Sequential Multidisciplinary Protocol for Dental Implant Rehabilitation in Ectodermal Dysplasia: A Clinical Case Report

Sequential Multidisciplinary Protocol for Dental Implant Rehabilitation in Ectodermal Dysplasia: A Clinical Case Report | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Sequential Multidisciplinary Protocol for Dental Implant Rehabilitation in Ectodermal Dysplasia: A Clinical Case Report Yihan Wang, Yanmin Zhou This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6739178/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 21 Apr, 2026 Read the published version in BMC Oral Health → Version 1 posted 14 You are reading this latest preprint version Abstract Background: Ectodermal dysplasia (ED) is a hereditary disorder affecting ectoderm-derived structures (teeth, skin, sweat glands), characterized by marked heterogeneity in oral manifestations, including congenital multiple tooth agenesis, abnormal residual tooth morphology, severe alveolar ridge atrophy, and sagittal discrepancy of the jaws. These complex anatomic-functional defects result in reduced masticatory efficiency, impaired speech clarity, and aesthetic concerns (e.g., midface collapse, insufficient lip/cheek support), further contributing to psychosocial maladjustment. Currently, multidisciplinary sequential intervention-through precise anatomical reconstruction and biomechanically optimized occlusal design-provides a reliable long-term therapeutic approach, demonstrating superior clinical outcomes compared to conventional prosthodontic solutions. Case presentation: Preoperative cone-beam computed tomography (CBCT) revealed multifocal dental agenesis at sites 12-16, 22-26, 34-35, 42, and 44-46, accompanied by alveolar bone dysplasia characterized by knife-edge ridges. Following interdisciplinary orthodontic preparation, implant placement was performed in the edentulous regions, succeeded by the delivery of an implant-supported fixed prosthesis. Postoperative radiographic evaluation demonstrated significant bone augmentation outcomes with optimal osseointegration and marginal bone resorption limited to <0.5mm. Conclusion: At the 12-month follow-up post-rehabilitation, significant improvements in oral function and psychosocial well-being were observed. All implants achieved 100% survival rate, with probing depth (PD)<3mm, bleeding on probing (BOP)<15%, and masticatory efficiency exceeding 90%. Aesthetic outcomes were rated as favorable based on the Pink Esthetic Score/White Esthetic Score criteria. The simultaneous hard and soft tissue augmentation protocol combined with implant-supported fixed rehabilitation proved to be an effective therapeutic strategy for congenital ectodermal dysplasia, achieving stable functional and aesthetic outcomes. This approach provides a reliable reference for managing similar cases with complex anatomical deficits. ectodermal dysplasia bone augmentation dental implants orthodontics case report Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Background Ectodermal dysplasia (ED) is a rare genetic syndrome (prevalence: ~1/100,000) caused by mutations in EDA (ectodysplasin A) and EDAR (ectodysplasin A receptor) genes, which disrupts signaling pathways (e.g., NF-κB) critical for ectodermal stem cell differentiation, leading to developmental failure of teeth, sweat glands, and hair follicles [ 1 , 2 , 3 ]. Dentally, most ED patients present with severe oligodontia/anodontia, accompanied by three-dimensional alveolar deficiency and sagittal jaw discrepancy. These anomalies result in loss of occlusal vertical dimension, midface hypoplasia, and psychosocial maladjustment [ 4 , 5 ]. Conventional prosthodontic approaches (e.g., removable partial dentures) frequently fail to address ED patients' functional and aesthetic demands due to poor biomechanical compatibility and low mucosal tolerance [ 6 ]. While contemporary implant rehabilitation-leveraging staged bone augmentation (guided bone regeneration, sinus floor elevation) and short implants achieves superior osseointegration rates [ 7 , 8 , 9 ], unpredictable post-grafting bone resorption remains a critical concern in ED management. This study summarizes an individual case that was managed through an interdisciplinary collaboration of prosthodontics, implantology and orthodontics. The aim of this study is to establish a theoretical framework for the function-aesthetic comprehensive treatment paradigm of ED patients by systematically describing the long-term clinical results of the prominent implant restoration treatment design with bone augmentation combined with reduction and extraction. Case presentation This case report presents a male patient with congenital ED. Chief complaint: multiple missing teeth in the dental arches, accompanied by masticatory difficulty during daily meals and compromised aesthetics. Dental history revealed that the patient underwent orthodontic treatment for the remaining teeth one year prior. Family history indicated no similar disease among first-degree relatives (including grandparents) or cousins. Clinical extraoral examination showed sparse, light-colored hair. Frontal view: symmetrical facial morphology, wide intercanthal distance, and normal lower facial third height. Temporomandibular joint evaluation: no tenderness or clicking was detected upon palpation, with unrestricted mouth opening. Lateral profile: no significant collapse of the upper lip, a right nasolabial angle, mandibular prognathism, and mildly deepened labiomental groove. Lip-tooth relationship: At rest position, the upper incisors were exposed 