Journal of Dental Health and Oral Research

Open Access Case Report

Pediatric Restorative Option for Congenitally Missing Anterior

Teeth: A Carolina Bridge Case Series
Puranik Chaitanya P1*, Yinger Sheaffer2, Ólafsson Vilhelm G3
1
Pediatric Dentistry, Children’s Hospital Colorado, School of Dental Medicine, University of Colorado,
Anschutz Medical Campus, Colorado, USA
2
Resident, Nationwide Children’s Hospital, Ohio, USA
3
Operative Dentistry and Cariology, Faculty of Odontology, University of Iceland, Iceland
*
Corresponding Author: Chaitanya Puranik P, BDS, MS, M. Dent. Sci., Ph.D., Director of Predoctoral
Education in Pediatric Dentistry, Children’s Hospital Colorado and School of Dental Medicine, University of
Colorado, Colorado, USA; Email: [email protected]

Received Date: 03-03-2022; Accepted Date: 24-03-2022; Published Date: 31-03-2022

Copyright© 2022 by Puranik CP, et al. All rights reserved. This is an open access article distributed under the
terms of the Creative Commons Attribution License, which permits unrestricted use, distribution and reproduction
in any medium, provided the original author and source are credited.

Abstract
Congenital absence of permanent maxillary lateral incisors can have a negative impact on
adolescent patients from a functional and psychological standpoint. Historically used treatment
options for hypodontia are invasive, warranting preparation of the abutment teeth and/or
comprehensive orthodontic treatment. Dental implants are a preferred modality without the
need for abutment preparation; however, are contraindicated until the completion of skeletal
growth. This case-series presents two case-reports of adolescent patients with congenitally
missing permanent maxillary lateral incisors restored using a novel resin-bonded bridge
(Carolina Bridge). The Carolina Bridge is a conservative, esthetic, cost-effective, reversible,
long-term, interim treatment option to replace missing teeth until implant-supported
restorations are indicated. The basics of the Carolina Bridge including indications,
contraindications, case selection criteria and clinical fabrication steps are presented in detail to
help clinicians with treatment planning and execution.

Puranik CP | Volume 3; Issue 1 (2022) | JDHOR-3(1)-044 | Case Report

Citation: Puranik CP, et al. Pediatric Restorative Option for Congenitally Missing Anterior Teeth: A
Carolina Bridge Case Series. J Dental Health Oral Res. 2022;3(1):1-10.

DOI: http://dx.doi.org/10.46889/JDHOR.2022.3107
 2

Keywords

Hypodontia, Carolina Bridge; Esthetic Restoration; Resin-Supported Bridge; Congenitally

Missing Teeth

Introduction

Congenital absence of teeth can be a significant restorative challenge in adolescent patients,

particularly when involving the anterior sextant. The permanent maxillary lateral incisors are
the most commonly missing anterior teeth, with a prevalence of 2.2% [1]. Congenital absence
of teeth affects form, function and esthetics during adolescence, when patients become aware
of self-image and esthetic social constructs [1,2]. These patients can experience bullying and
subsequent psychological distress, depression, anxiety and underachievement [2]. Dental-
specific implications such as tipping and supra-eruption of adjacent teeth also pose challenges
to future restorative management due to increased loading, wear and periodontal consequences
[3]. While generating a restorative treatment plan, multiple factors need to be considered
including the size, shape, position and integrity of adjacent teeth along with alveolar and
craniofacial bone growth.

Various restorative treatment options for hypodontia have been previously published and
advantages and disadvantages of each are presented in Table 1 [4]. A majority of these options
are considered invasive, involving preparation of adjacent teeth. Dental implants do not require
abutment tooth preparation and thus have been favored as a conservative treatment option.
Although dental implants are conservative, esthetic and functional, implant placement is
contraindicated in adolescent patients with incomplete skeletal growth [5-7]. Implants placed
before the completion of craniofacial growth can lead to future infra-occlusion and labial
position of the implant [8]. Hence, implant placement should be deferred until or even after the
completion of skeletal growth (females: 18-19 years, males: 20-21 years) [7].

