The Journal of EVIDENCE-BASED DENTAL PRACTICE

REVIEW ANALYSIS & EVALUATION // DIAGNOSIS/TREATMENT/PROGNOSIS

ORTHODONTIC CANINE SUBSTITUTION

FOR THE MANAGEMENT OF MISSING
MAXILLARY LATERAL INCISORS MAY HAVE
SUPERIOR PERIODONTAL AND ESTHETIC
OUTCOMES COMPARED TO AN IMPLANT-
OR TOOTH-SUPPORTED PROSTHESIS
REVIEWERS
THIKRIAT S. AL-JEWAIR, BRITTANY SWIDERSKI
To review evidence on the best treatment for maxillary lateral incisor agenesis in the permanent dentition by comparing
prosthetic tooth-/implant-supported replacements and orthodontic space closure.

ARTICLE TITLE AND BIBLIOGRAPHIC INFORMATION SORT SCORE

Prosthetic replacement vs space closure for maxillary lateral incisor agenesis: A
A B C N/A
systematic review. Silveira GS, Almeida NV, Pereira DMT, Mattos CT, Mucha JN. SORT, Strength of Recommendation Taxonomy.
Am J Orthod Dentofacial Orthop 2016; 150(2):228-37.
LEVEL OF EVIDENCE
1 2 3
See page 8A for complete details regarding SORT and LEVEL OF

SUMMARY EVIDENCE grading system.

Selection Criteria
This systematic review evaluated the best treatment alternative for patients with SOURCE OF FUNDING
maxillary lateral incisor agenesis by comparing orthodontic space closure, None listed
implant-supported, and tooth-supported dental prostheses. The review evalu-
ated the esthetic, occlusal, and periodontal results of the different alternatives for
patients with unilateral or bilateral maxillary lateral incisor agenesis in the per- TYPE OF STUDY/DESIGN
manent dentition. Five databases were searched in 2014, along with a manual Systematic review
search of the reference lists and an updated electronic search performed in
January 2015. All duplicate articles were removed. Two reviewers independently
evaluated the remaining articles and included studies according to the criteria KEYWORDS
selected. Disagreements between the 2 reviewers were resolved by discussion. Canine substitution, Tooth agenesis,
The initial search resulted in 2174 articles; after exclusion at different stages, a Systematic review
total of 9 case–control articles were included.

Key Study Factors

The studies were categorized according to prosthetic replacement or orthodontic
space closure modality. For prosthetic replacements, no distinction was made
between those who had a previous orthodontic intervention and those who did J Evid Base Dent Pract 2018: [153-156]
not. Three studies compared the periodontal and occlusal results in patients who
1532-3382/$36.00
had spaces closed with tooth- and implant-supported dental prostheses. In
ª 2018 Elsevier Inc.
addition to those outcomes, 1 of the 3 studies compared the esthetic results
All rights reserved.
using patient assessment, and the other 2 studies evaluated signs and symptoms doi: https://doi.org/10.1016/
of temporomandibular disorders (TMDs). The remaining 6 studies compared only j.jebdp.2018.02.004

