The management of mild hypodontia (less than five permanent teeth missing) in the aesthetic zone may be complicated by problems associated with the lack of interdental space and alveolar bone. Due to the complex nature of
hypodontia management, it is best accomplished by a team of dental specialists who are able to offer the best available techniques in a sequential and coordinated way.
Patient management is intended to give optimal aesthetic and functional outcome with the available dentoalveolar complex. It is our aim as dentists to provide reconstruction that minimises long-term care and replacement, bearing in mind that this is lifelong care. Bone augmentation may be undertaken by a variety of techniques such as bone grafts
(autogenous or xenograft, or a combination of the two), which are ever more popular in managing the narrow or underdeveloped alveolar ridges. Presented below is an alternative approach to the above management techniques.
Case presentation
A young hypodontic female patient was referred by a consultant colleague for a fixed reconstruction. She was a fit and healthy 18-year-old medical student suffering from mild hypodontia affecting the upper lateral incisors. She had undergone fixed orthodontic treatment with a consultant orthodontist in preparation for fixed reconstruction using titanium implant fixtures to sites 12 and 22 (fig 1).
Clinical examination revealed a well cared for dentition and radiographic analysis revealed good bone height and density. It was noted there was a horizontal buccal bone defect at site 12 (fig 2), which was planned for simultaneous augmentation at fixture placement.
Osteotomies were prepared with the use of osteotomes to widen the sites and compact the bone in a buccal direction. Two narrow platform Replace Select TiUnite root form titanium implant fixtures and healing abutments were placed using a single stage technique, and a buccal onlay composite graft of autogenous bone, derived from the implant osteotomy sites, and BioOss xenograft was placed in site 12 (fig 3). Healing was uneventful (fig 4).
Three months later fixture level impressions were recorded and the casts mounted on a Denar articulator with a soft tissue model. Custom gold abutments were constructed and secured with titanium screws. Temporary crowns were placed for development of papillary form with contact points at 5mm from the alveolar crest, and placed for 12 months whilst the papillae where allowed to reform (figs 5 and 6). Definitive porcelain bonded to gold crowns were tried in, and the occlusion checked and aesthetics agreed with the patient before being cemented with Temp Bond
(figs 7 and 8). Careful post insertion maintenance was prescribed and she is now under regular review with her general dental surgeon with a regular hygiene regime being followed. She is currently a practising general medical practitioner and a recent nine-year review showed excellent aesthetics with papillary reformation and colour (fig 9), and stable alveolar bone levels (figs 10 and 11).