1mm below the upper lip. During a full smile, no gingival display was observed, with two-thirds of the teeth exposed, consistent with a medium smile line. Intraoral examination (using the FDI World Dental Federation notation system) revealed congenital absence of teeth 12–16, 22–26, 34–35, 42, and 44–46. The edentulous spaces exhibited adequate occlusal vertical dimension and normal mesiodistal distances. Oral hygiene status: good, with no calculus detected. The edentulous regions displayed insufficient keratinized mucosa, with low, sharp alveolar ridges, and oral mucosa unsuitable for heavy occlusal loading. Cone-beam computed tomography (CBCT) demonstrated hypoplastic maxillary and mandibular bones with knife-edged, flattened alveolar ridges and moderate-to-severe bone resorption. Clinical and imaging findings were consistent with the classic features of ectodermal dysplasia (Fig. 1). Upon the patient’s arrival, a CBCT scan revealed prior bilateral posterior alveolar bone augmentation and orthodontic treatment. Based on the patient’s age and clinical demands, a treatment plan combining staged bone augmentation with simultaneous implant placement followed by implant-supported fixed prostheses was selected. Preoperative laboratory tests confirmed surgical eligibility, and informed consent was obtained after comprehensive discussion of the protocol, alternatives, risks, and mitigation strategies. Preoperative preparations included centrifugation of whole blood at 3,000rpm for 10 minutes to prepare platelet-rich fibrin (PRF), followed by three rounds of 0.12% chlorhexidine mouth rinsing and sterile draping. For the maxillary arch, local anesthesia (articaine with 1:100,000 epinephrine) was administered, and a mid-crestal linear incision with full-thickness mucoperiosteal flap reflection was performed under continuous saline irrigation. Step-wise osteotomy at sites 12, 13, 22, and 23 allowed placement of Astra Tech TX implants (3.5mm x 11mm) with primary stability (> 35 Ncm torque), while sites 15, 16, 25, and 26 received 4.0mm x 11mm implants. Circumferential bone defects (buccal plate dehiscence, residual gap > 2mm) were grafted with PRF-mixed Bio-Oss which enhanced the osteoinducibility of the bone graft material and covered with a collagen membrane, followed by PRF membrane application and loose suturing. For the mandible, bilateral nerve blocks were administered, and linear incisions exposed the atrophic ridges. After ridge plasty, 3.5mm x 11mm implants were placed at sites 34, 35, and 44, while 4.0mm x 8mm short implants were inserted at 45 and 46. The initial stability of the implant is good. Screw in the sealing screw and suture the wound tightly (Fig. 2). Eight months postoperatively, CBCT confirmed osseointegration, and second-stage surgery involved mid-crestal incisions to replace cover screws with healing abutments based on mucosal thickness, followed by interrupted sutures (Fig. 3,4). One month after second-stage surgery, peri-implant soft tissue healing was evaluated, confirming stable seating of healing abutments. PFA reflects the stiffness of bone-implant interface by implant stability quotient (ISQ) value. The ISQ value was above 65, meeting prosthetic loading criteria. Open-tray implant-level impressions were captured for both maxillary and mandibular arches, and a wax rim was fabricated to determine the occlusal vertical dimension. Prior to definitive restoration, a provisional screw-retained prosthesis was trial-seated to verify complete passivity. Occlusal adjustments were performed to eliminate centric and lateral excursive interferences, followed by evaluation of prosthesis contours, gingival emergence profile, and smile line aesthetics. After 1 month of provisional function, definitive implant-level impressions were made using polyvinyl siloxane material. The provisional prosthesis was mounted on a semi-adjustable articulator via facebow transfer to accurately reproduce maxillomandibular relationships. Post-treatment evaluation demonstrated harmonious facial proportions with adequate lip support and balanced lower facial third height, meeting Ricketts’ aesthetic plane criteria. Temporomandibular joint examination revealed symmetrical movement, absence of clicking/tenderness, and improved speech intelligibility. Occlusal analysis confirmed stable bilateral balanced occlusion with uniform force distribution, smooth anterior guidance, and absence of working/non-working side interferences. No mucosal ulcerations habit was observed (Fig. 5). At the 12-month recall, the definitive prosthesis exhibited intact structural integrity with negligible peri-implant bone loss (Fig. 6). Discussion Guided by evidence-based principles, contemporary ED rehabilitation prioritizes multidisciplinary phased approach [ 10 ]. Preoperative orthodontic intervention optimizes three-dimensional implant axis alignment while preserving residual natural dentition, thereby minimizing unnecessary bone grafting through strategic space redistribution [ 11 ]. Staged grafting with delayed implantation protocols enhances peri-implant bone density and reduces marginal bone resorption in ED patients [ 12 ]. Prosthetic design adheres to biomechanical risk-aversion principles: reduced-diameter prostheses mitigate bone-implant interface stress peaks, ensuring occlusal force dispersion in hypometabolic bone environments [ 13 ]. In addition, the selection of treatment timing needs to comprehensively consider the development status of the jawbone and psychosocial needs. Before the operation, deterministic repair should be