Bull Tokyo Dent Coll (2018) 59(1): 43–51

Case Report doi:10.2209/tdcpublication.2017-0006

Dental Implant Treatment with Computer-assisted Surgery

for Bilateral Agenesis of Maxillary Lateral Incisors:
A Case Report

Hodaka Sasaki1), Tomoki Hirano1), Syuntaro Nomoto2), Yasushi Nishii3) and

Yasutomo Yajima1)
1)
Department of Oral and Maxillofacial Implantology, Tokyo Dental College,
2-9-18 Kanda-Misakicho, Chiyoda-ku, Tokyo 101-0061, Japan
2)
Department of Crown and Bridge Prosthodontics, Tokyo Dental College,
2-9-18 Kanda-Misakicho, Chiyoda-ku, Tokyo 101-0061, Japan
3)
Department of Orthodontics, Tokyo Dental College,
2-9-18 Kanda-Misakicho, Chiyoda-ku, Tokyo 101-0061, Japan

Received 21 March, 2017/Accepted for publication 4 April, 2017

Abstract
Here, we report a case of dental implant treatment involving computer-assisted sur-
gery for bilateral agenesis of the maxillary lateral incisors. The patient was a 39-year-old
woman with the chief complaint of functional and esthetic disturbance due to maxillary
and mandibular malocclusion. The treatment plan comprised non-extraction compre-
hensive orthodontic treatment and prosthodontic treatment for space due to the absence
of bilateral maxillary lateral incisors. A preliminary examination revealed that the mesio-
distal spaces left by the absent bilateral maxillary lateral incisors were too narrow for
implant placement (right, 5.49 mm; left, 5.51 mm). Additional orthodontic treatment
increased these spaces to approximately 6 mm, the minimum required for implant place-
ment if risk of damage to the adjacent teeth due to inaccuracies in directionality of drill-
ing is to be avoided. For dental implant treatment with computer-assisted surgery, preop-
erative planning/simulation was performed using Simplant® ver.12 software and a tooth-
supported surgical template fabricated using stereolithography. Two narrow-diameter
implants were placed in a two-stage procedure. It was confirmed that there was sufficient
distance between the implant fixtures and the roots of the adjacent teeth, together with
no exposure of alveolar bone. Following a 4-month non-loading period, second-stage
surgery and provisional restoration with a temporary screw-retained implant crown were
performed. Cement-retained superstructures made of customized zirconia abutment
and a zirconia-bonded ceramic crown were fitted as the final restoration. At 5 years after
implant surgery, there were no complications, including inflammation of the peri-implant
soft tissue and resorption of peri-implant bone. Computer-assisted implant surgery is
useful in avoiding complications in bilateral agenesis of the maxillary lateral incisors
when only a narrow mesiodistal space is available for implant placement.
Key words: Dental implant — Maxillary lateral incisor agenesis — 
Computer-assisted implant surgery — Narrow implant

