A 17 year-old female presents to my office having just completed her orthodontics. She is congenitally missing both maxillary lateral incisors and is currently wearing a Hawley retainer with pontics in the #7 and 10 sites.
Initial presentation of missing #7 and 10
Her and her mother know that she needs implants. What is the next step?
First you must educate the patient and her mother that she is not ready for implant therapy yet. Why?
(1) Growth. We need to make sure that her maxilla has reached its full size. This can be measured by the orthodontist using serial lateral cephalometric films and/or serial hand-wrist films.
(2) Passive eruption. We need to make sure that her gingiva have settled to their final healthy resting position. This can be measured by the periodontist using a periodontal probe and periapical radiographs.
Patients in this position may get frustrated that they can’t have their implants right away. But help them understand the biology and say something like, “If we rush into treatment before your body is ready, we risk getting an ugly result that will be very difficult to correct.”
They will also be reassured when you present them with a provisional option that is superior to the Hawley.
When long term temporization is required, I like to use the Maryland bridge (resin-bonded bridge). For a full discussion of our provisional options, check out this post here.
So at the first visit I want to take a close look at the adjacent and opposing teeth.
The Maryland bridges will have metal wings that require some occlusal clearance. In this case, there is plenty of room. Deep overbites will pose a challenge and may prevent you from using this option. If there limited clearance, you will have to consider preparing the lingual surfaces to embed the wings inside. I try to make these wings extra-coronal rather than intra-coronal whenever possible to be conservative.
A minor concern here is the unique shade patterns of the teeth that were likely caused by fluorosis. Take a moment to pick your shades and, if you can, take a picture to help the lab out. Don’t be shy to send the patient to the lab for a custom shade if you feel it is appropriate.
A2 base shade with B1 highlights
Take your impression, counter, and bite and your on your way. I’ve experimented with different designs for the metal wings and have found this to work the best:
Aren't they adorable? These little buddies are ready for their new home.
Note the small perforations in the metal. This increases the surface area for retention but also, perhaps counter-intuitively, makes it easier to remove when you eventually need to do so. Just prep the holes where the composite pokes through and wiggle with a hemostat.
Anyway, use traditional bonding procedures: etch, prime and bond. I recommend using a total-etch technique rather than self-etch. Why? Using a separate step to etch with phosphoric acid will give you the highest strength bond, which we need here. There won’t be any concerns about post-operative sensitivity since we are only etching enamel and not dentin. Remember, there was no preparation of the teeth!
Completed case
Notice the terrific shade match we achieved. Thanks to Marotta Dental Studio for outstanding lab work.
You’re all done! Now go to your favorite restaurant and have a nice glass of wine.
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