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Treatment considerations for the

congenitally missing maxillary
lateral incisor
May 5, 2015

ByJames Schmidt, DDS, MS

This article first appeared in the newsletter, DE's Breakthrough Clinical with Stacey
Simmons, DDS

. Subscribe here.

Introduction
In the practice of dentistry, one of the more common dental anomalies we
encounter is hypodontia. By definition, hypodontia refers to a condition in which a
person is missing one to six teeth. Excluding wisdom teeth, hypodontia reportedly
affects between 3% and 8% of the population. (1) The long-term management of
hypodontia in the esthetic zone is a particularly challenging situation; therefore, in
this article we will limit the scope of discussion to the congenitally missing maxillary
lateral incisors.

ADDITIONAL READING | Ankylosed primary teeth with no permanent

successors: What do you do? -- Part 1
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premolars. (1) The patient with congenitally missing maxillary lateral incisors will
typically present with a complex set of challenges for the clinician to manage. In
order to achieve an optimal esthetic and functional result, it is often necessary to
establish a coordinated, interdisciplinary approach involving an orthodontist, oral
surgeon or periodontist, and a restorative dentist. Careful diagnosis and
communication among team members is necessary to formulate a treatment plan
that satisfies the patient’s needs and expectations. Some of the many factors that
the team must consider in their treatment planning include the patient’s age, facial
type and profile, occlusal scheme, spacing, tooth anatomy and condition (shape,
color, and size), alveolar bone quality and quantity, gingival display, and biotype.
(2-5) In the end, the ideal treatment plan should be predictable, stable, and the least-
invasive option available. The scope of this article is not to recommend one specific
treatment modality, but rather to identify a few of the clinical considerations that
might influence the case management and restorative plan.

Site development

The first step to the successful, long-term management of a congenitally missing

lateral incisor case is early detection and referral to the orthodontist. The role of the
orthodontist in the early mixed-dentition stage of development is to monitor and
guide the eruption of the permanent canine. If the crown of the permanent canine is
erupting apical to the primary canine root as it normally does, it may be necessary to
selectively extract the primary lateral incisor to encourage the permanent canine to
erupt adjacent to the central incisor. The reason for this is twofold. A mesially
positioned canine not only provides a natural means for augmenting the supporting
tissues, but it also allows for greater flexibility in future treatment planning.

ADDITIONAL READING | Impacted canines and orthodontic treatment

An absence of a permanent lateral incisor will result in restricted growth of the

alveolar ridge in the buccolingual dimension, since the only source of development
will be from the narrow root of the deciduous lateral incisor. On the other hand, if
the orthodontist can manipulate the much larger permanent canine to erupt
mesially through the alveolar ridge, its larger root will naturally develop a much
thicker buccolingual dimension to the alveolar ridge. Once the canine has erupted,
the orthodontist then has the option to distalize the canine into its natural position,
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four years) and may eliminate the need for an additional surgical procedure for
alveolar augmentation in the future. (3) This stability is particularly beneficial for
implant treatment since fixture placement cannot occur until facial growth is
complete. Regardless of whether the definitive restoration is to be an implant or a
fixed partial denture or even a removable prosthesis, the esthetics will be vastly
improved by this augmentation.

To open or to close
As orthodontists, we
are often confronted
with the decision to
open or close spaces.
In the case
management of
congenitally missing
lateral incisors, this
Figure 1: The canine was guided into the lateral position for purposes
becomes particularly of site development and was later distalized with the aid of orthodontics.
complex decision The ridge was significantly augmented but the patient will still likely need
since the result of additional grafting at the time of implant placement.
that decision will (Photos courtesy of Dr. Kevin Race)

