Puranik Chaitanya P^1*, Yinger Sheaffer², Ólafsson Vilhelm G³

¹Pediatric Dentistry, Children’s Hospital Colorado, School of Dental Medicine, University of Colorado, Anschutz Medical Campus, Colorado, USA
²Resident, Nationwide Children’s Hospital, Ohio, USA
³Operative Dentistry and Cariology, Faculty of Odontology, University of Iceland, Iceland

*Corresponding Author: Chaitanya Puranik P, BDS, MS, M. Dent. Sci., Ph.D., Director of Predoctoral Education in Pediatric Dentistry, Children’s Hospital Colorado and School of Dental Medicine, University of Colorado, Colorado, USA; Email: [email protected]

Published Date: 31-03-2022

Copyright^© 2022 by Puranik CP, et al. All rights reserved. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Abstract

Congenital absence of permanent maxillary lateral incisors can have a negative impact on adolescent patients from a functional and psychological standpoint. Historically used treatment options for hypodontia are invasive, warranting preparation of the abutment teeth and/or comprehensive orthodontic treatment. Dental implants are a preferred modality without the need for abutment preparation; however, are contraindicated until the completion of skeletal growth. This case-series presents two case-reports of adolescent patients with congenitally missing permanent maxillary lateral incisors restored using a novel resin-bonded bridge (Carolina Bridge). The Carolina Bridge is a conservative, esthetic, cost-effective, reversible, long-term, interim treatment option to replace missing teeth until implant-supported restorations are indicated. The basics of the Carolina Bridge including indications, contraindications, case selection criteria and clinical fabrication steps are presented in detail to help clinicians with treatment planning and execution.

Keywords

Hypodontia, Carolina Bridge; Esthetic Restoration; Resin-Supported Bridge; Congenitally Missing Teeth

Introduction

Congenital absence of teeth can be a significant restorative challenge in adolescent patients, particularly when involving the anterior sextant. The permanent maxillary lateral incisors are the most commonly missing anterior teeth, with a prevalence of 2.2% [1]. Congenital absence of teeth affects form, function and esthetics during adolescence, when patients become aware of self-image and esthetic social constructs [1,2]. These patients can experience bullying and subsequent psychological distress, depression, anxiety and underachievement [2]. Dental-specific implications such as tipping and supra-eruption of adjacent teeth also pose challenges to future restorative management due to increased loading, wear and periodontal consequences [3]. While generating a restorative treatment plan, multiple factors need to be considered including the size, shape, position and integrity of adjacent teeth along with alveolar and craniofacial bone growth.

Various restorative treatment options for hypodontia have been previously published and advantages and disadvantages of each are presented in Table 1 [4]. A majority of these options are considered invasive, involving preparation of adjacent teeth. Dental implants do not require abutment tooth preparation and thus have been favored as a conservative treatment option. Although dental implants are conservative, esthetic and functional, implant placement is contraindicated in adolescent patients with incomplete skeletal growth [5-7]. Implants placed before the completion of craniofacial growth can lead to future infra-occlusion and labial position of the implant [8]. Hence, implant placement should be deferred until or even after the completion of skeletal growth (females: 18-19 years, males: 20-21 years) [7].

In contrast with the existing treatment modalities, resin-bonded bridges, such as the Carolina Bridge (CB) provide a conservative, esthetic, cost-effective, reversible and long-term interim restorative option. This is especially beneficial when implants are planned after the completion of growth. CBs are ridge-lap design porcelain-pontics bonded to adjacent teeth using composite resin, with virtually no abutment teeth preparation. This paper provides two case-reports of adolescent patients with hypodontia in the maxillary anterior sextant with long-term (two-year) follow-up.

Table 1: Existing treatment modalities for hypodontia with advantages and disadvantages of each modality.

Case Report

The details of each case are presented in Table 2. In both cases, the patient and legal guardian were presented with various restorative treatment options including associated risks and benefits. Due to incomplete skeletal growth, implant placement was recommended as a future restorative option. The patients and families in both cases declined other options and opted for replacement of their missing tooth/teeth with a resin-supported CB as a long-term interim restoration until the completion of skeletal growth. Informed consent was obtained followed by preparation-fabrication of CBs. After CB placement, each case was followed at 1, 3, 6, 12 and 24 months. The parents provided permission for use of de-identified intra-oral. Indications, contraindications, case selection criteria and clinical steps for the CB are presented in Table 3.

