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Agenesis is a condition, generally congenital, involving the absence of one or more elements in the arch. It can involve both deciduous and permanent dentition, compromising the aesthetics, but also the function, of the patient’s dentition. The appropriate clinical approach does not involve the application of a single branch of dentistry, but rather a multidisciplinary approach is essential.
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1971-1441
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Matteo  Nagni
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Annali di stomatologia
Orthodontic treatment
Agenesis of an upper lateral incisor: case report and literature review
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Case Report
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2024-01-15
2024-01-19
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Matteo  Nagni
2023
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MSc, Dental School, Vita-Salute San Raffaele University, Milan, Italy and Department of Dentistry, IRCCS San Raffaele Hospital, Milan, Italy
1971-1441
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Orthodontic treatment
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Agenesis of an upper lateral incisor: case report and literature review
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                                                                                                         Case report


Agenesis of an upper lateral incisor: case report
and literature review



Irene Cusenza*                                                plan towards an initial orthodontic treatment that dis-
Vittorio Pensa*                                               talised the ectopic canine; it was subsequently treated
Marta Todaro*                                                 endodontically and prosthetically. Once the treatment
Luciano Pacifici***                                           was completed, after informed consent and drug treat-
Umberto Manica*                                               ment, implant placement was performed in site 2.2 and
Roberto Sgreccia*                                             subsequent prosthesis of the same.
Matteo Nagni**
                                                              Results
*Dental School, Università Vita-Salute San Raffaele, Mi-
                                                              Follow-up at 12 months after functional loading showed
lano, Italia e Dipartimento di Odontoiatria, IRCCS Ospe-
                                                              excellent healing of the patient’s hard and soft tissues
dale San Raffaele, Milano, Italia
                                                              on both intraoral objective examination and radiographic
**MSc, Dental School, Vita-Salute San Raffaele Univer-
                                                              examination.
sity, Milan, Italy and Department of Dentistry, IRCCS San
Raffaele Hospital, Milan, Italy
***Department of Oral and Maxillofacial Sciences Sa-          Conclusions
pienza University of Rome, Rome, Italy                        Agenesis of a tooth element can be treated optimally,
                                                              with a good prognosis over time, if the clinical approach
                                                              is multidisciplinary and accompanied by a correct clinical
Corresponding author: Pensa Vittorio                          evaluation of the patient.
E-mail: vittorio.pensa@yahoo.it
                                                              Introduction
Abstract                                                      Dental agenesis is defined as the failure to form a tooth
Agenesis is a condition, generally congenital, involv-        follicle, which therefore does not lead to the development
ing the absence of one or more elements in the arch. It       of the element itself [1,2]. The percentage of the popula-
can involve both deciduous and permanent dentition,           tion affected by agenesis is between 6-10% and there
compromising the aesthetics, but also the function,           are cases in which this failure to develop affects more
of the patient’s dentition. The appropriate clinical ap-      than one tooth: in this case, we will speak of multiple
proach does not involve the application of a single           agenesis [3,4]. The factors that can lead to problems of
branch of dentistry, but rather a multidisciplinary ap-       this type are divided into internal and external. The fac-
proach is essential.                                          tors defined as internal can be associated with genetic
                                                              disorders, hereditary and/or hormonal imbalances; those
Key words: Agenesis, Lateral incisor, Single implants,        defined as external can for example be due to trauma,
Orthodontic treatment.                                        malnutrition, systemic and/or local infections [5,6]. Agen-
                                                              esis can affect both milk and definitive teeth and tends to
                                                              occur in a greater percentage in the lower jaw, bilaterally
Purpose                                                       affecting the lateral incisors [5]. In the second case, it
The present study focuses on agenesis of the upper lat-       is important to assess the timing of tooth replacement.
eral incisors, in particular of the 2.2 element, by means     This is because we must neither be too hasty in giving
of a literature review and the description of a case report   a diagnosis of agenesis, nor too cautious and risk mak-
that aims to propose a possible clinical approach for the     ing the problem worse by not intervening. An agenesis,
treatment of agenesis of a 2.2. The treatment chosen          especially if multiple, can in fact bring various problems
was an implant-prosthetic rehabilitation, preceded by         to the patient such as problems with occlusion, social
orthodontic treatment for the distalisation of the ectopic    problems due to incorrect phonetics or aesthetics and
2.3 element. We therefore present the clinical results ob-    problems during chewing [7,8,9]. A dentist therefore has
tained following the choice of this treatment plan.           mainly three paths to follow to remedy this problem.
                                                              That of the orthodontic approach, aimed at closing the
Materials and Methods                                         spaces between the teeth left by the agenesis by means
                                                              of orthodontic appliances; that of implantology, should
Following the objective examination, it was possible to       the patient be at a useful age for implantation; and the
diagnose agenesis of element 2.2, the seat of which was       road of prosthetics, going to replace the missing element
occupied by element 2.3. This directed the treatment          with mobile solutions suitable even for young patients


