European Journal of Orthodontics, 2018 1–6

doi:10.1093/ejo/cjy061

Original article

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Treatment of missing maxillary lateral incisors:
a clinical and aesthetic evaluation
Eva Josefsson and Rune Lindsten
Department of Orthodontics, The Institute for Postgraduate Dental Education, Jönköping, Sweden

Correspondence to: Eva Josefsson, Department of Orthodontics, The Institute for Postgraduate Dental Education, Box 1030,
SE-551 11 Jönköping, Sweden. E-mail: eva.m.josefsson@rjl.se

Summary
Objective:  The aim of this study was to evaluate whether implant therapy or orthodontic space
closure was the best treatment option for patients with missing maxillary lateral incisors.
Subjects and methods:  The implant group (I group) consisted of 22 patients aged <26 years who
had one or both maxillary lateral incisors substituted by a single implant-supported crown. The
space-closure group (SC group) consisted of patients matched with I  group patients based on
diagnosis, gender, and number. Examinations were performed by one examiner and occurred
at least 5  years after the prosthetic therapy or orthodontic treatment was finished. Clinical
examination of the 44 patients involved assessing the aesthetics and gingival conditions of the
implant-supported crown and the replacement canine, the occlusal morphology and the extraoral
characteristics. Both the patient and examiner answered a question about their satisfaction with
the aesthetic result.
Results:  Of the 12 variables analysed by the examiner, one variable was significantly improved in
the I group and five variables were improved in the SC group. There were no significant differences
between the treatment groups for the remaining six variables. Gingival colour and crown length
were better in the SC group, and crown colour was better in the I group. There were no significant
differences between the groups with regards to the patient’s and examiner’s overall aesthetic
satisfaction of the maxillary anterior teeth or between the patient’s and examiner’s opinion.
Conclusion:  If both treatment alternatives are available, space closure is preferable.

Introduction treatment alternatives can compromise the aesthetics and periodon-

tal health and function.
A missing maxillary lateral incisor is a common feature in the ortho-
The most common treatment alternatives are space closure or
dontic diagnosis panorama. The prevalence of maxillary lateral inci-
tooth substitution by an implant-supported crown. The advantages
sor agenesis varies between 1.5% and 2% (1,2). Other reasons for
of space closure are that treatment can be finished at an earlier age
missing maxillary lateral incisors are extraction due to trauma or
and that no artificial material needs to be inserted in the jaw. If the
root resorption (3).
missing maxillary lateral incisor needs to be substituted, an osseoin-
The phenomenon of missing maxillary lateral incisors has always
tegrated implant is an alternative therapy. In this case, space open-
engaged orthodontists, prosthodontists, and patients as it is an aes-
ing is often required. Early pre-prosthetic space opening may reduce
thetic dilemma. Treating these patients requires an interdisciplinary
the bone volume in the alveolar ridge, therefore pre-prosthetic
approach that aims to rehabilitate the smile in terms of both func-
orthodontic treatment should be delayed as long as possible (7,8).
tion and aesthetics (4,5). Treatment options include orthodontic
Follow-up studies after implant-supported crown therapy identified
space closure, a resin-bonded bridge or tooth-supported fixed pros-
some unwanted complications, including soft tissue degeneration,
thesis, autotransplantation, or an implant-supported crown (6). All
discoloured gingiva, visible screws and infraocclusion (9). The soft

