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To Open or to Close Space – That is the Missing Lateral Incisor Question

Article  in  Dental Update · January 2005

DOI: 10.12968/denu.2005.32.1.16 · Source: PubMed

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R E S R E SR T
T O AOT IR VAET IDVEEN TD IES NT T
RYI S T R Y / O R T H O D O N T I C S

To Open or to Close Space – That is

the Missing Lateral Incisor Question
LEE SAVARRIO AND GRANT T. MCINTYRE

MANAGEMENT
Abstract: Developmentally absent permanent maxillary lateral incisors may be
associated with several problems. The decision whether to open or to close the space
should involve the patient/parent, orthodontist and restorative dentist. To optimize Deciduous/Mixed Dentition
function and aesthetics, space should be opened using fixed appliances to accommodate
an appropriate prosthesis. Implant-retained crowns offer several advantages, although Suspected absence of the permanent
adhesive bridges are more appropriate in certain circumstances. Removable partial maxillary lateral incisor should be
dentures may be necessary in some instances. Where space opening is not feasible, confirmed radiographically if the tooth
practical or desirable, any residual spacing can be closed using fixed appliances and the has failed to erupt by the age of 9 years,
permanent maxillary canines modified to resemble lateral incisors. or within 9 months of the contralateral
tooth.5 Where possible, the deciduous
Dent Update 2005; 32: 16-25 lateral incisor should be maintained for
Clinical Relevance: The appropriate clinical management of developmentally as long as possible to preserve alveolar
absent permanent maxillary lateral incisors is essential to provide optimum aesthetics bone for a potential implant-retained
and function. crown. Composite resin can be added to
maintain the mesial, distal and incisal
dimensions.6 However, if extraction of
the contralateral deciduous tooth is
indicated, both deciduous maxillary

T he incidence of developmentally
absent permanent maxillary lateral
incisors is 1–2% in Caucasian
populations1 and accounts for
approximately 20% of all missing
permanent teeth.2 The condition occurs
more commonly bilaterally than
unilaterally, and is classed as mild
hypodontia. Furthermore, the permanent
maxillary lateral incisors are frequently
developmentally absent in moderate and
severe hypodontia cases. Hypodontia is
often associated with microdontia
affecting other teeth.3 Developmentally
Lee Savarrio, BDS, FDS RCPS (Glasg.), FDS
(Rest. Dent.) RCPS (Glasg.), Consultant in
Restorative Dentistry, Glasgow Dental Hospital &
School, 378 Sauchiehall Street, Glasgow, G2 3JZ
and Grant T. McIntyre, BDS, FDS RCPS
(Glasg.), MOrth RCS(Edin.), PhD, FDS(Orth.)
RCPS(Glasg.), Consultant Orthodontist, Dundee
Dental Hospital & School, 2 Park Place, Dundee,
DD1 4HR.
absent permanent maxillary lateral
incisors present a specific set of
problems to the restorative dentist and
lateral incisors should ideally be
removed to maintain arch symmetry.
This also allows mesial eruption of the
orthodontist when compared to those permanent maxillary canines into a
lost by caries or trauma.
Problems Associated with
Developmentally Absent
Permanent Maxillary Lateral
Incisors
The developmental absence of
permanent maxillary lateral incisors may Figure 1. Bilaterally developmentally absent
result in a number of aesthetic problems. permanent maxillary lateral incisors associated
with spacing, a median diastema and drifting/
These include unsightly spacing
rotation of the adjacent teeth.
between the permanent central incisor
and canine, a median diastema and
drifting and rotation of the central
incisor and canine (Figure 1). In
unilateral cases, these effects are
asymmetric. Moreover, the centre-line
may be shifted to the affected side,
Figure 2. Unilaterally developmentally absent
whilst the contralateral tooth is permanent maxillary lateral incisor. Note the
frequently diminutive4 (Figure 2). diminutive contralateral tooth.