June 2018 153

 The Journal of EVIDENCE-BASED DENTAL PRACTICE
the esthetic results of the different treatment modalities. In 3
of these studies, dental professionals and laypeople evalu-
ated photographs without being aware of the type of
treatment performed. In the remaining 3 studies, different
esthetic criteria were used, including width-to-height ratio,
gingival zenith of the maxillary lateral incisor, golden pro-
portion in the 6 anterior teeth, and apparent contact
dimension in the same sample. The functional and peri-
odontal aspects for both space closure and implant-
supported dental prostheses were evaluated in this study.
Main Outcome Measures
The main outcome measures were periodontal status,
occlusal function, and esthetics. The periodontal evaluation
was based on indices that categorized edema and gingival
color, bleeding on probing, ulcerations, gingival recession
on the facial surface, and filling of the interdental space by
the papilla. The occlusal function evaluation involved 2
components—occlusal characteristics and TMD symptoms.
Esthetic evaluation was measured by questionnaires deliv-
ered to patients that assessed shape, color, and symmetry of
the teeth and distribution of spaces, along with patient
satisfaction. Clinically objective measures of esthetics
included the width-to-height ratio of the 6 anterior teeth
and the gingival zenith of the tooth or prosthesis. The
contact dimension was measured using the distance from
the gingival papilla crest to the point of contact.
Main Results
No study confirmed porcelain bonded to gold and resin-
bonded bridges could obtain better periodontal results
than orthodontic space closure. No study found a significant
difference in the prevalence of gingival dehiscence between
the treatment options. One study that compared implant-
supported dental prostheses and orthodontic space
closure reported less interdental papilla fill in the implant
group. Two studies found the periodontal status of ortho-
dontic space closure to be superior to other methods, and 1
study found no significant differences between treatments.
Two studies found group function occlusion to be signifi-
cantly more prevalent in the orthodontic space closure
groups at rates of 100% and 96%, whereas the prosthetic
replacement groups showed group function rates of 89%
and 67%. One article showed no significant difference in the
rate of abfraction between the orthodontic space closure
and prosthetic replacement groups.
When evaluating esthetics, 1 study using subjective ques-
tionnaires found no significant differences between the
groups except for the color of teeth near the central incisors.
Eighty percent of patients in the prosthetic replacement
group were satisfied, compared with 45% in the orthodontic
space closure group. One study that used a visual analog
scale to measure satisfaction found orthodontic space
154 Volume 18, Number 2
closure to be evaluated as best. Another study found no
differences between the groups when analyzing the width-
to-height ratio of the 6 anterior teeth and the gingival
zenith of the tooth or prosthesis. The contact dimension
showed greater exposure of the interdental space in the
implant group when compared to orthodontic space closure
and normal dentition groups.
When using intrabuccal photos as a measurement method, 2
studies showed evaluators of laypeople, specialists, and
general dentists perceived orthodontic space closure as more
esthetic than other treatments. One study found that general
dentists perceived natural dentition to be superior to all
treatments, whereas laypersons preferred orthodontic space
closure followed by natural dentition when ranking esthetics.
Conclusion
For maxillary lateral incisor agenesis, tooth-supported
dental prostheses resulted in worse scores on the peri-
odontal indices than orthodontic space closure. Patients
and dentists found orthodontic space closure to be more
favorable compared to fixed tooth-supported and implant-
supported prostheses. The patient’s occlusal function was
not related to symptoms of TMD. When evaluating occlu-
sion, it was found that patients with a class I canine rela-
tionship were not predisposed to having canine-protected
occlusion.
COMMENTARY AND ANALYSIS
Maxillary lateral incisor agenesis is a common develop-
mental anomaly in dentistry,1 with an incidence rate ranging
from 1.55% to 1.78%.2 The etiology of this anomaly is
unknown, but mutation of the paired box gene 9 (PAX9)3
and disturbances in early developmental stages are 2
proposed theories.4
The management of spaces resulting from maxillary lateral
incisors agenesis has been the subject of many studies.5–7
The treatment alternatives include orthodontic space
closure by canine substitution, single-tooth implant–
supported prosthesis, tooth-supported bridge, and tooth
transplantation.8–10 To choose between alternatives, one
must consider the patient’s age, type of dentoalveolar
malocclusion, facial profile, lip line, canine morphology,
condition of adjacent teeth, amount of crowding,8–10 and
patient preferences.
Orthodontic space closure by canine substitution has a
number of advantages, including less cost and time when
compared to tooth-supported prostheses or implant re-
placements, avoidance of the need for tooth extractions in
cases of severe crowding, and ability to render the treat-
ment before the patient completes growth.11 However, this
alternative requires esthetic treatment to modify the
morphology of both the canines to mimic lateral incisors

