Interdisciplinary Management of Patients With Ectodermal Dysplasia

A 15-year-old girl with ectodermal dysplasia who had been treated previously with minimal orthodontic intervention and removal prosthesis was seen and evaluated at the General Practice Program at the University of Kentucky. After consultations with orthodontics and oral and maxillofacial surgery, an interdisciplinary staged treatment plan was developed to address her skeletal and dental issues. The authors briefly review the literature with respect to current therapy for patients with ectodermal dysplasia and present the case as an example of the coordinated care provided for a patient with complex skeletal and dental issues.

Tooth autotransplantation in orthodontic patients

AIM

The aims of this report are to present three cases of autotransplantation along with a review of the indications, selection criteria for patient donor and recipient sites, and the major steps in the surgical procedure.

BACKGROUND

Autogenous tooth transplantation, or autotransplantation, is the surgical movement of a tooth from one location in the mouth to another in the same individual. It can be a good treatment option in many cases if the dentist knows the implications, indications, and contraindications.

CASE DESCRIPTIONS

Three cases with different treatment indications and plans are presented. All showed autotransplantation of teeth as part of orthodontic treatment. It emphasized the benefits of this treatment modality such as new bone formation and lower costs. One case, a rare example of multiple congenitally missing teeth treated by autotransplantation, also was presented.

SUMMARY

As shown in these case reports, there are instances where the autotransplantation of teeth is appropriate and may possibly simplify future planned orthodontic or prosthodontic treatment.

CLINICAL SIGNIFICANCE

Tooth autotransplantation is an easy and good treatment option, applicable in a lot of cases, substituting different types of prostheses, including dental implants.

Consequences of X-linked hypohidrotic ectodermal dysplasia for the human jaw bone

Mutations of the Eda gene, which encodes for ectodysplasin-A1, result in X-linked hypohydrotic ectodermal dysplasia (XLHED). This pathology may lead to severe oligodontia, subsequently requiring implant therapy. Since Eda is suspected to participate in bone development, the jaw bone status was investigated in XLHED patients in order to adjust the surgical protocol. Using computed tomography, densitometric profiles and 3D reconstructions, the bone structure was analyzed and compared to that of control individuals; our results showed that the morphological changes comprised mandibular bone flattening. Craniofacial CT scans showed medullary bone hyperdensity, including in the mandibular symphysis area, where implants must be placed. These alterations in bone structure were also observed in locations where the presence/absence of teeth cannot interfere. If the changes in jaw bone morphology can be a consequence of oligodontia, the changes in bone structure seem to be tooth-independent and suggest a direct effect of the mutation on bone formation and/or remodeling.

A treatment planning classification for oligodontia

PURPOSE

The aim of this research was to provide a classification for patients with oligodontia that could act as an aid in treatment planning.

MATERIALS AND METHODS

Panoramic radiograph records of 70 patients with oligodontia were used to categorize the extent of the disability and treatment modality. Patients were classified into types 1 through 3 depending on the number of missing primary and permanent teeth, as well as in relation to their prosthodontic requirements. The radiographs were then assessed independently on two separate occasions by three experienced clinicians to validate the classification.

RESULTS

There was a high level of intrarater consistency in allocating patients into the three different types with a Kappa (k) score of 0.77 for clinician 1, 0.87 for clinician 2, and 0.94 for clinician 3. There was also a strong interrater agreement (overall k score: 0.88). A k score greater then 0.6 is regarded as being good and greater than 0.8 as being very good.

CONCLUSIONS

Oligodontia is a heterogeneous condition. Patients with oligodontia can be classified as having three different types according to the extent of their disability and the complexity of their prosthodontic requirements. This classification is a reliable diagnostic tool based on the positive outcome of the inter- and intrarater consistency.

Invisalign and porecelain: the contemporary restorative powerhouse

For years, restorative practices and traditional orthodontics stood largely separate from one another save for the most extreme instances. Orthodontics has evolved over the years, and a new breed of orthodontic technology appeared in the late 1990s. A clear alternative to traditional orthodontics emerged, and Invisalign (Align Technology, Inc., Santa Clara, CA) was born. Historically, orthodontics and restorative work, within a practice, rarely coincided on the same patient, but the advances within both disciplines have afforded a new and innovative way of considering conservative dentistry. No longer does there have to be aggressive preparation to attain a desired result. With patient understanding, a negligible amount of patience, and the desire to achieve the very best dentistry has to offer, the potential is limitless.