implemented after evaluating the bone growth potential to avoid abnormal position of the implant due to the displacement of jawbone development. A two-phase strategy is implemented: Transitional phase (12-16years): Restore basic chewing and speech functions through transitional dentures; Definitive phase (≥ 18years): Digitally guided occlusal schemes establish anterior guidance and bilateral load equilibrium via CAD/CAM prostheses. Postoperative management requires the establishment of a risk stratified follow-up system to maintain the health around the implant. From the perspective of molecular mechanism, the pathological core of ED is the abnormal developmental signaling pathway of ectoderm-derived tissues. EDA mutation interferes with the NF-κB signal transduction pathway, leading to the block of the differentiation of ectodermal stem cells into ameloblasts. Although gene editing technology has successfully repaired the phenotype of EDA mutant mice in animal models, the use of gene editing technology to achieve clinical transformation in the future still needs to break through the technical bottlenecks such as delivery vector efficiency and off-target effects [ 14 – 17 ]. Conclusion This study reports a successful case of functional reconstruction in an ED patient through simultaneous hard and soft tissue augmentation combined with implant-supported fixed prostheses. The clinical protocol, which included preservation of natural dentition through preliminary orthodontic treatment, prominent bone augmentation techniques during surgery, and "reduced-diameter and reduced-number" implant design combined with growth-adaptive prostheses, demonstrated biomechanical adaptability and long-term bone metabolic effects in craniofacial developing patients. This approach may become a mainstream therapeutic paradigm for such complex cases. Future multicenter, large-sample, long-term follow-up studies are still required for further validation. Future research could focus on developing ED-specific implant surface treatment technologies and explore the possibility of personalized interventions combined with gene therapy. Declarations Availability of data and materials All data analyzed during this study are included in this published article. Clinical trial number Not applicable Funding The author(s) declare financial support was received for the research, authorship, and/or publication of this article. This work was supported by National Natural Science Foundation of China: 82371006. Author information Authors and Affiliations Yihan Wang 1 Hospital of Stomatogy, Jilin University, Changchun, China Yanmin Zhou 1 Hospital of Stomatogy, Jilin University, Changchun, China Contributions YW: Conceptualization, Investigation, Project administration, Software, Writing—original draft, Writing—review & editing. YZ: Data curation, Funding acquisition, Investigation, Software, Writing—review & editing. Corresponding author Correspondence to Yanmin Zhou Ethics declarations This study has been reviewed and approved by the Medical Ethics Committee of Jilin University (IRB number: JDKQ2023), and strictly follows the relevant provisions of the Declaration of Helsinki and the Ethical Review Measures for Biomedical Research involving Human Subjects in China. Consent for publication Written informed consent was obtained from the patient for publication of this case report and any accompanying images. Competing interests The authors declare that they have no competing interests. References Gao YZ, Jiang XH, Wei Z, Long H, Lai WL. The EDA/EDAR/NF-κB pathway in non-syndromic tooth agenesis: A genetic perspective. Front Genet. 2023;14. Yamada A, Kawasaki M, Miake Y, Yamada Y, Blackburn J, Kawasaki K, Trakanant S, Nagai T, Nihara J, Kudo T, Meguro F, Schmidt-Ullrich R, Liu BG, Hu YL, Page A, Ramirez A, Sharpe PT, Maeda T, Takagi R, Ohazama A. Overactivation of the NF-κB pathway impairs molar enamel formation. Oral Dis. 2020;26(7):1513–22. Yavuz Y, Dogan MS, Goncharuk-Khomyn M. Ectodermal Dysplasia: A Review. Makara J Health Res. 2021;25(3):200–4. Cammarata-Scalisi F, Willoughby CE, El-Feghaly JR, Tadich AC, Castillo MA, Alkhatib S, Elsherif MA, El-Ghandour RK, Coletta R, Morabito A, Callea M. Main genetic entities associated with tooth agenesis. Clin Oral Investig. 2024;29(1). Dev A, Malhi K, Mahajan R. Ectodermal Dysplasia-An Overview and Update. Indian Dermatol Online J. 2024;15(3):405–14. Rios-López AI, Alcantara-Chavez D. Percepción de la calidad de vida y satisfacción en pacientes portadores de dentadura parcial removible: Revisión de Literatura Sistematizada X1 - Perception of quality of life and satisfaction in patients with removable partial denture. Systematized Literature Rev Odontología Vital. 2024;(40):42–51. Ali M, Noor S, Mohamad H, Ullah F, Javed F, Hamid ZAA. Advances in guided bone regeneration membranes: a comprehensive review of materials and techniques. Biomed Phys Eng Express. 2024;10(3). Gaspar J, Mazor Z, Bonfante EA. Osseodensification technique in crestal maxillary sinus elevation-A narrative review. Clin Implant Dent Relat Res. 2025;27(1). Muddebihal F, Veetil RGA, Feroz SMA, Saini RS, Khan SS, Preethanath RS, Babu JS, Swarnalatha C, Nayyar AS. Guided bone regeneration-assisted bone augmentation and early implant placement protocols: A case report. J Clin Sci. 2025;22(1):51–6. Appelbaum MB, Arvay JM. Phased-in comprehensive care: A concept and case report. J Am Dent Assoc. 