16 Dental Update – January/February 2005

 R E S T O R AT I V E D E N T I S T RY

orthodontic or restorative treatment, parafunctional grinding/clenching, pen-

even in ostensibly motivated and co-
operative patients.
The teeth should be examined for their
size, shape, colour and position,
especially in relation to the facial and
dental midlines (Figure 5). The static
occlusal relationship and, in particular
the interocclusal space available in the
lateral incisor region, should be
investigated. The dynamic occlusal
relationship should also be examined, to
determine if anterior guidance is present,
and whether it can be preserved.
Adverse habits such as
Figure 3. Palatally ectopic maxillary permanent
canine associated with a developmentally absent
permanent maxillary lateral incisor.
Assessment
chewing or nail biting should be
identified as these can adversely impact
on the success of implant-retained
crowns9 and resin-retained bridgework.
TREATMENT OPTIONS
In patients with developmentally absent
permanent maxillary lateral incisors,
orthodontic treatment will usually be
required. This will either be to create/
redistribute space for an implant-
retained crown or an adhesive bridge or,
alternatively, to close residual space,


position more amenable to space


Is treatment required? No Monitor
closure. Moreover, the developmental
absence of permanent maxillary lateral
incisors is associated with an increased Yes
prevalence of ectopic permanent

maxillary canines7 (Figure 3) and early Joint planning
extraction of the deciduous maxillary Restorative Dentist / Orthodontist / GDP
canine may be indicated to normalize the
eruption pathway of the aberrant



permanent maxillary canine.8 Space opening Space closing

 
Is tooth movement required? No No Is tooth movement required?
Permanent Dentition
Definitive treatment planning should Yes Yes
ideally be undertaken by the
orthodontist and restorative dentist  
Orthodontic Treatment Orthodontic Treatment
during a joint appointment when the Fixed appliances to open space for Fixed appliances to close residual
permanent dentition has established, in prosthetic teeth lateral incisor space
particular following the eruption of the
 
permanent maxillary canine teeth (Figure Orthodontic Retention Orthodontic Retention
4). This will determine the most Hawley / pressure-formed retainer Bonded retainer +/- Hawley /
appropriate treatment for the individual incorporating acrylic teeth +/- pressure-formed retainer
Bonded retainer
patient. 



The extra-oral clinical examination Is the shape of canine acceptable?

should pay special attention to the smile Restorative Dentistry


Prosthetic lateral incisor

line, gingival display, dentofacial
Implant-retained crown No
symmetry and the facial profile. The
Adhesive bridge
intra-oral investigation should assess  Yes
Restorative Dentistry
the periodontal tissues to identify any Canine reshaping
mucogingival problems that may require
Composite resin
periodontal plastic surgery as part of the
Cuspal grinding

Laminate veneer
overall treatment. This may include



augmentation of ridge defects or Restorative Maintenance / Orthodontic Retention

surgical crown lengthening. Gingivitis, Regular monitoring of occlusion, orthodontic retainers and restorations
caries and tooth surface loss should be
controlled before initiating any Figure 4. Space opening/space closing decision pathway.