© The Author(s) 2018. Published by Oxford University Press on behalf of the European Orthodontic Society. All rights
1
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2 European Journal of Orthodontics, 2018
tissue can be affected both in the adjacent gingiva and the papillae.
Regeneration of gingival papillae after single-implant treatment is
classified according to Jemt’s index (10).
Different biotypes with different anatomical conditions (i.e. bone
volume, papilla size, and arch form) influence the prognosis and treat-
ment outcomes (11). Several studies showed that craniofacial skeletal
alterations continue during adulthood (12), and Iseri and Solow also
found continued tooth eruption until 25 years of age (13). These obser-
vations have raised questions about the long-term aesthetic results of
implant-supported crown therapy and if this is a good treatment alter-
native in the long run.
During treatment planning, the orthodontist needs to take some fac-
tors into consideration, including the available space in the dental arch and
alveolar bone, occlusion, profile, inclination of the incisors, and exposure
of the gingiva. Both treatment alternatives are possible in most patients.
The aim of this study was to evaluate, both functionally and aesthetic-
ally by professionals and patients, whether implant therapy or orthodontic
space closure in the aesthetic zone was the best long-term treatment option
in patients with missing maxillary lateral incisors. The hypothesis was that
there was no difference between the two different treatment strategies.
Subjects
The study was approved by the Local Ethics Committee, Linköping,
Sweden (number 2013/428–31), and conducted at the Institute
for Postgraduate Dental Education, Jönköping, Sweden. Patients
with oligodontia or congenital clefts in the lip, jaw, or palate were
excluded.
The implant group (I group) consisted of patients born between
1979 and 1989, who were ≤25  years of age at implant surgery, and
who had one or both maxillary lateral incisors substituted by a single
implant-supported crown. The surgical procedure was performed at
the Department of Oral and Maxillofacial Surgery or the Department
of Periodontology between 2001 and 2008. A total of 41 patients (20
males and 21 females) with implants met the criteria. These patients were
contacted by letter and informed about the study at the Orthodontic
Department, and 22 (8 male and 14 female patients) agreed to partici-
pate. The surgical procedure was performed by eight different special-
ists, and the prosthetic treatment was performed by seven prosthodontic
specialists. Examination was performed at least 5 years after prosthetic
therapy when the age of the patients varied between 24.6 and 33.7 years.
The space-closure group (SC group) consisted of 22 patients
who were consecutively selected based on diagnosis, gender and
number of patients. The patients were born between 1984 and
1994 and registered at the Department of Orthodontics between
2002 and 2004 due to missing one or two maxillary lateral inci-
sors due to agenesis or extraction. All patients were treated with
fixed orthodontic appliances in one or both jaws, and the ortho-
dontic treatment was performed by 11 different specialists. The
patients were contacted by letter and informed about the study
at the Department of Orthodontics, and all 22 agreed to par-
ticipate. Examination was performed at least 5  years after the
Table 1.  Number of patients with missing maxillary lateral incisors treated with implant-supported crowns (I group) or orthodontic space
closure (SC group)
Group Number of patients (n)
Implant (I group) 22
Space closure (SC group) 22
Total 44
orthodontic treatment was finished when the age of the patients
varied between 20.5 and 30.7  years. The final study groups are
presented in Table 1.
Methods
The interviews and clinical examinations of the 44 patients were
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conducted by one examiner (EJ). The clinical examination composed
of three areas:
1. The aesthetics of the implant-supported crown and the canine
replacing the lateral incisor:
(a) Colour of the adjacent gingiva (normal, different, or not
acceptable)
(b) Crown colour (optimal, acceptable, or not acceptable)
(c) Crown length (normal or abnormal (long or short) in relation
to the central incisors)
2. The gingival conditions of the implant-supported crown and the
