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Case
5
A missing incisor
SUMMARY
A 9-year-old boy is referred to you in the orthodontic
department with an unerupted upper left central
incisor. What is the cause and how may it be treated?
Medical history
The patient has suffered from asthma since he was 4 years
old. This is controlled using salbutamol (Ventolin).
Examination
Extraoral examination
There are no extraoral signs or symptoms and the patient is
an active, happy boy.
Intraoral examination
The appearance of the mouth is shown in Figure 5.1. What
do you see?
The patient is in the early mixed dentition stage and the
teeth present are:
6 1 6
6 21 12 6
EDCB BCDE
EDC DE
No upper left central incisor is present, but there is a pale
swelling high in the upper labial sulcus above the edentulous
space and the upper left B. There has been some loss of
space in the region of the absent upper central incisor.
There is a tendency to an anterior open bite which is slightly
more pronounced on the right.
There is mild upper and lower arch crowding and a unilateral
crossbite on the left. If you were able to examine the patient
you would discover that this is associated with a lateral
displacement of the mandibular position. The lower centre
line is shifted to the left.
There are no restorations but the mouth is not very clean.
What are the possible causes of an apparently absent upper
central incisor?
The incisor may be missing or have failed to erupt. Possible
causes include the following:
Missing Developmentally absent
Extracted
Avulsed
Failure to erupt Dilaceration and/or displacement as a result of trauma
Scar tissue preventing eruption
Supernumerary tooth preventing eruption
Insufcient space as a result of crowding
Pathological lesion (e.g. cyst or odontogenic tumour)
What specifc questions would you ask the parents?
The most important questions are related to trauma. Avulsion
or dilaceration would follow signifcant trauma which is likely
to be recalled by the parent. The parent should be asked
whether the deciduous predecessor was discoloured. If it was
this would provide evidence of loss of vitality, perhaps related
to trauma.
Extraction would be unusual and a cause should be readily
obtained in the history.
In response to your questioning the parent reports that the
patient fell on his face when he was much younger. At the
time of the accident there was considerable injury to his lips
Fig. 5.1 The appearance of the patient on presentation.
History
Complaint
The patients upper left central incisor has not erupted
although he is 9 years old. The mother is very concerned
about her sons appearance and is anxious for him to be
treated.
History of complaint
The upper left deciduous predecessor had been present
until about 4 months ago. It was extracted by the patients
general dental practitioner in an attempt to speed up the
eruption of the permanent successor. Despite this, there has
been no change in appearance. The upper permanent central
incisor on the opposite side erupted normally at 7 years of
age.
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What radiographic views would you request and why?
See Table 5.1.
The radiographs of the patient are shown in Figures
5.25.4.
What do the radiographs show?
The panoramic radiograph confrms the presence of a full
complement of developing permanent successors, excluding
the third molars, which would not be expected to have
formed. However, a crypt should be present between the
ages of 8
1
/
2
and 10 years of age and there is a suggestion of
early crypt formation in the lower left quadrant. The
unerupted permanent upper left central incisor is clearly
visible on this radiograph; its shape is not normal but the root
shape cannot be seen in this view. It is not possible to
establish the labiopalatal position of the tooth in this flm nor
to detect an adjacent supernumerary tooth which may lie
outside the tomographic focal trough.
The periapical view gives considerably more detail. The upper
left central incisor has an intact but distorted root. Its apical
development appears normal and similar to that of the right
central incisor but the foreshortened appearance suggests
dilaceration. Using this flm in conjunction with the
panoramic view and applying the principle of vertical parallax
you can see that the crown of the central incisor is labially
positioned. This is consistent with the swelling in the sulcus
being caused by the crown of the tooth. No supernumerary
tooth is present.
The lateral view completes the picture and shows clearly the
displaced crown of the central incisor. From the three flms it
is possible to deduce that the crown and root of the tooth
are misaligned, the crown defected labially with its incisal
edge pointing forwards into the labial sulcus and the root
developing in the normal direction.
What is your fnal diagnosis?
The upper left central incisor is dilacerated, probably as a
result of intrusion of the deciduous predecessor in the injury
sustained in infancy.
Treatment
What are the options for treatment?
If the dilaceration were severe, the tooth would require
extraction. Then either of the following options could be
selected:
1. Align the adjacent teeth, ideally with fxed appliances,
using the central incisor space. The lateral incisor would
replace the central incisor and could be masked to
simulate it. In the short term this could be accomplished
by an adhesive restoration but in the longer term a
permanent restoration would be necessary. The canine
might also need restoration or masking so that it would
not appear incongruous, especially in a patient with
slender lateral incisors. This option is not ideal because
the fnal appearance is often poor.
and teeth, but no tooth loss was noticed and no dental
opinion was sought.
What are the likely causes of the anterior open bite and
shift in the lower centre line?
The anterior open bite is probably associated with a thumb-
sucking or similar habit. The shift in the centre line is probably
caused by the combination of crowding and early exfoliation
of the lower left C.
Give a diferential diagnosis for the cause of the missing
incisor. Explain each possibility.
Dilaceration of the central incisor as a result of the injury
appears the most likely cause. However, it is unclear whether
the injury was severe enough to cause dilaceration.
Dilaceration usually follows intrusion and the intruded tooth
might well have re-erupted into its normal position. The
swelling in the sulcus does not lie on the normal eruption
path of the central incisor, and dilaceration could explain the
abnormal position.