Dental Update – January/February 2005 17

 R E S T O R AT I V E
Figure 5. Significant midline shift of the
maxillary teeth due to the developmental
absence of a permanent maxillary lateral
incisor.
usually in conjunction with modification
of the shape of the adjacent permanent
canine tooth (Table 1).
It is unusual for patients to be
prepared to accept the aesthetics
associated with developmentally absent
permanent maxillary lateral incisors
(Figure 6). Furthermore, where these
teeth are developmentally absent,
restorative treatment is seldom indicated
in the absence of any orthodontic
treatment. Nevertheless, the judicious
placement of composite build-ups or
porcelain laminate veneers can often
successfully disguise permanent
maxillary canines or retained deciduous
teeth, where the pre-treatment positions
of these teeth are acceptable. Rarely,
adequate space exists in the lateral
Treatment options for developmentally absent permanent maxillary lateral incisors
Bilateral cases
1. No treatment
2. Canine reshaping, adhesive bridgework or
implant-retained crowns without
orthodontic treatment
3. Space closure and canine reshaping
4. Space opening for implant-retained
crowns or adhesive bridgework
Table 1. Treatment options for developmentally absent permanent maxillary lateral incisors.
18
D E N T I S T RY
incisor region to allow the placement of
an implant-retained crown or adhesive
bridge, without any prior orthodontic
treatment.
Autotransplantation of a caries-free
and pathology-free mandibular premolar
into the maxillary central incisor area is a
viable treatment option.10 This should
also be considered for developmentally
absent permanent maxillary lateral
incisors where adequate space exists
and the extraction of such a tooth is
required as part of the orthodontic
treatment plan. However, the outcome of
autotransplantation is less predictable
than the 90–95% success rates for
implant dentistry.11
Open Space/Close Space
Decision
Generalized spacing in the arch
indicates that space opening for a
subsequent prosthesis will usually be
more appropriate than space closure
(Table 2). Conversely, where crowding
is present, space closure is preferable.
This is because, although space
opening for prosthetic maxillary lateral
incisors provides optimal function and
aesthetics, the sacrifice of pathology-
free maxillary premolars in cases with
mild crowding is invariably an
excessive biological cost for a modest
functional and aesthetic gain. It is
preferable to consider distal movement
of the maxillary buccal segment teeth
using either headgear or orthodontic
implant(s) as an alternative to premolar
Unilateral cases
1. No treatment
2. Canine reshaping, adhesive bridgework or
implant-retained crown without
orthodontic treatment
3. Space closure and canine reshaping
4. Space opening for implant-retained crown
or adhesive bridgework
5. Extraction of the contralateral permanent
maxillary lateral incisor followed by
orthodontic space closure on both sides
and canine reshaping
Dental Update – January/February 2005
Figure 6. Developmentally absent permanent
maxillary lateral incisors in a patient who was
happy with the position and morphology of the
permanent canines.
extractions where space opening is
planned.
Unilateral developmental absence of
a permanent maxillary lateral incisor is
more difficult to manage than the
corresponding bilateral situation. This
is because it is difficult to achieve near-
perfect dental symmetry, even with
excellent orthodontic and restorative
treatment. This is particularly evident
when the canine teeth are yellow and/or
pointed (Figure 7). Notably, bilateral
absence facilitates the use of similar
techniques on both sides. Even when
the result is a compromise, the
aesthetics can be excellent because
dental symmetry has been achieved.
The greater the amount of tooth show,
the poorer the aesthetics of space
closure, especially because the
relatively high gingival margin of the
permanent maxillary canine compared to
the lateral incisor adversely impacts on
the aesthetics of space closure.
In unilateral cases of developmental
absence of a permanent maxillary lateral
incisor, extraction of the contralateral
tooth and space closure (followed by
canine reshaping) may be considered to
be an acceptable compromise in order
to achieve dental symmetry, particularly
if this tooth is diminutive or ‘peg
shaped’ (Figure 2). However, when
space opening is planned in unilateral
cases, consideration can be given to
placing a porcelain veneer or dentine-
bonded crown on the diminutive
contralateral tooth, if adequate space
can be made available and if a
reasonable root structure exists.