canine replacing the lateral incisor:
(a) Visible screws (yes or no)
(b) Buccal gingival recession measured from the cementoenamel
junction to the gingival margin (to the nearest 0.5 mm)
(c) Bleeding when probing (six sites for each study tooth)
(d) Papilla formation according to Jemt (10):
(i)  Score 0: No papilla present
(ii)  Score 1: Less than half of the height of the papilla is present
(iii)  Score 2: Half or more of the height of the papilla is present
but does not extend all the way up to the contact
point between the teeth
(iv)  Score 3: The papilla fills up the entire space
(v)  Score 4: The papilla is hyperplastic
3. Occlusal morphology and extraoral assessment:
(a) Sagittal dental relationship (Angle classification I, II, or III)
(b) Space condition (normal, spacing, or crowding)
(c) Overjet (the distance from the most labial point of the incisal
edge of the maxillary incisors to the most labial surface of the
corresponding mandibular incisor. Measured to the nearest
0.5 mm, parallel to the occlusal plane)
(d) Overbite (measured vertically from the incisal edge of the most
inferior maxillary incisor to the incisal edge of the correspond-
ing mandibular incisor. Measured to the nearest 0.5 mm)
(e) Inclination of maxillary incisors (normal, proclined or
retroclined)
(f) Midline in the upper jaw (normal or midline shift)
(g) Lip closure (normal or strained)
(h) Appearance when smiling (normal, acceptable, or not
acceptable)
(i) Harmony of the study tooth to the rest of the dentition (nor-
mal, acceptable, or not acceptable)
The patients and examiner were asked if they were satisfied with the
aesthetic result of the appearance of the anterior teeth. The response
was designed with fixed statements: ‘yes’, ‘acceptable’, or ‘no’.
Patients with
One tooth (n) Two teeth (n) Number of teeth (n)
16 6 28
10 12 34
26 18 62
E. Josefsson and R. Lindsten
Method error
Reliability test
To test the interexaminer reliability, intraoral and extraoral photo-
graphs of 10 randomly selected patients were assessed by the main
examiner (EJ) and another examiner (RL, an orthodontist). The
variables tested included the colour of the adjacent gingiva, crown
colour of the implant-supported crown and of the canine-replaced
lateral incisor, appearance when smiling, and overall satisfaction
with the appearance of the maxillary anterior teeth. Weighted
Kappa statistics and percentage were used for the reliability test,
with weighted Kappa equalling 0.73 and the percentage agreement
varying between 75% and 90%.
Intraexaminer reliability was also tested using the same pho-
tographs and variables used in the interexaminer reliability test.
Examiner EJ performed the second assessment 1 week after the first
assessment. The intraexaminer reliability was 0.62 according to
the weighted Kappa statistics, and the percentage agreement varied
between 72% and 82%.
Reliability tests were also performed on five young adults aged
25–35  years old who were randomly selected at the Institute for
Postgraduate Dental Education. The intraexaminer reliability of the
‘bleeding on probing’ measurement was tested when probing at six
sites for the six anterior maxillary teeth (a total of 36 sites) by exam-
iner EJ. A second examination was performed in the same manner
and by the same examiner on the day after the first examination.
Reliability was analysed by Cohen’s Kappa statistics and was found
to be 0.83.
Statistical methods
All data were analysed using SPSS software (version 22; IBM Corp.,
Armonk, NY, USA). The sample size was calculated based on the
possibility of detecting a difference of 35% in rating outcome of
crown and gingival appearance with a significance level of 0.05 and
power of 80%. The power analysis showed that 22 patients in each
group were sufficient.
Table 2.  Comparison between the two groups with missing maxillary lateral incisors with regards to the aesthetic evaluation of the teeth
and adjacent gingiva. The implant group contained 22 patients with 28 implant-supported crowns, whereas the space-closure group con-
tained 22 patients with 34 missing lateral incisors substituted by canines
Implant group
Variables Number of teeth
Different or non-acceptable gingival colour 17
Non-acceptable crown colour 0 0
Abnormal crown length (long or short) 17
*P < 0.05; **P < 0.01.
Table 3.  Gingival conditions at the 28 implants and 34 maxillary canines substituted for lateral incisors in patients with missing maxillary
