|Year : 2022 | Volume
| Issue : 3 | Page : 305-309
Prosthetic management of partial anodontia with microdontia from 11 to 20 years of age - 10 years of follow up
Natarajan Kalavathy1, Athimuthu Anantharaj2, Nikhil Anantharaj1, Harshita Mundhra1, Bishakha Kanrar1
1 Department of Prosthodontics, Crown and Bridge and Implantology, DA Pandu Memorial RV Dental College, Bengaluru, Karnataka, India
2 Department of Pedodontics, Crown and Bridge and Implantology, DA Pandu Memorial RV Dental College, Bengaluru, Karnataka, India
|Date of Submission||21-Feb-2022|
|Date of Decision||27-Apr-2022|
|Date of Acceptance||28-Apr-2022|
|Date of Web Publication||18-Jul-2022|
Department of Prosthodontics, Crown and Bridge and Implantology, DA Pandu Memorial RV Dental College, CA-37, 24th Main, JP Nagar Phase I, Bengaluru - 560 078, Karnataka
Source of Support: None, Conflict of Interest: None
Treatment of pediatric patients with partial anodontia is a challenge requiring interdisciplinary approach. Growth period, reduced vertical dimension, microdontia, and unacceptable esthetics present difficulties at various stages of prosthetic rehabilitation. Congenital absence of teeth impairs the nutritional status of the growing child and causes a psychological setback. This article describes the prosthetic management of a patient suffering from partial anodontia done over a period of 10 years. Considering the age and psychological and financial requirements of the patient, removable and fixed prostheses were fabricated at different phases of the treatment. The ultimate aim was restoration of function, improvement of esthetics, and overall psychological upliftment of the patient which was achieved by maxillary metal ceramic bridge and mandibular implant retained hybrid prosthesis.
Keywords: Hybrid prosthesis, microdontia, partial anodontia
|How to cite this article:|
Kalavathy N, Anantharaj A, Anantharaj N, Mundhra H, Kanrar B. Prosthetic management of partial anodontia with microdontia from 11 to 20 years of age - 10 years of follow up. J Indian Prosthodont Soc 2022;22:305-9
|How to cite this URL:|
Kalavathy N, Anantharaj A, Anantharaj N, Mundhra H, Kanrar B. Prosthetic management of partial anodontia with microdontia from 11 to 20 years of age - 10 years of follow up. J Indian Prosthodont Soc [serial online] 2022 [cited 2022 Oct 1];22:305-9. Available from: https://www.j-ips.org/text.asp?2022/22/3/305/351288
| Introduction|| |
Anodontia or congenital failure of odontogenesis can present itself in many forms, ranging from a single missing tooth to total anodontia. Partial anodontia, the congenital absence of one or more teeth, can affect both deciduous and permanent dentition. The overall incidence ranges from 1.6% to 9.6%. It is generally identified in younger age group of children and may or may not be associated with ectodermal dysplasia.
Prosthetic rehabilitation of children presents unique and special challenges to the dental profession due to reduced vertical dimension (VD), leading to temporomandibular disorders, growth period, microdontia, multiple missing teeth, and psychological problems arising from unacceptable esthetics.,
However, an early diagnosis of the problem and a team approach will help in better planning of treatment and achieve the ultimate goal of a functionally rehabilitated patient.
| Case Report|| |
An 11-year-old male patient presented with the chief complaint of multiple missing teeth. Intraoral examination revealed multiple retained deciduous teeth, erupting permanent maxillary central incisors, generalized microdontia, and loss of VD of occlusion. The patient did not exhibit any other characteristic of ectodermal dysplasia and did not present any remarkable medical or family history. Clinical and radiographic examination confirmed a diagnosis of partial anodontia. The case has a long treatment span which was divided into four phases. The sequence of different phases of the treatment is illustrated in [Figure 1].
Opinion was obtained periodically from an experienced pedodontist, an oral surgeon, and an orthodontist, and a soft cap splint was given to re-establish the VD at 11 years of age. Niswonger's method was used to check freeway space at rest and in occlusion. VD was increased incrementally by 2 mm at one stage making sure that there was a freeway space of 5 mm and Silverman's closest speaking space of 2 mm. This was done periodically as and when the transitional dentures were fabricated as the patient was in growing age. The overall increase in VD was approximately 6 mm for this patient. Thus, the initial phase was fabrication of overdenture for maxilla taking support from the underlying partially edentulous arch and microdontic teeth. During phase I, the patient was given a soft splint for mandible, thus improving the VD periodically. In phase II of treatment planning, transitional maxillary and mandibular heat-cured acrylic overdentures were fabricated for the patient at the age of 11 at the increased VD to improve esthetics, and periodic recall was done every 3–6 months. The overdentures were refabricated as and when required till the age of 16 to accommodate the growth of the jaws and increase in facial height.
At 16 years of age, multiple retained deciduous teeth and generalized microdontia were observed on intraoral examination [Figure 2]. Only eight permanent teeth were present namely 13, 11, 21, 23, 36, 37, 46, and 47. Investigations including diagnostic casts, orthopantomograph, and intaoral periapical radiograph showed two impacted permanent teeth, and hand wrist radiograph revealed completion of sagittal skeletal growth. Thus, phase III of treatment included fabrication of metal ceramic bridge using the existing deciduous and permanent teeth for maxillary arch at the established vertical dimension as the esthetics with the removable maxillary overdenture was satisfactory. Preparation of the teeth was kept minimal due to microdontia and large pulp chamber. Hence, a modified tooth preparation was carried out. This was followed by final impression, provisional prosthesis, permanent metal ceramic bridge fabrication, and cementation using type I glass ionomer cement (GIC). Maxillary restoration improved the esthetics, mastication, and phonation. Permanent restoration of the mandibular arch was deferred till the age of 20 due to certain financial and personal problems.