In contrast with the existing treatment modalities, resin-bonded bridges, such as the Carolina
Bridge (CB) provide a conservative, esthetic, cost-effective, reversible and long-term interim
restorative option. This is especially beneficial when implants are planned after the completion
of growth. CBs are ridge-lap design porcelain-pontics bonded to adjacent teeth using composite
resin, with virtually no abutment teeth preparation. This paper provides two case-reports of
adolescent patients with hypodontia in the maxillary anterior sextant with long-term (two-year)
follow-up.

Puranik CP | Volume 3; Issue 1 (2022) | JDHOR-3(1)-044 | Case Report

Citation: Puranik CP, et al. Pediatric Restorative Option for Congenitally Missing Anterior Teeth: A
Carolina Bridge Case Series. J Dental Health Oral Res. 2022;3(1):1-10.

DOI: http://dx.doi.org/10.46889/JDHOR.2022.3107
 3

Treatment Advantages Disadvantages

Removable -Conservative option -Limited use in children and adolescents
Partial -Can replace multiple missing teeth due to continued jaw growth
Denture and soft tissue defects -Increased plaque retention
-Can act as a transitional prosthesis -Poor compliance
Conventional -Esthetic option -Potential loss of tooth vitality
Fixed Partial -Good option when abutments have -Irreversible, invasive treatment
Denture enamel defects or require restorations -Subgingival margins can lead to
or endodontic treatment periodontal complications
-Does not require bone or tissue -Active and passive eruption may
support expose restoration margins
Canine -Relatively esthetic option -Strict initial occlusal relationship
Substitution -Great in cases of maxillary criterion
prognathism or increased overjet -Canines differ in color, morphology
-No adverse impact on and emergence profile from other
temporomandibular joint incisors
-Early intervention possible -Extensive orthodontic treatment needs
-Group function occlusion after
treatment
Resin- -Relatively conservative option -Requires bondable enamel substrate
Bonded requiring minimal abutment tooth -Metal wings compromise esthetics
Metal- preparation -Frequent bond-failure with differential
Framework -Ease of repair and adjustment tooth movement
Bridges -Relatively inexpensive -Not indicated in presence of
parafunctional habits
Dental -Conservative option -Contraindicated until completion of
Implants -Highly esthetic option skeletal growth
-Functional and predictable outcomes -Requires adequate bone and soft tissue
Resin- -Most conservative option -Increased swallowing/aspiration risk
Bonded -Re-intervention is possible -For use in short edentulous spaces only
Bridge -Decreased fabrication time and costs -Requires bondable enamel substrate
-Ease of repair and adjustment -Not indicated in presence of
-Highly esthetic option parafunctional habits
-Requires optimum overjet and overbite
Table 1: Existing treatment modalities for hypodontia with advantages and disadvantages of
each modality.

Puranik CP | Volume 3; Issue 1 (2022) | JDHOR-3(1)-044 | Case Report

Citation: Puranik CP, et al. Pediatric Restorative Option for Congenitally Missing Anterior Teeth: A
Carolina Bridge Case Series. J Dental Health Oral Res. 2022;3(1):1-10.

DOI: http://dx.doi.org/10.46889/JDHOR.2022.3107
 4

Case Report

The details of each case are presented in Table 2. In both cases, the patient and legal guardian
were presented with various restorative treatment options including associated risks and
benefits. Due to incomplete skeletal growth, implant placement was recommended as a future
restorative option. The patients and families in both cases declined other options and opted for
replacement of their missing tooth/teeth with a resin-supported CB as a long-term interim
restoration until the completion of skeletal growth. Informed consent was obtained followed
by preparation-fabrication of CBs. After CB placement, each case was followed at 1, 3, 6, 12
and 24 months. The parents provided permission for use of de-identified intra-oral. Indications,
contraindications, case selection criteria and clinical steps for the CB are presented in Table 3.