Space closure in the maxillary arch
may worsen a Class III incisor
relationship. Thus, in these cases
space opening is usually undertaken.
Where the skeletal discrepancy is not
 R E S T O R AT I V E
F A C T O R
Dental health
Unilateral absence
Bilateral absence
Generalized hypodontia/microdontia
Skeletal pattern
Arch alignment
Colour and morphology of adjacent
teeth
Smile line
Planned buccal segment relationship at
end of treatment
Other factors
Table 2. Factors to consider in the space opening/closing decision.
severe, the space opening mechanics
may also produce a stable Class I
incisor relationship at the end of
treatment, if sufficient overbite is
present. In cases with Class II skeletal
patterns, the forces used to open space
may further increase the overjet.
Therefore, if space opening for a
prosthetic tooth is to be undertaken,
anchorage support or distal movement
of the buccal segment teeth may be
required. Where orthognathic surgery
is required, space can be successfully
closed in Class III cases and opened in
Class II cases, as the surgical
movements will accommodate any
adverse changes in the incisor
relationship. Interestingly, an
alternative strategy has been proposed
using surgically-assisted rapid
maxillary expansion where the
Figure 7. Yellow/pointed permanent maxillary
canines.
20
D E N T I S T RY
Caries risk potential
Oral hygiene
Periodontal diseases
Toothwear
Ideally space opening to achieve dental symmetry
Space opening or space closure will achieve symmetry
Space opening usually more appropriate
Class 3 more suited to opening space
Class 2 more suited to closing space
Spacing: Space opening usually more appropriate
Crowding: Space closing usually more appropriate
Yellow/pointed teeth are difficult to modify
Microdontia can make space closure difficult to achieve
Space opening better in ‘toothy’ smile
Gingival equilibration may be necessary in ‘gummy’ smile
Class I with non-extraction lower arch is usually
amenable to space opening
Habits
Co-operation and motivation
Age of patient
osteotomy cut was modified to open
space in the lateral incisor region, in
contrast to the more conventional
midline expansion.12
Diagnostic Set-up
A prediction of the outcome of the open
space/close space options can be
generated using duplicated models, on
which the relevant plaster teeth are
repositioned, modified with wax or
replaced with acrylic teeth (Figure 8).
This process should be conducted
before treatment commences to allow
patient and parent input (where
relevant) into the treatment planning
process. Furthermore, it provides an
opportunity to evaluate the feasibility of
the exact orthodontic tooth movements
and the nature of the restorative
treatment thereafter.
OPENING SPACE
Orthodontic Treatment
In adolescent patients, it is prudent to
assume that implant-retained crowns
Dental Update – January/February 2005
may be used at some point in the future.
Orthodontic treatment should therefore
be planned accordingly.
How much Space do We Require in the
Maxillary Lateral Incisor Region?
Most permanent maxillary lateral incisor
crowns are 7 mm mesio-distally and are
in ‘golden proportion’ to the width of
the permanent central incisor (i.e. in a
ratio of 1:1.618). This is generally
accepted to provide optimal dental
aesthetics.13 Where a contralateral
diminutive permanent maxillary lateral
incisor is to be retained, this tooth
should ideally be built up using
composite resin before orthodontic
treatment commences, if space is
available. This assists space localization
and the production of dental symmetry
during orthodontic treatment (Figure 9a,
b). Sufficient interocclusal clearance is
required for both adhesive bridgework
and implants,14 whilst adequate inter-
radicular space is a pre-requisite for
implant-retained crowns.
Fixed appliances are required for
three-dimensional tooth control when
opening space and, in particular,
facilitating root uprighting and bodily
movement of the permanent maxillary
central incisor and canine teeth. When
using a pre-adjusted edgewise fixed
appliance system, ‘push-pull’ mechanics
are frequently used, involving open-coil
spring in the lateral incisor region (the
‘push’) and lacebacks to retract the
canine (the ‘pull’). Once appropriate
space has been opened, closed-coil
spring (Figure 10) or an acrylic denture
tooth attached to the orthodontic
archwire via a bonded bracket (Figure
Figure 8. Diagnostic set up to illustrate the
feasibility of opening/closing space (Centre = pre-
treatment, Left = space closure followed by
canine reshaping with wax and Right = space
opening followed by prosthetic replacement of
permanent maxillary lateral incisors).

