Treatment of missing lateral incisors

Abstract

Diagnosing and treating growing children who are missing lateral incisors continues to be a problem for many clinicians. A number of factors complicate treatment options. When the teeth are congenitally missing, permanent canines frequently erupt mesial to their normal positions. Even when this doesn't happen, the need to maintain alveolar bone for several years until growth has ceased presents another dilemma. Psychosocial pressures are also of concern for parents who want an early resolution of their child's esthetic problems. Zachrisson1Zachrisson B. Author's response.Am J Orthod Dentofacial Orthop. 2003; 124: 18A-19AAbstract Full Text Full Text PDF Google Scholar recognized this scenario and noted, “The young patient with a missing permanent incisor and a coexisting malocclusion must therefore be managed with an overall treatment plan in which esthetics and long-term dental health are given priority.” Possible solutions for missing lateral incisors include orthodontic space closure, resin-bonded bridgework, single-tooth implants, and autotransplantation of developing premolars. Each of these treatments can be technically challenging. Before making a decision, consider the existing skeletal pattern, the dental relationship, the tooth size-arch length discrepancy, the shape and color of the adjacent canines, and the level of cooperation expected. Several excellent studies focus on the replacement of missing incisors. One of these, published by Nordquist and McNeill in 1975,2Nordquist G.G. McNeill R.W. Orthodontic vs. restorative treatment of the congenitally absent lateral incisor—long-term periodontal and occlusal evaluation.J Periodontol. 1975; 46: 139-143Crossref PubMed Scopus (110) Google Scholar is considered a classic. Thirty-three orthodontic patients with at least 1 congenitally missing maxillary lateral incisor were examined an average of 9 years 8 months posttreatment. Maxillary quadrants were separated into groups, based on the presence or absence of the lateral incisors and whether the spaces were retained or closed. All subjects were examined for gingival index, irritant index, plaques index, periodontal pocket depth, and occlusal function. These findings have served clinicians for over 25 years: patients with maxillary lateral incisor spaces closed by substituting permanent canines were significantly healthier periodontally than patients with prosthetic lateral incisors; fixed partial dentures replacing maxillary laterals were more conducive to gingival and periodontal health than were removable partial dentures; and no differences existed in adequacy of occlusal function between groups with open lateral incisor spaces and those with closed spaces. The presence or absence of canine rise was not related to periodontal status. In a more recent study, Robertsson and Mohlin3Robertsson S. Mohlin B. The congenitally missing upper lateral incisor. A retrospective study of orthodontic space closure versus restorative treatment.Eur J Orthod. 2000; 22: 697-710Crossref PubMed Scopus (183) Google Scholar assessed 50 treated patients with agenesis of the maxillary lateral incisors. They had a mean age of 26 years and were examined 7.1 years posttreatment. The patients with space closure were more satisfied with the treatment results than those treated with prosthetic replacement of the missing teeth. There were no differences between groups regarding signs and symptoms of temporomandibular joint dysfunction, but those with prosthetic replacements had impaired periodontal health characterized by gingivitis and plaque. In summarizing these studies, it is clear that space closure produces results that are well accepted by patients, does not impair temporomandibular joint function, and encourages periodontal health when compared with the prosthetic replacement of the missing lateral incisors. Before concluding that there is nothing more to be learned on this topic, I have a few final questions. Is it possible that the level of restorative care by referring dentists and prosthodontists has improved dramatically since the 1950s and 1960s, when many patients in these studies were treated? Are the public's expectations regarding the esthetics of smiles any different now than they were 40 years ago? If the answer to either of these questions is yes, we need additional long-term studies. Early studies of canine substitution did not call for the evaluation of smile dynamics. Recent studies (in press) document increased awareness of the lay public to smile esthetics. I am interested in your comments regarding this diagnostic and treatment planning concern. Letters to the editor: Close space to treat missing lateral incisorsAmerican Journal of Orthodontics and Dentofacial OrthopedicsVol. 125Issue 5Preview Full-Text PDF Optimal therapy for missing lateral incisors?American Journal of Orthodontics and Dentofacial OrthopedicsVol. 126Issue 3PreviewWe would like to provide a counterpoint to the editorial concerning closing spaces for missing maxillary lateral incisors (Turpin DL. Treatment of missing lateral incisors. Am J Orthod Dentofacial Orthop 2004;125:129). Specifically, we question the contention that the optimal therapy in these cases is the mesial movement of the canine into the lateral site with fixed orthodontic devices. Although this is a viable treatment option, tooth morphology, facial esthetics, and occlusal relationship should first be evaluated. Full-Text PDF