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    Agenesis of an upper lateral incisor: case report and literature review

    [9,10,11,12]. The literature also suggests that dental im-    2.3 element. All surgical procedures were carried out in
    plants are currently a successful therapeutic alternative     compliance with the rules laid down in the wake of the
    that can also be used in patients with systemic diseases      Covid-19 pandemic situation, so as to promote patient
    [13, 14].                                                     and staff safety [18].
    Although in some situations the placement of axial im-
    plants in basal bone may be hindered by insufficient re-      CASE REPORT
    sidual bone height, the placement of fixtures in native
    bone, when possible, should be preferred [15].                A 29-year-old female patient, a smoker, came to the De-
    The choice of fixture type and prosthetic mode can in-        partment of Dentistry of the IRCCS San Raffaele Hospi-
    fluence implant success in the short and long term; it        tal in Milan with the aim of improving the aesthetics of the
    follows that pre-surgical planning is a key point of reha-    anterior sector of her smile. A clinical and radiographic
    bilitation [16, 17].                                          examination was then performed (Figure 1,2) from which
    The present study focuses on agenesis of the upper lat-       multiple agenesis was revealed. Specifically, this clinical
    eral incisors, in particular of the 2.2 element, by means     case deals with the rehabilitation of the agenesis of ele-
    of a literature review and the description of a case report   ment 2.2.
    that aims to propose a possible clinical approach for the     The case evaluation also revealed that tooth 23 was in
    treatment of agenesis of a 2.2. The treatment chosen          a mesial position compared to its usual position, which
    was an implant-prosthetic rehabilitation, preceded by         caused a reduction of the arch space between elements
    orthodontic treatment for the distalisation of the ectopic    2.1 and 2.3.




    Figure 1. Pre-operative orthopantomography.




                                                                                    Figure 2. Intra-oral photo.



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I. Cusenza et al.

