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Year : 2020  |  Volume : 23  |  Issue : 3  |  Page : 425-428

How to address a biological complication by using advanced platelet-rich fibrin during the interdisciplinary management of congenitally missing maxillary lateral incisors

1 Department of Oral and Maxillofacial Surgery, Near East University Faculty of Dentistry, Nicosia, Mersin.10, Turkey
2 Department of Prosthodontics, Near East University Faculty of Dentistry, Nicosia, Mersin.10, Turkey

Date of Submission08-Jul-2019
Date of Acceptance03-Oct-2019
Date of Web Publication5-Mar-2020

Correspondence Address:
Dr. M G Caymaz
Near East University, Yakin Doğu Bulvari, Post Code: 99138, Nicosia, Mersin - 10
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/njcp.njcp_346_19

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Congenital agenesis of lateral incisor is one of the most prevalent dental anomalies and is commonly treated by correcting the axes of maxillary central and canine teeth deviated toward the deficient area orthodontically, replacing the missing maxillary lateral incisor with dental implants and prosthetic restorations. Conducting treatment in interdisciplinary manner is the main criterion for the successful outcome. If this is ignored, clinicians may experience biological, mechanical or combined complications. As encountered in this case, bone resorption may occur if there is very limited bone-width or if there is a past of orthodontic treatment. In contemporary dentistry, this biological complication can be treated with the aid of a mixture including bovine bone graft material and advanced platelet-rich fibrin.

Keywords: Advanced platelet-rich fibrin, anterior aesthetic, congenitally missing teeth, dental implant, interdisciplinary approach

How to cite this article:
Caymaz M G, Onoral O. How to address a biological complication by using advanced platelet-rich fibrin during the interdisciplinary management of congenitally missing maxillary lateral incisors. Niger J Clin Pract 2020;23:425-8

How to cite this URL:
Caymaz M G, Onoral O. How to address a biological complication by using advanced platelet-rich fibrin during the interdisciplinary management of congenitally missing maxillary lateral incisors. Niger J Clin Pract [serial online] 2020 [cited 2020 Apr 6];23:425-8. Available from:

   Introduction Top

Tooth agenesis is an etiologically complex abnormality characterized by the developmental absence of one or more teeth and is known to be related to both genetic and environmental factors.[1] Excluding third molars, the prevalence of tooth agenesis ranges from 2% to 10%, and it occurs mostly in maxillary lateral incisor (MLI). Due to its prominence in the aesthetic zone, the replacement of MLI is a challenging process.[2] It was, therefore, aimed to actualize an interdisciplinary treatment modality for the patient with congenitally missing lateral incisors and to explain the way of solution for the biological complication encountered during treatment procedures.

   Case Report Top

A 35-year-old woman was referred to the department with the complaint of aesthetic concerns resulting from congenital bilateral agenesis of MLI. As a result of oral examination and orthodontic model analysis, Angle Class II molar occlusion was detected. Moreover, deviation of maxillary central and canine teeth towards the deficient areas narrowed the space. To address these problems, stripping and protrusion mechanics were performed for 12 months.

Bone quality and quantity were virtually assessed by using conical-beam computerized tomography (CBCT) data. Following the application of infiltrative local anesthesia, bilateral mucoperiosteal flaps were elevated; pre-determined implants (3.5 × 10 mm Nobel Replace, Conical Connection RP, Sweden) were inserted. No complications were encountered during the operation, and no bone dehiscence occurred. One month later, oral examination reinforced with CBCT data indicated aggressive bone resorption around left implant, especially on the buccal wall. Moreover, the grayish silhouette of the implant reflecting through gingival tissues was observed. Silhouette reflection was also seen on the right side, although not as much as the left side [Figure 1].
Figure 1: Metallic silhouette reflection of dental implants

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To address this biological complication, the left implant was removed. A bovine bone graft (BEGO Implant Systems GmbH and Co. KG, Bremen, Germany) mixed with advanced platelet-rich fibrin (A-PRF) obtained by centrifugation (Elektro-mag M415P, Istanbul, Turkey) of patient's own blood collected in 10 mL of vacuumed plain glass tubes (A-PRF+: Jiangsu Kangjlan Medical Apparatus Co. Ltd, Jiangyan City, China) at 1,500 rpm for 14 min, as described in a previous in-vivo study,[3] was applied to the implant cavity and to the buccal wall in order to increase the bucco-palatal bone width. Grafting area was covered with the membrane obtained from A-PRF, and the flap was primarily closed with 5/0 silk suture [Figure 2]. No postoperative complications were detected on recalls. At the end of the third month, the same type of implant was replaced on the left side with the same technique. In the same session, previous procedures were conducted for right side, but without removal of implant itself [Figure 3]. After 3 months, the healing caps were inserted, and the prosthetic input was started after 1 week waiting for gingival-tissue-management [Figure 4].
Figure 2: (a) Cavity after removal of implant on left side. (b) Advanced platelet-rich fibrin (A-PRF) obtained from patient's own blood. (c) A mixture of bovine bone graft material with A-PRF. (d) Closure by using A-PRF membrane. (e) Suturing of wound after operation

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Figure 3: (a) Re-implantation of same type implant on left-side. (b) Appearance of implant on right side. (c) Grafting of implantation area on right side by using a mixture of Bovine bone and advanced platelet-rich fibrin (A-PRF). (d) Closure by using A-PRF membrane. (e) Suturing of wound after operation

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Figure 4: Management of gingival tissues