and the first premolars to imitate the mesialized canines.
There is also a risk of creating a tooth size arch length
discrepancy (Bolton discrepancy) as well as a tendency for
creating a class III relationship, flattening the profile,
increasing the nasolabial angle,12 and deepening the bite.
Opening the space for a single-tooth implant-supported
prosthesis is another common option. The survival rate of this
option is around 90% at 10 years.13 This approach, however,
can pose long-term esthetic challenges, including progres-
sive infraocclusion of the prosthetic crown as a result of the
continuous eruption of the adjacent teeth,14 resorption of the
labial cortical plate and darkening of the overlying labial
gingiva, gingival height discrepancies, and increased
plaque accumulation and gingivitis in periodontally healthy
patients.15,16 Studies have also shown that the spaces
prepared for implants are associated with a significant
decrease in alveolar bone height and width as well as
increased labial concavity (more lingually positioned
alveolar bone ridge).17
Another commonly reported approach, although not evaluated
in this systematic review, is autotransplantation of premolars
before complete root formation into the missing maxillary
lateral incisors’ spaces. The long-term survival and success
rates of this approach are 90% and 79%, respectively.18 The
patients’ perceptions about this alternative are positive.
Autotransplantation is indicated in cases of multiple agenesis,
including missing mandibular second premolars and maxillary
lateral incisors, hypodivergent growth pattern, and normal
facial profile.13 Compared to an implant-supported pros-
thesis, which is indicated for adult patients, this modality is
performed in growing patients. Czochrowska et al19 evaluated
the gingival and periodontal conditions around 45
autotransplanted premolars that were restored (bonded) to
imitate lateral incisors after an observation period of 4 years
and compared them to natural teeth. They found that the
clinical variables were similar to those of natural teeth except
for increased tooth mobility, plaque accumulation, and pulp
obliteration in the autotransplantation group. This modality
also induced alveolar bone growth. Plakwicz et al20 reported
9-year outcomes in a patient who was treated with
developing third molar transplant on one side and a
single-tooth implant on the other side; the central incisor served
as the control. The outcomes included periodontal and
radiographic assessments. The authors found that there were
no significant differences between the transplanted tooth and
the control except for pulp obliteration in the transplanted
tooth. The periodontal outcomes of the single-tooth implant
were worse than those for the transplanted tooth. They were
marked by greater total bacterial count and progressive signs of
recession in the tissue around the implant.
To summarize, many variables affect the success and long-term
stability of the treatment alternatives for the management of
The Journal of EVIDENCE-BASED DENTAL PRACTICE
maxillary lateral incisor agenesis. These include patient com-
fort; treatment timing; functional, periodontal, and esthetic
clinical variables21,22; and the practitioner’s experience. The
jury is still out when it comes to which approach is superior in
terms of objective and subjective clinical outcomes. A multi-
disciplinary approach is obviously required to manage these
cases. Clinical trials comparing the short- and long-term out-
comes of the 3 principal modalities are needed, given the
heterogeneity of the current literature.
REFERENCES
1. Matteeuws N, Dermaut L, Martens G. Has hypodontia
increased in Caucasians during the 20th century? A meta-
analysis. Eur J Orthod 2004;26:99-103.
2. Polder BJ, Van’t Hof MA, Van der Linden FP, Kuijpers-
Jagtman AM. A meta-analysis of the prevalence of dental
agenesis of permanent teeth. Community Dent Oral Epidemiol
2004;32:217-26.
3. Mitsui SN, Yasue A, Masuda K, et al. Novel PAX9 mutations cause