lateral incisors
Implant group
Variables Number of teeth
Buccal gingival retraction 8 29
Bleeding when probing 7 25
Papilla defect 20
NS, non-significant.
3
Descriptive statistics were used. The differences between groups
were tested for significance using the non-parametric Pearson’s chi-
square test and Fisher’s exact test. Differences with probabilities less
than 5% (P < 0.05) were considered statistically significant.
Results
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A total of 22 patients received 28 implant-supported crowns in the
region of the maxillary lateral incisor, and 34 maxillary lateral inci-
sors were substituted by maxillary canines in 22 patients (Table 1).
Aesthetics
A discoloured gingiva (classified as different or not acceptable) adjacent
to the implant-supported crown was found in 61% (n = 17) of patients:
eight were classified as not acceptable. In the SC group, 9% (n = 3) of
maxillary canines had a discoloured adjacent gingiva. There was a signifi-
cant difference between the two treatment groups (P = 0.001; Table 2).
All 28 implant-supported crowns showed an optimal or accept-
able colour. In the SC group, 21% (n = 7) of maxillary canines did
not show an optimal or acceptable colour. The difference between
the groups was significant (P = 0.02).
A total of 17 (61%) implant-supported crowns were judged as
short, and five (15%) maxillary canines substituting the upper lateral
incisors had an abnormal crown length (P = 0.01; Table 2).
Gingival condition
In the I group, one of the 28 implant-supported crowns had a visible
screw and eight showed buccal gingival recession of 0.5–2.0  mm.
In the SC group, five canines showed buccal gingival recession of
0.5–2.0  mm. The distribution of different gingival conditions is
shown in Table 3. The frequency of teeth and implants with probe-
induced bleeding at any site was 25% in the I group and 35% in the
SC group.
In the I group, 20 implant-supported crowns had one or two papilla
defects (score = 0, 1, 2, or 4) and eight implants had normal papilla on
both the mesial and distal surfaces. In the SC group, 20 canines had
Space-closure group
% Number of teeth % P
61 3 9 **
7 21 *
61 5 15 *
Space-closure group
% Number of teeth % P
5 15 NS
12 35 NS
71 20 59 NS
4 European Journal of Orthodontics, 2018
one or two papilla defects (score = 2). When spacing occurred and the
papilla did not fill up the interdental space, the papilla was classified as
defective (score = 2). A total of 14 canines showed normal papilla on
both the mesial and distal surfaces (Table 3).
Gingival bleeding when probing
To put the variable ‘bleeding when probing’ in the correct context,
a total bleeding score for the six anterior teeth in each patient was
assessed with the study teeth excluded. The distribution of gingival
score in the two groups (I and SC) is shown in Figure 1. The mean score
for the I group and SC group was 17.2% and 19.4%, respectively.
Occlusal morphology and extraoral assessment
Angle Class I occlusion was found in 77% of patients in the I group
and 86% of patients in the SC group. In the I  group, the overjet
varied between 0 and 5 mm (mean = 3 mm), and the overbite varied
between −1.5 and 7 mm. In the SC group, the overjet varied between
1 and 5 mm (mean = 2.8 mm), and the overbite varied between 0 and
7  mm. For the Angle classification variables, overjet and overbite,
there were no significant differences between the two groups.
A total of 11 and 15 patients in the I group and SC group, respect-
ively, had some spacing in the maxillary anterior region. Crowding
was rare in both groups. For the maxillary midline deviation and
space condition variables, there were no significant differences
between the groups (Table  4). The upper incisors were signifi-
cantly more proclined in the I group (32%) than the SC group (4%;
P = 0.03; Table 4), and strained lip closure was significantly more
frequent in the I group (n = 5) than the SC group (n = 0; P = 0.048).
The appearance when smiling was not acceptable in seven
patients (32%) in the I group and two patients (9%) in the SC group
(P = 0.03). The harmony of the study teeth with the rest of the den-
tition was not acceptable in four patients in the I group and in two
patients in the SC group. There was no significant difference between
the groups (Table 4).
Satisfaction with the overall appearance of the
maxillary anterior teeth