1998;129(1):98–102. Taban M, Fatemi A, Soleimani M. Risk factors associated with implant sites prepared by orthodontic treatment: a systematic review. Eur J Transl Myol. 2023;33(4). Henn P, Gehrke P, Happe A, Neugebauer J. Retrospective Evaluation of Peri-implant Marginal Bone Level of Reduced-Diameter Implants by Mixed Model Analysis. Int J Oral Maxillofac Implants. 2025;40(2):188–96. Naguib GH, Hashem AH, Natto ZS, Abougazia AO, Mously HA, Hamed MT. The Effect of Implant Length and Diameter on Stress Distribution of Tooth-Implant and Implant Supported Fixed Prostheses: An In Vitro Finite Element Analysis Study. J Oral Implantol. 2023;49(1):46–54. Itin PH. Etiology and Pathogenesis of Ectodermal Dysplasias. Am J Med Genet A. 2014;164(10):2472–7. Kovalskaia VA, Cherevatova TB, Polyakov AV, Ryzhkova OP. Molecular basis and genetics of hypohidrotic ectodermal dysplasias. Vavilovskii Zhurnal Genet Sel. 2023;27(6):676–83. Puel A, Picard C, Ku CL, Smahi A, Casanova JL. Inherited disorders of NF-κB-mediated immunity in man. Curr Opin Immunol. 2004;16(1):34–41. Yu K, Huang CH, Wan FT, Jiang CL, Chen J, Liu XP, Wang F, Wu J, Lei M, Wu YQ. Structural insights into pathogenic mechanism of hypohidrotic ectodermal dysplasia caused by ectodysplasin A variants. Nat Commun. 2023;14(1). Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 21 Apr, 2026 Read the published version in BMC Oral Health → Version 1 posted Editorial decision: Revision requested 29 Jul, 2025 Reviews received at journal 17 Jul, 2025 Reviewers agreed at journal 17 Jul, 2025 Reviewers agreed at journal 11 Jul, 2025 Reviewers agreed at journal 11 Jul, 2025 Reviews received at journal 10 Jul, 2025 Reviewers agreed at journal 09 Jul, 2025 Reviewers agreed at journal 28 Jun, 2025 Reviews received at journal 27 Jun, 2025 Reviewers agreed at journal 19 Jun, 2025 Reviewers invited by journal 18 Jun, 2025 Editor assigned by journal 16 Jun, 2025 Submission checks completed at journal 16 Jun, 2025 First submitted to journal 24 May, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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A. clinical photographs of facial features; B. Intraoral views of the maxillary and mandibular arches; C. Radiographic image.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-6739178/v1/0a9124d78bd934f5a5409036.png"},{"id":85320145,"identity":"c1f4a31c-131f-47f5-8a3d-0d555851c381","added_by":"auto","created_at":"2025-06-24 15:11:29","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":3181106,"visible":true,"origin":"","legend":"\u003cp\u003eStage I Surgical Procedure.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-6739178/v1/b7b27f5b97d0a8169f0ae59f.png"},{"id":85320353,"identity":"18726946-39ae-4e67-9b7d-2eae1d356dc2","added_by":"auto","created_at":"2025-06-24 15:19:29","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":957452,"visible":true,"origin":"","legend":"\u003cp\u003ePostoperative Radiographic Evaluation.\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-6739178/v1/cb55c9b5167b527783a02358.png"},{"id":85320144,"identity":"6c131a83-1844-4f97-a99c-e45992bbc97a","added_by":"auto","created_at":"2025-06-24 15:11:29","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":2586251,"visible":true,"origin":"","legend":"\u003cp\u003eStage II Surgical Procedure.\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-6739178/v1/15cc068274c838cc3efde47c.png"},{"id":85320355,"identity":"b1f989e0-5880-4feb-9a5f-b866250a6a58","added_by":"auto","created_at":"2025-06-24 15:19:29","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":2166519,"visible":true,"origin":"","legend":"\u003cp\u003eProsthetic Try-in and Definitive Restoration Protocol.\u003c/p\u003e","description":"","filename":"5.png","url":"https://assets-eu.researchsquare.com/files/rs-6739178/v1/0817324a377598180f19aa77.png"},{"id":85320155,"identity":"6b16d63d-eb3f-4f6e-a89e-815e0d9938c8","added_by":"auto","created_at":"2025-06-24 15:11:29","extension":"png","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":675890,"visible":true,"origin":"","legend":"\u003cp\u003eOne-Year Postoperative Follow-Up: Clinical and Radiographic Documentation.\u003c/p\u003e","description":"","filename":"6.png","url":"https://assets-eu.researchsquare.com/files/rs-6739178/v1/8d0d6ac7246cf29a29db022a.png"},{"id":107929282,"identity":"b7ed9eee-34b0-4a18-90d8-4a262af7d8f4","added_by":"auto","created_at":"2026-04-27 16:14:35","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":9622212,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6739178/v1/d9b3b682-bf46-48fc-adb4-ddfd77e20f67.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Sequential Multidisciplinary Protocol for Dental Implant Rehabilitation in Ectodermal Dysplasia: A Clinical Case Report","fulltext":[{"header":"Background","content":"\u003cp\u003eEctodermal dysplasia (ED) is a rare genetic syndrome (prevalence: ~1/100,000) caused by mutations in EDA (ectodysplasin A) and EDAR (ectodysplasin A receptor) genes, which disrupts signaling pathways (e.g., NF-κB) critical for ectodermal stem cell differentiation, leading to developmental failure of teeth, sweat glands, and hair follicles [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Dentally, most ED patients present with severe oligodontia/anodontia, accompanied by three-dimensional alveolar deficiency and sagittal jaw discrepancy. These anomalies result in loss of occlusal vertical dimension, midface hypoplasia, and psychosocial maladjustment [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eConventional prosthodontic approaches (e.g., removable partial dentures) frequently fail to address ED patients' functional and aesthetic demands due to poor biomechanical compatibility and low mucosal tolerance [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. While contemporary implant rehabilitation-leveraging staged bone augmentation (guided bone regeneration, sinus floor elevation) and short implants achieves superior osseointegration rates [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e], unpredictable post-grafting bone resorption remains a critical concern in ED management.