The missing upper lateral incisor

Submitted by junction-orthod... on Mon, 2017-01-30 00:28

Missing upper lateral incisor(s) occur in approximately 5% of the general population. Given that only 25-35% of the population seek orthodontic treatment, missing lateral incisor cases occupy a surprisingly large amount of the orthodontist's time.

When faced with options to deal with the missing lateral incisor we can close the spaces that are normally present, we can open space to allow artificial replacement of the missing tooth or we can choose not to treat.

The correct option depends on several factors including the bite pattern between the top and bottom teeth, the size, shape and colour of the adjacent canine teeth, crowding, excessive spacing, whether there are unilateral or bilateral missing laterals, the position of the lips at rest and when smiling, and finally the wishes of the patient and parent. Costs associated with these options will also vary and may be a factor in arriving at a decision.

Problems associated with closing space include potential difficulty in complete space closure, minor reopening of space after treatment and potential aesthetic concerns associated with the size, shape and colour of the canine teeth. Restorative measures may be necessary to address these aesthetic concerns.

The primary issues associated with opening space include gaining sufficient space to accommodate an implant supported false tooth, retaining the space and adjacent tooth positions for several years until the patient is mature enough to allow implant placement (this creates a heightened risk of orthodontic retreatment and should be viewed as an acceptable risk when treating teenagers), and the costs associated with replacing missing teeth.
In 2017, the cost of orthodontic treatment for our adolescent patients ranges between six and seven thousand dollars. The cost of a single tooth implant is in excess of $6000. You are strongly urged to discuss costs with your restorative dentist when budgeting for such treatment. Dental implants are not the only restorative option and for a variety of reasons, including costs, certain cases will not suit implants. Again, you should discuss these restorative options with your dentist, preferably prior to commencing or in the early stages orthodontic treatment.

The following images are examples of cases treated for missing lateral incisors.

Patient missing upper lateral incisors bilaterally, over retained deciduous teeth, crowding of the lower teeth and deep bite.

Because of the crowding and size of the canine teeth, we elected to extract two lower premolars to balance the missing lateral incisors and to close the upper incisor space. Photo is immediately following brace removal hence the gums are inflamed but in a few weeks they will appear healthy. Note that the pointy canine teeth have been reshaped to square off the tips. Should the patient desire, they can be reshaped with the addition of composite resin by your dentist to more closely resemble lateral incisors.

A similar case where spaces were closed however as the lower teeth were not crowded, no lower extractions were required.

Unilateral missing lateral incisor. The angles of the canine and lateral have been improved to the point where they are similar in appearance. The gap between the front teeth was closed with the retainer. Note that the upper midline is a millimetre to the patient's right. This can be difficult to control when closing unilateral spaces.

Bilateral missing upper lateral incisors where spaces were opened for the placement of two artificial teeth. In this case the teeth have been added to an orthodontic retainer which is designed to hold the teeth in their corrected positions until the patient is old enough to proceed to permanent replacement. Today, more cases are retained with bonded bridges where the dentist attaches the false teeth to the neighbouring teeth with composite resin. Bonded bridges offer reduced chances of relapse and retreatment.

Bilateral missing upper lateral incisors. Case retreated after several years to re-establish correct space and angulation of the adjacent teeth for implant placement. Note the cobalt-chromium denture. This was worn for several years but despite this, space has reopened between the two central incisors and the roots of the adjacent teeth have drifted into positions which prohibit implant placement. As patient treated as adult, the implants were placed during orthodontic treatment so retention was not necessary.