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The Space-Closure Alternative For Missing Maxillary Lateral Incisors: An Update
The Space-Closure Alternative For Missing Maxillary Lateral Incisors: An Update
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TABLE 1
ADVANTAGES AND COMPLICATIONS OF IMPLANT SUBSTITUTION FOR
MISSING MAXILLARY LATERAL INCISORS
Advantages of Single Implants Common Complications of Single Implants
• Optimal posterior occlusion • Progressive infraocclusion (even in mature adults)
• Satisfactory short-term esthetics • Lack of uprighting compared to natural incisors
• Comparatively short and simple • No means of orthodontic adjustment
orthodontic treatment
• Blue coloring of labial gingiva
• No need for build-ups of neighboring teeth
• Visibility of metal or porcelain abutment over time
• Long-term implant osseointegration
• Interdental recession (particularly distal papilla)
• Difficulty of making natural-looking porcelain crown
• No long-term observations (>10-15 years)
consequences. Finally, it should be remarked that together, these methods can provide the improve-
it is not easy to make implant crowns that blend ments needed to approach the appearance of a
perfectly with the neighboring teeth. Indeed, natural intact dentition and thus make orthodontic
Tuverson remarked that the color of the canine space closure a more attractive treatment alterna-
usually comes closer to that of adjacent teeth than tive, especially in young patients and in those who
to the color of porcelain crowns.19 show a substantial amount of gingiva when smil-
Our appreciation of the space-closure alter- ing. A biological, esthetic, and stable result using
native has increased during the last decade as we natural teeth in the anterior maxilla appears more
have tried to improve our results by combining appealing to us than the insertion of foreign bodies
carefully detailed orthodontic treatment with tech- that will remain in place throughout the patient’s
niques from esthetic dentistry20,21 (Fig. 2). Used lifetime.
A B C
Fig. 1 A. 20-year-old female patient with upper lateral incisor space reopened for implant placement.
B. Temporary crown on implant looks ideal at end of orthodontic treatment. C. Only five years later, infraoc-
clusion of implant restoration is evident due to continuous eruption of adjacent teeth.
A B C
Fig. 2 A. Adolescent female patient with maxillary right lateral incisor agenesis and peg-shaped left lateral
incisor (same case as shown in Figure 4 of previous article20). B. Right canine extruded during orthodontic
space-closure treatment and recontoured solely by grinding; porcelain laminate veneer crown placed over
peg-shaped lateral. C. Natural gingival and incisal contours maintained 19 years after treatment, with no
sign of infraocclusion; gingivae show normal pink color, stippling, and intact interdental papillae.
We have also recommended that clinicians tients, however, the resulting dentitions did not
should evaluate and eventually restore the central appear entirely natural; in others, the composite
incisors in many patients with missing lateral inci- resin build-ups20 needed more maintenance than
sors.21 Widening and lengthening the central inci- expected. In this article, we have selected two dif-
sors allows such patients to optimally display their ficult and challenging patients from Dr. Rosa’s
dentition during speech and smiling. pool of recently treated maxillary lateral agenesis
We have achieved satisfactory, stable out- cases to demonstrate further improvements and
comes over many years of using canine substitu- provide new clinical guidelines for the space-
tion for missing lateral incisors.20,21 In some pa- closure alternative.
A
Fig. 3 Case 1. A. 17-year-old female patient after previous orthodontic
treatment to open maxillary lateral spaces for dental implants. Occlusion
appears normal, but upper incisors were protruded in attempt to cor-
rect overjet, profile, and Class III skeletal tendency. B. Lateral incisors
temporarily replaced on removable plate. B
A
Fig. 5 Case 1. A. Patient after 11 months of orthodontic finishing.
B. Superimposition of pre- and post-treatment cephalometric tracings.
control20,21 (Fig. 5A). The marked improvement in Retention consisted of a maxillary six-unit
facial esthetics was obtained mainly by an increase lingual retainer (4-3-1-1-3-4, with the distal ends
in the vertical dimension at the maxillary level and bonded to the mesial occlusal surfaces of the first
concomitant mandibular rotation, rather than sag- premolars) and a mandibular 3-3 lingual retainer.
ittal modifications, while the position of the upper
lip in the face was unchanged (Fig. 5B).
Case 2
The cosmetic phase (performed by Dr.
Patrizia Lucchi, Trento, Italy) began on the day of A 34-year-old male presented with a Class
debonding. The upper six anterior teeth were re II, division 2 malocclusion in a hypodivergent
built with composite resin to obtain an ideal tooth- skeletal pattern (Fig. 7). Both maxillary lateral
to-tooth and tooth-to-soft-tissue relationship (Fig. incisors were missing. The upper left deciduous
6A). Vital bleaching was performed after the com- canine was retained, but was severely resorbed and
posite build-ups to match the yellowish canine to splinted to the adjacent permanent canine and first
the white composite (Fig. 6B); the resin build-ups premolar. The upper right and lower left first
will later be replaced by porcelain laminate molars were also missing. A marked asymmetry
veneers. The final occlusion showed the first of the dental arches and the occlusal plane made
molars in a Class II relationship, with canines the patient’s gummy smile more evident on the
substituting for the missing lateral incisors and right side.
first premolars replacing the canines (Fig. 6C). Considering the gummy smile and the rela-
The smile line and upper incisor display with the tively young age of the patient, we felt the place-
lips at rest were ideal for a woman of this age. ment of two implants in the esthetic zone would
B B
C
Fig. 6 Case 1. A. Composite restorations of central incisors and relocated canines and first premolars.