\u003c/p\u003e \u003cp\u003eThis study summarizes an individual case that was managed through an interdisciplinary collaboration of prosthodontics, implantology and orthodontics. The aim of this study is to establish a theoretical framework for the function-aesthetic comprehensive treatment paradigm of ED patients by systematically describing the long-term clinical results of the prominent implant restoration treatment design with bone augmentation combined with reduction and extraction.\u003c/p\u003e"},{"header":"Case presentation","content":"\u003cp\u003eThis case report presents a male patient with congenital ED. Chief complaint: multiple missing teeth in the dental arches, accompanied by masticatory difficulty during daily meals and compromised aesthetics. Dental history revealed that the patient underwent orthodontic treatment for the remaining teeth one year prior. Family history indicated no similar disease among first-degree relatives (including grandparents) or cousins.\u003c/p\u003e \u003cp\u003eClinical extraoral examination showed sparse, light-colored hair. Frontal view: symmetrical facial morphology, wide intercanthal distance, and normal lower facial third height. Temporomandibular joint evaluation: no tenderness or clicking was detected upon palpation, with unrestricted mouth opening. Lateral profile: no significant collapse of the upper lip, a right nasolabial angle, mandibular prognathism, and mildly deepened labiomental groove. Lip-tooth relationship: At rest position, the upper incisors were exposed 1mm below the upper lip. During a full smile, no gingival display was observed, with two-thirds of the teeth exposed, consistent with a medium smile line. Intraoral examination (using the FDI World Dental Federation notation system) revealed congenital absence of teeth 12\u0026ndash;16, 22\u0026ndash;26, 34\u0026ndash;35, 42, and 44\u0026ndash;46. The edentulous spaces exhibited adequate occlusal vertical dimension and normal mesiodistal distances. Oral hygiene status: good, with no calculus detected. The edentulous regions displayed insufficient keratinized mucosa, with low, sharp alveolar ridges, and oral mucosa unsuitable for heavy occlusal loading. Cone-beam computed tomography (CBCT) demonstrated hypoplastic maxillary and mandibular bones with knife-edged, flattened alveolar ridges and moderate-to-severe bone resorption. Clinical and imaging findings were consistent with the classic features of ectodermal dysplasia (Fig.\u0026nbsp;1).\u003c/p\u003e \u003cp\u003eUpon the patient\u0026rsquo;s arrival, a CBCT scan revealed prior bilateral posterior alveolar bone augmentation and orthodontic treatment. Based on the patient\u0026rsquo;s age and clinical demands, a treatment plan combining staged bone augmentation with simultaneous implant placement followed by implant-supported fixed prostheses was selected. Preoperative laboratory tests confirmed surgical eligibility, and informed consent was obtained after comprehensive discussion of the protocol, alternatives, risks, and mitigation strategies. Preoperative preparations included centrifugation of whole blood at 3,000rpm for 10 minutes to prepare platelet-rich fibrin (PRF), followed by three rounds of 0.12% chlorhexidine mouth rinsing and sterile draping. For the maxillary arch, local anesthesia (articaine with 1:100,000 epinephrine) was administered, and a mid-crestal linear incision with full-thickness mucoperiosteal flap reflection was performed under continuous saline irrigation. Step-wise osteotomy at sites 12, 13, 22, and 23 allowed placement of Astra Tech TX implants (3.5mm x 11mm) with primary stability (\u0026gt;\u0026thinsp;35 Ncm torque), while sites 15, 16, 25, and 26 received 4.0mm x 11mm implants. Circumferential bone defects (buccal plate dehiscence, residual gap\u0026thinsp;\u0026gt;\u0026thinsp;2mm) were grafted with PRF-mixed Bio-Oss which enhanced the osteoinducibility of the bone graft material and covered with a collagen membrane, followed by PRF membrane application and loose suturing. For the mandible, bilateral nerve blocks were administered, and linear incisions exposed the atrophic ridges. After ridge plasty, 3.5mm x 11mm implants were placed at sites 34, 35, and 44, while 4.0mm x 8mm short implants were inserted at 45 and 46. The initial stability of the implant is good. Screw in the sealing screw and suture the wound tightly (Fig.\u0026nbsp;2).\u003c/p\u003e \u003cp\u003eEight months postoperatively, CBCT confirmed osseointegration, and second-stage surgery involved mid-crestal incisions to replace cover screws with healing abutments based on mucosal thickness, followed by interrupted sutures (Fig.