An Interdisciplinary Approach for Management of Missing Canines with Implant Supported Cantilevered Prosthesis

Missing tooth in the anterior region of the maxilla lies in aesthetic zone and create quite noticeable discrepancies. With a paradigm shift in the patient expectations towards functional as well as aesthetically appealing replacements for edentulism, the implant based oral rehabilitation has emerged as a sole winner in fulfilling all aspects of patient needs. Interdisciplinary team treatment planning is a paramount approach for achieving optimal final aesthetics. This article aims to present a case report of replacement of bilaterally missing maxillary canine and lateral incisors with cantilever prosthesis using an interdisciplinary approach.


INTRODUCTION
An issue that frequently presents to clinicians is missing anterior teeth. 1 Incidence of impacted maxillary canine range from 0.92-3.58% 2 and maxillary lateral incisor 1-5%. 3Osseointegrated implants are the most biologically conservative and commonly used option for replacing missing teeth provided the available space is enough for implant placement. 1Cantilever fixed partial denture is a fixed restoration which has one or more abutments at one end while the other end is unsupported which can be successfully given in anterior quadrant. 4Regardless of the type of replacement, interdisciplinary treatment considerations are required for restorative excellence. 5       A B

DISCUSSION
Interdisciplinary approach to optimize aesthetics and longevity are frequently needed in patients with missing teeth. 1 A thorough diagnosis and treatment plan must precede orthodontic therapy.Dental implants provide promising treatment options for the replacement of missing teeth.Advantages include preservation of adjacent natural tooth structure, alveolar ridge and achievement of optimal aesthetics and restorative results. 6e limitations includes inadequate available space, inadequate alveolar ridge thickness and inadequate alveolar bone support for gingival papilla. 7According to Carl E Mish, minimum of 1.0 mm bone should be present around the implant. 8So, by placing narrow diameter implant of 3.5mm, we preserve not only the remaining alveolar bone from resorption but also helps in achieving optimal aesthetics.This case is slight different from conventional guidance regarding the use of cantilever fixed partial dentures, which suggests using two abutments.Particularly when replacing a maxillary canine the first option would be to utilize a single-tooth implant.The second option would likely be a conventional fixed partial denture utilizing the adjacent abutment teeth, possibly using double abutments.Due to the patient's existing occlusion, personal preferences, a third option was used for this patient -cantilever fixed partial denture utilizing maxillary first premolars as the lone abutments.
Cantilevered bridge is the second most conservative option, followed by full-coverage bridge. 3systematic review of cantilever fixed partial dentures reported 18.2 % failure rate at 10 years, as compared to 10.9% with use of a conventional fixed partial denture. 9e most frequent complication was loss of retention, with the second being fracture of the restorative material.
There are occasions, however, when complicated medical history or financial constraints make a cantilever fixed partial denture a reasonable option, as opposed to implant or conventional fixed partial denture.

SUMMARY
Effective treatment planning is crucial to successful outcomes.Dental implants offer a predictable solution to replace missing teeth, provided there is enough available space.Interdisciplinary team treatment planning is emphasized as a requirement for achieving function and aesthetics.

A1
25-year-old female reported to Periodontology and Oral Implantology unit, Bir Hospital with the chief complaint of replacement of missing teeth.She was undergoing active orthodontic treatment for past two years.No specific medical history was elicited.No any abnormality was present during extra oral examination.On oral examination, the patient had bilateral missing permanent maxillary canines and lateral incisors with Dr. Anugya Karanjit, 1 Dr. Shaili Pradhan, 1 Dr. Ranjita Shrestha Gorkhali, 1 Dr. Pramod Kumar Koirala, 1 Dr. Suchana Adhikari 1 Periodontology and Oral Implantology unit, Department of Dental Surgery, Bir Hospital, National Academy of Medical Sciences, Mahabouddha, Kathmandu, Nepal.retained deciduous maxillary lateral incisors and deciduous maxillary left canine.Maxillary arch presented with spacing between 11 and 52 and 21 and 22.Similarly, mandibular arch presented with mild spacing on anterior teeth with missing left mandibular canine.Preliminary investigations including cone beam computed tomography and routine blood investigations were done.Based on the history, clinical and radiographic examination, diagnosis of impacted 13, 23, 33 with retained deciduous teeth w.r.t 52,53,63 was made.Interdisciplinary approach was discussed which included patient and clinicians from orthodontic, surgery, prosthodontic and periodontic units.Tentative treatment plan was agreed upon as a team which included oral prophylaxis, followed by extraction of deciduous teeth.Orthodontic therapy would be carried out for alignment and achievement of sufficient space for placement of dental implant and prosthesis followed by Supportive periodontal treatment.Correspondence Dr. Anugya Karanjit Email id: karanjitanugya@gmail.com Citation Karanji A, Pradhan S, Gorkhali RS, Koirala PK, Adhikari S.An Interdisciplinary Approach for Management of Missing Canines with Implant Supported Cantilevered Prosthesis.J Nepal Soc Perio Oral Implantol.2022 Jul-Dec;6(12):91-4.

Figure 3 :
Figure 3: Space gained between 14 and 11 for implant placement after orthodontic therapy.

Figure 6 :
Figure 6: A) Osteotomy site for implant placement, B) Dental implant of size 3.5 * 10mm,0 C) After placement of implant fixture with Coverscrew.

Figure 8 :
Figure 8: A) Gingival cuff after placement of healing abutment, B) Impression was with open tray technique.