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Table of Contents
CASE REPORT
Year : 2015  |  Volume : 5  |  Issue : 3  |  Page : 145-149

Restoring function and esthetics in an adolescent with idiopathic multiple unerupted permanent teeth: A clinical report


1 Department of Prosthodontics, A.J. Institute of Dental Sciences, Mangalore, Karnataka, India
2 Department of Endodontics and Restorative Dentistry, ABSMIDS, Mangalore, Karnataka, India
3 Department of Periodontics, A.J. Institute of Dental Sciences, Mangalore, Karnataka, India

Date of Web Publication28-Apr-2016

Correspondence Address:
Vidya K Shenoy
Department of Prosthodontics, A.J. Institute of Dental Sciences, Mangalore, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2229-5194.181375

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   Abstract 


Idiopathic multiple unerupted teeth have several debilitating oral and psychological manifestations, especially with young children and adolescents. The multiple unerupted permanent teeth can cause serious problems in terms of treatment time and outcome. This clinical report presents a multidisciplinary approach for the management of an adolescent girl with idiopathic multiple unerupted teeth. At the 2-year follow-up, there was a significant improvement in the oral function and psychosocial activities without any prosthetic complications.
CLINICAL RELEVANCE TO INTERDISCIPLINARY DENTISTRY

  • Interdisciplinary team including Prosthodontist, Restorative Dentist, Periodontist and an Oral Surgeon will help in significantly improving the quality of life of the patient
  • Special emphasis is placed on early diagnosis, careful treatment planning, and co-.ordination and timing of different phases of the treatment
  • A system for integrating all the specialities will be a guarantee for a successful outcome.

Keywords: Depigmentation, esthetics, unerupted teeth


How to cite this article:
Hegde M, Shetty A, Shenoy VK, Nagaratna D V, Prabhu B, Upadhya M. Restoring function and esthetics in an adolescent with idiopathic multiple unerupted permanent teeth: A clinical report. J Interdiscip Dentistry 2015;5:145-9

How to cite this URL:
Hegde M, Shetty A, Shenoy VK, Nagaratna D V, Prabhu B, Upadhya M. Restoring function and esthetics in an adolescent with idiopathic multiple unerupted permanent teeth: A clinical report. J Interdiscip Dentistry [serial online] 2015 [cited 2019 Oct 19];5:145-9. Available from: http://www.jidonline.com/text.asp?2015/5/3/145/181375




   Introduction Top


Development of the tooth is a continuous process with a number of physiologic growth processes and various morphologic stages in interplay to achieve the final form and structure of the tooth.[1] Eruption is an axial or occlusal movement of the tooth from its developmental position within the jaw to its functional position in the occlusal plane.[2] Teeth which do not have the eruptive forces fail to determine their final occlusal position in the arch and remain impacted in the jaws.[3]

According to review by Bishara [4] the causes of tooth impaction are divided into general and local factors. The common causes are usually localized: Lack of space for an eruption, prolonged retention or early loss of deciduous tooth bud, the presence of alveolar cleft, ankylosis, cystic or neoplastic formation, alveolar or dental trauma, and dilacerations of the root. The general factors include Cleidocranial dysplasia, endocrine deficiency, febrile disease, Down syndrome, and irradiation.

Multiple unerupted permanent teeth can cause serious problems in terms of treatment time and outcome. Age at the start of the treatment, the degree of dilaceration, stage of root formation, position, and the distance of the tooth from the occlusal plane are the factors reported to increase treatment time and complexity.[5],[6] Impaction of multiple permanent teeth is an uncommon condition and rarely reported in the literature. Hence, clinical evidence to develop a proper treatment protocol is lacking.

This clinical report describes prosthodontic management of an adolescent girl with idiopathic multiple unerupted permanent teeth with the primary objective of restoring function and esthetics. At the 2-year follow-up, the patient exhibited significant improvements in the oral function and psychosocial activities without any prosthetic complications.