At the age of 20, the patient presented with multiple mobile mandibular deciduous teeth and knife edge ridge clinically and D1 type of mandibular bone radiographically. Extraction of the mobile deciduous teeth and permanent first molars followed by rehabilitation with an implant supported fixed prosthesis was planned at this stage.
Existing overdenture of the patient was used to fabricate surgical stent. Six implants were decided to be placed in the mandible; four in the interforaminal region and two in the molar region on either side. Six endosseous threaded implants (Nobel Biocare) of suitable dimensions were selected. Two implants each of narrow platform, regular platform, and wide platform variety were used. Surgical placement was carried out under local anesthesia. Bed preparation was done by shaping the mandibular knife edged ridge. Osteotomy of the planned implant sites was done, and implants were placed. Necessary postsurgical medications were prescribed.
After the healing period of 4 months, second-stage surgery was carried out and healing caps were placed [Figure 3].
After healing, custom tray was fabricated and final impression was made by open tray technique using polyether monophase impression material and impression copings. Master casts were prepared using implant analogues and soft tissue replica to duplicate the contours of the soft tissues. Resin pattern with universal castable long abutment was fabricated which was then tried and adjusted in the patient's mouth [Figure 4]. Pick up impression of the resin pattern was made using putty.
The pattern was then casted with cobalt chrome alloy and the metal framework tried in patient's mouth. Passivity of fit was evaluated, and a diagnostic orthopantomograph was made to ensure that no marginal gap existed between the framework and the implants. Centric relation was recorded using interocclusal record material. Individual copings were fabricated on the existing framework, and trial of the same was done intraorally. Porcelain build up on the copings and gingival porcelain build up on the framework were done and tried.
The fit of the cobalt chrome framework and the individual crowns on the framework was verified clinically, and centric occlusion was also established opposing the existing maxillary metal ceramic bridge. The VD was rechecked to make sure that there was sufficient freeway space as well as closest speaking space within the physiologic limit and satisfactory esthetics.
After glazing of the restoration, the cobalt chrome framework was seated on the existing implants intraorally and torqued to 35 N. Individual crowns were also cemented using type I GIC [Figure 5].
|Figure 5: Final placement of mandibular prosthesis against maxillary bridge|
Click here to view
Thus, a hybrid implant retained prosthesis was fabricated for mandible while a metal ceramic fixed bridge was designed on the retained primary and permanent teeth for the maxilla. A mutually protected occlusal scheme was incorporated in the prostheses.
The patient was recalled after 24, 48, and 72 h for recall checkup. Oral hygiene maintenance instructions were given along with directions for use of floss and waterpik. The patient was quite satisfied with respect to esthetics as well as function.
| Discussion|| |
Clinical features of partial anodontia in young patients pose special challenges to a clinician. Different stages of the treatment provided at various ages - starting from childhood to adulthood requires multidisciplinary approach with meticulous planning and patient cooperation.
Total extraction of the existing teeth followed by fabrication of conventional complete denture was not advised in this case considering the age of the patient and the need of reducing the residual alveolar ridge resorption and the psychological trauma that he and his family might undergo due to the extraction. Orthodontic correction and extrusion of impacted teeth was not possible because of the microdontia. Hence, overdentures were fabricated for both the arches in the first phase of the treatment which were refabricated as per requirement.
Dental implants have expanded the scope of prosthetic rehabilitation of severely debilitated dentition. Fixed metal ceramic maxillary bridge and hybrid implant-retained mandibular prosthesis was fabricated for the above-mentioned patient.
Titanium alloy framework could have been used instead of a cobalt chrome framework for the hybrid implant prosthesis to reduce the total load on the mandibular implants as weight of cobalt chrome alloy would be more than titanium alloy of same size. However, it could not be done due to financial constraints. Moreover, ceramic occlusal table was given to provide superior esthetic results. Retained maxillary deciduous teeth were used as abutments for maxillary bridge. The presence of permanent tooth germ stimulates root resorption of the deciduous teeth. However, even in case of anodontia, the primary teeth may eventually fall. In such a situation, implant retained fixed prosthesis for maxillary arch can be planned depending upon the quality and quantity of available bone. Patient motivation and education play a pivotal role in management of such scenarios.
Due to this oral condition at a young age, the patient initially presented with signs of psychological trauma, low self-esteem, and impaired nutritional status. Fixed prosthesis was highly satisfactory in every aspect and boosted the confidence of the patient and his family members.
The drawback of this prosthetic management was the unfavorable crown-to-root and crown-to-implant ratio. The possible consequences of this line of treatment were explained to the patient. However, 15 years of follow-up of the maxillary prosthesis and 5 years of follow-up of mandibular prosthesis have not shown any signs of failure.
| Conclusion|| |
Rehabilitation of the partial anodontia patient with the fixed prosthesis provided satisfactory results in terms of esthetics and function.
The authors would like to acknowledge the contribution of Dr. Girish Rao, Oral Surgeon, for the surgical phase of the treatment and Dr. Prafulla Thumathi, Prosthodontist, for laboratory support.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]