ultimately divide our

treatment options into one of two categories. One option is to open space for the
prosthetic replacement of the missing lateral incisor. The other option is to
completely close the space and set up the occlusion for canine substitution.
Selecting the appropriate treatment approach is not as simple as it sounds, but
rather depends on the patient’s existing malocclusion, growth pattern, profile, smile
line, and the size, shape, and color of the canines. Hypodontia is a life-long problem,
thus it is important to consider treatment options that are functional, conservative,
flexible, and repairable. Opening space allows for multiple prosthetic options to
choose from and switch between over the course of one’s life. Closing the space
does not offer you quite as much restorative flexibility but it does have numerous
other advantages. The substitution of the cuspid for the lateral incisor allows for the
early rehabilitation of the patient with conservative reshaping and minimally invasive
restorations (e.g., bonding or veneers). This treatment approach eliminates many of
the complications that are associated with prosthetic rehabilitation, such as
excessive reduction of tooth structure, gingival inflammation, surgical morbidity,
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natural state, making it better suited to respond to the changes over time. (8)

Facial development and continuous tooth eruption

The human dentition and supporting structures must be viewed as dynamic entities,
which change in response to age, orthodontic relapse, facial growth, dental eruption,
tooth wear, and recession throughout life. Unlike canine substitution, or other tooth-
supported prosthetic treatment, implant-supported restorations lack the ability to
adapt to the changes. The absence of a periodontal ligament causes the implant to
act like an ankylosed tooth, hence requiring that implant placement be delayed until
growth cessation has been confirmed by the superimposition of serial cephalometric
radiographs taken six months to one year apart. (9,10) Typically male and female
patients, with normal growth patterns, are ready for implant placement by the age
of 21 and 17, respectively. (11) However, studies have shown that changes in the
incisal edge position and facial height are not limited, as often assumed, to just
puberty, but can actually continue well after the age of 18 years. Benard et al.
followed the vertical changes of maxillary incisors adjacent to implants in adults (40
to 55 years old) for a period of four years and found an infraocclusion ranging from
0.12 mm to 1.65 mm. (12) In a 20-year follow-up study, Forsberg et al. also showed
that the anterior facial height increased by 1.6 mm on average with an approximate
1 mm contribution from the eruption of the maxillary incisors. (13)

It is important to note that not all faces should be treated the same. Patients with
excessively horizontal or vertical growth patterns will show a greater degree of facial
change beyond the typical growing years. The short facial type is known as a
horizontal grower and has a tendency for a deep bite, while the vertical growing
patient has a propensity to develop a skeletal open bite. A cephalometric analysis
done by the orthodontist can be used to identify these deviant facial patterns. In a
“normal” facial pattern, the relationship between the cranial base and the inferior
border of the mandible would create a 32-degree angle, but in short and vertical
facial patterns, the angles would be less than 28 degrees and greater than 38
degrees, respectively. In these types of patients, implant restorations can assume an
overly palatal or vertical position, respectively over time; therefore, implant
placement might need to be delayed even longer. (14) Ultimately, complications are
inevitable with any type of rehabilitation, but those associated with implant
restorations in a deviant facial type can be especially difficult. Alternate treatments
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Figure 2: Schematic images depict the characteristics of the “normal,” short, and long facial types. The
reference lines represent the cephalometric measurement of SN-GoGn. The cranial base reference line
runs through the sella tursica (S) and nasion (N), and the mandibular plane (MP) is created by a line
that bisects the angle of the mandible (Gonion) and connects to the point on the chin called gnathion
(Gn). A “normal” SN-GoGn angle is 32 degrees +/- 5 degrees.

