Bianca Marques Santiago, DDS
Postgraduate student, Department of Pediatric Dentistry and Orthodontics, School of Dentistry, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil.
Daniella Della Valle Sigmaringa, DDS, MSD
Master of Pediatric Dentistry, School of Dentistry, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil.
Lucianne Cople Maia, DDS, MSD, PhD
Associate professor, Department of Pediatric Dentistry and Orthodontics, School of Dentistry, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil.
Corresponding author: Lucianne Cople Maia - Av. Marques do Paraná, 189/1804, Centro, Niterói, Rio de Janeiro, Brazil. Zip Code:24030-210. Telephone number: 55(21)2629-3738. E-mail address: firstname.lastname@example.org
The smile is very important for adults as well as for children and their guardians. Its harmony could be negatively influenced by the presence of dental anomalies like alterations in shape, size, position, color or texture. In this article a case of a single unilateral peg-shaped maxillary lateral incisor is described along with the conservative treatment proposed. The esthetic approach is reported step by step and also discussed.
A peg-shaped lateral incisor could be defined as a tooth with reduced mesio-distal diameter and with proximal surfaces converging markedly in the incisal direction (1). Generally, its diameter is reduced from the cervix to the incisal edge (2). The inheritance of peg-shapped upper lateral incisors has been rather commonly assumed to be associated with the genetic mechanism that causes the missing of upper lateral incisors (1). Grahnen (3) claimed that this shape and size's alteration is a modified manifestation of the genotype that causes hypodontia. The available literature suggests that missing and peg-shaping of upper lateral incisors are different expressions of one dominant autossomal gene (1,3).
The prevalence rate of peg-shaped permanent lateral incisors in the general population ranges from slightly less than 1% to slightly more than 2 % (1,4). No significant sexual differences in the frequencies have been found although the frequencies in the women are, on an average, slightly higher (1). It can be unilateral (1,5), mainly on the left side of the maxilla (6), or bilateral (1,5). It has not been reported any kind of race predilection in the reviewed literature.
Conical crown-size reduction of the maxillary lateral incisor is usually associated with other dental anomalies like tooth agenesis (4,7), maxillary canine-first premolar transposition (5), palataly displacement of one or both maxillary canine teeth (8) and mandibular lateral incisor-canine transposition (9). In this cases with concomitant dental anomalies, the prevalence suffers significant increase from normal prevalence (1,5,8).
There are two treatment options for malformed lateral incisors: 1) to move the maxillary canines forward and reshape them to simulate the extracted malformed lateral incisors; 2) to stand the canines in a Class I relationship and to restore the missing tooth structure by increasing the size of a peg-shaped lateral incisor (10). The second option is more conservative and could be done by placing a full-coverage crown on the lateral incisors (11) or reshaping them with acid etch technique and bonded composite resin (10,12).
This paper reports a case of single unilateral peg-shaped maxillary lateral incisor along with the conservative treatment proposed, that is described step by step and also discussed.
An 8-year-old caucasian female was referred to the pediatric dental clinic of a public university in Rio de Janeiro, Brazil by one of the public dental services of the same county. Her mother's main complaint was the presence of a reduced anterior tooth that affected her child's smile. The patient also showed dissatisfaction about this situation when asked about it, and a slight introspection was noticeable. Her medical history was uneventful, except for the presence of respiratory allergy.
Intraoral clinical examination revealed that the patient was in early mixed dentition. The upper arch presented spaces among incisors and a peg-shaped right lateral incisor (Fig. 1A e 1B).
FIGURE 1 - A) Intra-oral aspect, frontal view, presenting spaces among incisors; B) lateral view, note the peg-shaped right maxillary lateral incisor; C) panoramic radiograph.
The lower arch presented
amalgam restorations on the primary first molars. All other erupted teeth were
caries-free. Both primary canines and permanent first molars presented Class
I relationship. There were no soft tissues alterations and oral hygiene was
Panoramic radiographic examination (Fig. 1C) demonstrated a complete dentition, with no other suspect of dental anomalies on permanent teeth. The mother was asked about the presence of similar anomalies in other family members, but reported no one in the family had teeth resembling these presented by the child.
Since there was an esthetic dissatisfaction, treatment plan for the patient included a composite resin restoration of the peg-shaped right lateral incisor. After tooth color selection, the patient was anesthetized and rubber dam was placed to the teeth. A modified #212 clamp (KSK® - Dentech Corporation - Tokyo - Japan) associated to molten graystick compound was used to stabilize the rubber dam and also to gain access to the cervical region of the pegged incisor (Fig. 2).
FIGURE 2 - Aspect of the rubber dam stabilized by a modified #212 clamp (KSK® - Dentech Corporation - Tokyo - Japan) associated to molten graystick compound.
No dental preparations were performed. After prophylaxis and protection of the adjacent teeth, acid etch (Conditioning Dental Gel® - 37%, Dentsply - Petrópolis - RJ/Brasil) was applied for 15 seconds (Fig. 3A).
