Case 96: Baby Tooth Dilemma

This 10-year-old girl presented at her initial exam with several congenitally missing permanent teeth. Her chief concern was “spaces between the teeth” and discolored permanent incisors. Her oral hygiene was excellent. Both the patient and her parents were concerned about the number of missing permanent teeth and were very receptive to a treatment plan that would address esthetics as well as function.

Medical History


Diagnostic Findings

TMJ/Mandibular Range of Motion/Muscles of Mastication and Facial Expression

  • TMJ: No pain, sounds within normal limits.
  • No deviation on opening.
  • Normal range of motion.
  • Muscles of mastication within normal limits.
Initial maximum intercuspation.

Intraoral Findings


  • No caries.
  • Congenitally missing teeth nos. 1, 4, 5, 6, 11, 16, 17, 20, 29, and 32.
  • Ankylosed primary teeth nos. K and T.
  • Discolored enamel on teeth nos. 7, 8, 9, and 10.
  • Undersized maxillary lateral incisors teeth nos. 7 and 10.


  • Soft tissue findings were within normal limits.
Initial right lateral view.
Initial left lateral view.
Initial maxillary occlusal view.
Initial mandibular occlusal view.


  • All retained primary teeth will eventually be lost.
  • Good for all other teeth.

Summary of Concerns

  • Will the patient be compliant for a long-term treatment plan of possibly ten years or more?
  • How do we address both the patient and parents’ esthetic concerns while building a functional occlusion?
  • What is the long-term prognosis for the retained primary teeth?
  • Which primary teeth will be extracted and which will be retained?
  • How do we restore the size discrepancies of teeth nos. 7 and 10 and address the discolored maxillary incisors?
  • Where and when will future implants be placed?
  • Do we have adequate bone volume for future implants?
  • How do we coordinate the orthodontic treatment with the restorative treatment during the patient’s growth and development?

Proposed Treatment Plan

Phase I: Diagnostic Work-up

  • Once orthodontic and oral surgery consultations have been completed a treatment plan will be developed and presented to the patient and her parents.

Phase II: Orthodontics

  • After extracting primary teeth nos. A, H, K, and T the patient will be treated as a bicuspid extraction case due to the large number of missing permanent premolars.
  • Primary teeth nos. I, J, L, and S will be lost naturally.
  • For final gingival symmetry and ease of treatment the decision was made to idealize and maintain the no. 11 space for future implant placement rather than move tooth no. 12 into the no. 11 position and then close the no. 12 space either with an implant or orthodontically.

Phase III: Preliminary Restorative Treatment

  • Transitional bonding to create normal widths and contours of teeth nos. 7 and 10 will be completed during orthodontic treatment to aid in correct spacing.

Phase IV: Final Restorative Treatment

  • Teeth nos. C, 7, 8, 9, and 10 will be restored with direct resin restorations or porcelain veneers depending on the patient’s esthetic demands at that time.
  • An implant will be placed and restored in the tooth no. 11 area.
  • In the future when teeth nos. B and C are lost, an implant will be placed in the tooth no. 5 area and a two-unit fixed bridge with cantilever pontic tooth no. 6 will be placed.
I/C=implant supported crown V=veneer

Active Clinical Treatment

Phase I: Diagnostic Work-up

After the patient had consulted with the oral surgeon and orthodontist, an interdisciplinary treatment plan was developed and accepted by the patient and her parents.

Phase II: Oral Surgery Treatment

Primary teeth nos. A, H, K, and T were extracted.

Phase III: Orthodontic Treatment

Orthodontic treatment was initiated to level and align the arches, close the teeth nos. A, K, and T extraction site spaces, and idealize and maintain the tooth no. 11 space for future implant placement.

Phase IV: Preliminary Restorative Treatment

During orthodontic treatment, transitional bonding was placed on teeth nos. 7 and 10 to help guide the orthodontic spacing.

Before bonding maxillary laterals.
After bonding maxillary laterals.
Post first ortho, midline off.
Warped and canted midline correction mock-up.

