EDITORIAL

Treatment of missing lateral incisors

David L. Turpin, DDS, MSD, Editor-in-Chief Seattle, Wash

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 doesnt 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 childs esthetic problems. Zachrisson 1 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, 2 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 Mohlin3 assessed 50 treated patients with agenesis of the maxillary lateral incisors. They had a mean age of 26 years

iagnosing and treating growing children who

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 publics 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.
REFERENCES 1. Zachrisson B. Authors response. Am J Orthod Dentofacial Orthop 2003;124(4):18A-19A. 2. Nordquist GG, McNeill RW. Orthodontic vs. restorative treatment of the congenitally absent lateral incisor long-term periodontal and occlusal evaluation. J Periodontol 1975;46:139 -43. 3. Robertsson S, Mohlin B. The congenitally missing upper lateral incisor. A retrospective study of orthodontic space closure versus restorativ e treatment. Eur J Orthod 2000;22:697 -710.
Am J Orthod Dentofacial Orthop 2004;125:129 0889-5406/$30.00 Copyright 2004 by the American Association of Orthodontists. doi:10.1016/j.ajodo.2003.12.011

129

Source: AJO-DO on CD-ROM (Copyright 1998 AJO-DO), Volume 1998 Aug (195 - 207): Report of four familial cases with congenitally missing mandibular incisors George V. Newman, DDS, and Richard A. Ne... -------------------------------Report of four familial cases with congenitally missing mandibular incisors George V. Newman, DDS, and Richard A. Newman, DMD West Orange and Randolph, N.J. Heredity is one of the possible factors associated with congenitally missing mandibular incisors. We report four casesa mother and three daughtersin an attempt to examine this hypothesis. Different treatment modalities have been used to treat malocclusions stemming from this problem The treatment philosophy of consolidating mandibular spaces and obtaining a stable occlusion, thereby preventing the removal of maxillary teeth or the use of a mandibular prosthesis, is presented. (Am J Orthod Dentofacial Orthop 1998;114:195-207.) Heredity or a familial distribution of congenitally missing mandibular incisors was suggested as one of the possible causes in an article published in the July 1967 issue of the American Journal of Orthodontics. In this article, patients with two congenitally missing mandibular incisors were reported.1 Even though the occurrence of patients exhibiting congenitally missing mandibular incisors is low, clinical orthodontists should be familiar with treatment alternatives. Techniques for treating malocclusions stemming from this problem vary by case and clinician. The following case reports document three sisters and their mother, all of whom had at least one congenitally missing mandibular incisor. We treated these patients and present their cases for the interest of their genetic background and selected treatment modality. LITERATURE REVIEW The orthodontic literature reveals four main theories for the cause of missing mandibular incisors, as follows: Heredity or familial distribution has been suggested as the primary cause.2-4 Graber5 stated, Congenital partial anodontia appears to be the result of one or more point mutations in a closely linked polygenic system, most often transmitted in an autosomal dominant pattern incomplete penetrance and variable expressivity. He further stated, It is the dental clinician's challenge to recognize the congenital absence of teeth and evaluate other family members for possible manifestations of this primarily heritable condition. Second, anomalies in the development of the mandibular symphysis may affect the dental tissues forming the tooth buds of the lower incisors6-9 Third, a reduction in the dentition is regarded by some researchers as nature's attempt to fit the shortened dental arches (an expression of the evolutionary trend).10,11

