Replacing Congenitally Missing Lateral Incisor?

There is a small implant-bone contact surface. The forces are the same. Bone is cortically --> that means not the best blood supply. Age is 10+, so the aesthetic result has to work at least 40years. Who thinks it will work for a long time in the aesthetic region? Is there osseointegration the question?

The first consideration is whether or not the patient is under orthodontic treatment. The space left between the permanent central inciser and permanent canine is not ideal, if the area to be implanted is the width of a deciduous lateral inciser. Obviously, the buccal - palatal thickness of the bone will be less since the deciduous lateral has a small root. With the current techniques we have, as developed by Dr. O'Hilt Tatum, bone can be manipulated and stretched to recieve a conventional sized implant. I have had the experience of replacing bilateral missing upper laterals; where on one side the orthodontist left adequate space for a conventional sized implant and normal sized crown; and on the other side...inadequate space, which forced me to use a mini implant. The minis do work very well, but the crown esthetics must be compromised in the sense that if the two laterals are suppose to resemble each other, the one with less mesial distal space must be made to look like it overlaps the central. For best results, do insist that the young patient see a good orthodontist who will make your job easier, and will satisfy the patient's demands. Gerald Rudick dds Montreal

Most of the time they have a bony concavity and tissue thickness (biotype) issue. If the smile line shows the gingiva, it should be addressed to optimize esthetics. Then, space allowing, traditional implants are placed and if the inter-radicular distance is less than 8mm, consider using a CT create surgical guide (materialise's surgiguide for instance).

make sure they are done developing

Definitely make sure the patient is done with growth and development. My experience in post-orthodontic replacement of missing lateral incisors is excellent, I used Xive 3.0mm implants and 3.4mm implants. Very nice results. I do not suggest using minis due to questionable aesthetics on the long run. Removal of a mini from a relatively narrow space in aesthetic region is not something I would want to do.

I concur with the last two posts about waiting for full growth of the jaws. If you have ever reimplanted an avulsed anterior tooth on a growing patient it will become apparent that the face grows foward,bringing the other anterior teeth with it,leaving the former avulsed tooth behind.These teeth if they ankylose will not be able to be moved orthodontically.Many clinicians will not place implants in children.There are implants made specifically for ortho, and are meant to be retrieved.

Use the Thommen Medical 2.7mm apical to a 3.5 head if you have room. There is a great study done by Dr Philippe Ledermann. Pediatric Dentistry Sept.Oct. 1993 Volume 15 number 5. Impants in young patients 9 to 18 yeras old. The benifit if useing two piece implants is that later you can gp back and re store the crowns after any final movement. The mini's are not approved for permenant restoration and are for long term but who is to say what is long term accepatble. Ceramic abutments are available as well so you should be able to get graet translucency and light reflection as opposed to the metal over a one piece implant

This looks like an attractive use for a mini, but it actually is an abuse. A maxillary lateral takes alot of occlusal abuse. Don't use a mini. Man up and use a real implant.

I would go with Dr. Rudick's comment. A good orthodontist comes in very handy. I had one case where the orthodontist moved the canine to lateral position, then moved it back to canine position. Then the lateral incisor surgical site was wide enough to get the regular implant. I was skeptical due to possible root resorption, but orthodontist did her part and I was able to do my part. Good luck.

Another thing to watch is the space between the roots apically especially if the coronal portions of the teeth have been moved orthodontically. We did a case about 4 years ago where there was only 1.5 mm between the apices so used a mini and today it still looks great and there has been no bone loss.

Dr Fairbrain comment that using the canine for a more desirable labial thickness of bone works well but dont use orthodontics to move the canine across ..Let it drift naturally as it erupts and then open the space up Orthodontically when you're ready for the implant.The arch length can be held with a simple palatal arch for a few years making the subsequent space adjustment a doddle.Much much less root resorption possibilitywith the simple one step. Implants at the very early teens opens up seriously long term maintenance issues for the patient.

