorder were evident.

DISCUSSION A comprehensive interdisciplinary treatment of adolescents with a large number of congenitally missing teeth to achieve a functional and esthetic long-term result is a great challenge.30,31 At this stage, further orthodontic treatment was postponed until adulthood to avoid external root resorption as a consequence of the large amount of cumulative forces. The physiologic Class II molar relationship was maintained, because of its functional stability. Dueled et al32 reported a high risk of severe root resorption in patients with tooth agenesis after orthodonic treatment. In their retrospective study, 36% of the patients showed evident root resorption.32 This is in accordance with other studies in the dental literature.33-35 The oral functional and psychosocial impact of oligodontia on oral health-related quality of life (OHRQoL) of children is substantial.36,37 In this context, the retention of the primary teeth was beneficial from an esthetic and functional point of view.38,39 Additionally, it has been demonstrated that the alveolar bone growth is associated with the natural dentition, therefore in the absence of permanent successors intact primary teeth should be retained as long as possible.28 The possibility to preserve retained primary molars until adult age without exfoliation is mentioned in the literature.40-44 A significant reciprocal association was found between agenesis of permanent successors and the infraocclusion of respective retained primary molars.45 Thus a number of issues in the treatment planning of infraoccluded primary teeth have to be taken into consideration: condition of the primary teeth (crown-to-root ratio, integrity of the bone), caries prevalence, oral hygiene, vertical tooth position according to the occlusion, jaw relationships (dental and skeletal), patient’s chronologic and dental age, and the patient’s treatment preference.28,43 Considering all these facts the aim of the subsequent prosthetic rehabilitation was to

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increase the VDO in order to correct the deep bite and to restore oral function. In this particular case, it was decided to increase the VDO up to 3 mm with additive noninvasive all-ceramic onlay restorations. The permanent first and second molars overerupted into antagonist’s occlusal contact by the dentoalveolar compensation mechanism.46 A recent systematic review comprising an adult patient population showed that a permanent increase of the VDO of up to 5 mm with fixed restorations can be considered as a safe and predictable procedure and results in a high adaptation level of the treated patients.47 In case of multiple congenitally missing permanent teeth, removable partial dentures followed by dental implants were used in most cases.31 However, removable partial dentures reveal several limitations in terms of phonetic, functional, esthetic, and psychosocial aspects for adolescent patients. Moreover, inflexible maxillary/mandibular arch-crossing prosthetic rehabilitations, which impede growth, should be avoided.23 Implant integration in young patients mostly results in an infraocclusion of the implant restoration.48 Thilander et al49 showed that changes of the dento-alveolar height and slight continuous eruption of implant adjacent teeth have to be considered during treatment planning even in postadolescence.49 In particular, a vertical craniofacial growth associated with a clockwise mandibular rotation can result in a labial exposure of the implant due to bone remodeling, especially in the anterior dentition.49 Considering the compromised anatomic situation, a 5-year survival rate of 89.8% for implants in adult patients with oligodontia is mentioned in the literature.19 In contrast to this, 5-year survival rates of implants supporting single crowns and fixed dental prostheses inserted in non-affected patients were 97.2% and 95.6%, respectively.50 Direct composite restorations28 or non-prep allceramic onlays represent a more conservative approach for transitional rehabilitation of oligodontia patients. In this context indirect all-ceramic restorations seem to be advantageous in terms of their mechanical properties such as shrinkage and wear behavior.51 Moreover, the reestablishment of the required ana-

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tomical form in complex cases with direct techniques is very time-consuming and highly dependent on the operator’s clinical skills.51 Deterioration of the surface structure, marginal quality with increased discoloration, and augmented plaque accumulation were frequently observed with extended composite restorations.52 Due to a limited occlusal wear resistance, composite resin could also be problematic in terms of maintaining the established VDO over time.51 In contrast to this, all-ceramic restorations are fatigue and fracture resistant even when reduced ceramic thicknesses (0.6 mm to 1.4 mm) are applied.53,54 According to Passos et al,55 leucite-reinforced glass-ceramic showed antagonistic wear rates that are comparable to normal enamel, provided that the surface of the ceramic restoration is adequately polished. Short-, medium- and longterm clinical data on leucite-reinforced glass-ceramic onlay restorations are very promising with survival rates between 97% and 100%.56,57 Further reevaluation of the present patient after the completion of growth is required to determine a definitive treatment plan, which may include the ongoing clinical function of the non-prep all-ceramic restorations or the extraction of the persisting primary teeth followed by implant placement.