43
44 Sasaki H et al.
Introduction
Missing teeth can result from acquired
causes such as trauma, caries, periodontal
disease, and other infections, or dental agen-
esis. Dental agenesis is responsible for between
2% and 10% of missing teeth7). In Japanese
people, the incidence of agenesis is highest
for the mandibular second premolar, fol-
lowed by the mandibular lateral incisors, the
maxillary second premolar, and the maxillary
lateral incisors5), and bilateral agenesis most
commonly affects the maxillary lateral inci-
sors17). Dental treatment aimed at rectifying
functional disorder and esthetic disturbance
due to agenesis of the maxillary lateral inci-
sors involves orthodontic and/or prosthetic
treatment, and will include a conventional
bridge, a removable partial denture, and a
dental implant10).
Dental implant treatment for missing inter-
mediate teeth is well established. Its advan-
tage is that it protects the remaining natural
teeth as it does not impair transmission of
occlusal force, unlike with conventional
prosthodontic treatment involving a bridge
and removable partial denture. In cases of
agenesis, however, it is not always possible to
ensure sufficient mesiodistal space for implant
placement, as the remaining adjacent teeth
may move and tilt into the edentulous area.
Furthermore, even if the mesiodistal space is
preserved by the presence of a deciduous
tooth, there may still be insufficient space for
implantation if there is agenesis of a maxillary
lateral incisor. This is because the width of the
crown of the maxillary lateral incisor in the
permanent dentition is only 7.07±0.43 mm,
making it the narrowest in the maxilla,
although still wider than that in the primary
dentition4,13). Earlier studies have noted that
an implant fixture should be 1.5 to 2.0 mm
away from adjacent teeth to avoid various
complications, including damage to the root
and peri-implant bone loss. Therefore, a
minimum mesiodistal space of 6  mm is
required to insert a narrow implant (diameter
3.0–3.5  mm) in a single-tooth edentulous
area8,9,11,16). This indicates that dental implant
treatment in cases of agenesis of the maxillary
lateral incisors is going to be problematic as it
carries a high risk of complications such as
damage to the root of the adjacent tooth due
to inaccuracies in the directionality of
drilling9,21).
Recently, the development of stereolitho-
graphic technology has allowed the faithful
reproduction of 3-dimensional virtual data.
This and the advent of computer-assisted
design and manufacturing (CAD/CAM)
technology have facilitated computer-assisted
implant surgery, which has improved the
accuracy of implant placement compared to
with conventional freehand insertion2,3).
Here, we report a case of bilateral agenesis of
the maxillary lateral incisors with insufficient
mesiodistal space for implant insertion. A
good outcome was achieved, with pre-implant
orthodontic treatment securing approxi-
mately 6 mm of mesiodistal space and com-
puter-assisted implant surgery allowing vari-
ous potential complications to be avoided.
Case
The patient was a 39-year-old woman who
presented at the Department of Orthodon-
tics, Tokyo Dental College Chiba Hospital in
September 2008 with the chief complaint of
functional and esthetic disturbance due to
maxillary and mandibular malocclusion. Her
systemic medical history contained nothing
of note. At the age of 7–8 years, she had
undergone deciduous lateral incisor extrac-
tion at a local dental clinic, but no prosthetic
treatment was performed. On her initial visit
to our hospital, spacing in the dentition of the
maxillary dental arch due to the absence of
bilateral maxillary incisors and crowding of
the lower incisors was noted. The molar rela-
tionship showed Class I on the left side and
Class I with a slight Class II tendency on the
right side (Fig. 1). The findings on a pan-
oramic radiograph were all normal, except
for agenesis of the maxillary lateral incisors
(Fig. 2). Lip protrusion was balanced, how-
ever, due to a normal E-line value. As her
 【版面】W：396 pt（片段　192 pt）　H：588 pt　【本文】行数不明（手組み） 　10pt　12pt 送り
【図】●図番号・タイトル・説明：11.3Q　12.7H　New Baskerville ITC Std　図タイトルと説明のアキ　9Q　●タイトル折り返し：番号の後（続
く説明の先頭は字下げ不要）　●図説の幅　片段：片段固定　全段：図幅　　
【表】●番号・タイトル・説明：11.3Q　12.7H　New Baskerville ITC Std　タイトルと表のアキ　10.5Q　●罫線　表はじめのみ双罫　表中の
罫の太さ　1.411mm ●表中：11.3Q　12.7H　New Baskerville ITC Std　●脚注　11.3Q　12.7H　New Baskerville ITC Std　 字下げなし　
斜体は New Baskerville ITC Std Italic（タグはImplant Placement-（for
<l>）　半角ダーシは Incisor Agenesis
ハイフン）に F50：tohaba の文字スタイルをかけて作成 45

396 pt（片段　192 pt）　H：588 pt　【本文】行数不明（手組み）　10pt　12pt 送り

号・タイトル・説明：11.3Q　12.7H　New Baskerville ITC Std　図タイトルと説明のアキ　9Q　●タイ
Fig.　1　Intraoral トル折り返し：番号の後
view at initial examination for orthodontic（続
treatment
頭は字下げ不要）　●図説の幅　片段：片段固定　全段：図幅　　
・タイトル・説明：11.3Q　12.7H　New Baskerville ITC Std　タイトルと表のアキ　10.5Q　●罫線　表はじめのみ双罫　表中の
.411mm ●表中：11.3Q　12.7H　New Baskerville ITC Std　●脚注　11.3Q　12.7H　New Baskerville ITC Std　 字下げなし　
Baskerville ITC Std Italic（タグは <l>）　半角ダーシは -（ハイフン）に F50：tohaba の文字スタイルをかけて作成