Dr. G, You have received a lot of good information. I would suggest that now you look at some of the research to help you decide on your philosophy. Each patient will have a different situation depending on their age, the orthodontist they use, their willingness to wear a removable transitional, involve the adjacent teeth for a fixed restoration, their finances, their esthetic concerns, and their willingness to have implant surgery and bone grafting. I lecture for Dentatus about their narrow diameter implants. After seeing your question I looked for some more information about this. I looked up at an article from an online newsletter that I subscribe to, Implant News and Views. The article is titled “Temporarily Replacing Congenitally Missing Maxillary Lateral Incisors in Teenagers Using Transitional Implants” by Dr. G. William Keller: Jan/Feb 2001 After reading the article, I called and spoke with Dr. Keller. Dr. Keller has been using narrow diameter implants on adolescents to maintain space and provide an esthetic and functional transitional restoration for almost eight years. He has found other transitional options have been problematic especially using a removable with adolescents due to the negative effect on their social development and self esteem. Other fixed transitional restorations involve virgin teeth and tend to debond. Since these implants do integrate like conventional implants, which have been shown with histological studies, Dr. Keller has found it is easier to cut these implants out of the bone and remove them labialy. (they can also be cored out with a trephine) This is not a problem because he needs to bone graft these sites on the labial routinely. He has found that these ridges, especially the labial plate, do not fully develop; when there is no permanent tooth development the bony ridge is deformed in appearance with a labial concavity. These sites always need labial bone grafting when placing the definitive (3.0-3.3mm) implant. This is true even when there is an over retained deciduous tooth present. He does the grafting with the first stage surgery of the definitive implant. Dr. Keller is now generally waiting until the patient is 15yrs to 16yrs old for females and 16yrs old for males, he also looks at the dental development to help determine growth age. He has now done close to 80 cases and has not had any problems. He does inform the patients/parent of the need to replace the implant and to do labial grafting when they are done with significant bone growth. As expected the transitional implant will submerge in these growing teenagers. I would suggest using a screw retained Narrow Diameter Implant with a processed composite transitional so that you can lengthen the temporary crown if needed for esthetics. This will create a “funneling” of the bone which will now be lower vertically than the adjacent teeth. However, Dr, Keller has found it to be insignificant; there is still enough crestal height to place the implant in an ideal position. If it was decided to place the transitional implant at a younger age, the consequences are not irreversible. The sight would need bone augmentation prior to the second implant. Dr. Keller attended a lecture by Dr. Vincent Kokich a well known orthodontist and lecturer for the Seattle Institute of Advanced Dental Education. Dr. Kokich speaks about the importance of considering jaw growth when planning implants. Vertical growth of the maxilla usually continues to age 17-18 in girls and 19-20 in boys. However there are individually variations that can bring this into the 20’s. So there is a period of 3-5 years, between the completion of orthodontics and the placement of a definitive implant, which requires a provisional restoration for function, esthetics, and space maintenance. Dr. Kokich has a web site at www.kokichorthodontics.com on which he has posted his articles. My philosophy is this: If it were my child I would like them to be able to eat pizza with friends without the social embarrassment of having to remove a retainer with two teeth attached or become worried about smiling or kissing. Therefore, I would offer this routinely to patients in this situation. I would use the Anew Narrow Diameter Implant because it is the only screw retained NDI on the market. It has been approved for two uses; either a transitional (temporary) implant or a definitive implant for a final restoration. The FDA states that they are “approved for long-term use and for any length of time as decided by the healthcare provider.” This language is used to differentiate NDI’s from conventional implants which are only approved for long term use not short term transitional uses. If you are not doing implant surgery and bone grafting routinely, I would send the patient to a specialist for the surgery. A transitional crown should be placed the same day as the surgery. In addition the Anew NDI offers an additional option to patients with limited bone volume at the time of final implant placement they come in 1.8, 2.2 and 2.4 mm. In a long term clinical study published in The International Journal of Periodontics and Restorative Dentistry (Volume 27, Number 5, Oct.2007) 48 Anew screw retained implant were used and followed: “In this study, 27 patients received 48 NDI’s, which were loaded for periods of 12 to 64 months post-insertion. To date no implant or prosthesis has had to be removed or replaced. Two screw-retained crowns loosened; the composite was removed and the screw cap was tightened without patient discomfort of interruption of the function of the implant restoration. Each patient has been recalled at 2- to 3-month intervals for maintenance and reexamination.” In the discussion it was noted that “The 100% success rate of NDI’s as used and documented in the present study is similar to that observed by Mazor and colleagues, who reported 32 single-tooth replacements in 32 patients.” I hope this has helped. If you would like to contact me feel free to send me an Email.

I thought that my Email would be linked to my name but it was the website. So here is my Email Information: fjoubertdds@dentatus.com

Thanks Rick, I've been trying to gather more information on mini or narrow diameter implant. Your comment bove was very comprehensive on the use of them in that case. I noticed dentists either hate them or love them. Comment like yours based on atual research is very helpful.

Lots of sensible advice above but the issue is restoring for life.Mini implants have on any research I have read less success prosthodontically and Biologically.The best aestetics and integration is too create early space for the lateral and the canine and let the canine naturally drift mesially so that it tends to sit twix the premolar and the central .Provisional bonded lateral will suffice till 18 years is reached .Then shift the canine back distally .This is a Very simple inhouse orthodontic proceedure.This delivers an ideal operating and prosthodontic workspace.

Kudos to Rick for being the only one to address the self esteem and social concerns associated with a removable retainer. My 15 year old son HATED his. He didn't like removing it to eat (particularly when girls were present). The straw that broke the camels back was when he bit into a piece of pizza and opened his mouth, the rrtainer hsd come out and was stuck on top of the piece of pizza. It ruined his and his friend's appetites. We opted for a Maryland bridge at this point because we were unaware of temporary implants. Unfortunately, they used metal wings instead of ceramic...better than we had but still not the aesthetic result we were hoping for.