Oligodontia ectodermal dysplasia--on signs, symptoms, genetics, and outcomes of dental treatment

The general aim of this thesis was to broaden our knowledge of the signs and symptoms, genetics, and outcomes of dental implant treatment in individuals with oligodontia or ectodermal dysplasia. Article I is a population-based study in three Swedish counties of 162 individuals with oligodontia, which was a prevalence of 0.09%. The intent was to explore ways for dentists to assess symptoms from other ectodermal structures than teeth through a clinical interview and chair-side analyses. Thirty per cent had low salivary secretion rates while only 11% with no known syndrome reported symptoms from hair, nails, or sweat glands. These are, together with teeth, the ectodermal structures on which it is proposed that a clinical diagnosis of ectodermal dysplasia (ED) be based. Article II screened 93 probands with oligodontia for mutations in six genes known to cause oligodontia and hypohidrotic ED. Sequence alterations predicted to be damaging or potentially damaging were revealed in the AXIN2, MSX1, PAX9, and EDARADD genes in 14 (15%) of the probands. All mutations but one were novel. For the first time, EDARADD mutations were shown to cause isolated oligodontia. No individual who had reported ectodermal symptoms from hair, nails, or sweat glands had a mutation. Article III assessed orofacial function in individuals with different types of EDs using the Nordic Orofacial Test-Screening (NOT-S) protocol. Individuals with ED scored significantly higher in orofacial dysfunction than a healthy reference sample, especially in the Chewing and swallowing, Dryness of the mouth, and Speech domains. Article IV surveyed treatment outcome of dental implants in Swedish children up to age 16 years. In a 20-year period, only 26 patients were treated, 5 of whom had hypohidrotic ED and anodontia of the mandible. Individuals with ED had 64% failed implants compared to 6% among subjects with teeth missing due to trauma or agenesis. The main conclusions of this thesis were that (i) a check of whether one or more permanent incisors are missing will identify 65% of individuals with oligodontia and 84% of individuals missing nine teeth or more, (ii) evaluation of salivary secretion is indicated in children with oligodontia, (iii) a majority of individuals with oligodontia did not report other abnormal ectodermal organ function besides teeth, (iv) no clinical indicator discriminated between individuals with and without mutations in the tested genes, and more unidentified genes are involved in tooth morphogenesis, (v) EDARADD mutations are associated with isolated oligodontia, (vi) evaluation of orofacial function is indicated in individuals with ED, and many individuals with ED would benefit from orofacial skills training, (vii) dental implant placement is a rare treatment modality in children, (viii) individuals with hypohidrotic ED seem to present special challenges due to structural as well as direct effects of the mutations on bone, which seem to compromise osseointegration, (ix) central registers on signs and symptoms in individuals with rare disorders would help establish prevalences of various diagnoses and define treatment needs, and (x) quality registers for monitoring treatment outcomes of dental implants would promote early detection of risks and side-effects in individuals with rare disorders.

Combined periodontal and orthodontic treatment in a patient with aggressive periodontitis: a 9-year follow-up report

A combined periodontal and orthodontic treatment demands a detailed evaluation in both specialties, particularly when the periodontium is reduced. This is especially true for adult patients, but young patients can also suffer from advanced periodontitis. This article describes combined periodontal and orthodontic therapy in a young patient with severe localized and aggressive periodontitis, tooth crown abnormalities, and missing maxillary second premolars. Periodontal treatment was carried out. Once attachment gain and bone stability were confirmed, orthodontic therapy commenced. It lasted 32 months, during which segmented mechanics and only light forces were used. The result of this intervention was satisfactory, and long-term stability (9 years) with periodontal maintenance was achieved.