not decided on which option to go for at this

‌ anoramic radiograph at initial examination
Fig.　2　‌P
for orthodontic treatment
L1-Apo value was 5.5 mm, as opposed to a
normal value of 3 mm, slight flaring of the
lower incisors was revealed by a Rickett’s
analysis. Following a comprehensive clinical
and database analysis, a treatment plan was
developed. This comprised non-extraction;
lingual movement of the lower anterior teeth;
and an increase in the space left by the absent
bilateral maxillary lateral incisors by closure
of the median diastema and distal movement
of the bilateral canines. It was decided to cre-
ate sufficient space in the upper left lateral
incisors to allow for either a conventional
bridge or a dental implant, as the patient had
point. Orthodontic treatment was com-
menced at the Department of Orthodontics
in January 2009, during the course of which,
the patient decided on the dental implant
option. At this point, however, it was still not
clear as to whether this would be feasible, in
which case, a bridge would be the fallback
option. By October 2010, space had been
secured for placement of an implant by clo-
sure of the median diastema and distal move-
ment of the bilateral canines. At this point,
the patient visited the Department of Oral
and Maxillofacial Implantology for a prelimi-
nary examination. Cone-beam computed
tomography (CBCT) was used to measure the
buccolingual width and mesiodistal spaces in
the area of the missing maxillary lateral inci-
sors for assessment of implant placement.
The results of buccolingual width measure-
ment revealed that the right side was 6.05 mm
and the left side 6.28 mm. On the other hand,
mesiodistal space showed 5.49 mm on the
right side and 5.51 mm on the left side. Based
these results, it was decided that additional
orthodontic treatment would be required to
make these spaces sufficient for a dental
implant. Both these mesiodistal spaces were
【版面】W：396 pt（片段　192 pt）　H：588 pt　【本文】行数不明（手組み） 　10pt　12pt 送り
【図】●図番号・タイトル・説明：11.3Q　12.7H　New Baskerville ITC Std　図タイトルと説明のアキ　9Q　●タイトル折り返し：番号の後（続
く説明の先頭は字下げ不要）　●図説の幅　片段：片段固定　全段：図幅　　
【表】●番号・タイトル・説明：11.3Q　12.7H　New Baskerville ITC Std　タイトルと表のアキ　10.5Q　●罫線　表はじめのみ双罫　表中の
罫の太さ　1.411mm ●表中：11.3Q　12.7H　New Baskerville ITC Std　●脚注　11.3Q　12.7H　New Baskerville ITC Std　 字下げなし　
46 Sasaki-（H
斜体は New Baskerville ITC Std Italic（タグは <l>）　半角ダーシは et al.
ハイフン）に F50：tohaba の文字スタイルをかけて作成

Fig.　3　Intraoral view at baseline of implant treatment

less than 6  mm, which is the minimum
required for implant placement. Therefore,
on our suggestion, the patient agreed to
undergo additional orthodontic treatment to
increase these spaces. In April 2011, orth-
odontic treatment transitioned from tooth
movement to retention, and further examina-
tion was carried out aimed at dental implant
treatment (Fig. 3). The second round of
CBCT involved a scanning template compris-
ing radiopaque artificial teeth (Fig. 4a). The
results revealed that the bilateral buccolin-
gual and mesiodistal spaces were greater than
6 mm (Fig. 4b). For dental implant treatment
with computer-assisted surgery, dicom data
extracted from the CBCT data were imported
into the preoperative planning/simulation
software (Simplant® ver.12; Materialise Den-
tal, Leuven, Belgium) and the diameter,
length and positioning of the implant fixtures
investigated (Fig. 5). Based on these data, a
tooth-supported surgical template for com-
puter-assisted implant surgery (Universal-
Guide®; Materialise Dental) was fabricated
using stereolithography (Fig. 6a).
In July 2011, computer-assisted implant
placement surgery was performed in a two-
stage procedure. After application of local
anesthesia, a mucoperiosteal flap was opened
and the tooth-supported surgical template
mounted (Fig. 6b). Drilling for implant bed
preparation was performed according to the
manufacturer’s protocol. A 2-mm diameter
twist drill with a guide key inserted into the
master tube of the surgical template was used
to drill to a depth of 10 mm (Fig. 6c), and a
2.4/2.8-mm-diameter twist step drill was used
for the final drilling step in implant fixture
placement (Fig. 6d). The surgical template
was then removed and the bilateral implant
fixtures (NobelActive Internal NP; Nobel Bio-
care, Gothenburg, Sweden; diameter, 3.5 mm;
length, 10 mm) inserted into the created
implant beds using a torque wrench. The
depth of implant insertion was confirmed
under direct-viewing conditions (Fig. 6e). Pri-
mary stability was recognized at ≥35 N for
both implants. In the two-stage procedure, a
cover screw was fitted into both of the implant
fixtures and the mucoperiosteal flap sutured
to achieve wound closure (Fig. 6f). Figure 7
shows the CBCT images obtained after
implant surgery. These revealed that a suffi-
cient distance had been achieved between the
implant fixtures and the roots of the adjacent
teeth, and that there was no exposure of
【版面】W：396 pt（片段　192 pt）　H：588 pt　【本文】行数不明（手組み） 　10pt　12pt 送り
【図】●図番号・タイトル・説明：11.3Q　12.7H　New Baskerville ITC Std　図タイトルと説明のアキ　9Q　●タイトル折り返し：番号の後（続
く説明の先頭は字下げ不要）　●図説の幅　片段：片段固定　全段：図幅　　
【表】●番号・タイトル・説明：11.3Q　12.7H　New Baskerville ITC Std　タイトルと表のアキ　10.5Q　●罫線　表はじめのみ双罫　表中の
罫の太さ　1.411mm ●表中：11.3Q　12.7H　New Baskerville ITC Std　●脚注　11.3Q　12.7H　New Baskerville ITC Std　 字下げなし　
斜体は New Baskerville ITC Std Italic（タグはImplant Placement-（for
<l>）　半角ダーシは Incisor Agenesis
ハイフン）に F50：tohaba の文字スタイルをかけて作成 47