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After the gingival margins were equalized using diode laser (Biolase, San Clemente, CA, USA); impression was taken by using vinyl-polyether-siloxane elastomeric impression material [Figure 5]. Digitization of impression was achieved by using an extraoral digital scanner (inEos X5, Sirona). Zirconia infrastructures were designed as a 3D model using computer-aided design software (InLab 15, Sirona) and saved in standard tessellation language format. The infrastructures were subtracted from a pre-sintered zirconia block (High translucent zirconia, 14 mm, Vita YZ) using a five-axis computer-aided manufacturing device (inLab MC X5, Sirona), and then sintered. Subsequently, multi-layer porcelain veneering was applied. Surface characterization of the restorations was completed by glaze treatment. Zirconia abutments were screwed onto the corresponding implants with a torque force of 30 Ncm [Figure 6]. Consequently, ceramic crowns were cemented (Panavia F2.0, Kuraray) [Figure 7].
Figure 5: (a) Impression copings on corresponding implants. (b) Obtainment of impression by using vinyl-polyether-siloxane elastomeric impression material

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Figure 6: Zirconia abutments on corresponding implants

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Figure 7: Final outcome after prosthetic replacement

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   Discussion Top

The changing expectations of patients cause the development of new modalities for the management of congenitally missing teeth. However, ideal treatment is a controversial issue.[2],[4]

Congenital agenesis of MLI is commonly treated with three different options. In the first option, canine substitutes for the lateral incisor with the aid of orthodontic forces and is subjected to minimal anatomic recontouring within enamel tissue. In the second option, deficient zone is restored by using resin-bonded fixed partial dentures, which have contemporarily been full-ceramic tooth supported prostheses that partially cover the abutment tooth from lingual aspect. Even so, debonding is still one of the most common complications.[5] In the third option, a single implant is inserted into the deficient area where the implantation merits are ensured, and it is subsequently restored with fixed partial denture. However, deviation of adjacent teeth toward deficient area is frequently encountered complication in dental practice. Prior performing prosthetic solutions or implantation, it necessitates to conduct orthodontic treatment. Ideally, 7 mm of interproximal space is required for preserving peri-implant bone and inter-implant papilla while using a standard 4 mm diameter implant, and a buccopalatal dimension of 7 mm is required to obstruct buccal wall resorption. Otherwise, bone resorption may not be avoided, as occurred in the present case.[4] Moreover, the prognosis of adjacent teeth is better with the choice of single implant treatment.[6]

In implant cases where the gingiva is thin or transparent and in cases where full ceramic restorations should be used due to the aesthetic requirements; the use of ceramic abutments is recommended.[7] Supportively, Andersson et al.[8] reported 0.4-mm marginal bone loss in cases restored with titanium abutment and 0.2 mm loss in cases restored with ceramic abutment. Researchers investigating bacterial accumulation also showed that titanium surface was more susceptible to bacterial adhesion than zirconium surface.[9],[10]

Replacement of congenital tooth deficiency with the aid of implants is a very common treatment option. Care should be taken for the conduction of coordinated interdisciplinary treatment among the orthodontist, periodontist, oral surgeon, prosthodontist, and dental technician, with careful reputation of patient demands to achieve a successful consequence and to satisfy the patient. Sufficient inter-coronal and inter-radicular distance should be provided orthodontically between adjacent teeth. Once the space required for the implant has been provided orthodontically, the maintenance of the result (retention) takes on paramount importance.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

   References Top

Viera AR, Meira R, Modesto A, Murray JC. MSX9 and TGFA contribute to tooth agenesis in humans. J Dent Res 2004;83:723-27.  Back to cited text no. 1
Priest G. The treatment dilemma of missing maxillary lateral incisors- Part I: Canine substitution and resin-bonded fixed dental prostheses. J Esthet Restor Dent 2019;31:311-8.  Back to cited text no. 2
Caymaz MG, Uyanık LO. Comparison of the effect of advanced platelet-rich fibrin and leukocyte- and platelet-rich fibrin on outcomes after removal of impacted mandibular third molar: A randomized split-mouth study. Niger J Clin Pract 2019;22:546-52.  Back to cited text no. 3
[PUBMED]  [Full text]  
Priest G. The treatment dilemma of missing maxillary lateral incisors-Part II: Implant restoration. J Esthet Restor Dent 2019;31:319-26.  Back to cited text no. 4
Chen X, Zhang Y, Zhou J, Chen C, Zhu Z, Li L. Effect of different surface treatment and retainer designs on the retention of posterior Pd-Ag porcelain-fused-to-metal resin-boded fixed partial dentures. Exp Ther Med 2018;15:2006-14.  Back to cited text no. 5
Priest G. Single-tooth implants and their role in preserving remaining teeth: A 10-year survival study. Int J Oral Maxillofac Implants 1999;14:181-8.  Back to cited text no. 6
Eǧilmez F, Biçer Yıldırım ZA, Ergün G. Zirconia ceramics and their use in dental implantology. Cumhuriyet Dent J 2010;13:72-80.  Back to cited text no. 7
Andersson B, Scharer P, Simion M, Bergstrom C. Ceramic implant abutments used for short-span fixed partial dentures: A prospective 2- year multicenter study. Int J Prosthodont 1999;12:318-24.  Back to cited text no. 8
Scarano A, Piatelli M, Caputi S, Favero GA, Piatelli A. Bacterial adhesion on commercially pure titanium and zirconium oxide disks: An in vivo human study. J Periodontol 2004;75:292-6.  Back to cited text no. 9
Rimondini L, Cerroni L, Carrassi A, Torricelli P. Bacterial colonization of zirkonia ceramic surfaces: An in vitro and in vivo study. Int J Oral Maxillofac Implants 2002;17:793-8.  Back to cited text no. 10


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]


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