Aesthetic evaluation in subjects treated due to congenitally missing maxillary laterals. A comparison of perception in patients, parents and dentists

The treatment of the congenitally missing maxillary lateral incisor is a challenge to the dental profession. The demand for optimal orthodontic and prosthetic treatment is high because the condition has an impact on facial aesthetic. The aims of the present study were to determine how different outcome of treatment were perceived by professionals and laypeople and to identify situations that caused dissatisfaction or satisfaction after space closure or tooth replacement. A panel of four groups (patients with missing laterals, parents to these subjects, patients with other malocclusion and general dental practitioners) were included. Sixteen cases with uni- or bilateral missing maxillary lateral incisors, treated with space closure or with prosthetic replacements were presented photographically to the panel. The prosthetic replacements included resin-bonded bridges, porcelain bonded to gold bridges and implants. The panel was asked to rate the overall appearance of the mouth, to rank up to three disturbing features and to rank the most important treatment goals in case of treatment need. An obvious difference between the panel groups was found. The general practitioners were less critical than laypeople in rating the overall appearance. Amongst dentists the tooth colour, the tooth shape and asymmetry were the most disturbing factors whilst laypeople were disturbed by colour, spacing and tooth shape. Half of the dentists did not find any treatment need whilst the corresponding figure amongst laypeople was 19 per cent.When a treatment need was confirmed the most common treatment goals amongst dentists were to change the colour or the shape of the teeth. The laypeople wanted to change the colour, the space condition or the shape of the teeth. The study has shown that professionals and laypeople are of different opinion when rating treatment outcome in cases with missing maxillary laterals. Careful planning to achieve optimal aesthetics should be performed.

Treatment of an adolescent with total ankyloglossia

This is a report about the orthodontic treatment of a 13-year, 10-month-old boy with total ankyloglossia combined with a Class III occlusion. The patient's tongue was fixed to the floor of his mouth and could not be elevated at all. He had a maxillary deficiency and a mandibular protrusion with a negative overjet. However, he was able to retrude his mandible to an edge-to-edge position. Before orthodontic treatment, the ankyloglossia was surgically rectified. Orthodontic treatment was initiated to improve the patient's occlusion and facial appearance by correcting his retruded maxilla by means of a face mask, fixed appliances, and Class III elastics. This led to a functional occlusion and an acceptable facial appearance.

Augmentation of the mandible via a "tent-pole" procedure and implant treatment in a patient with type III osteogenesis imperfecta: clinical and histologic considerations

The present report describes the oral rehabilitation of a female patient suffering from type III osteogenesis imperfecta. Agenesis of the mandibular anterior teeth and malocclusion caused partly by heavily worn teeth made dental rehabilitation necessary. Before a decision to use implants following a grafting procedure, the osseointegration of microimplants was tested. After 4 and 12 months, bone plugs containing two microimplants were retrieved from the patient. Histologic evaluation showed very sparse/poor osseointegration, and the healing time seemed to be much longer than normal. A decision was made to use the "tent-pole" procedure described by Marx et al, followed by prolonged healing. Surgery was uneventful, and the patient was provided with four implants that were partly covered with bone obtained from the iliac crest. Platelet-rich plasma was used to accelerate bone healing. After 9 months, the implants were uncovered and the prosthetic construction was completed. The implant-supported metal-ceramic restoration was serving well at the 1-year and 3-year follow-ups. Minimal resorption of marginal bone was detected during the first year.

The role of endosseous implants in the management of alveolar clefts

In individuals with cleft lip and palate, there is a high prevalence of hypodontia, particularly of the maxillary lateral incisor on the cleft side. The edentulous space in patients with a repaired alveolar cleft was traditionally treated with a fixed or removable partial denture, but this approach is not optimal. The purpose of this paper was to review the dental literature for infant orthopedic treatment, timing of alveolar bone grafting, timing of implant placement, and type of implants used in individuals with repaired alveolar clefts. There seems to be a consensus in the literature that the optimal timing for initial secondary alveolar bone grafting is between 8 and 11 years of age. Implants cannot be placed this early but should be placed within 6 months of augmentation bone grafting to avoid resorption of the grafted area. Longer implants--those at least 13 mm in length--reportedly have a higher survival rate compared to shorter implants. Other implant parameters such as surface characteristics and diameter do not seem to influence significantly the long-term longevity of implants placed into grafted alveolar clefts.

Treatment of a Class II subdivision malocclusion with multiple congenitally missing teeth

This case report describes the treatment of a patient with a Class II Division 1 subdivision right malocclusion with 8 congenitally missing teeth, incompetent lips, and incisor protrusion. The treatment plan included extractions and space closure with retraction of the anterior teeth; symmetric mechanics were used in the mandibular arch and asymmetric mechanics in the maxillary arch. Because of the mechanics used, some midline deviations were expected. Knowledge of diagnosis and treatment planning of asymmetric malocclusions and dental esthetics are essential for success when correcting asymmetic problems, but, even so, small clinical compromises should be expected.