【版面】W：396 pt（片段　192 pt）　H：588 pt　【本文】行数不明（手組み） 　10pt　12pt 送り

【図】●図番号・タイトル・説明：11.3Q　12.7H　New Baskerville ITC Std　図タイトルと説明のアキ　9Q　●タイトル折り返し：番号の後（続
く説明の先頭は字下げ不要） 　●図説の幅　片段：片段固定　全段：図幅　　
Fig.　4　Scanning template (a) and CBCT photograph at baseline of implant treatment (b)
【表】●番号・タイトル・説明：11.3Q　12.7H　New Baskerville ITC Std　タイトルと表のアキ　10.5Q　●罫線　表はじめのみ双罫　表中の
罫の太さ　1.411mm ●表中：11.3Q　12.7H　New Baskerville ITC Std　●脚注　11.3Q　12.7H　New Baskerville ITC Std　 字下げなし　
斜体は New Baskerville ITC Std Italic（タグは <l>）　半角ダーシは -（ハイフン）に F50：tohaba の文字スタイルをかけて作成

Fig.　5　Preoperative planning using dental implant simulation software

alveolar bone. Following a 4-month non- screw-retained implant crown was performed
loading period, second-stage surgery and in November 2011.
provisional restoration with a temporary Giving priority to esthetic factors, cement-
 【版面】W：396 pt（片段　192 pt）　H：588 pt　【本文】行数不明（手組み） 　10pt　12pt 送り
【図】●図番号・タイトル・説明：11.3Q　12.7H　New Baskerville ITC Std　図タイトルと説明のアキ　9Q　●タイトル折り返し：番号の後（続
く説明の先頭は字下げ不要）　●図説の幅　片段：片段固定　全段：図幅　　
【表】●番号・タイトル・説明：11.3Q　12.7H　New Baskerville ITC Std　タイトルと表のアキ　10.5Q　●罫線　表はじめのみ双罫　表中の
罫の太さ　1.411mm ●表中：11.3Q　12.7H　New Baskerville ITC Std　●脚注　11.3Q　12.7H　New Baskerville ITC Std　 字下げなし　
48 Sasaki-（H
斜体は New Baskerville ITC Std Italic（タグは <l>）　半角ダーシは et al.
ハイフン）に F50：tohaba の文字スタイルをかけて作成

pt（片段　192 pt）　H：588 pt　【本文】行数不明（手組み）　10pt　12pt 送り

タイトル・説明：11.3Q　12.7H　New Baskerville ITC Std　図タイトルと説明のアキ　9Q　●タイトル折り返し：番号の後（続
字下げ不要）　●図説の幅　片段：片段固定　全段：図幅　　 Fig.　6　Implant surgery using tooth-supported surgical template
イトル・説明：11.3Q　12.7H　New Baskerville ITC Std　タイトルと表のアキ　10.5Q　●罫線　表はじめのみ双罫　表中の
mm ●表中：11.3Q　12.7H　New Baskerville ITC Std　●脚注　11.3Q　12.7H　New Baskerville ITC Std　 字下げなし　
kerville ITC Std Italic（タグは <l>）　半角ダーシは -（ハイフン）に F50：tohaba の文字スタイルをかけて作成

implant maintenance by professional care was

performed every 6 months after completion
of implant treatment. At 7 months after pros-
thetic treatment, in March 2013, the abut-
ment and superstructure of the maxillary left
lateral incisor implant were refabricated due
to partial fracture of the zirconia abutment
caused by crown loosing. At over 5 years after
implant surgery and 4 years after final restora-
tion (November 2016), progress was unevent-
ful, with no prosthetic complications, inflam-
mation of the peri-implant soft tissue, and/or
bone resorption (Figs. 8, 9).