FIGURE 3 - A) Acid etch conditioning for 15 seconds (Conditioning Dental Gel® - 37%, Dentsply - Petrópolis - RJ/Brasil); B) Placement of a primer- bonding agent (Prime & Bond® NT, Dentsply - Petrópolis - RJ/Brasil).
Then, the tooth was rinsed and dried and a primer-bonding agent (Prime & Bond® NT, Dentsply - Petrópolis - RJ/Brasil) was placed (Fig. 3B) and light cured for 20 seconds.
After that, the composite resin was applied through incremental layers (Fig. 4A).
FIGURE 4 - A) Placement of an increment of the opaque micro hybrid composite resin (Esthet X - A2O, Dentsply - Petrópolis - RJ/Brasil); B) Aspect after the placement of the last increment of a micro matrix composite resin (Estheth X - A2, Dentsply - Petrópolis - RJ/Brasil).
An opaque micro hybrid composite resin (Esthet X - A2O, Dentsply - Petrópolis - RJ/Brasil) was used to simulate the missing dentin and posteriorly, a micro matrix composite resin (Estheth X - A2, Dentsply - Petrópolis - RJ/Brasil) was applied superficially to simulate enamel (Fig. 4B). Each increment was light cured for 20 seconds.
Resin excesses were firstly removed with a surgical blade #12 (Fig. 5A) and secondly with finishing diamond burs (KG Sorensen - São Paulo - SP/Brasil) like 2200F diamond, that also helped on the sculpture (Fig. 5B).
FIGURE 5 - A) Finishing with a surgical blade #12; B) Final sculpture with finishing diamond burs (2200F - KG Sorensen - São Paulo - SP/Brasil).
Polishing was made with discs (Sof-lex®, KG Sorensen - São Paulo - SP/Brasil). After removing the rubber dam, occlusion and esthetics were checked and verified. Her guardian was advised to not allow the child to ingest any liquid or food containing corants for the first 24 hours after restoration.
The patient became very happy with the final result (Fig. 6A and 6B) and her mother also commented on the natural look of the restoration. Patient's follow-up visits are being scheduled twice a year.
FIGURE 6 - A) Final aspect of the composite resin restoration, frontal view; B) Lateral view of the peg-shaped right lateral incisor after composite resin restoration.
Peg-shaped maxillary lateral incisors could be responsible for smile implications, that varies from case to case, but could also cause alterations on psychological behavior. A patient could be shy or even avoid social contacts depending on the alteration degree (13,14). Children may demonstrate esthetic dissatisfaction (16) as well as adults (15). Therefore, any esthetic problem that influences social and personal relationships must be corrected, whenever possible (13,14, 15).
The case presented could be considered as an example of slight introspection caused by a peg-shaped maxillary lateral incisor. The guardian reported that her child was very vain and worried about her appearance, being anxious for a solution to her conical crown-size reduced tooth. It is necessary to emphasize that in this case the mother was even more anxious than the child, which is usually common in pedodontic practice (16).
Literature has reported a higher prevalence of peg-shaped upper lateral incisor in females (1,4), which corresponds to the case presented. Kook et al. (6) in their study found it to occur more frequently on the left side of the maxilla, however the current case presented a right pegged lateral. Many previous reports, in the reviewed literature, have described the association between the presence of peg-shaped maxillary lateral incisor and other developmental anomalies (1,4,5,7,8), which increases its prevalence (1,5,8). So, the case reported is some kind of unusual since panoramic radiographic did not reveal any missing teeth or other dental anomaly.
Treatment plan consisted in retaining peg-shaped right maxillary lateral incisor and reshaping it with bonded composite resin. This conservative option was chosen because it preserves tooth structure once it is not necessary to make any preparations on tooth, like the ones needed for the crowing technique (11). In addition, this technique is not time consuming like orthodontic approach (10), which was discarded since the patient was in the early mixed dentition still with the presence of primary canines and the permanent first molars in Class I relationship. Others advantages of this esthetic bonding procedure are the small cost when compared to indirect technique and the fact that this kind of procedure is reversible (17), allowing other treatment approaches in the future if necessary.
Nevertheless, bonding procedures like the one proposed need some cautions. The rubber dam is an imperative step since it must not exist saliva or crevicular fluid. It is necessary to check the occlusion (10) and to observe contralateral tooth to simulate it and give a natural appearance to the tooth restored by careful sculpture.
The authors of the present case agree with Miller et al. (10) that treatment choice should be made on the basis of some considerations: need for extractions, posterior relationships, position of the canines at the time of diagnosis; and add others like patient's age, dentition's stage and patient's esthetic needs.
Direct composite resin restoration is a worthy conservative treatment option to restore peg-shaped maxillary lateral incisors to normal contours. This esthetic bonding procedure gives a natural look and improves smile, favoring esthetics that is a current need nowadays and an important influence factor on personal and social relationships.
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