CONCLUSION The present case report describes a novel treatment concept for patients with oligodontia that can be also successfully applied for remaining primary teeth with erosive defects or molar-incisor hypomineralization, which are increasingly prevalent. Due to the noninvasiveness and long-term predictability of the present approach, non-prep all-ceramic restorations could serve as a reliable alternative to direct composite resin restorations for general practitioners. Esthetics, phonetics, and masticatory function could be adequately restored over an observation time of 3 years. The preservation of the persisting primary teeth enabled an undisturbed skeletal growth, space maintenance, and the preservation of the alveolar bone volume for implant placement in adulthood.

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ACKNOWLEDGMENT The authors thank MDT Lamott, Freiburg, Germany, for technical assistance.

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40. Kurol J, Thilander B. Infraocclusion of primary molars with aplasia of the permanent successors. A longitudinal study. Angle Orthod 1984;54:283–294. 41. Bjerklin K, Al-Najjar M, Karestedt H, Andren A. Agenesis of mandibular second premolars with retained primary molars. A longitudinal radiographic study of 99 subjects from 12 years of age to adulthood. Eur J Orthod 2008;30:254–261. 42. Bjerklin K, Bennett J. The long-term survival of lower second primary molars in subjects with agenesis of the premolars. Eur J Orthod 2000;22:245–255. 43. Rune B, Sarnäs KV. Root resorption and submergence in retained deciduous second molars. A mixed-longitudinal study of 77 children with developmental absence of second premolars. Eur J Orthod 1984;6:123–131. 44. Ith-Hansen K, Kjaer I. Persistence of deciduous molars in subjects with agenesis of the second premolars. Eur J Orthod 2000;22:239–243. 45. Baccetti T. A controlled study of associated dental anomalies. Angle Orthod 1998;68:267–274. 46. Crothers A, Sandham A. Vertical height differences in subjects with severe dental wear. Eur J Orthod 1993;15:519–525. 47. Abduo J. Safety of increasing vertical dimension of occlusion: a systematic review. Quintessence Int 2012;43:369–380. 48. Finnema KJ, Raghoebar GM, Meijer HJ, Vissink A. Oral rehabilitation with dental implants in oligodontia patients. Int J Prosthodont 2005;18:203–209. 49. Thilander B, Oedman J, Lekholm U. Orthodontic aspects of the use of oral implants in adolescents: a 10-year follow-up study. Eur J Orthod 2001;23: 715–731. 50. Albrektsson T, Donos N; Working Group 1. Implant survival and complications. The third EAO consensus conference 2012. Clin Oral Implants Res 2012;23:63–65. 51. Kuijs RH, Fennis WM, Kreulen CM, Roeters FJ, Verdonschot N, Creugers NH. A comparison of fatigue resistance of three materials for cusp-replacing adhesive restorations. J Dent 2006;34:19–25. 52. Gresnigt M, Kalk W, Oezcan M. Randomized clinical trial of indirect resin composite and ceramic veneers: up to 3-year follow-up. J Adhes Dent 2012;15:181–190. 53. Guess PC, Schultheis S, Wolkewitz M, Zhang Y, Strub JR. Influence of preparation design and ceramic thicknesses on fracture resistance and failure modes of premolar partial coverage restorations. J Prosthet Dent 2013;110:264–273. 54. Ma L, Guess PC, Zhang Y. Load-bearing properties of minimal-invasive monolithic lithium disilicate and zirconia occlusal onlays: finite element and theoretical analyses. Dent Mater 2013;29:742–751. 55. Passos SP, de Freitas AP, Iorgovan G, Rizkalla AS, Santos MJ, Santos Júnior GC. Enamel wear opposing different surface conditions of different CAD/CAM ceramics. Quintessence Int 2013;44:743–751. 56. Guess PC, Selz CF, Steinhart YN, Stampf S, Strub JR. Prospective clinical splitmouth study of pressed and CAD/CAM all-ceramic partial-coverage restorations: 7-year results. Int J Prosthodont 2013;26:21–25. 57. Guess PC, Strub JR, Steinhart N, Wolkewitz M, Stappert CF. All-ceramic partial coverage restorations: midterm results of a 5-year prospective clinical splitmouth study. J Dent 2009;37:627–637.

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An interdisciplinary noninvasive all-ceramic treatment concept for nonsyndromic oligodontia in adolescence.

Oligodontia has a substantial oral functional and psychosocial impact on the quality of life of children. The treatment of oligodontia in adolescence ...
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