a b
Figure 9. Diminutive contralateral permanent maxillary lateral incisor: (a) pre-treatment; (b)
built up prior to orthodontic treatment.
11) should be placed to maintain space.
As inadequate interocclusal space could
result in failure of the final restoration,
intrusion of the mandibular canine may
be required (Figure 12), using a
mandibular fixed appliance. Any
remaining overjet reduction and space
closure can then be accomplished and
the occlusion finished and detailed.
Where implant-retained crowns are
being contemplated, each case should
be reassessed by the restorative dentist
with the assistance of appropriate intra-
oral radiographs, to determine primarily
whether appropriate space exists for
both the implant fixture (where required)
and the coronal prosthesis. Several
other features must also be examined
and assessed. These are detailed in
Table 3. This reassessment should be
Figure 10. Closed coil spring to maintain space
opened earlier during orthodontic treatment.
Figure 11. Acrylic denture teeth with bonded
brackets to maintain space.
Dental Update – January/February 2005
R E S T O R AT I V E
done before removal of the fixed
appliance. If insufficient space exists for
the implant fixture, then further root
divergence of the canine and central
incisor may be accomplished by
judicious wire-bending.15 It is
recommended that, even where it is
planned to restore the developmentally
absent permanent maxillary lateral
incisor with an adhesive bridge, the
roots of the canine and central incisor
are uprighted to allow for any
subsequent implant placement. Adults
who have had earlier (adolescent)
orthodontic treatment to open space are
frequently referred regarding the
feasibility of placing an implant-retained
crown to replace an existing prosthesis.
Unfortunately, radiographic examination
often reveals either insufficient inter-
radicular space available for an implant
fixture, or an absence of canine and
central incisor root parallelism,
necessitating further pre-restorative
orthodontic treatment (Figure 13 a, b).
Orthodontic Retention
Following active orthodontic treatment,
the occlusion can be retained with either
a pressure-formed retainer (Figure 14) or a
Hawley-type retainer incorporating
prosthetic teeth15 (Figure 15). Pressure-
formed retainers are preferable, as they
can prevent relapse in all three
dimensions.16 When a Hawley-type
retainer is used, the baseplate acrylic
should ‘wrap-round’ the gingival one-
third of the mesial and distal surfaces of
the canine and central incisor,
respectively. Alternatively, wire stops
may be incorporated mesially on the
canine and distally on the central incisor,
if the occlusion precludes thicker acrylic
D E N T I S T RY
in these areas (Figure 15). Removable
retention is often supplemented with a
bonded retainer placed on the palatal
surfaces of the central incisors (Figure
16), especially where a pre-treatment
median diastema was present. As
orthodontic retainers usually require
extensive modification during the
restorative dentistry phase, a replacement
should be provided following
cementation of the implant-retained
crown or adhesive bridge.
Intermediate Restorative
Treatment
Definitive replacement of the
developmentally absent permanent lateral
incisor is not usually undertaken until the
gingival margins have stabilized and
alveolar growth has been completed.14
This is of particular relevance where
implant-retained crowns are under
consideration, because implants can
become infra-occluded if placed before
growth has been completed.17
Nonetheless, removable orthodontic
retainers are not usually designed for
extended use over several years, whilst
removable partial dentures are usually
reserved for patients with multiple
edentulous spaces. Thus, a durable
intermediate fixed restoration may be
required. This will usually involve an
adhesive design of bridge preferably
without preparation to preserve enamel:
one recent advance utilizes glass fibre
reinforced composite material, such as
Ribbond (Ribbond Inc., Seattle,
Washington, USA) and filled composite
resin shaped into a maxillary lateral
Figure 12. Supra-erupted mandibular canine
requiring intrusion to create sufficient
interocclusal space for restoration of a
developmentally absent permanent maxillary
lateral incisor.
21
R E S T O R AT I V E D E N T I S T RY