\u0026nbsp;3,4). One month after second-stage surgery, peri-implant soft tissue healing was evaluated, confirming stable seating of healing abutments. PFA reflects the stiffness of bone-implant interface by implant stability quotient (ISQ) value. The ISQ value was above 65, meeting prosthetic loading criteria. Open-tray implant-level impressions were captured for both maxillary and mandibular arches, and a wax rim was fabricated to determine the occlusal vertical dimension. Prior to definitive restoration, a provisional screw-retained prosthesis was trial-seated to verify complete passivity. Occlusal adjustments were performed to eliminate centric and lateral excursive interferences, followed by evaluation of prosthesis contours, gingival emergence profile, and smile line aesthetics. After 1 month of provisional function, definitive implant-level impressions were made using polyvinyl siloxane material. The provisional prosthesis was mounted on a semi-adjustable articulator via facebow transfer to accurately reproduce maxillomandibular relationships. Post-treatment evaluation demonstrated harmonious facial proportions with adequate lip support and balanced lower facial third height, meeting Ricketts\u0026rsquo; aesthetic plane criteria. Temporomandibular joint examination revealed symmetrical movement, absence of clicking/tenderness, and improved speech intelligibility. Occlusal analysis confirmed stable bilateral balanced occlusion with uniform force distribution, smooth anterior guidance, and absence of working/non-working side interferences. No mucosal ulcerations habit was observed (Fig.\u0026nbsp;5). At the 12-month recall, the definitive prosthesis exhibited intact structural integrity with negligible peri-implant bone loss (Fig.\u0026nbsp;6).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eGuided by evidence-based principles, contemporary ED rehabilitation prioritizes multidisciplinary phased approach [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Preoperative orthodontic intervention optimizes three-dimensional implant axis alignment while preserving residual natural dentition, thereby minimizing unnecessary bone grafting through strategic space redistribution [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Staged grafting with delayed implantation protocols enhances peri-implant bone density and reduces marginal bone resorption in ED patients [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Prosthetic design adheres to biomechanical risk-aversion principles: reduced-diameter prostheses mitigate bone-implant interface stress peaks, ensuring occlusal force dispersion in hypometabolic bone environments [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn addition, the selection of treatment timing needs to comprehensively consider the development status of the jawbone and psychosocial needs. Before the operation, deterministic repair should be implemented after evaluating the bone growth potential to avoid abnormal position of the implant due to the displacement of jawbone development. A two-phase strategy is implemented: Transitional phase (12-16years): Restore basic chewing and speech functions through transitional dentures; Definitive phase (\u0026ge;\u0026thinsp;18years): Digitally guided occlusal schemes establish anterior guidance and bilateral load equilibrium via CAD/CAM prostheses. Postoperative management requires the establishment of a risk stratified follow-up system to maintain the health around the implant.\u003c/p\u003e \u003cp\u003eFrom the perspective of molecular mechanism, the pathological core of ED is the abnormal developmental signaling pathway of ectoderm-derived tissues. EDA mutation interferes with the NF-κB signal transduction pathway, leading to the block of the differentiation of ectodermal stem cells into ameloblasts. Although gene editing technology has successfully repaired the phenotype of EDA mutant mice in animal models, the use of gene editing technology to achieve clinical transformation in the future still needs to break through the technical bottlenecks such as delivery vector efficiency and off-target effects [\u003cspan additionalcitationids=\"CR15 CR16\" citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study reports a successful case of functional reconstruction in an ED patient through simultaneous hard and soft tissue augmentation combined with implant-supported fixed prostheses. The clinical protocol, which included preservation of natural dentition through preliminary orthodontic treatment, prominent bone augmentation techniques during surgery, and \"reduced-diameter and reduced-number\" implant design combined with growth-adaptive prostheses, demonstrated biomechanical adaptability and long-term bone metabolic effects in craniofacial developing patients. This approach may become a mainstream therapeutic paradigm for such complex cases. Future multicenter, large-sample, long-term follow-up studies are still required for further validation. Future research could focus on developing ED-specific implant surface treatment technologies and explore the possibility of personalized interventions combined with gene therapy.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll data analyzed during this study are included in this published article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial number\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe author(s) declare financial support was received for the research, authorship, and/or publication of this article. This work was supported by National Natural Science Foundation of China: 82371006.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003einformation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAuthors and Affiliations\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eYihan Wang\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e1\u003c/sup\u003eHospital of Stomatogy, Jilin University, Changchun, China\u003c/p\u003e\n\u003cp\u003eYanmin Zhou\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e1\u003c/sup\u003eHospital of Stomatogy, Jilin University, Changchun, China\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eContributions\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eYW: Conceptualization, Investigation, Project administration, Software, Writing—original draft, Writing—review \u0026amp; editing.