Finally, localized inflammation or infections in the jaw may have destroyed the tooth buds, or disturbance of the endocrine system may have caused an ectodermal dysplasia.12 Schwarz13 ported treating a 10-year-old boy with a Class II Division II malocclusion and congenitally missing mandibular incisors ( inherited from his mother ). Schwarz aligned the maxillary arch and proclined the incisors. In the mandibular arch, the teeth were moved mesially to close anterior spaces, and the mandible was moved forward. Schwarz's ideal goal of intercuspation was not attained. However, 20 years out of retention the overbite improved grinding in a new safe occlusion, resulting in favorable long-term stability. Reidel14,15 iscussed indications and contraindications for the removal of one or two mandibular incisors in treating certain malocclusions and suggested the removal of maxillary first premolars and laterals to balance tooth material in selected cases. He also states that reapproximation (trimming) of the mandibular incisors may be required to produce harmonious tooth relationship between these five teeth and the maxillary six anterior teeth. Reidel and Little16 noted that treatment with missing mandibular incisors had greater potential stability than most treated malocclusions. Valinoti tended to confirm these findings.17Fukawa18 describes case reports of twins having congenitally missing mandibular incisors in which the maxillary first premolars were extracted because of the severity of the malocclusion. Tuverson19 described the diagnosis and treatment of a missing mandibular incisor. He stresses the use of a diagnostic set-up and the establishment of a mutually protected occlusion. He was concerned about an excessive overbite resulting from the absence of a mandibular incisor. Buchner20 reported treatment of a Class II Division I malocclusion with a congenitally missing lower incisor. The maxillary left lateral incisor was extracted, and the case was treated with typical Class II treatment. The maxillary central incisor contacted the left canine. TREATMENT PLAN The treatment techniques used in resolving malocclusions with missing mandibular incisors depend on a myriad of diagnostic criteria such as dental, skeletal, and aesthetic considerations. For example, in a case with a hypodivergent skeletal pattern and a flat facial profile, removal of maxillary bicuspids to balance deficient tooth material may be contraindicated. One of the possible treatment procedures involves obtaining a functionally adapted occlusion less the congenitally missing mandibular incisors by protracting the mandibular canines and posterior teeth forward. A second treatment modality includes the creation of space and uprighting and aligning the mandibular anteriors to receive a fixed prosthesis. Finally, the third method involves the removal of maxillary premolars or lateral incisors to balance tooth material resulting the absence of mandibular incisors. The first method of space closure of the mandibular anterior teeth was selected for all four of the following cases. It was believed that the opening of spaces for the insertion of a prosthetic replacement would prolong treatment and prolong management problems. As for the removal of maxillary premolars, we believed this would cause disharmony by flattening the facial profiles in these particular cases. The results of this treatment philosophy can be evaluated by the out-ofretention results offered in these case reports. It should be noted that the removal of first premolars or the creation of space for a fixed prosthesis may be necessary in other individual cases on the basis of diagnostic analysis and treatment objectives. A Bolton analysis and diagnostic wax setup were completed for the treated cases.21 Case 1

The patient was 12 years 6 months old at start of treatment. The medical history was noncontributory relative to the malocclusion, as it was in the three following cases reported. A dental history revealed that the patient's mother had a congenitally missing mandibular incisor. On panoramic radiography, the mandibular left incisor and the third molars were absent. The panoramic radiographs are not shown in this article for the sake of brevity, but the essentials are described. We will supply copies of these radiographs on request. A deep overbite and lingually locked maxillary canines were evident on dental and photographic analysis. The patient was in the late mixed-dentition stage, and the second deciduous molars were present. The molars were in Class I relationship (Fig. 1). The extraoral photographs reveal a moderately balanced profile; however, the mandible appears recessive (Fig. 2). Note the Kobyashi ties to receive the Class II elastics (Fig. 3). Arch wires containing Class II hooks were also used. Before treatment the patient exhibited an ANB difference of 8.3. However, she evidenced a brachyfacial skeletal-growth pattern. The maxillary incisors were too upright at U1 to NS of 85, and the mandibular incisors were proclined with an IMPA of 102. (Table I). The objectives of treatment were to open the bite, correct the lingually locked maxillary canines, and close the mandibular spaces. The maxillary and mandibular anteriors would be leveled and aligned. Occlusal equilibration would be necessary with the newly positioned dentition to attain a mutually protected occlusion. The maxillary and mandibular molars were banded with .022-inch .028-inch rectangular (pretorqued and preangulated) tubes. The brackets were bonded with .022-inch .028-inch preadjusted straight arch-wire brackets. The arches were leveled with progressive .016 nickeltitanium, .016-inch, .018-inch, and .020-inch stainless-steel arch wires with molar tip-backs. For the sake of brevity, we note here that the other case reports had similar banded and bonded appliances. The canines were brought into alignment with arch-wire configurations in combination with a bite plate with a bite ledge and springs activated against the lingual surfaces of the canines. Class II elastic mechanics were used. The use of Class II elastics corrected any latent overjet or overbite and waswere essential for obtaining optimum functionally adapted occlusion. Maxillary and mandibular Hawley wraparound retainers were used for retention, in this case, as well as in the following cases. Active treatment lasted 16 months. The midlines are not coincidental; however, this is to be expected. The mandibular incisors appear well-aligned; however, the overbite has tended to recur (Fig. 4). The 3-year out-of-retention extraoral photographs reveal a balanced profile even with a prominent nose and chin (Fig. 5). The panoramic radiograph reveals the presence of the maxillary third molars and a mandibular right third molar. However, the mandibular left third molar was absent. The patient's parents did not want crown-and-bridge prostheses in the mandibular arch, and her out-of-retention extraoral photographs certainly show why extraction of maxillary first premolars was not considered. Superimposition of the before-treatment and out-of-retention cephalometric radiograph tracings indicates the mandible predominantly grew horizontally in this brachyfacial pattern (Fig. 6). The maxillary superimposition indicates that the maxillary incisor roots were torqued lingually; however, additional lingual root torque would have been preferable to diminish the out-of-retention bite-closing tendency. The mandibular superimposition shows the