Table

Table 2: Detailed description of the two Carolina Bridge cases.

Table 3:  Basics of the Carolina Bridge, indications, contraindications, case selection criteria and clinical steps involved in fabrication.

Discussion

Case selection criteria and clinical steps for restoring teeth with CBs were discussed by Heymann in 2006 [9]. The pontic is fabricated with Feldspathic porcelain, providing advantages of esthetics, color stability, strength and the ability to etch the proximal surfaces for retention. CB use in adolescent patients is especially indicated since it requires virtually no abutment preparation; deeming it reversible and reducing the risk of dental pulp exposure in immature teeth. Additionally, CBs are associated with less periodontal complications due to the ridge-lap pontic design and margin placement [10].

Retention in CBs is entirely dependent on the proximal resin connectors, necessitating appropriate case selection [9]. Optimal occlusion, periodontal health and adequate interproximal surface bonding are imperative for success of the restoration. The most favorable occlusion demonstrates optimum (2 mm) overjet and overbite [9]. Interproximal abutment height of >5 mm inciso-gingivally in sound enamel is desirable for adequate bonding [9]. Patients with previously restored abutments, severe enamel defects, deep bite and/or evidence of bruxism or parafunction are not ideal candidates for CBs (Table 3). Missing canines or posterior teeth are also contraindications for CB treatment [5,9]. All anterior teeth need to be fully erupted prior to fabrication.

Inappropriate case selection can lead to bond-failure due to differential tooth movement and low flexural strength of the ceramic [5]. The cantilever design (bonding on one proximal side of the pontic) has demonstrated higher retentive success when compared to allownce of fixed-fixed designs (bonding on both proximal sides of the pontic) [11]. This is attributed to differential tooth movement with unilateral bonding [6,10]. However, bond-failure in a cantilever design leads to immediate prosthesis failure, revealing the edentulous area, compromising esthetics and posing a risk of swallowing or aspiration of the pontic [6]. Bond-failure of one proximal area in a fixed-fixed design could be attributed to the differential tooth movement. Additionally, such bond-failure could be seen in the immediate post-operative period [6]. However, bond-failure of one proximal area in fixed-fixed design could be esthetically inconsequential and reduce aspiration risk, but potentially predisposes the patient to secondary caries [6]. Fortunately, even in cases of bond-failures, the abutment teeth are not compromised and repair is easily achievable using a similar adhesive protocol as shown in Table 3 [9,10]. In both our cases, CBs were fabricated with fixed-fixed design. In our second case, bond failure was noted between pontic and canine in the one month post-operative period. The debonded area was repaired and no bond failure was noted thereafter, throughout the two year follow-up period.

There are no Randomized Clinical Control Trials (RCTs) demonstrating the relative success rates of all plausible restorative options for treatment of hypodontia in the anterior sextant. Until a time when RCTs can provide enough evidence, longevity can only be considered anecdotally, as presented in this case-series (Fig. 1-4). Absolute adherence to case selection criteria is integral in increasing the chances of CB success. Furthermore, it is critical to provide anticipatory guidance to the patients and families regarding dietary instructions such as avoiding chewing hard candies with incisors and recommending use of mouthguard during contact sports. It is pertinent to provide anticipatory guidance regarding bond failure in the immediate post-operative period and prompt reporting to the dentist for repair of the CB to avoid secondary caries, space loss, complete debonding, or aspiration.

Figure 1: Pre-operative right lateral (A), centric (B), and left lateral (C) photographs from Case #1 demonstrating congenitally missing FDI #12 and #22. Maxillary incisors after bleaching (D), micro-abrasion (E) and restoration with direct partial resin composite veneer (F).

Figure 2: Intra-operative photographs from Case #1 demonstrating shade selection with natural light (A), black-and-white (B) and dental lamp (C). Clinical photographs of Feldspathic porcelain pontics after fabrication from facial (D and E) and lingual (F) aspects.