Canine substitution
Canine substitution is a conservative, viable treatment approach for the
management of missing lateral incisors, but as with any treatment it is up to the
clinician to recognize which cases are best suited for a functional and esthetic
outcome. According to Kokich and Kinzer, the patient’s facial profile must be straight
or slightly convex, and the malocclusion must fall into one of two categories. The
first is an Angle Class II malocclusion with minimal crowding in the mandibular arch.
This type of malocclusion is essentially a Class II camouflage treatment, which
finishes with the molars in Class II and the first premolar functioning as the canine.
The second malocclusion suggested by Kokich is an Angle Class II with sufficient
crowding in the mandibular arch to justify mandibular premolar extractions and a
Class I molar finish. In both scenarios, canine-protected occlusion is not possible, so
the final occlusion should finish with an anterior group function in all lateral
excursions. (15)
In
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on your device a clinician
described must
in
critically evaluate the overbite and overjet of each tooth and anticipate any additions
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orthodontist places the brackets to esthetically align the gingival margins, the
substituted cuspid and bicuspid will end up in supra- and infra-occlusion,
respectively. Once the ideal position of the gingival framework is properly
established, the shapes of the teeth must be adjusted to mimic the replaced tooth.
The dimensions of the bicuspid will need to be increased mesio-distally and inciso-
gingivally, and the lingual cusp will need to be reduced. The cuspid, on the other
hand, will need reduction in the incisal-gingival and mesial-distal dimensions,
flattening of the labial surface, and a steepening of the lingual convexity. In order to
avoid excessive enamel removal and an increase in color saturation, it is best to
perform canine substitution in patients who have teeth of similar overall dimensions
to those that they are replacing. Almost all substitution cases will also require
additive recontouring of teeth in the form of bonding or veneers with the preferred
long-term restoration being the veneer. If an excessive addition or reduction is
anticipated, a full-coverage restoration may be necessary and the clinician might
want to discuss an alternative treatment approach with the patient, such as opening
space and preparing for prosthetic replacement.

Prosthetic
treatment
Several restorative
options exist for the
replacement of the
missing lateral
incisors. These
options include Figure 3: Varying results achieved by canine substitution. A: Pleasing
resin-bonded fixed contours and positioning were achieved. B: M/D dimensions a bit
partial denture excessive and gingival margin positioned to apical. C: Significant
cervical bulge and discoloration evident after recontouring.
(Maryland bridge),
cantilevered fixed
partial denture, conventional fixed partial denture (bridge), and single-tooth implant.

Resin-bonded, fixed partial denture

Of the possibilities for a restorative approach, the resin-bonded FPD is the most
conservative option. The resin-bonded FPD requires little to no preparation on the
abutment teeth since it relies solely on the bonding adhesive for retention. The
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orthodontist must finish the anterior occlusion with the incisors in an upright
position with at least 1 mm of overjet and just enough overbite to disclude the
posterior teeth in excursions. (16) Controlling the overbite will decrease the duration
and the degree of tipping forces placed on the prosthesis, as well as maximize the
surface area available for retainer coverage. Similarly, the proclination of the incisors
also plays a vital role in retention of the prosthesis, because as the proclination
increases, the functional load changes from a vertical seating load to a tipping
tensile load that stresses the adhesive interface. Research has also shown that a
more vertically positioned incisor loaded with a shear/compressive force can
withstand 40% more load prior to failure than a proclined incisor loaded with a
tipping/tensile force. (17) Therefore, the ideal candidate for a resin-bonded FPD is a
nonbruxer with short cusps on the posterior dentition and vertically positioned
incisors with limited mobility and a shallow overbite.

Removable partial
denture
Before the days of
bonding technology
and implants, the
options for
prosthetic
Figure 4: Resin-bonded, fixed partial denture. (Photos courtesy of
replacement were Dr. Steve Koutnik)
limited to removable
partial dentures and
conventional fixed partial dentures. By modern standards of care, neither option is
considered the treatment of choice in a typical case. Having said this, it does not
mean that there is not a use for them in the management of congenitally missing
lateral incisors. In fact, the removable partial denture can serve as a relatively
inexpensive, conservative, and reversible means in which to replace the missing
teeth and supporting tissues. Some of the disadvantages to the removable partial
denture are their fragility, bulky design, lack of retention, interference with speech
and taste, and compromised esthetics. The biggest downside to a removable partial
denture is the potential for the breakdown of a potential future implant site. With a
removable partial denture, the orthodontically created interradicular space is prone
to relapse, and the hard and soft supporting tissues are susceptible to breakdown as
a result of long-term, functional loading. For many clinicians, the ideal interim
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Conventional, fixed
partial denture
The least
conservative of all
tooth-supported
restorations is a
conventional, full-
coverage, fixed
partial denture.
Although
Figure 5: Removable partial denture.
conventional, fixed
bridges are more
comfortable and esthetic than removable partial dentures, they require gross
reduction of healthy tooth structure, which is generally contraindicated in young
patients. With today’s materials, fixed bridges offer excellent results from an esthetic
and functional perspective, but because they still require a significant amount of
tooth reduction, their use should be limited to situations where a conventional
bridge already exists or the condition of the abutment teeth (i.e., wear, caries,
fracture, etc.) would dictate a more aggressive preparation.