Case 1 An 11-year-old healthy Caucasian male presented for orthodontic treatment.

Upon a clinical and radiographic examination, he was diagnosed with
congenitally missing teeth FDI #s 12 and 22. After radiographic and clinical
records were obtained, a treatment plan was generated establishing ideal class I
relationship and open spaces for #12 and #22. After completion of orthodontic
treatment in 2015 at age 16, the patient was referred for restorative treatment.
The patient and family provided informed consent for fabrication of the
Carolina Bridge, with future plans of implant placement after completed skeletal
growth. The patient had dental fluorosis and hence, nightguard vital bleaching
was undertaken for three weeks initially. The remaining dark and white
discolorations were conservatively removed using a round diamond bur and
copious water spray. The teeth were then restored with composite resin under
rubber dam isolation. Finishing and polishing was carried out, creating age-
appropriate form, texture and polish. Carolina Bridges were then fabricated and
bonded to the adjacent teeth
Case 2 A 14-year-old healthy Caucasian male presented for restorative treatment for
congenitally missing FDI #12. Space between FDI #13 and #11 was regained
orthodontically six months before fabrication of the Carolina Bridge.
Table 2: Detailed description of the two Carolina Bridge cases.

Puranik CP | Volume 3; Issue 1 (2022) | JDHOR-3(1)-044 | Case Report

Citation: Puranik CP, et al. Pediatric Restorative Option for Congenitally Missing Anterior Teeth: A
Carolina Bridge Case Series. J Dental Health Oral Res. 2022;3(1):1-10.

DOI: http://dx.doi.org/10.46889/JDHOR.2022.3107
 5

Advantages Reversible, esthetic, cost-effective, conservative (no abutment tooth

preparation), easy to repair, and able to act as a long-term interim prosthesis
Disadvantages Need for excellent laboratory/bonding protocol, staining of composite resin
connectors (if not finished and polished), possible risk of aspiration in cases of
bond-failure (unilateral failure more common, protecting against aspiration),
requires sufficient (~5 mm inciso-gingival) interproximal bondable enamel
substrate, and potential for failure in patients with parafunctional habits
Ideal Conditions Optimal overjet and overbite (1-2 mm), >5 mm inciso-gingival sound enamel
on proximal surfaces of periodontally stable abutment teeth, and single-tooth
edentulous span
Indications Long-term interim prosthesis for missing incisors in young patients (implant
treatment planned after completion of skeletal growth) or permanent prosthesis
when other treatments are neither practical nor affordable
Contraindications Short abutment teeth, deep bite, severe enamel defects, proximal restorations or
caries in abutment teeth, large diastemas, evidence of parafunction, or
periodontally compromised abutment teeth
Detailed Clinical Steps Involved in Fabrication of the Carolina Bridge
1st Appointment -Evaluation of case selection criteria and consultation with periodontists,
(Duration: 45-60 orthodontists, and endodontists (if required) and informed consent
minutes) -Shade selection prior to dehydration of teeth
-Clinical photographs with/without shade guide in normal day light and black
background along with black-and-white photographs
-Clinical photographs to show arch form and emergence profile
-Elastomeric impression of both arches and bite registration
-Laboratory prescription for a Feldspathic porcelain pontic with ridge-lap
design
Laboratory steps -Laboratory fabrication of Feldspathic porcelain pontic (variable lab price range
$400-$800) with ridge-lap design and creation of putty index (lingual matrix)
-Etching of the entire proxiomal surfaces (between facial and lingual line
angles) of the pontic with hydrofluoric acid*
nd
2 Appointment -Isolation of arch segment with rubber dam and pharyngeal curtian for safety
(Duration: 45-60 -Try-in to evaluate proximal/incisal fit, arch form, emergence profile and
minutes) esthetics
-Cleaning of the pontic with phosphoric acid to remove glassy residue
-Silanating the etched proximal surfaces (between facial and lingual line
angles)*
-Adhesive application on pontic, air-thinning and light-curing*
-Cleansing of abutment teeth with pumice

Puranik CP | Volume 3; Issue 1 (2022) | JDHOR-3(1)-044 | Case Report

Citation: Puranik CP, et al. Pediatric Restorative Option for Congenitally Missing Anterior Teeth: A
Carolina Bridge Case Series. J Dental Health Oral Res. 2022;3(1):1-10.