B. After vital bleaching of relocated canines. C. Final result, with maxillary molars in Class II relationship
and six anterior teeth rebuilt with composite resin to produce optimal tooth-to-tooth and tooth-to-soft-tissue
relationships. Incisor display with lips at rest is ideal for young adult woman. Upper and lower six-unit retain-
ers were bonded; resin build-ups will eventually be replaced by porcelain laminate veneers.
be an unsatisfactory long-term solution. Therefore, anterior region) and correction of root angulation
the treatment plan involved: on the lower left side, without reopening the space
• Space closure to replace the upper left deciduous of the missing lower left first molar.
canine and correct the midline. • Correction of the asymmetrical occlusal plane.
• Space opening between the upper right first and • Achievement of a functional, balanced occlusion
second premolars to allow insertion of an implant with canine and incisal guidance through ortho
that would expedite the midline correction. dontic treatment and restorations.
• Closure of the upper right first molar space. • Porcelain crown restoration over the first premo-
• Leveling and alignment (with stripping in the lar implant.
B
Fig. 8 Case 2. A. Patient after 18 months of treatment, showing diastemas mesial and distal to upper central
incisors and space opened for implant between upper right first and second premolars. B. Upper central
incisor contact points built up with composite to balance smile; dental implant inserted in space between
upper right premolars. Canines were extruded, and first premolars in canine positions intruded, to produce
optimal gingival margins.
• Porcelain laminate veneers on the six anterior sion, and torque control.20-22 The upper canines
teeth (following composite build-ups during ortho were slightly reshaped on the buccal and palatal
dontic treatment). surfaces, but were not ground or reduced in vol-
After 18 months of fixed-appliance treat- ume. Although the alignment of the six upper
ment, the upper midline had been corrected, and anterior crowns was ideal, a 3mm overjet persisted
space had been opened between the upper right palatal to the upper central incisors (Fig. 9B); this
premolars (Fig. 8A). Diastemas mesial and distal was later filled by restorations (Fig. 9C).
to the central incisors were filled with composite The cosmetic phase, performed by Dr.
build-ups to make those teeth appear bigger and Giovanni Manfrini, Riva del Garda, Italy, began
thus balance the smile, and an osseointegrated during treatment with build-ups on the central
implant was placed by Dr. Francesca Manfrini, incisors and continued with composite build-ups
Riva del Garda, Italy (Fig. 8B). on the “new” lateral incisors and canines a few
Orthodontic finishing took 11 months; over- days before debonding. In the 10 months after
all treatment time was 30 months. The final occlu- orthodontic treatment, stabilization was achieved
sion involved three maxillary premolars on the by occlusal equilibration. A porcelain crown was
right side and the first molars in a Class II relation- placed on the implant, while the upper six anterior
ship on the left side, with canines substituting for teeth were restored with porcelain laminate veneers
the missing lateral incisors and first premolars (Fig. 9A). The macroesthetic elements of the smile
replacing the canines on both sides (Fig. 9A). The were in better balance than before treatment, pri-
marginal periodontal contours and smile line were marily because the canines were not reduced to
optimized by the premolar intrusion, canine extru- substitute for the lateral incisors, but the central
incisors were enlarged to match the “new” lateral With the space-closure alternative, the
incisors. This solution is often the best strategy in healthy gingival tissues and intact interdental gin-
lateral agenesis cases, in which the central incisors gival papillae will mature in synchrony with the
tend to be small.23 patient’s own teeth, so that long-term modifica-
A mandibular six-unit lingual retainer was tions will appear naturally (Fig. 2). This is in
bonded; in the upper arch, an Essix* retainer was contrast to long-term experiences with single-
used for six months after occlusal equilibration. implant crowns in the esthetic zone.9,10,13 In an
Two years after maxillary retention, there was no award-winning article describing 10-year follow-
tendency for space reopening, probably because of ups of oral implants, Thilander and colleagues
the occlusal equilibration with no CO/CR discrep- found increasing degrees of infraocclusion even
ancy and with lateral working excursions of the after completion of growth, and significant mar-
lateral incisors, canines, and first premolars. ginal bone loss at tooth surfaces adjacent to the
implants.9 Marked infraocclusion of single-implant
crowns in mature adults was also reported by
Discussion
Bernard and colleagues10 and by Jemt.13 Our con-
These and previous case reports have dem- clusion is that lateral incisor agenesis in patients
onstrated that by using a combination of carefully with gummy smiles should be treated with space
performed orthodontic space closure and cos- closure. If the treatment plan must include space
metic build-ups of several teeth with either com- reopening, it is preferable to open the spaces pos-
posite resin or porcelain laminate veneers, it is teriorly and insert implants in the premolar areas11
possible to treat patients with one or both missing (Figs. 7,8).