Endosseous implant
As we have seen thus far, there are multiple restorative options that exist for the
replacement of the congenitally missing lateral incisor. In recent years, the most
common treatment alternative has undoubtedly been the single-tooth, endosseous
implant. The predictability, conservative nature, and long-term success rates of
implants have made them an obvious restorative choice, especially in cases where
the adjacent teeth are healthy, unrestored, and of normal size and shape. (18,19,20)
In modern dentistry, osseointegration is no longer the benchmark for success.
Success is measured by the esthetics and the clinician’s ability to replicate a natural-
looking crown while maintaining a hard- and soft-tissue framework that blends in
seamlessly with the surrounding tissues. This is no easy task. In order to achieve
success, several factors must be evaluated and accounted for in the early stages. The
first and foremost is space appropriation.
In
By restorative
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determine the
appropriate space
for a missing tooth.
The simplest way is
Figure 6: Interdisciplinary management and restoration: A.
to assess the Orthodontic
contralateral side. site development. B. Final restorations: No. 7 implant crown and No.
Unfortunately, this 10
method is not veneer. (Photos courtesy of Dr. Steve Koutnik)

adequate if there is a
missing or peg-shaped contralateral tooth.

The second is the golden proportion, which states that each tooth in the smile should
be visually 61.8% bigger than the tooth distal to it. (3) The golden proportion is good
in assessing the visual harmony of a restoration, but it is not as useful in
determining the exact mesial/distal dimension that is required for the implant
restoration.

The third method is the Bolton analysis. This method allows the clinician to
mathematically determine the amount of mesial/distal tooth dimension that is
needed in the maxillary anterior to establish an ideal overbite and overjet while
placing the canines in a Class I relationship with the mandibular teeth. Bolton’s
measurement involves dividing the sum of the mesiodistal width of the mandibular
six anterior teeth by the sum or the mesiodistal width of the maxillary six anterior
teeth. The ideal ratio comes out to be 0.78 and can be used to back-calculate the
ideal missing tooth dimension.

The fourth and final method simply allows the occlusion to dictate spacing. The
orthodontist will set up an occlusal scheme that allows for canine disclusion and
ideal esthetic positioning of the existing anterior teeth; then the restorative dentist
can follow up with a diagnostic wax-up. In many cases the remaining space will be in
the range of 5 mm to 7 mm. (21)

Now that we have we have determined how to establish the space required for a
proportional restoration, we must determine if the space requirements will allow for
the placement of the implant fixture. As a general rule, it is recommended to allow
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the papilla. If the
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7 mm and we need a minimum of 3 mm for papilla formation, then that leaves the
surgeon an adequate amount of space (4 mm) for the implant fixture. But if the
edentulous space only measures 5 mm, then there would be insufficient space for
both a traditional narrow platform implant and papilla formation. (22) In the later
situation, a compromise has to be made and the patient should be properly
informed.

The orthodontist and

the surgeon must
also take into
account the space
appropriation in the
interradicular area as
well. The minimum
spacing between the
roots is generally 5
mm. This amount of
space will allow the
Figure 7: Virtual treatment planning using CBCT. Numerical values
implant to be
represent the recommended spacing parameter to establish a stable
surrounded by 0.75 and esthetic replacement of the maxillary lateral incisor.
mm and 1.0 mm of
bone, which is
sufficient to support normal functional loading and ensure good long-term
osseointegration. (22) During the space opening aspect of orthodontic care, the
orthodontist must make a compensating bend to diverge the roots, especially when
canines are initially distal angulated, since the canine root apex inevitably lags
behind the crown when distalized. The orthodontist also has to pay particular
attention to the skeletal relationship of the patient in these cases because in an
Angle Class III tendency type case, the maxilla is narrow and the crowns tend to be
tipped labially, which in turn results in adequate space for the restoration but
insufficient space at the apex for fixture placement and may necessitate an
alternative type of restoration or a shorter implant fixture. (3,6)