DOI: http://dx.doi.org/10.46889/JDHOR.2022.3107
 6

-Roughening of abutment teeth using a diamond bur at low speed to remove the
outermost fluoride-rich layer (impervious to etching)
-Etching of the entire proxiomal surfaces (past facial and lingual line angles) of
abutment teeth*
-Pre-warmed hybrid composite (with higher filler content) application to the
pontic
-Placement of pontic with the aid of a putty index (lingual matrix, supplied by
the laboratory)
-Shaping of the connectors and defining the facial embrasures for esthetics.
Bulking-up lingual embrassures (without occlusal interference) for strength and
retention
-Creation of adequate gingival embrasure contours for hygiene
-Addition of composite in any deficient areas, if needed
-Light-curing from both lingual and buccal aspects*
-Finishing and polishing to define final shape and occlusal adjustment for
minimal centric and functional contacts
*According to the manufacturer’s instructions
Table 3: Basics of the Carolina Bridge, indications, contraindications, case selection criteria
and clinical steps involved in fabrication.

Discussion

Case selection criteria and clinical steps for restoring teeth with CBs were discussed by
Heymann in 2006 [9]. The pontic is fabricated with Feldspathic porcelain, providing
advantages of esthetics, color stability, strength and the ability to etch the proximal surfaces
for retention. CB use in adolescent patients is especially indicated since it requires virtually no
abutment preparation; deeming it reversible and reducing the risk of dental pulp exposure in
immature teeth. Additionally, CBs are associated with less periodontal complications due to
the ridge-lap pontic design and margin placement [10].
Retention in CBs is entirely dependent on the proximal resin connectors, necessitating
appropriate case selection [9]. Optimal occlusion, periodontal health and adequate
interproximal surface bonding are imperative for success of the restoration. The most favorable
occlusion demonstrates optimum (2 mm) overjet and overbite [9]. Interproximal abutment
height of >5 mm inciso-gingivally in sound enamel is desirable for adequate bonding [9].
Patients with previously restored abutments, severe enamel defects, deep bite and/or evidence
of bruxism or parafunction are not ideal candidates for CBs (Table 3). Missing canines or
posterior teeth are also contraindications for CB treatment [5,9]. All anterior teeth need to be
fully erupted prior to fabrication.

Puranik CP | Volume 3; Issue 1 (2022) | JDHOR-3(1)-044 | Case Report

Citation: Puranik CP, et al. Pediatric Restorative Option for Congenitally Missing Anterior Teeth: A
Carolina Bridge Case Series. J Dental Health Oral Res. 2022;3(1):1-10.