A supernumerary tooth or an odontome would be the
next most likely possibility if trauma is not the cause.
Supernumerary teeth are not uncommon in the premaxilla
(13% of the population), and the late-forming (tuberculate)
type which often lies adjacent to the crown of the permanent
incisor frequently causes delay or failure of eruption.
A pathological lesion appears unlikely but cannot be
excluded. There is no evidence of alveolar expansion to
suggest a cyst, which would be the most likely cause and
could arise from the tooth itself, a supernumerary or an
odontome. An unexpected lesion remains a remote possibility.
What causes have you excluded and why?
Crowding appears to be an unlikely cause. It would have to
be very severe to cause a delay of up to 2 years and this
patients teeth are only mildly crowded. Crowding is a very
unusual cause for failure of eruption of a central incisor
because resorption and loss of the B would provide enough
space for eruption.
Scarring of the alveolus delays eruption because it slows
resorption of bone over the tooth and because fbrosis and
thickening of the mucoperiosteum resists tooth movement.
This is an unlikely cause because there is no reason to suspect
scarring, the deciduous predecessor having been extracted
only 4 months ago.
Avulsion can be excluded because it seems that the tooth
has never erupted and there is no recent history of trauma.
Developmental causes of absence appear most unlikely.
The swelling in the upper sulcus would seem to indicate that
the tooth is present but has failed to erupt. A missing central
incisor without other missing teeth would be an extremely
rare fnding.
Investigations
Radiographs are required to determine whether or not the
unerupted tooth is present, to establish whether it is the
cause of the swelling in the sulcus and detect possible
supernumerary teeth.
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Table 5.1 Radiographic views and their purposes
View Reason
Dental panoramic radiograph To provide a general view of the developing dentition and establish the presence or absence of the permanent teeth and any supernumeraries.
Upper standard occlusal or periapicals of the
edentulous area, taken with a paralleling
technique
To provide a more detailed view of the region, in particular the root morphology and any adjacent structures such as supernumerary teeth or
pathological lesions. These may lie outside the focal trough of the radiograph or be obscured by superimposition of other structures in the panoramic
view. If periapical views are taken they should include the adjacent teeth in case these were damaged in the original accident. In addition the standard
occlusal and panoramic view can be used together to establish the relationship of unerupted structures relative to the dental arch, using the principle
of (vertical) parallax. Objects lying nearer to the X-ray tube (labially positioned) appear to move in the opposite direction to the tube relative to a fxed
point. Those further away (palatally positioned) appear to move in the same direction as the tube.
Lateral view Confrms the presence of any distortion of the tooth, if dilacerated, and confrms the relationship of the tooth to the labial swelling in a third
dimension.
Fig. 5.2 Dental panoramic
radiograph.
Fig. 5.3 Periapical views.
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Should a fxed or removable appliance be used?
As the tooth movements are relatively simple an upper
removable appliance can be used at this stage. More control
and more accurate tooth positioning would be achieved with
a fxed appliance. However, the patient will probably require
further fxed appliance treatment at a later age and the fne
adjustment of tooth position could be performed then.
Design a suitable removable appliance.
2. Immediate replacement of the extracted central incisor
by a denture or adhesive bridge with a permanent
restoration or possibly a single tooth implant in
adulthood (see Case 35).
If, on the radiographs, the dilaceration does not appear to be
too severe or lies in the apical portion of the root,
consideration could be given to aligning the tooth
orthodontically. This would involve regaining any lost space
followed by localized surgical exposure of the crown of the
tooth and applying extrusive traction with an orthodontic
appliance.
What factors afect the selection of a particular treatment?
Position and severity of the dilaceration (see above)
The size of overjet
Degree of crowding
Position and condition of the other permanent teeth
The general condition of the mouth
The attitude of the child and parent
Assuming none of these factors prevents the ideal
treatment, what would you recommend for this case?
In this case the ideal treatment is to extrude and align the
dilacerated tooth into the arch.
The dilaceration appears to be in the root and relatively mild.
Therefore, an attempt should frst be made to regain the lost
space to accommodate the central incisor crown. This would
be best achieved by extraction of both upper Cs and the
upper left B to encourage eruption of permanent lateral
incisors. Some months later the dilacerated tooth should be
surgically exposed and an orthodontic attachment with a
length of gold chain placed on its palatal surface for
extrusion.
Fig. 5.4 Lateral view.
Fig. 5.6 After 18 months of treatment.
Fig. 5.5 The ftted extrusion appliance.
The appliance consists of:
cribs on D D (0.6-mm wire)
cribs on 6 6 (0.7-mm wire)
fnger springs on
1
and
2
(0.5-mm wire) to retract and
regain the space for the
1
a buccal arm to extrude
1
(0.7-mm wire) attached to the
gold chain bonded to
1
Figure 5.6 shows the position of the dilacerated tooth after
approximately 18 months of active treatment. What further
treatment may be necessary at a later stage of dental
development?
Ideally it would be appropriate to relieve the crowding in the
permanent dentition and align the teeth, correcting the
unilateral posterior crossbite and eliminating the mandibular
displacement. Details of appropriate treatment cannot be
fnalized until the patient passes from mixed dentition to
permanent dentition at about 1012 years of age.