The dilemma of missing maxillary lateral incisors

Clinical Case

E, a 12-year-old patient, presents for a dental check-up at your practice; she and her mother are worried about her ‘gappy smile’. They want some advice about orthodontics and what might be the best treatment option. 

You determine from the panoramic radiograph that the maxillary permanent lateral incisors are congenitally missing. E is involved in performing arts and has high aspirations to pursue it as a career.

Your undergraduate training has provided you with the ability to put together an orthodontic problem list, which consists of the following information:

• congenitally missing maxillary lateral incisors
• excess space in the maxillary arch
• slightly increased anterior overjet (4mm) and overbite (3mm)
• half-unit class II posterior dental malocclusion
• increased gingival display upon smiling (3mm of gingival display).

What other diagnostic records might be required to supplement your current knowledge of E’s case? What advice can you offer to E and her mother about her cosmetic concerns? Do you feel comfortable discussing the potential treatment options with respect to risks, costs and benefits in the short, medium and long-term?

Overview 

Congenitally missing maxillary lateral incisor cases are relatively common and are often associated with both short and long-term clinical dilemmas. Numerous factors must be carefully considered in the diagnostic and treatment planning process. It is imperative that every relevant treatment option is evaluated from a cost-benefit perspective, and thoroughly discussed with the patient as part of the informed consent process. 
 
The respective advantages and disadvantages of both orthodontic space closure and the prosthetic replacement for missing lateral incisors must be clearly outlined to prospective patients. Restorative dental implants were once perceived to be the panacea for replacement of missing or severely compromised teeth. However, ongoing research and clinical experience has highlighted significant issues with restorative implants, particularly when planned for the critical aesthetic zone of an adolescent or young adult patient.
 
Patient expectations and demands are increasing, which places the onus on clinicians to provide pleasing aesthetics and a reliable, functional outcome within a reasonable timeframe. In addition to this, particular attention must be paid to the likely ongoing maintenance and expected longevity of the treatment.