Figure 3: Case #1 photographs showing rubber dam isolation of maxillary anterior sextant and try-in of pontics with putty index (lingual matrix) (A). Immediate post-operative photograph after cementation of pontics (B). Pre- (C) and post-operative (D) photographs after 6 months.

Figure 4: Pre- and post-operative photographs in Case #2 showing the Carolina Bridge for replacement of missing FDI #12.

The CB provides an esthetic, conservative, reversible, cost-effective and long-term interim restorative option. The CB is ideal for adolescent patients with congenitally missing anterior teeth and incomplete skeletal growth, while awaiting future implant-supported restorations.

Conflict of Interest

There are no conflicts of interest.

References

1. Robertsson S, Mohlin B. The congenitally missing upper lateral incisor. A retrospective study of orthodontic space closure versus restorative treatment. Euro J Orthodont. 2000;22(6):697-710.
2. Araújo EA, Oliveira DD, Araújo MT. Diagnostic protocol in cases of congenitally missing maxillary lateral incisors. World J Orthodont. 2006;7(4).
3. Craddock HL, Youngson CC. A study of the incidence of overeruption and occlusal interferences in unopposed posterior teeth. Br Dent J. 2004;196(6):341-8.
4. Puranik C, Skadsen S. Restorative options for hypodontia in the anterior sextant of adolescent patients. Open Access J Dent Sci. 2020;5(3):1-5.
5. Hebel K, Gajjar R, Hofstede T. Single-tooth replacement: bridge vs. implant-supported restoration. J Canad Dent Assoc. 2000;66(8):435-8.
6. Watson RM, Gilmour AG. Modern solutions for limited tooth loss in the dental arch. Euro J Prosthodont Restort Dent. 1994;2(4):171-7.
7. Kokich Jr VO, Kinzer GA. Managing congenitally missing lateral incisors. Part I: Canine substitution. J Esthetic Restorat Dent. 2005;17(1):5-10.
8. Thilander B. Orthodontic space closure versus implant placement in subjects with missing teeth. J Oral Rehabil. 2008;35:64-71.
9. Heyman HO. The Carolina Bridge: a novel interim all porcelain bonded prostheses. J Esthet Restor Dent. 2006;18:81-92.
10. Chan AW, Barnes IE. A prospective study of cantilever resin‐bonded bridges: An intial report. Aus Dental J. 2000;45(1):31-6.
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Article Type

Case Report

Publication History

Received Date: 03-03-2022
Accepted Date: 24-03-2022
Published Date: 31-03-2022

Copyright© 2022 by Puranik CP, et al. All rights reserved. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Citation: Puranik CP, et al. Pediatric Restorative Option for Congenitally Missing Anterior Teeth: A Carolina Bridge Case Series. J Dental Health Oral Res. 2022;3(1):1-10.

Figure 1: Pre-operative right lateral (A), centric (B), and left lateral (C) photographs from Case #1 demonstrating congenitally missing FDI #12 and #22. Maxillary incisors after bleaching (D), micro-abrasion (E) and restoration with direct partial resin composite veneer (F).

Figure 2: Intra-operative photographs from Case #1 demonstrating shade selection with natural light (A), black-and-white (B) and dental lamp (C). Clinical photographs of Feldspathic porcelain pontics after fabrication from facial (D and E) and lingual (F) aspects.

Figure 3: Case #1 photographs showing rubber dam isolation of maxillary anterior sextant and try-in of pontics with putty index (lingual matrix) (A). Immediate post-operative photograph after cementation of pontics (B). Pre- (C) and post-operative (D) photographs after 6 months.

Figure 4: Pre- and post-operative photographs in Case #2 showing the Carolina Bridge for replacement of missing FDI #12.

Table 1: Existing treatment modalities for hypodontia with advantages and disadvantages of each modality.

Table 2: Detailed description of the two Carolina Bridge cases.

Ta

Table 3:  Basics of the Carolina Bridge, indications, contraindications, case selection criteria and clinical steps involved in fabrication.