retraction of the mandibular incisors from 102 to 95, whereas the molars were protracted. The mandibular superimposition was registered on corpus axis at PM for maximum accuracy (Table I). Case 2 Treatment was instituted in the mixed-dentition stage when the patient was 10 years old. Her mother and older siblings had missing mandibular incisors. The mandibular left-central incisor was congenitally missing. The patient had all her third molars. The permanent first molars were in a Class I relationship. The maxillary and mandibular incisors were crowded and rotated. Posterior deciduous teeth were present, and a moderate overbite was evident (Fig. 7). A balanced facial profile with slight mandibular recessiveness was visible. Fullness in the oral area was evident (Fig. 8). The patient exhibited an ANB difference of 7. Her SNB was 75, contributing to her retrognathic mandible. The Holdaway soft tissue angle was 18. The patient had a mesocephalic dentofacial growth pattern (Table II). We sought to correct the deep overbite and align the crowded maxillary and mandibular anteriors. Maxillary and mandibular arches were banded and bonded in a fashion similar to that used in case 1. Both arches were leveled and aligned with superelastic nickel-titanium and stainless-steel arch wires. Class II elastics were used. Class II elastic force was the common denominator in all the described cases; it promoted arch approximation optimal overbite and overjet and a functionally adapted occlusion. The 2-year out-of-retention intraoral photographs demonstrate that the midlines are not coincident, as a result of the congenitally absent mandibular incisor. The mandibular anteriors are well-aligned, the overbite has been corrected, and the molars have come into a Class I relationship (Fig. 9). The patient's profile appears well-balanced (Fig. 10). The superimposition of before-treatment and out-of-retention cephalometric tracings revealed favorable downward and forward growth in the patient's mesocephalic facial pattern. However, the out-of-retention tracings indicate more vertical than horizontal growth, which apparently contributed to the favorable overbite. (Fig. 11). The maxillary superimposition reveals that the molars continued to erupt downward and forward, whereas the incisors remained in their original sagittal position but grew vertically. The mandibular superimposition illustrates that the molars moved mesially and extruded, whereas the incisors were retracted.22 The ANB difference improved from 7 to 4 (Table II). The soft tissue angle improved from a before-treatment measurement of 18 to a posttreatment ideal of 10. The maxillary third molars appeared impacted at this writing, whereas the mandibular third molars have sufficient room for eruption, as is visible in the out-of-retention panoramic radiograph. Case 3