In the I group, 15 patients were satisfied with the overall appearance
of the maxillary anterior teeth, 6 thought it was acceptable, and 1
thought it was not acceptable. In the SC group, 13 patients were
satisfied and 9 thought it was acceptable (Table 5).
In the I  group, the examiner was satisfied with the result in 5
patients, thought the result was acceptable in 13 patients, and
Figure  1.  Distribution of the number of patients with sites of gingival
bleeding when probing the six anterior teeth (except the study teeth) in the
percentage of total examined sites. No significant differences were identified
between the two groups.
thought the result was not acceptable in 4 patients. In the SC group,
the examiner was satisfied with the result in 9 patients, thought the
result was acceptable in 10 patients, and thought the result was
not acceptable in 3 patients. There were no significant differences
between the groups with regards to the patient’s and examiner’s
overall satisfaction with the maxillary anterior teeth (P  =  0.731;
Table 5).
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Discussion
In this study, 22 patients with 28 anterior implant-supported crowns
were compared to 22 patients with 34 maxillary canines substituting
lateral incisors. The aesthetics of the study teeth, gingival conditions,
and occlusal morphology were assessed by one examiner, and the
overall aesthetics of the maxillary anterior teeth were assessed by
both the patient and examiner. Of the 12 variables analysed by the
examiner, there were significant improvements in 1 variable in the
I group and in 5 variables in the SC group. There were no significant
differences between the treatment groups for the remaining six vari-
ables (Tables 2–4).
The crown length and gingival colour adjacent to the study teeth
were better in the SC group, and the crown colour was better in the
I group. Increased inclination of the maxillary incisors and strained
lip closure were more common in the I group. When evaluating the
overall aesthetic results, both patients and the examiner thought that
the aesthetics were equal in the two groups.
The aesthetics of the adjacent gingiva were significantly worse
in the I group than the SC group. This finding is in accordance with
Dueled et  al. (14) who found mucosal discolouration in 57% of
patients treated with implant- or tooth-supported crowns. The dis-
colouration is caused by resorption of the alveolar bone below the
mucosa (15). When the bone volume is reduced, bone augmentation
may be mandatory to avoid insertion of the implant in a nonoptimal
position. Unfortunately, even if the implant is well supported by the
bone at the time of insertion, progressive bone resorption can occur
due to the absence of periodontal ligaments (15).
Teeth colouration is a very important factor for patients. In this
study, all implant-supported crowns had an optimal or acceptable
colour that was better than the colour of the canines substituting
the lateral incisor (Table 2). The observation that the canines were
more yellow in colour is probably one reason for this result. This
result was also reported in other studies (16,17); however, it may
be possible to bleach the canines to achieve a better aesthetic result
and overcome this problem. In a study of self-perceived orthodontic
treatment needed in 18–19-year-olds in Sweden, dissatisfaction with
anterior teeth colour was more common than dissatisfaction with
irregularity or increased overjet or spacing (18).
Most of the implant-supported crowns were short (Table 2), and
this observation was reported in several earlier studies. One prob-
able explanation is that patients still had a growth in the alveolar
bone, with continuing tooth eruption of the adjacent teeth after the
crown therapy (9,15,19).
In the I group, the papilla adjacent to the implant was more fre-
quently assessed as worse when compared to the papilla adjacent to
canines in the SC group; however, this difference was not statistic-
ally significant (Table 3). Differences in papilla conditions adjacent
to implants and natural teeth were reported by other authors (20).
This study did not find any difference in bleeding upon prob-
ing between the groups (Table 3). In a follow-up study, Chang et al.
(21) found that implant-supported crowns had a higher frequency
of bleeding upon probing when compared to contralateral natural
E. Josefsson and R. Lindsten 5