non-syndromic tooth agenesis. J Dent Res 2014;93:245-9.
4. Cobourne MT. Familial human hypodontia–is it all in the genes?
Br Dent J 2007;203:203-8.
5. Zarone F, Sorrentino R, Vaccaro F, Russo S. Prosthetic treatment
of maxillary lateral incisor agenesis with osseointegrated im-
plants: a 24-39-month prospective clinical study. Clin Oral Im-
plants Res 2006;17:94-101.
6. da Costa MG, Melgaco CA, Correa-Faria P, Marques LS.
Functional and esthetic treatment of lateral incisor agenesis
with a mini-implant in a young patient: a case report. Int J
Orthod Milwaukee 2015;26:55-7.
7. Antonarakis GS, Prevezanos P, Gavric J, Christou P. Agenesis of
maxillary lateral incisor and tooth replacement: cost-
effectiveness of different treatment alternatives. Int J Prostho-
dont 2014;27:257-63.
8. Kokich VO Jr, Kinzer GA. Managing congenitally missing lateral
incisors. Part I: canine substitution. J Esthet Restor Dent
2005;17:5-10.
9. Kinzer GA, Kokich VO Jr. Managing congenitally missing lateral
incisors. Part II: tooth-supported restorations. J Esthet Restor
Dent 2005;17:76-84.
10. Kinzer GA, Kokich VO Jr. Managing congenitally missing lateral
incisors. Part III: single-tooth implants. J Esthet Restor Dent
2005;17:202-10.
11. Zachrisson BU, Rosa M, Toreskog S. Congenitally missing
maxillary lateral incisors: canine substitution. Point. Am J
Orthod Dentofacial Orthop 2011;139:434-44.
12. Bizetto MS, Tessarollo FR, Jimenez EE, Guariza-Filho O,
Camargo ES, Tanaka OM. Implant rehabilitation of canines in
case of bilaterally missing maxillary lateral incisors. Am J
Orthod Dentofacial Orthop 2013;144:110-8.
June 2018 155
 The Journal of EVIDENCE-BASED DENTAL PRACTICE
13. Zachrisson BU, Stenvik A, Haanaes HR. Management of
missing maxillary anterior teeth with emphasis on auto-
transplantation. Am J Orthod Dentofacial Orthop 2004;126:
284-8.
14. Bernard JP, Schatz JP, Christou P, Belser U, Kiliaridis S. Long-
term vertical changes of the anterior maxillary teeth adjacent to
single implants in young and mature adults. A retrospective
study. J Clin Periodontol 2004;31:1024-8.
15. Dierens M, Vandeweghe S, Kisch J, Persson GR, Cosyn J, De
Bruyn H. Long-term follow-up of turned single implants placed
in periodontally healthy patients after 16 to 22 years: microbi-
ologic outcome. J Periodontol 2013;84:880-94.
16. Robertsson S, Mohlin B. The congenitally missing upper lateral
incisor. A retrospective study of orthodontic space closure
versus restorative treatment. Eur J Orthod 2000;22:697-710.
17. Uribe F, Chau V, Padala S, Neace WP, Cutrera A, Nanda R.
Alveolar ridge width and height changes after orthodontic
space opening in patients congenitally missing maxillary lateral
incisors. Eur J Orthod 2013;35:87-92.
18. Czochrowska EM, Stenvik A, Bjercke B, Zachrisson BU.
Outcome of tooth transplantation: survival and success rates
17-41 years posttreatment. Am J Orthod Dentofacial Orthop
2002;121:110-9. quiz 93.
156 Volume 18, Number 2
19. Czochrowska EM, Stenvik A, Album B, Zachrisson BU. Auto-
transplantation of premolars to replace maxillary incisors: a
comparison with natural incisors. Am J Orthod Dentofacial
Orthop 2000;118:592-600.
20. Plakwicz P, Fudalej P, Czochrowska EM. Transplant vs implant in
a patient with agenesis of both maxillary lateral incisors: a 9-
year follow-up. Am J Orthod Dentofacial Orthop 2016;149:
751-6.
21. Babacan H, Kilic B, Bicakci A. Maxillary canine-first premolar
transposition in the permanent dentition. Angle Orthod
2008;78:954-60.
22. Doruk C, Babacan H, Bicakci A. Correction of a mandibular
lateral incisor-canine transposition. Am J Orthod Dentofacial
Orthop 2006;129:65-72.
REVIEWERS
Thikriat S. Al-Jewair, BDS, MS, MSc, FRCD(C), Dipl. ABO
Assistant Professor and Program Director, Department of
Orthodontics, State University of New York at Buffalo, 140
Squire Hall, 3435 Main Street, Buffalo, NY, USA, Thikriat@
buffalo.edu
Brittany Swiderski, DDS
Postgraduate Orthodontic Resident, University of Detroit
Mercy, MI, USA, Brittany.swiderski@gmail.com