The patient was 9 years 6 months old at the start of treatment. Her mother and siblings all have congenitally missing mandibular incisors. The third molars were not visible. The mandibular central incisors were congenitally absent. The posterior deciduous teeth were present. The molars were in a Class II end-on relationship. The patient had a deep overbite and an 8.5-mm overjet. Two mandibular central incisors were absent (Fig. 12). As a result of the proclined maxillary incisors, the patient exhibited lip incompetence with a hyperactive mentalis muscle and a deep mentolabial sulcus (Fig. 13). An ANB discrepancy of -6 was noted, and the Wits analysis was 2.1 mm (Table III). The patient evidenced a brachyfacial growth pattern. The U1 to NS was a protrusive -116, and the mandibular incisors were slightly proclined at 93. The soft tissue angle was 18. We sought to achieve retraction of the maxillary incisors to obtain a more aesthetic profile, opening of the deep overbite, and closing of the lower spaces to preclude the need for a prosthesis. All the maxillary and mandibular teeth were banded and bonded as described in the preceding cases. The lower spaces were closed with elastomeric chains and were leveled and aligned with superelastic nickel-titanium and stainless-steel arch wires from .016-inch to .018-inch .025-inch archwires. Class II elastics were used to approximate the upper and lower arches. The intraoral photographs demonstrate a well-aligned mandibular arch. A functional (adaptation) occlusion was established, requiring some equilibration of the posterior right segments, which that ended up in a Class III relationship. A midline discrepancy is present (Fig. 14). The 2-year out-ofretention extraoral photographs reveal favorable improvement in the orofacial area (Fig. 15). Activetreatment time was 18 months. All four third molars were present in the panoramic radiograph. The out-of-retention tracing reveals that growth of the mandible continued in a favorable downward and forward direction. The maxillary superimposition indicated that the molars continued to erupt downward and forward and the upper incisors extruded slightly (Fig. 16). The mandibular molars were protracted and extruded. The incisors were extruded. The soft tissue angle has been reduced from 18 to a more esthetically favorable 14. Facial balance and harmony have been achieved (Table III). Treatment resulted in a Class I mutually protected occlusion despite the congenitally missing incisors and midline discrepancies. Facial balance was achieved. The temporomandibular joints functioned asymptomatically in all four cases before, during, and out of retention.23 Case 4 The mother of the three siblings also had a congenitally missing mandibular incisor. Her intraoral and extraoral photographs, 26 years after partial treatment, are presented (Figs. 17 and 18). Note the midline discrepancy and the slightly crowded mandibular incisors. The patient's dentition demonstrated occlusal abrasion (bruxism), anteriorly and posteriorly. The mother had started treatment at age 12 but after 10 months it was discontinued because she returned to India (Table IV). The mandibular spaces were closed, but Class II elastics were not used. Her cephalometric

tracing is shown in Fig. 19. A recent observation revealed that her temporomandibular joints function asymptomatically and with good range of motion, similar to that in her daughters' cases.

CONCLUSION Congenitally missing mandibular incisors are occasionally noted in orthodontic treatment. However, their absence does create a diagnostic decision involving three options of treatment: the creation of space for a fixed prosthesis to replace the missing incisors, the removal of maxillary premolars or a lateral incisor to balance the deficient mandibular tooth material, and consolidation of the mandibular incisor spaces to facilitate correction of the malocclusion. In treating the cases presented in this report, we used the third approach. These cases tend to imply a hereditary factor in the congenital absence of mandibular incisors. It is noteworthy that the temporomandibular joints were asymptomatic in these cases before and out of retention despite the congenitally missing incisors and midline discrepancy. Evidently these unusual occlusions of six maxillary anteriors occluding with four or five mandibular incisors did not play a part in causing temporomandibular joint problems in these cases. We agree with Valinoti's17findings that the absence of a mandibular dental midline does not apparently affect occlusion, aesthetics, periodontal health, or stabilitythe principal requirements of orthodontic therapy. It must be noted that the treatment modality employed for cases involving congenitally missing mandibular incisors must take into consideration all diagnostic criteria, including the patient's profile and skeletal growth pattern.