Table 4.  Intraoral and extraoral evaluation (at clinical examination) of the two groups with missing maxillary lateral incisors. The implant
group consisted of 22 patients with implant-supported crowns, and the space-closure group consisted of 22 patients with lateral incisors
substituted by canines

Implant group Space-closure group

Variables n % n % P

Midline deviation maxilla 10 45 9 41 NS

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Spacing anterior maxilla 11 50 15 68 NS
Proclination of maxillary incisors 7 32 1 4 *
Strained lip closure 5 23 0 0 *
Non-acceptable appearance when smiling 7 32 2 9 *
Non-acceptable harmony of the study tooth with other teeth 4 18 2 15 NS

NS, non-significant; *P < 0.05.

Table 5.  Comparison between the implant group and space-closure group, and between the patient’s opinion and the examiner’s opinion,
with regards to satisfaction with the overall appearance of maxillary anterior teeth

Patient’s opinion Examiner’s opinion

Satisfied Acceptable Not acceptable Satisfied Acceptable Not acceptable

Group n % n % n % n % n % n %

Implant 15 68 6 27 1 5 5 23 13 59 4 18
Space closure 13 59 9 41 0 0 9 41 10 45 3 14

teeth; however, they had a much lower prevalence of bleeding (7%).
Pocket depth was not examined because of the different anatomical
structures in the gingival pocket.
Evaluation of the occlusion revealed an increased inclination
and increased prevalence of strained lip closure in the I  group
(Table  4). One explanation may be that some of the cases were
borderline for space closing. When creating enough space for an
implant, there is a risk of increased inclination of the upper inci-
sors; however, there are no studies with which to compare these
results. Uprighting of the maxillary incisors normally occurs from
adolescence to adulthood (22), which may influence the aesthetic
result as the implant-supported crown is still in its original pos-
ition (15).
There was no difference in midline shift between the two groups.
This must be assessed as a good result as some of the cases had a
unilateral missing lateral incisor. Other studies showed that asym-
metry is considered a disturbing factor for both patients and gen-
eral dentists (16,17); however, there are several treatment options to
overcome this problem if needed (15).
Orthodontists are reported to be less tolerant to aesthetic discrep-
ancies than patients (14,23,24), and this finding was supported by
the results of this study (Table 5). In a study assessing photographs
of treatment alternatives, Armbruster et  al. showed that the lay
population ranked photographs of canines replacing lateral incisors
as the best treatment result, whereas orthodontists preferred canines
as lateral incisors over implant therapy (25,26). In a Swedish study,
the results of space closure or prosthetic treatment were evaluated
by general dentists and the lay population. The general dentists were
less critical than the lay people when concerning overall appearance.
The most prevalent disturbing factor was the colour of the canine in
the position of the lateral incisor (16).
The limitations of this study were the small number of patients
and that the examinations were only performed by one examiner.
However, this was a clinical investigation and not a photo evalua-
tion study and therefore the reliability test made on photos is of less
importance. Despite this, it evaluates the agreement on the aesthetic
outcome. Nothing is known about the patients with implants who
declined to participate in the study. It may be that the patients who
participated did so because they were discontented with their own
teeth or because they think all dental care is important. It is also
difficult to attract young people (20–30  years old) to take part in
studies. All patients in the SC group participated in the study, prob-
ably as they were more prone to attend because of their interest in
orthodontic post-treatment check-ups.
Missing maxillary lateral incisors are often a problem for
patients, especially young patients. Therefore, early treatment
planning and early treatment are necessary. The most common
treatment alternatives are space closure and implant-supported
crowns. Different drawbacks were reported for both of the treat-
ment alternatives (27); for example, implant-supported crowns
commonly require a period of temporary prosthesis. This study
was performed to provide guidelines for choosing the best treat-
ment alternative when both therapies are an option. The evalu-
ation of implant (28) and space closing has shown different results
in different studies (6,7,9,15,29,30).
Andrade et al. (31) performed a systematic review and showed
that there was no scientific evidence to support any of the most com-
mon treatments for agenesis of maxillary lateral incisors, and there
is still a lack of good quality evidence regarding the best approach
for this clinical situation. In a study of eight study teeth, implants or
canines, Schneider et al. (28) showed that orthodontists and dentists
ranked implants and canine substitution as equally pleasing; how-
ever, laypersons preferred space closure. Therefore, it is difficult to
recommend one treatment as the superior option.
Finally, the overall aesthetic results of maxillary anterior teeth,
assessed by both orthodontists and patients, did not reveal any dif-
ference between the SC and I groups in this study, which confirmed
the hypothesis. There were some disadvantages with regards to the
aesthetics of soft tissue and clinical crowns in both treatment groups;
therefore, for this part, the hypothesis was rejected.
6 European Journal of Orthodontics, 2018
In conclusion, there were more variables with a significantly bet-
ter result in the SC group compared to the I group. Therefore, when
possible, space closure should be recommended. A  team approach
that combines carefully performed treatment planning and ortho-
dontic space closure is necessary for a good result. The advantages
of this are that the child will finish treatment as a young teenager and
the long-term adaptations of the teeth and supporting structures will
appear natural (15).
Funding
Futurum, Region Jönköping County, Sweden.
Acknowledgement
The authors thank Bo Rolander for help with the statistical analysis and
Associate Professor K. Bjerklin for the support.
Conflict of interest
None declared.
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