Smile line and gingival contour

Height and width of bone at the implant
site

Radiographic assessment of bone quality,
volume and anatomy

Interocclusal space

Root position of the teeth adjacent to
the implant site

Local gingival thickness and architecture

Width, height and form of the adjacent
teeth

Amount of incisal wear of the adjacent
teeth

Presence of parafunctional activity and
occlusal forces

Probing depths and marginal gingival
position in relation to the amelocemental
junction
Table 3. Factors to consider when considering
implant-retained crowns.
incisor as a non-invasive method of
provisionalization.18
Definitive Restorative
Treatment
Implant-Retained Crowns
Implant-retained crowns are usually the
treatment of choice for the prosthetic
replacement of developmentally absent
permanent maxillary lateral incisors (Figure
17). This is because the success rates of
dental implants are 90–95%.11
Unfortunately, maxillary bone quality is
not as good as that in the mandible for
implant placement although, where the
permanent maxillary canine has been
a b
Figure 13. (a, b) Insufficient inter-radicular
space in a patient who had recently
completed orthodontic treatment to open
space for an implant-retained crown.
distalized from the lateral incisor space
orthodontically, bone quality is improved
due to appositional bone formation.
Nevertheless, ridge expansion can often
compensate for a lack of bone volume or
poor quality bone. Bone grafting may also
be necessary. Unfortunately, in patients
with a congenital cleft of the lip or palate
involving the alveolus, the bone-grafting
carried out during the late mixed dentition
stage may have resorbed, necessitating a
second alveolar bone graft at the
completion of growth to facilitate the
placement of an implant fixture.
Implant treatment can be complicated
by a lack of interocclusal space for the
restorative superstructure. Usually 7 mm
of clearance is required interocclusally,
although this can be minimized to around
4 mm when fixture head impressions and
customized abutments are employed.
Inadequate clearance may necessitate soft
or hard crestal tissue to be removed,
although ideally the opposing teeth
should be orthodontically intruded
beforehand.19 These factors should be
taken into account at the treatment
planning stage.
The minimum coronal mesio-distal
restorative space required is usually 7
mm. Standard Straumann (Waldenburg,
Switzerland) implants are 3.75 mm in
diameter at the body and 4.1 mm at the
platform. Therefore a minimum of 6.5
mm space is desirable between the
canine and central incisor roots.
However, narrow platform implants with
a coronal diameter of 3.3 mm can be
used where the mesio-distal restorative
Figure 14. Pressure-formed retainer
incorporating a maxillary prosthetic lateral
incisor.
Figure 15. Hawley-type retainer incorporating
maxillary prosthetic lateral incisors. (Note the
wire stops present on the mesial and distal
aspects of the permanent canines and central
incisors, respectively).
space is only 6 mm (Figure 18).
Adhesive Bridgework
Adhesive bridges are minimally
invasive. The ten-year survival rate for
anterior ‘Maryland’ type bridges is
around 60%.20 They are therefore
popular intermediate and definitive
restorations following orthodontic
treatment for developmentally absent
permanent maxillary lateral incisors
(Figure 19). A cantilever design is
usually preferred for retrievability
(Figure 16), although lack of crown
height can result in insufficient surface
area for bonding, lack of room for
framework connectors, as well as metal
‘show-through’ at the incisal one-third
of the canine. As a result, surgical crown
lengthening may be necessary. Bridge
design may involve developing wide
contact points in the porcelain. These
can prevent the proximal contacts from
slipping when the cantilever design is
used. Importantly, patients should be
aware that, when an adhesive bridge
debonds following orthodontic treatment,
space loss can be surprisingly rapid.