Phase V: Secondary Orthodontic Treatment

Upon completion of the initial orthodontic treatment the maxillary right spacing and the maxillary midline were not quite correct. One wax-up was made leaving the midline discrepancy in place and another wax-up was made simulating a corrected midline. At this time the patient was more than ready to ready to move on to the final restorative treatment. After demonstrating the difference between the “acceptable” but not ideal midline discrepancy and the ideal corrected discrepancy using intraoral “mock ups” made from the two wax-ups, the patient and her parents chose to start a second phase of orthodontic treatment. Retreatment was completed with Invisalign.

Post second ortho, midline corrected.

Phase VI: Oral Surgery Treatment

After orthodontic retreatment was completed retainers incorporating a temporary tooth no. 11 were created. Cone beam imaging of implant site no. 11 showed the need for bone grafting to fill out the width of the implant site. A mixture of Geistlich Bio-Oss and Zimmer Puros grafting material was placed utilizing Baxter Tisseel fibrin sealant and a Puros pericardium membrane and allowed to heal for four months. Upon re-evaluation the facial bone thickness was adequate but the lingual bone contour had an apical “crater.” A second bone graft on the lingual side was completed with Geistlich Bio-Oss and allowed to heal another five months. Once adequate bone contour was confirmed a Zimmer Eztetic implant was placed using a flapless technique, a healing abutment was placed flush to the tissue surface, and the patient continued to wear her retainer.

Phase VII: Restorative Treatment

Once the site no. 11 implant was integrated a diagnostic wax-up was completed for the final restorative phase and a new intraoral “mock up” was made and tried in for patient and parent approval. Preparation of the teeth was broken up into gross prep and fine prep appointments so that any minor adjustments could be achieved. At the gross prep appointment an impression for the zirconia implant abutment was obtained and laser soft tissue recontouring was completed on teeth nos. C, 7, and 12. Three weeks later the final veneer preparations on teeth nos. B, C, 7, 8, 9, 10, 12, and 13 were completed. The site no. 11 zirconia abutment was seated. Impressions, final shade photos, and models of the provisional restorations were obtained.

Four weeks later the final Ivoclar e-Max restorations for teeth nos. B, C, 7, 8, 9, 10, 12, and 13 were cemented with 3M RelyX Veneer Cement. The final Ivoclar e-Max restoration for implant site no. 11 was cemented with Premier Implant Cement.

The occlusion was finalized and a progressive group function was established on teeth nos. 3, B, and C.

Phase VIII: Maintenance

The patient received a maxillary nightguard/retainer with a shallow anterior guidance and is being seen on a regular six-month recall schedule. Patient is maintaining excellent oral hygiene, is using an OTC fluoride mouthwash, and is wearing her nightguard. Patient is also maintaining orthodontic and oral surgery recalls.

The occlusion and the retained primary teeth nos. B and C are being closely monitored at recall appointments and to this date show no signs of being lost.

Definitive Treatment

Definitive right lateral view.
Definitive left lateral view.
Definitive maxillary occlusal view.
Definitive mandibular occlusal view.


This case demonstrates restorative options for young patients with multiple congenitally missing permanent teeth. Retaining primary teeth as long as possible rather than extracting and replacing with implants at an early age is a viable treatment option and can be accomplished with proper interdisciplinary dentistry. The patient demonstrated exemplary compliance during the many years and phases of treatment. Even though the patient was ready to be finished after the first round of orthodontics both the patient and her parents agreed to go through the additional orthodontic treatment so we could achieve an optimal aesthetic end result.

There were many challenges during the treatment of this patient but at the end we accomplished all our goals. The patient and her parents were very pleased with the final result and understand that teeth nos. B and C will eventually fail and require implant placement. The end result could not have been accomplished without an extremely compliant and cooperative patient as well as the trust of her parents.

This case also demonstrates the importance of ongoing communication and cooperation between patient, parents and treating clinicians.

Definitive full face.

Dr Lena Fermback practices restorative dentistry in Warsaw, Indiana, and is a member of The Fort Study Club advisory board.

Dr Michael Stronczek practices oral and maxillofacial surgery in Fort Wayne, Indiana, and is the director of The Fort Study Club.

Dr Aron Dellinger practices orthodontics in Fort Wayne, Indiana, and is a member of The Fort Study Club advisory board.

Wayne Payne is a master ceramist and owner of Payne Dental Lab in San Clemente, California.