Discussion

Computer-assisted surgery was performed

Fig.　7　CBCT photograph after implant placement
retained superstructures were selected for the
final restoration; customized zirconia abut-
ments (Nobel Procera Abutment; Nobel
Biocare) and zirconia-bonded ceramic crowns
were fitted with temporary cementation (HY-
BOND TEMPORARY CEMENT, Shofu Inc.,
Kyoto, Japan) in June 2012. Occlusal adjust-
ment of these superstructures was performed
with mutually protected occlusion. Dental
to avoid complications such as damage to the
roots of the adjacent teeth in a case where
insufficient space had been left for placement
of an implant by bilateral agenesis of the max-
illary lateral incisors. One meta-analysis has
shown that tooth agenesis in Caucasian
patients most commonly affects the mandibu-
lar second premolar (41.0%), followed by the
maxillary lateral incisors (22.9%), and the
maxillary second premolar (21.2%)15). Agen-
esis of the maxillary lateral incisor was
reported to have the fourth highest inci-
dence5) and bilateral agenesis to most com-
monly affect the Japanese17). The mean width
 【版面】W：396 pt（片段　192 pt）　H：588 pt　【本文】行数不明（手組み） 　10pt　12pt 送り
【図】●図番号・タイトル・説明：11.3Q　12.7H　New Baskerville ITC Std　図タイトルと説明のアキ　9Q　●タイトル折り返し：番号の後（続
く説明の先頭は字下げ不要）　●図説の幅　片段：片段固定　全段：図幅　　
【表】●番号・タイトル・説明：11.3Q　12.7H　New Baskerville ITC Std　タイトルと表のアキ　10.5Q　●罫線　表はじめのみ双罫　表中の
罫の太さ　1.411mm ●表中：11.3Q　12.7H　New Baskerville ITC Std　●脚注　11.3Q　12.7H　New Baskerville ITC Std　 字下げなし　
斜体は New Baskerville ITC Std Italic（タグはImplant Placement-（for
<l>）　半角ダーシは Incisor Agenesis
ハイフン）に F50：tohaba の文字スタイルをかけて作成 49

396 pt（片段　192 pt）　H：588 pt　【本文】行数不明（手組み）　10pt　12pt 送り

号・タイトル・説明：11.3Q　12.7H　New Baskerville ITC Std　図タイトルと説明のアキ　9Q　●タイトル折り返し：番号の後（続
頭は字下げ不要）　●図説の幅　片段：片段固定　全段：図幅　　 Fig.　8　Intraoral view at 5 years after implant surgery
・タイトル・説明：11.3Q　12.7H　New Baskerville ITC Std　タイトルと表のアキ　10.5Q　●罫線　表はじめのみ双罫　表中の
.411mm ●表中：11.3Q　12.7H　New Baskerville ITC Std　●脚注　11.3Q　12.7H　New Baskerville ITC Std　 字下げなし　
Baskerville ITC Std Italic（タグは <l>）　半角ダーシは -（ハイフン）に F50：tohaba の文字スタイルをかけて作成