   Case Report Top


An apparently healthy 16-year-old girl reported with a complaint of multiple unerupted teeth [Figure 1]. She was self-conscious about the appearance of her teeth. She had no history of trauma, and her medical history was uneventful.
Figure 1: Preoperative frontal view

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Extraoral examination revealed a reduction in the lower vertical face height. Intraoral examination revealed a mixed dentition, anodontia, and generalized spacing. Twenty-four teeth were erupted into the oral cavity of which 12 were permanent teeth, and 12 were deciduous teeth. The crowns were thin and short. Multiple diastemata, Angle Class I dental relationship, gummy smile, and prominent anterior alveolus were also evident. The patient had good oral hygiene and did not exhibit any periodontal problems. Attrition of the deciduous molars had resulted in a decreased vertical dimension of occlusion. The centric occlusion position was coincident with the maximum intercuspal position. Significant melanin hyperpigmentation of the labial gingiva in both maxillary and mandibular arches and high maxillary labial frenum were also noted [Figure 2].
Figure 2: Intraoral view showing the hyperpigmentation of the gingiva

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Panoramic and full mouth periapical radiographs were obtained. Radiographic examination revealed carious lesions involving the pulp in the mandibular permanent first molars, incompletely formed impacted permanent teeth and several close root approximations [Figure 3]. Hand wrist radiographs suggested completion of the growth process [Figure 4].
Figure 3: Preoperative panoramic view

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Figure 4: Hand wrist radiograph

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Laboratory studies were not remarkable. Blood chemistries included serum calcium, phosphorus, and alkaline phosphatase. Other tests used were urinalysis, serology (liver function tests), fasting blood glucose, hematology, and thyroid function tests.

Diagnostic casts [Figure 5] were mounted on a semi-adjustable articulator using a face bow (Hanau Wide-Vue, Whip Mix Corporation, Fort Collins, CO, USA) and interocclusal records (Jet-Bite, Coltene Whaledent AG, Altstatten, Switzerland). Due to the complex needs of the patient, an interdisciplinary approach for complete maxillary and mandibular rehabilitation was planned to restore function and appearance.
Figure 5: Diagnostic casts

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A treatment plan was formulated consisting of extraction of all the deciduous molars, initial periodontal therapy followed by depigmentation procedure and frenectomy procedure to correct the high frenal attachment. Orthodontic treatment and extraction of impacted teeth were ruled out as the impacted teeth were incompletely formed and deeply embedded close to the vital structures. Endodontic treatment plan included root canal treatment for mandibular first molars and postendodontic restoration with custom post and core. Prosthodontic phase was planned with crown lengthening procedure to improve the clinical crown height. As the patient had 5–6 mm of interocclusal distance, it was planned to raise the vertical dimension by 2 mm. Fabrication of metal ceramic crowns were planned for the maxillary and mandibular teeth. It was also planned to restore the edentulous space in the maxillary arch with metal ceramic fixed dental prosthesis and in the mandibular arch using splint bar and internal clip attachment supported cast partial denture as the abutment was weak. Informed consent was obtained from the patient before starting the procedure.

The initial stage periodontal therapy consisted of oral hygiene instructions and prophylaxis. After 2 weeks depigmentation procedure was done by slicing the pigmented epithelial layer from the underlying connective tissue, i.e., raising split thickness flap and excising the flap from its base denuding the connective tissue epithelial extension. A uniform layer of the epithelium was sliced from the underlying connective tissue to prevent nicks, cuts, and underlying alveolar bone exposure. During the same appointment, frenectomy and crown lengthening procedures were performed. A periodontal pack (Coe-Pack™, Periodontal Dressing Regular Set, GC America Inc., Alsip, IL, USA) was placed to reduce the postoperative discomfort. The healing was uneventful with a considerable improvement in esthetics.

After the removal of the periodontal pack, teeth were prepared for metal ceramic restorations and provisional restorations were cemented to maintain the position of the gingiva. Laboratory processed provisional restorations were fabricated with heat polymerizing tooth-colored acrylic resin (Acry C and B, Ruthinium, Italy) at an increased occlusal vertical dimension (2 mm) and cemented with noneugenol cement (RelyX™, Temp Cem NE Zinc Oxide Eugenol cement, 3M ESPE, USA). The patient wore the provisional restorations at the newly established occlusal vertical dimension for 2 months without any complications.

Irreversible hydrocolloid impressions of the provisional restorations were obtained and poured in Type IV dental stone. A custom incisal guide table was fabricated from self-polymerizing acrylic resin (SR Triplex Cold, Ivoclar Vivadent AG, Schaan, Liechtenstein).