It was proposed to the patient to perform an orthodontic      Biosafin, Ancona, Italy) with open technique (figure 4-5).
correction, distalising tooth 23 and thus creating space      The previously raised flap was then repositioned and
for the subsequent implant-prosthetic rehabilitation          adjusted with 4-0 non-resorbable suture (Vicryl; Ethicon,
of the edentulous site. The first phase of treatment in-      Johnson & Johnson, New Brunswick, NJ, USA).
volved orthodontic therapy in order to distalise element      After surgery, the patient was prescribed post-surgical
2.3 which, due to agenesis, had occupied the site of ele-     drug therapy including: Medrol 0.16 mg (1\2 two days
ment 2.2. Once the orthodontic treatment was complet-         after surgery and 1\4 three days after surgery) and Tora
ed, it was possible to obtain the necessary space for an      Dol drops 20 ml (25 drops as needed). Finally, the pa-
implant-prosthetic rehabilitation of element 2.2. The sec-    tient was advised to avoid any brushing trauma at the
ond phase of treatment included endodontic treatment          surgical site as well as smoking. After one week, the pa-
of element 2.3, which was subsequently prosthetised by        tient underwent a follow-up examination and at the same
performing a prosthetic preparation with modified cham-       time the sutures were removed.
fer (Figure 3).                                               Approximately six months after surgery, in order to
After this procedure was completed, it was decided            achieve complete healing of the tissues and proper
to schedule surgery for the insertion of the endosse-         osseointegration of the implant, a definitive prosthetic
ous implant. Before starting surgery, the following drug      crown could be inserted.
therapy was prescribed: Levoxacin 500 mg (1 per day
for 10 days to be started the day before surgery) and
Medrol 0.16 mg (1 tablet the morning of surgery). The         FOLLOW-UP
surgical phase was performed under local anaesthesia
                                                              The patient was placed in a follow-up program to moni-
(Optocaine 20 mg/ml with adrenaline 1:80,000; Molteni
                                                              tor hard and soft tissue healing following implant place-
Dental, Florence, Italy).
                                                              ment. The patient was monitored one week after implant
It then proceeded with implant insertion, in site 2.2, TTSI
                                                              placement, then after 6 and 12 months. Meanwhile, the
Winsix 2.9 mm diameter x 11 mm length (TTx, Winsix,
                                                              patient was instructed in home oral hygiene manoeuvres
                                                              in order to maintain proper implant health. The home oral
                                                              hygiene sessions were flanked by quarterly, and then
                                                              six-monthly, professional oral hygiene sessions. Home
                                                              and professional hygiene maintenance is one of the
                                                              main prerequisites for implant success [19, 20]


                                                              RESULTS
                                                              The patient was then reassessed at a follow-up of ap-
                                                              proximately 12 months after functional prosthetic loading
                                                              (Figure 6). The radiographic evaluation was performed
                                                              by taking an endoral radiograph from which a correct im-
                                                              plant osseointegration was revealed (Figure 7). On the
                                                              other hand, the healing of the peri-implant soft tissues
                                                              was assessed by means of an intraoral clinical examina-
Figure 3. Prosthetic preparation of the modified chamfer      tion, from which it was inferred that they had excellent
                                                              osseointegration.




Figure 4 e 5. Implant placement.



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    Agenesis of an upper lateral incisor: case report and literature review

                                                                coordination between the orthodontist and oral surgeon,
                                                                in collaboration with the restorative dentist and periodon-
                                                                tist [22].
                                                                Among the various treatment options, implants seem to
                                                                be the best therapeutic solution as they are more pre-
                                                                dictable than traditional prosthetic solutions such as
                                                                bridges over natural teeth or adhesive bridges such as
                                                                Maryland [2,9,11].
                                                                Although the clinical case presented itself with a need for
                                                                prosthetic rehabilitation related to tooth 23, with a view
                                                                to a correct diagnosis, preservation of tooth substance
                                                                and an aesthetically performing rehabilitation, in this
                                                                rare case we proceeded with the rehabilitation of tooth
                                                                22 with an implant-prosthetic solution.
                                                                A correct diagnosis and an appropriate treatment strat-
                                                                egy for these rare conditions are mandatory to prevent
                                                                future complications. Furthermore, this rare case could
                                                                contribute to future studies on the incidence of agenesis
    Figure 6. Prosthetic finalisation.
                                                                of lateral incisors in cases already treated prosthetically.
                                                                In conclusion, implants appear to be an excellent thera-
                                                                peutic option for the rehabilitation of agenesis in aesthet-
                                                                ic areas provided the clinical conditions are favourable.
                                                                Indeed, it is necessary that the bone thickness and qual-
                                                                ity, as well as the tissue phenotype, are adequate.


                                                                CONCLUSION
                                                                The Authors of this paper agree that implant-prosthetic
                                                                rehabilitation of one or more agenesis in aesthetic ar-
                                                                eas can be an excellent treatment option provided the
                                                                patient’s clinical condition is favourable. This predictable
                                                                and safe procedure will allow the restoration of adequate
                                                                masticatory function.


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