DOI: http://dx.doi.org/10.46889/JDHOR.2022.3107
 7

Inappropriate case selection can lead to bond-failure due to differential tooth movement and
low flexural strength of the ceramic [5]. The cantilever design (bonding on one proximal side
of the pontic) has demonstrated higher retentive success when compared to allownce of fixed-
fixed designs (bonding on both proximal sides of the pontic) [11]. This is attributed to
differential tooth movement with unilateral bonding [6,10]. However, bond-failure in a
cantilever design leads to immediate prosthesis failure, revealing the edentulous area,
compromising esthetics and posing a risk of swallowing or aspiration of the pontic [6]. Bond-
failure of one proximal area in a fixed-fixed design could be attributed to the differential tooth
movement. Additionally, such bond-failure could be seen in the immediate post-operative
period [6]. However, bond-failure of one proximal area in fixed-fixed design could be
esthetically inconsequential and reduce aspiration risk, but potentially predisposes the patient
to secondary caries [6]. Fortunately, even in cases of bond-failures, the abutment teeth are not
compromised and repair is easily achievable using a similar adhesive protocol as shown in
Table 3 [9,10]. In both our cases, CBs were fabricated with fixed-fixed design. In our second
case, bond failure was noted between pontic and canine in the one month post-operative period.
The debonded area was repaired and no bond failure was noted thereafter, throughout the two
year follow-up period.
There are no Randomized Clinical Control Trials (RCTs) demonstrating the relative success
rates of all plausible restorative options for treatment of hypodontia in the anterior sextant.
Until a time when RCTs can provide enough evidence, longevity can only be considered
anecdotally, as presented in this case-series (Fig. 1-4). Absolute adherence to case selection
criteria is integral in increasing the chances of CB success. Furthermore, it is critical to provide
anticipatory guidance to the patients and families regarding dietary instructions such as
avoiding chewing hard candies with incisors and recommending use of mouthguard during
contact sports. It is pertinent to provide anticipatory guidance regarding bond failure in the
immediate post-operative period and prompt reporting to the dentist for repair of the CB to
avoid secondary caries, space loss, complete debonding, or aspiration.

Figure 1: Pre-operative right lateral (A), centric (B), and left lateral (C) photographs from
Case #1 demonstrating congenitally missing FDI #12 and #22. Maxillary incisors after
bleaching (D), micro-abrasion (E) and restoration with direct partial resin composite veneer
(F).
Puranik CP | Volume 3; Issue 1 (2022) | JDHOR-3(1)-044 | Case Report

Citation: Puranik CP, et al. Pediatric Restorative Option for Congenitally Missing Anterior Teeth: A
Carolina Bridge Case Series. J Dental Health Oral Res. 2022;3(1):1-10.

DOI: http://dx.doi.org/10.46889/JDHOR.2022.3107
 8

Figure 2: Intra-operative photographs from Case #1 demonstrating shade selection with

natural light (A), black-and-white (B) and dental lamp (C). Clinical photographs of
Feldspathic porcelain pontics after fabrication from facial (D and E) and lingual (F) aspects.

Puranik CP | Volume 3; Issue 1 (2022) | JDHOR-3(1)-044 | Case Report

Citation: Puranik CP, et al. Pediatric Restorative Option for Congenitally Missing Anterior Teeth: A
Carolina Bridge Case Series. J Dental Health Oral Res. 2022;3(1):1-10.

DOI: http://dx.doi.org/10.46889/JDHOR.2022.3107
 9

Figure 3: Case #1 photographs showing rubber dam isolation of maxillary anterior sextant
and try-in of pontics with putty index (lingual matrix) (A). Immediate post-operative
photograph after cementation of pontics (B). Pre- (C) and post-operative (D) photographs
after 6 months.

Figure 4: Pre- and post-operative photographs in Case #2 showing the Carolina Bridge for
replacement of missing FDI #12.

Conclusion
The CB provides an esthetic, conservative, reversible, cost-effective and long-term interim
restorative option. The CB is ideal for adolescent patients with congenitally missing anterior
teeth and incomplete skeletal growth, while awaiting future implant-supported restorations.

Puranik CP | Volume 3; Issue 1 (2022) | JDHOR-3(1)-044 | Case Report

Citation: Puranik CP, et al. Pediatric Restorative Option for Congenitally Missing Anterior Teeth: A
Carolina Bridge Case Series. J Dental Health Oral Res. 2022;3(1):1-10.

DOI: http://dx.doi.org/10.46889/JDHOR.2022.3107
 10

Conflict of Interest

There are no conflicts of interest.

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Puranik CP | Volume 3; Issue 1 (2022) | JDHOR-3(1)-044 | Case Report

Citation: Puranik CP, et al. Pediatric Restorative Option for Congenitally Missing Anterior Teeth: A
Carolina Bridge Case Series. J Dental Health Oral Res. 2022;3(1):1-10.

DOI: http://dx.doi.org/10.46889/JDHOR.2022.3107