After 2 months, definitive impressions of the prepared teeth were obtained using vinyl polysiloxane impression material (Acquasil, Dentsply International Inc., Milford, USA). Working casts were generated from Type IV die stone (Alpenrock, Amann Girrbach AG, Austria, Germany) using Giroform system for precision models (Giroform system, Amann Girrbach AG, Austria, Germany) and mounted onto the articulator using half and half technique of obtaining interocclusal records.[7]

Maxillary full arch splinted complete veneer metal-ceramic (Wirobond, Bego, Bremen, Germany and Creation CC (Willi Guiller International, Austria, Germany) fixed dental prosthesis was fabricated, evaluated intraorally, adjusted and cemented using Glass ionomer cement (GC luting and lining cement, GC corporation, Tokyo, Japan).

In the mandibular arch, milled wax patterns for splinted metal ceramic crowns were fabricated in the anterior teeth and for a single metal ceramic crown in the first molar.

A commercially available splint bar (OT Bar Multiuse, Rhein 83, NY, USA) was positioned to follow the crest of the ridge anteroposteriorly facilitating the esthetic arrangement of artificial teeth. The bar should have minimum contact with the tissues. Later, the finished bar was attached to the adjacent abutment teeth pattern. The assembly was cast (Wironit, Bego, Bremen, Germany) and ceramic build up was done [Figure 6].
Figure 6: Bar and internal clip assembly

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A pick-up impression for the partial denture was made, and a definitive cast was obtained. The denture framework was designed on the definitive cast to fit the abutments and rest upon the splint bar. The framework pattern was cast using lost wax technique. Finished cast metal framework was verified in the mouth, and jaw relation was recorded. Teeth arrangement was completed. Commercially, available nylon internal clip attachment (Medium Retention Clip, Rhein 83, NY, USA) enclosed in a metal housing was selected and contoured to fit the bar. Denture was processed using heat polymerizing acrylic resin (SR Triplex Hot, Ivoclar Vivadent AG, Schaan, Liechtenstein). The splint bar assembly [Figure 7] was cemented permanently to the abutment teeth using Glass ionomer cement (GC luting and lining cement, GC Corporation). The denture was tried, and necessary adjustments were made [Figure 8] and [Figure 9].
Figure 7: Bar and internal clip attachment cemented in place

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Figure 8: Final prostheses in situ

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Figure 9: Postoperative frontal view

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The patient was given oral hygiene instructions. Recall evaluations were done at 4 months interval up to 1 year and later after 2 years [Figure 10]. The patient did not report of tooth sensitivity or any other complication associated with the oral rehabilitation. The patient's esthetic and functional experiences were also satisfactory.
Figure 10: Follow-up

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   Conclusion Top


This clinical report describes an multidisciplinary approach for the rehabilitation of an young adolescent girl with idiopathic multiple unerupted permanent teeth using periodontal surgery, postendodontic restorations, metal-ceramic fixed partial dentures, splint bar, and internal clip attachment system. While planning the treatment, patient expectations, age and socioeconomic status, type, and severity of the disorder are critical for a successful outcome.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
   References Top

1.
Kumar GS. Orban's Oral Histology and Embryology. 12th ed. India: Mosby; 2009.  Back to cited text no. 1
    
2.
Daskalogiannakis J. Glossary of Orthodontic Terms. 1st ed. Berlin, Germany: Quintessence Publishing; 2000. p. 142  Back to cited text no. 2
    
3.
Jacoby H. The etiology of maxillary canine impactions. Am J Orthod 1983;84:125-32.  Back to cited text no. 3
    
4.
Bishara SE. Impacted maxillary canines: A review. Am J Orthod Dentofacial Orthop 1992;101:159-71.  Back to cited text no. 4
    
5.
Becker A, Lustmann J, Shteyer A. Cleidocranial dysplasia: Part 1 – General principles of the orthodontic and surgical treatment modality. Am J Orthod Dentofacial Orthop 1997;111:28-33.  Back to cited text no. 5
    
6.
Kuroda S, Yanagita T, Kyung HM, Takano-Yamamoto T. Titanium screw anchorage for traction of many impacted teeth in a patient with cleidocranial dysplasia. Am J Orthod Dentofacial Orthop 2007;131:666-9.  Back to cited text no. 6
    
7.
Song MY, Park JM, Park EJ. Full mouth rehabilitation of the patient with severely worn dentition: A case report. J Adv Prosthodont 2010;2:106-10.  Back to cited text no. 7
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10]



 

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