22 Dental Update – January/February 2005

 R E S T O R AT I V E D E N T I S T RY
Figure 16. Bonded retainer placed on the
palatal surfaces of the permanent maxillary
central incisor teeth to retain the orthodontic
closure of a pre-treatment median diastema.
Adhesive bridges were then placed to replace the
developmentally absent permanent maxillary
lateral incisors.
Figure 17. Implant-retained crown placed
following space opening with fixed appliances.
Conventional full-preparation
bridgework is now usually only reserved
for patients where the supporting teeth
are heavily restored.
CLOSING SPACE
Orthodontic Treatment
Closing space to avoid the need for
prosthetic maxillary lateral incisors has
traditionally been considered a
compromise since the aesthetics are
inferior to those of the ‘full smile’.
Nevertheless, where appropriate, this
option can produce very good results. As
with space opening, fixed appliances are
essential for optimal tooth positioning.
When using a pre-adjusted edgewise
prescription with positive canine torque,
the canine bracket can be inverted.
Alternatively, a lateral incisor bracket
could be bonded to the canine (Figure
20). Both methods torque the canine root
palatally, reducing the canine eminence
and locate the canine root similar to the
24
position that should have been occupied
by the permanent maxillary lateral incisor.
Elastomeric chain is most frequently used
to close space. Subtle orthodontic
movements may include additional palatal
root torque for the canine,21 mesial
rotation of the first premolars for
aesthetics19 or canine extrusion to allow
the gingival margin to be positioned more
incisally to mimic that of a lateral incisor.19
Buccal root torque can also be added to
the archwire in the first premolar region to
eliminate non-working side contacts on
excursive movements of the mandible
and improve aesthetics. As with space
opening cases, when both the
orthodontist and restorative dentist are
satisfied that the canine is in its optimal
position and the occlusion has been
finished and detailed, the fixed appliances
can be removed.
Orthodontic Retention
In cases with pre-treatment spacing, it is
usually advisable to place a bonded wire
retainer on the palatal surfaces of the
permanent maxillary central incisors and
canines. As this may interfere with the
reshaping of the canines, the placement
of the bonded retainer may need to be
postponed until the restorative treatment
has been completed. A Hawley-type
retainer, or preferably a pressure-formed
retainer, should also be provided,
accepting that a replacement will be
required on completion of the restorative
treatment.
Restorative Reshaping
Restorative reshaping or
Figure 18. Dimensions of various Straumann
(Waldenburg, Switzerland) implant systems
(NN = narrow neck, RD = regular diameter,
SS = solid screw).
Dental Update – January/February 2005
‘remorphologization’ can be carried out
before, during or after the orthodontic
treatment. The pre-treatment canine
shape will determine whether enamel
reduction, composite build-up, veneer
placement or a combination will be
required in order to achieve optimal
aesthetics. In addition to producing a
more incisiform shape, mesial and distal
canine reduction can also eliminate any
tooth size discrepancy with the
mandibular incisors. Composite additions
may also be necessary to create incisal
corners (Figure 21). However, oversized
canines mesiodistally or buccolingually,
and a prominent cusp tip or cingulum can
all be contra-indications to reshaping,
especially when contemplating porcelain
veneers,19 not least because any veneer
preparation in this situation may need to
extend heavily into dentine.22 Where
composite build-up is appropriate in
isolation, any colour difference between
the new ‘laterals’ and incisors can be
reduced using vital bleaching with 10%
carbamide peroxide, if available.
Reduction of the palatal aspect of the
canine should be considered where there
is excessive anterior guidance.
Furthermore, adjustment of the palatal
aspect of the buccal cusp of the first
premolar should also be considered to
provide canine guidance or eliminate any
non-working side contacts. However, the
presence of a large palatal pulp horn in
children should not be ignored.23
MAINTENANCE
Maintenance treatment involves regular
monitoring for occlusal changes,
periodontal diseases and caries. Retainer
wear and appropriate oral hygiene
instruction require periodic
re-emphasis.
SUMMARY
Opening space with fixed appliances,
followed by either an implant-retained
crown or an adhesive bridge, provides
optimal aesthetics and function for
patients where permanent maxillary lateral
incisors are developmentally absent.

Figure 19. Adhesive bridges placed following
orthodontic treatment to open space in the
maxillary lateral incisor region.
Figure 20. Lateral incisor brackets bonded to
the permanent maxillary canines. (Note the
markings on the brackets.)
Figure 21. Composite additions to
‘remorphologize’ the permanent maxillary
canines into a permanent maxillary lateral
incisor following fixed appliance orthodontic
treatment to close space.
Where space opening is not feasible,
practical or desirable, any residual space
should be closed using a fixed appliance,
and the shape of the adjacent permanent
maxillary canines modified to resemble
that of permanent maxillary lateral incisors.
ABSTRACT
ALLYOU WANTED TO KNOW
ABOUT Ni-Ti INSTRUMENTS BUT
WERE AFRAID TO ASK!
Clinical Techniques in Endodontics.
Nickel-Titanium Usage and Breakage:
An Update. J. Wolcott. Compendium of
Continuing Education in Dentistry
2003; 24: 852–859.
Practitioners attending postgraduate
education courses are frequently
confused about the plethora of different
Dental Update – January/February 2005
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R E S T O R AT I V E
ACKNOWLEDGEMENTS
The authors are grateful to Mr Arshad Ali and Mr Iain
Buchanan for their helpful and constructive
comments on an earlier draft of this paper. Thanks
are due to Dr Manar Elkhazindar for the kind
permission to reproduce Figure 17. Mr James
Forrest is thanked for the laboratory work involved
in producing Figure 8. Institut Straumann AG
(Waldenburg, Switzerland) are also thanked for the
production of Figure 18.
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He stresses the importance of irrigation
and lubrication, of low speed with
controlled torque, and a very gentle
technique. In addition, the factors that
contribute to instrument fracture are
considered, with helpful hints to avoid
this disturbing event!
I particularly liked his closing
sentence – ‘Change is always fraught
with challenge, but when the skills are
developed, canal preparation can be
better, safer and more efficient’.
Peter Carrotte
Glasgow Dental School
25