In any case, but especially Angle Class III cases, it is good practice for the restorative
dentist or surgeon to take a periapical radiograph prior to the removal of the
orthodontic appliances to ensure that adequate interradicular space has been
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prevent relapse of the root position. Removable appliances are adequate to
maintain the interradicular spacing in the short-term, but many times these cases
need to be retained for a number of years until growth is complete and a more long-
term provisional is recommended. In cases with a high relapse potential, a resin-
bonded fixed partial denture should be considered. This type of restoration has the
advantage of being esthetic, conservative, and eliminates compliance issues, all
while maintaining the established tooth positions and site development.

Summary
The treatment of
congenitally missing,
maxillary lateral
incisors is very
challenging and
complex, requiring
very careful case
selection, treatment
planning, and often
the coordinated
interdisciplinary Figure 8: Angle’s Class III tendency type skeletal relationships
efforts of the and a narrow maxilla limits the orthodontist’s ability to torque the
roots and creates a convergence of the roots, which limits the
orthodontist,
apical interradicular space for implant placement.
periodontist or oral
surgeon, and
restorative dentist. The orthodontist plays a very vital role in the early management
of these types of cases and ultimately requires that the orthodontist think like a
restorative dentist and a surgeon, for he or she must understand where the teeth
are best positioned for each different type of restorative situation. It is imperative
that there is continuous communication among team members. The two categories
of treatment options, which include space closure with canine substitution and
space opening with prosthetic replacement, each have their own separate criteria
for tooth placement, and many times the final esthetics are determined by the initial
evaluations and recommendations made by the orthodontist. The orthodontist is
responsible for assessing facial types, growth patterns, tooth positions, occlusal
schemes, but more importantly the orthodontist is responsible for putting the teeth
in a position where the surgeon and the restorative dentist can execute a
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unless you haverestoration.
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the current time, thewithout cookies.
two most commonly recommended ways to manage
congenitally missing laterals are canine substitution and a single-tooth implant. The
other prosthetic alternatives that include the resin-bonded, fixed partial denture, the
conventional fixed partial denture, and removable partial denture can also be used
with a high degree of success if used in the correct situation. In the realm of
contemporary dentistry, implants are probably the most favored treatment modality
for replacing missing anterior teeth. The implant approach in the anterior region,
however, is a delicate situation, which can be challenging esthetically, especially in
the long term. In this scenario, it is necessary to work as a team in order to develop
the ideal conditions before and after implant placement. In today’s dentistry, where
there is such a high degree of emphasis placed on esthetics, it is not possible for a
dentist to work alone, especially when dealing with challenging situations like the
congenitally missing lateral incisor.

Although this article did not specifically attempt to recommend a particular

treatment modality, it did identify the available options and discussed some of the
advantages and disadvantages of each one. In this particular clinical situation, there
is no treatment that is clearly the best for every case. Therefore, it is imperative to
manage these patients from an interdisciplinary diagnostic and treatment
perspective. Together with teamwork and open communication we can produce
predictable and esthetic treatment results.

This article first appeared in the newsletter, DE's Breakthrough Clinical with Stacey
Simmons, DDS. Subscribe here.

James Schmidt, DDS, MS, graduated from St. Norbert College in 2000
with bachelor’s degrees in biology and chemistry. In 2004 he earned his
Doctor of Dental Surgery from Marquette University and then
continued his education at The Ohio State University where he received
a master’s degree and a Certificate in Prosthodontics. After four years of
practicing prosthodontics in Chicago, he made the switch to
orthodontics. He headed back to school and in 2014, SUNY–Buffalo
awarded him his Certificate in Orthodontics. Currently, Dr. Schmidt is in private practice
Milwaukee, Wisconsin.
ADDITIONAL READING
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Orthodontics case study: treat 'the face' not 'the teeth'

References
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Maxillofac Implants.
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unless you have disabled them. You can change your cookie settings at any
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