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eYZ: Data curation, Funding acquisition, Investigation, Software, Writing—review \u0026amp; editing.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eCorresponding author\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eCorrespondence to Yanmin Zhou\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics declarations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study has been reviewed and approved by the Medical Ethics Committee of Jilin University (IRB number: JDKQ2023), and strictly follows the relevant provisions of the Declaration of Helsinki and the Ethical Review Measures for Biomedical Research involving Human Subjects in China.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eConsent for publication\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eWritten informed consent was obtained from the patient for publication of this case report and any accompanying images.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eCompeting interests\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eGao YZ, Jiang XH, Wei Z, Long H, Lai WL. The EDA/EDAR/NF-κB pathway in non-syndromic tooth agenesis: A genetic perspective. Front Genet. 2023;14.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYamada A, Kawasaki M, Miake Y, Yamada Y, Blackburn J, Kawasaki K, Trakanant S, Nagai T, Nihara J, Kudo T, Meguro F, Schmidt-Ullrich R, Liu BG, Hu YL, Page A, Ramirez A, Sharpe PT, Maeda T, Takagi R, Ohazama A. Overactivation of the NF-κB pathway impairs molar enamel formation. Oral Dis. 2020;26(7):1513\u0026ndash;22.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYavuz Y, Dogan MS, Goncharuk-Khomyn M. Ectodermal Dysplasia: A Review. Makara J Health Res. 2021;25(3):200\u0026ndash;4.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCammarata-Scalisi F, Willoughby CE, El-Feghaly JR, Tadich AC, Castillo MA, Alkhatib S, Elsherif MA, El-Ghandour RK, Coletta R, Morabito A, Callea M. Main genetic entities associated with tooth agenesis. Clin Oral Investig. 2024;29(1).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDev A, Malhi K, Mahajan R. Ectodermal Dysplasia-An Overview and Update. Indian Dermatol Online J. 2024;15(3):405\u0026ndash;14.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRios-L\u0026oacute;pez AI, Alcantara-Chavez D. Percepci\u0026oacute;n de la calidad de vida y satisfacci\u0026oacute;n en pacientes portadores de dentadura parcial removible: Revisi\u0026oacute;n de Literatura Sistematizada X1 - Perception of quality of life and satisfaction in patients with removable partial denture. Systematized Literature Rev Odontolog\u0026iacute;a Vital. 2024;(40):42\u0026ndash;51.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAli M, Noor S, Mohamad H, Ullah F, Javed F, Hamid ZAA. Advances in guided bone regeneration membranes: a comprehensive review of materials and techniques. Biomed Phys Eng Express. 2024;10(3).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGaspar J, Mazor Z, Bonfante EA. Osseodensification technique in crestal maxillary sinus elevation-A narrative review. Clin Implant Dent Relat Res. 2025;27(1).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMuddebihal F, Veetil RGA, Feroz SMA, Saini RS, Khan SS, Preethanath RS, Babu JS, Swarnalatha C, Nayyar AS. Guided bone regeneration-assisted bone augmentation and early implant placement protocols: A case report. J Clin Sci. 2025;22(1):51\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAppelbaum MB, Arvay JM. Phased-in comprehensive care: A concept and case report. J Am Dent Assoc. 1998;129(1):98\u0026ndash;102.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTaban M, Fatemi A, Soleimani M. Risk factors associated with implant sites prepared by orthodontic treatment: a systematic review. Eur J Transl Myol. 2023;33(4).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHenn P, Gehrke P, Happe A, Neugebauer J. Retrospective Evaluation of Peri-implant Marginal Bone Level of Reduced-Diameter Implants by Mixed Model Analysis. Int J Oral Maxillofac Implants. 2025;40(2):188\u0026ndash;96.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNaguib GH, Hashem AH, Natto ZS, Abougazia AO, Mously HA, Hamed MT. The Effect of Implant Length and Diameter on Stress Distribution of Tooth-Implant and Implant Supported Fixed Prostheses: An In Vitro Finite Element Analysis Study. J Oral Implantol. 2023;49(1):46\u0026ndash;54.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eItin PH. Etiology and Pathogenesis of Ectodermal Dysplasias. Am J Med Genet A. 2014;164(10):2472\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKovalskaia VA, Cherevatova TB, Polyakov AV, Ryzhkova OP. Molecular basis and genetics of hypohidrotic ectodermal dysplasias. Vavilovskii Zhurnal Genet Sel. 2023;27(6):676\u0026ndash;83.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePuel A, Picard C, Ku CL, Smahi A, Casanova JL. Inherited disorders of NF-κB-mediated immunity in man. Curr Opin Immunol. 2004;16(1):34\u0026ndash;41.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYu K, Huang CH, Wan FT, Jiang CL, Chen J, Liu XP, Wang F, Wu J, Lei M, Wu YQ. Structural insights into pathogenic mechanism of hypohidrotic ectodermal dysplasia caused by ectodysplasin A variants. Nat Commun. 2023;14(1).