by the presence of a deciduous tooth, it will be

‌ anoramic radiograph at 5 years after implant
Fig.　9　‌P
surgery
of the maxillary lateral incisor has been
reported to be 7.07±0.43 mm, and be small-
est in the maxilla13). Implant-tooth distance
should be greater than 1.5 mm to 2.0 mm to
avoid various complications, including peri-
implant bone loss and damage to the adjacent
tooth root. Therefore, a minimum mesiodis-
tal space of 6 mm is required for a single miss-
ing intermediary tooth, with the diameter of
the implant being 3.3–3.5  mm8,9,11,16). With
maxillary lateral incisor agenesis after decidu-
ous tooth loss, the mesiodistal space may be
insufficient for implant insertion if the adja-
cent teeth tilt into the edentulous area. More-
over, even if the mesiodistal space is preserved
too narrow for implant fixture insertion fol-
lowing tooth extraction, as the width of the
crown of the deciduous maxillary lateral inci-
sor is less than 6 mm (male, 5.50±0.43 mm;
female, 5.35±0.43 mm)6). For these reasons,
agenesis of the maxillary lateral incisors often
results in a deficiency in the mesiodistal space
for implant placement.
In the present case, there was a significant
bilateral deficiency in the mesiodistal space at
the initial examination, which was subse-
quently improved by orthodontic treatment.
The risk of damage to the adjacent tooth by
inaccuracy in the directionality of drilling
remained, however, as these spaces were still
only approximately 6.0 mm. Recently, com-
puter-assisted implant surgery employing a
surgical template fabricated based on planned
data using computerized patient CT data and
implant simulation software has been used to
increase the accuracy of implant positioning.
This has also been helped by the develop-
ment of stereolithographic technology, which
allows the faithful reproduction of 3-dimen-
sional virtual data, and computer-assisted
design and manufacturing (CAD/CAM)
technology2,3). Some studies reported that
50 Sasaki H et al.
deviation in the implant position between at
preoperative planning and postoperative
implant placement with computer-assisted
surgery was within approximately 1 mm, and
that of angle deviation approximately 5°1,3,19).
One in vitro study also revealed that implant
placement with a surgical template repro-
duced the planned position more accurately
than conventional freehand insertion14). In
addition, in another study, use of implant
positioning based on virtual planning data
and a surgical template in patients with Ken-
nedy Class II mandibular defects was more
accurate than conventional freehand implant
insertion in the anatomical cast of the same
patient. Deviation in actual implant place-
ment using a surgical template (implant
shoulder, 0.9 mm; implant apex, 0.6–0.9 mm)
was significantly smaller than that with con-
ventional free-hand placement (implant
shoulder, 2.4–3.5  mm; implant apex, 2.0–
2.5 mm)(p<0.01)12). Surgical templates can
be categorized into 3 types depending on
where they are placed: 1) tooth-supported; 2)
mucosa-supported; and 3) bone-supported.
One in vitro experiment comparing the accu-
racy of these 3 different types of surgical tem-
plate revealed no statistically significant
difference in angular deviation. On the other
hand, liner deviation at the implant neck and
apex with the tooth-supported surgical tem-
plate was the lower than that with the other 2
templates, and a significant difference was
observed between the tooth-supported and
mucosa-supported surgical templates (p<
0.05)18). These results suggest that computer-
assisted implant surgery using a tooth-sup-
ported surgical template is suitable in cases of
intermediary missing teeth with a narrow
mesiodistal space for implant placement.
However, implant placement with surgical
templates is associated with several complica-
tions, particularly a significant risk of over-
heating bone tissue during drilling with insuf-
ficient irrigation due to the mounting of the
surgical template20). This was avoided in the
present case by performing open flap implant
surgery and creating a window on the buccal
side of the surgical template to allow irriga-
tion with additional saline water.
Partial fracture of the zirconia abutment
occurred at 7 months after prosthetic treat-
ment. Possible reasons for this complication
are as follows: 1) use of zirconia as the abut-
ment material and the thinness and uneven-
ness of the material around the access hole;
and 2) exertion of abnormal occlusal force on
a loose superstructure due to temporary
cementation. To avoid this potential compli-
cation, we proposed some corrective strate-
gies, including the use of higher-strength
abutment material such as titanium and/
or a retaining superstructure by permanent
cement to prevent superstructure loosening.
The patient disagreed with these proposals,
however, as they would have incurred a nega-
tive esthetic effect due to the visibility of metal
color by gingival recession and the loss of
removability to enable retightening of the
abutment screw without destroying the super-
structure. Furthermore, the interval of rou-
tine maintenance was reduced to ensure
rapid detection of superstructure and/or
abutment screw loosening to prevent fracture
of the prosthesis. At 4 years after refitting the
superstructure, there were no complications,
including inflammation of the peri-implant
soft tissue, resorption of peri-implant bone,
and prosthetic problems such as abutment
and/or superstructure looseness.
In cases of bilateral agenesis of the maxil-
lary lateral incisors, the edentulous spaces will
be too narrow to place an implant, and there
is a high risk of damaging the adjacent tooth
root due to inaccuracies in the directionality
of drilling. Computer-assisted implant sur-
gery, which allows more accurate placement
of the implant body than the freehand
method, is useful in avoiding the complica-
tions associated with such cases.
Acknowledgements
We would like to sincerely thank Dr. Junya
Nagata and Dr. Satoshi Togo at the Depart-
ment of Orthodontics, Tokyo Dental College,
for their academic advice on this work.
 Implant Placement for Incisor Agenesis 51

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