maxillary lateral incisors and a coexisting maloc- Our experience with currently available
clusion to a result that provides the look of a materials for composite build-ups has been unsat-
healthy, natural dentition.20,21 isfactory, since such restorations need frequent
A major advantage of such an approach is the maintenance and renewal. Except for composite
permanence of the finished result. The alveolar “corners” on canines in lateral incisor positions,
bone height is maintained by early mesial move- we therefore prefer to use the more durable porce-
ment of the canine, and the need for removable or lain veneers.24,25 If desired, these can be made after
resin-bonded retainers until the implant insertion a retention period and after functional occlusal
is avoided. At the end of orthodontic treatment, adjustments by selective grinding. Porcelain
porcelain veneers can be placed directly on any of veneers on the canines and first premolars,20,21 as
the anterior teeth, because the two common rea- well as on the central incisors if these need to be
sons for postponing permanent restorations in widened or elongated,16,23 are more expensive for
young and adolescent patients—risk of pulp per- the patient than grinding and build-ups, but their
foration and exposure of gingival crown margins cost compares favorably with that of restorations
during tooth eruption—are not contraindications on single-tooth implants. Long-term maintenance
for the minimally invasive preparations with of composite resin build-ups can also be expensive.
enamel-bonded porcelain.24,25 The tendency of the The porcelain veneers have shown excellent long-
spaces to reopen after treatment can be overcome term durability and esthetics, even when the gin-
with properly finished occlusal contacts and long- gival margin retracts with time. Light reflection
term retention. A bonded retainer should be sup- appears normal, in contrast to ceramic crowns and
plemented with a removable plate to be worn porcelain-fused-to-gold teeth, where the shadow-
continuously for six months and then at night. No ing effect of the incoming light results in a dark
apparent side effects were noticed from this regi- background.24
men in a 10-year follow-up study.26 Agenesis of lateral incisors in Class III mal-
occlusions, especially with narrow maxillae and
*Dentsply Raintree Essix, 6448 Parkland Drive, Sarasota, FL pronounced spacing, has traditionally been regard-
34243; www.essix.com. ed as an undebatable indication for space reopen-
ing and prosthetic rehabilitation. It is held that the illary teeth adjacent to single implants in young and mature
adults: A retrospective study, J. Clin. Periodontol. 31:1024-
reopening of spaces facilitates expansion of the 1028, 2004.
maxillary arch and provides dentoalveolar com- 11. Zachrisson, B.U.: Single implant-supported crowns for the
pensation, significantly improving the profile. The anterior maxilla: Potential esthetic long-term (> 5 years) prob-
lems, World J. Orthod. 7:306-312, 2006.
Class III case shown here (Figs. 3,4), like similar 12. Dueled, E.; Gotfredsen, K.; Damsgaard, M.T.; and Hede, B.:
cases described previously,21,27 demonstrates that Professional and patient-based evaluation of oral rehabilita-
space closure can be a valid alternative. The tion in patients with tooth agenesis, Clin. Oral Impl. Res.
20:729-736, 2009.
changes in the face and profile are more corre- 13. Jemt, T.: Measurements of tooth movements in relation to
lated to modifications made in the vertical dimen- single-implant restorations during 16 years: A case report,
sion than to sagittal changes at the incisor level. It Clin. Impl. Dent. Related Res. 7:200-208, 2005.
14. Jemt, T.; Ahlberg, G.; Henriksson, K.; and Bondevik, O.:
is remarkable that in the patient shown here, even Changes of anterior clinical crown height in patients provided
after a 7mm retraction of the upper incisors with with single-implant restorations after more than 15 years of
a resulting anterior crossbite, there was no notice- follow-up, Int. J. Prosthod. 19:455-461, 2006.
15. Jemt, T.: Single implants in the anterior maxilla after 15 years
able profile change. Recent developments in mini of follow-up: Comparison with central implants in the edentu-
screws may facilitate anchorage in such cases. lous maxilla, Int. J. Prosthod. 21:400-08, 2008.
Class III patients with missing lateral incisors are 16. Björk, A. and Palling, M.: Adolescent age changes in sagittal
jaw relation, alveolar prognathy, and incisal inclination, Acta
obviously difficult to treat, and good compliance Odont. Scand. 12:201-232, 1955.
is mandatory, but long-term stability can still be 17. Bondevik, O.: Does pregnancy or use of contraceptives influ-
achieved without negative side effects on the face ence adult facial changes? J. Orofac. Orthop. 71:32-39, 2010.
18. Chang, M.; Wennström, J.L.; Odman, P.; and Andersson, B.:
and profile. Implant supported single-tooth replacements compared to
contralateral natural teeth: Crown and soft tissue dimensions,
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