Hypodontia in a patient with actinic prurigo: a case report

Actinic prurigo is a rare form of light sensitivity not previously described with hypodontia in the dental literature. The purpose of this report was to describe both the medical and dental management of a 12-year-old boy presenting with actinic prurigo, hypodontia, crowding, caries, and tooth tissue loss. The phases of dental treatment and the multidisciplinary treatment of hypodontia are discussed.

Dental implants in patients with ectodermal dysplasia and tooth agenesis: a critical review of the literature

PURPOSE

The aims of this article are to critique the available literature on dental implants in patients with ectodermal dysplasia (ED) syndrome and tooth agenesis, review the outcomes of implant therapy in these patients, and provide recommendations on the timing of implant placement for these patients.

MATERIALS AND METHODS

Searches were performed using Medline, Embase, All EBM Reviews, and Pre-Medline for articles relating to implant patients suffering from ED. Articles unrelated to the topic of dental implants in patients with ED and tooth agenesis, without abstracts, or in languages other than English were excluded. Selected articles were graded according to levels of evidence based upon guidelines set forth by the Agency for Health Care Policy and Research. Articles found to have a level of evidence of IV were excluded from this study.

RESULTS

The literature on dental implants in patients with ED and tooth agenesis was found to be scarce. No randomized controlled or case-controlled studies were found. Only 12 articles were found to satisfy all inclusion criteria.

CONCLUSION

Implant survival rates vary between 88.5% and 97.6% in patients with ED and between 90% and 100% in patients with tooth agenesis. Implants placed in adolescent ED patients do not have a significant effect on craniofacial growth, while implants placed in ED patients younger than 18 years have a higher risk of failure.

A multi-disciplinary approach to congenitally missing anterior teeth

Congenitally missing teeth are not an unusual occurrence. What makes this case study unique is the combination of restorative challenges offered. The patient presented with the permanent upper right cuspid and lower anterior right and left central incisors congenitally missing, and with an underdeveloped upper right lateral incisor. Distinctive existing occlusion and tooth alignment difficulties precluded a simple approach of merely extracting the residual primary teeth and replacing the missing teeth prosthetically. Using orthodontics to create ideal interocclusal and interarch space was critical in preparing this case for prosthetic restoration.

Implant-prosthetic partial-arch restoration in a patient with ectodermal dysplasia characterized by oligodontia and localized bone deficiency: a case report

Ectodermal dysplasia (ED) is a genetic disorder that is often associated with anomalies of teeth such as hypodontia and oligodontia. Individuals affected by ED have abnormalities of the epithelial tissue of the hair, nails, teeth, or sweat glands. Implant-prosthetic rehabilitation is often necessary because the severity of disease may limit other treatment options. This is a report of a 30-year-old man affected by ED who exhibited severe hypodontia and atrophy of the jaws. Radiographic and clinical evaluations showed inadequate quantity of bone for immediate implant rehabilitation. Osteogenetic vertical distraction and grafting of autogenous bone were performed to obtain the correct bone volume, and implants were inserted in the anterior mandible to support a prosthetic restoration.

Strategies to finish orthodontic treatment with a Class III molar relationship: three patient reports

The purpose of this article is to review treatment concepts for patients with congenitally missing teeth in the mandible, for patients in whom teeth in only the mandibular arch were extracted, or for patients with Class III camouflage treatment. The therapy result in these situations is a Class III molar relationship. With this type of intercuspation, esthetic and functional aspects must be observed.

Orthodontics and its interactions with other dental disciplines

Preservation or alteration of the natural dentition to an optimal state of health, function, comfort, and esthetics remains the primary goal of dentistry. However, referral of patients by general dentists to orthodontic specialists may be complex as it involves the interaction of the two dental professionals and the patient. Because there is a marked variation in referral rates between the dentists and many patients may be referred inappropriately, a clear understanding of what is known about current orthodontic treatment possibilities, limitations and inherent risks is necessary. The purpose of this article is to outline the existing orthodontic therapeutic possibilities for adjunctive dental work and to emphasize the importance of teamwork among the general dentist, the orthodontic specialist and possibly other dental specialists during treatment planning.