\u003c/span\u003e\u003c/li\u003e \u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-oral-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ohea","sideBox":"Learn more about [BMC Oral Health](http://bmcoralhealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/ohea/default.aspx","title":"BMC Oral Health","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"ectodermal dysplasia, bone augmentation, dental implants, orthodontics, case report","lastPublishedDoi":"10.21203/rs.3.rs-6739178/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6739178/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground: \u003c/strong\u003eEctodermal dysplasia (ED) is a hereditary disorder affecting ectoderm-derived structures (teeth, skin, sweat glands), characterized by marked heterogeneity in oral manifestations, including congenital multiple tooth agenesis, abnormal residual tooth morphology, severe alveolar ridge atrophy, and sagittal discrepancy of the jaws. These complex anatomic-functional defects result in reduced masticatory efficiency, impaired speech clarity, and aesthetic concerns (e.g., midface collapse, insufficient lip/cheek support), further contributing to psychosocial maladjustment. Currently, multidisciplinary sequential intervention-through precise anatomical reconstruction and biomechanically optimized occlusal design-provides a reliable long-term therapeutic approach, demonstrating superior clinical outcomes compared to conventional prosthodontic solutions.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCase presentation: \u003c/strong\u003ePreoperative cone-beam computed tomography (CBCT) revealed multifocal dental agenesis at sites 12-16, 22-26, 34-35, 42, and 44-46, accompanied by alveolar bone dysplasia characterized by knife-edge ridges. Following interdisciplinary orthodontic preparation, implant placement was performed in the edentulous regions, succeeded by the delivery of an implant-supported fixed prosthesis. Postoperative radiographic evaluation demonstrated significant bone augmentation outcomes with optimal osseointegration and marginal bone resorption limited to \u0026lt;0.5mm.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion: \u003c/strong\u003eAt the 12-month follow-up post-rehabilitation, significant improvements in oral function and psychosocial well-being were observed. All implants achieved 100% survival rate, with probing depth (PD)\u0026lt;3mm, bleeding on probing (BOP)\u0026lt;15%, and masticatory efficiency exceeding 90%. Aesthetic outcomes were rated as favorable based on the Pink Esthetic Score/White Esthetic Score criteria. The simultaneous hard and soft tissue augmentation protocol combined with implant-supported fixed rehabilitation proved to be an effective therapeutic strategy for congenital ectodermal dysplasia, achieving stable functional and aesthetic outcomes. This approach provides a reliable reference for managing similar cases with complex anatomical deficits.\u003c/p\u003e","manuscriptTitle":"Sequential Multidisciplinary Protocol for Dental Implant Rehabilitation in Ectodermal Dysplasia: A Clinical Case Report","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-06-24 15:11:24","doi":"10.21203/rs.3.rs-6739178/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-07-29T11:00:09+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-17T19:49:59+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"91653498335378046099730909652747134394","date":"2025-07-17T05:25:46+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"73935099638470055811361069433236316134","date":"2025-07-11T08:27:10+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"117799918024379587227174409311646518409","date":"2025-07-11T07:30:04+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-11T03:39:17+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"336037045092023902107541079875911736181","date":"2025-07-09T05:32:32+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"190076917849329622610168585890357730281","date":"2025-06-28T12:56:30+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-06-27T15:28:21+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"290414970936211505654588856941742736108","date":"2025-06-19T10:37:14+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-06-18T10:33:55+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-06-16T05:36:10+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-06-16T05:35:09+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Oral Health","date":"2025-05-24T12:51:47+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-oral-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ohea","sideBox":"Learn more about [BMC Oral Health](http://bmcoralhealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/ohea/default.aspx","title":"BMC Oral Health","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"5edd3856-bea6-4398-a9ea-6d562000a92e","owner":[],"postedDate":"June 24th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-04-27T16:13:43+00:00","versionOfRecord":{"articleIdentity":"rs-6739178","link":"https://doi.org/10.1186/s12903-026-08326-2","journal":{"identity":"bmc-oral-health","isVorOnly":false,"title":"BMC Oral Health"},"publishedOn":"2026-04-21 16:00:06","publishedOnDateReadable":"April 21st, 2026"},"versionCreatedAt":"2025-06-24 15:11:24","video":"","vorDoi":"10.1186/s12903-026-08326-2","vorDoiUrl":"https://doi.org/10.1186/s12903-026-08326-2","workflowStages":[]},"version":"v1","identity":"rs-6739178","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6739178","identity":"rs-6739178","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}