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Inside Dentistry

February 2014, Volume 10, Issue 2
Published by AEGIS Communications

Conservatively Treating a Congenitally Missing Lateral Incisor

Treatment plan addresses patient’s short- and long-term esthetic goals

Amir N. Esfandiari, DDS

Maxillary lateral incisors are the second most commonly congenitally missing teeth and a major esthetic and functional concern for patients.1,2 Among the many treatment options documented in the literature3-9 is the widely used orthodontic canine substitution method. This technique involves moving the canine into the lateral space, then using enamelplasty to make the canine look like a lateral.2,4,5 Canine substitution is rarely esthetic, and it leads to a lack of ideal canine guidance. Another traditional but more aggressive treatment option is a tooth-supported restoration and fabrication of a fixed partial denture.3,6 A more current option is to provide the patient with an implant-supported restoration and orthodontic treatment.3,4,7,8

When treatment planning and presenting treatment options to patients, considerable weight should be given to non-destructive treatment options. Advances in dental technology and materials, accompanied by their proper use, have elevated the conservative options now available to the dentist. The author’s private practice is constantly seeking more conservative, simpler, and more practical techniques to restore teeth while being sensitive to their patients’ demands for minimally invasive and esthetic solutions.10,11

These days, patients are more knowledgeable about available treatment options and demand conservative restorations as their treatment of choice.12 The single-tooth implant has thus become the first choice for replacing missing teeth.7,9,13,14 The main advantage of single-tooth implant treatment, which leaves the adjacent tooth untouched, is its conservative benefit.4 However, providing implant-supported restorations for congenitally missing maxillary lateral incisors involves special consideration ranging from esthetic criteria, coronal space, inter-radicular space, osseous ridge deficiency, and timing of implant placement, among others, including cost.4,8,15-17

Once the decision to replace the missing lateral with an implant-supported restoration has been made, determining the timing, which depends on facial growth, is key. As the face grows, the dentition erupts, but implants do not. Therefore, implants placed prematurely may cause critical negative effects on the peridontium, occlusion, and appearance of the patient.4,16,18 According to Kokich, the most predictable way to determine the completion of facial growth is by evaluating the serial cepahlometic radiographs every 6 months. The implant can be placed if two sequential radiographs show no growth.4,19,20

Although it is well-established that these implants can be placed after the growth is completed,4,19,20 if the growth is not completed or if the patient is not ready to move forward with the implant placement after orthodontic treatment, it is important to retain the space that was created.

This article represents a conservative treatment option to restore the congenitally absent maxillary lateral incisor post-orthodontic treatment and pre-implant placement. In this case, the patient’s facial growth was not completed and she was not ready financially to move forward with implant placement. However, she had a very high esthetic and functional expectation, and wanted the most conservative restoration until she was ready to proceed with the implant placement. In this case, it was determined that a resin-bonded lithium disilicate fixed partial denture with proximal wings would provide the most predictable esthetics, strength, and retention.

Case Presentation

A 12-year-old patient presented with congenitally missing maxillary lateral incisors (Figure 1). After discussing all her options, an implant-supported restoration and orthodontic treatment were chosen. The patient would not be able to proceed with implant placement immediately after the completion of orthodontic treatment. Therefore, she wanted to improve her smile while retaining the edentulous area for a more sustainable restorative option in the future. The patient requested an esthetic orthodontic treatment option to avoid the less esthetic traditional brackets and wires. The chosen method in this case was Invisalign® (Align Technology, Inc., Clear brackets were bonded using a dual-cure bonding agent (Clearfil™ DC Bond, Kuraray America, Inc., on the maxillary canines and lower first molars. The patient was provided with clear elastic bands (5/16 in, 4.5 oz, Align Technology, Inc.) to help assure distalization of the canines. The orthodontic movement was completed after 24 months (Figure 2 through Figure 4).

The last Invisalign trays were used to help develop the gingival contour for ovate pontic. This was done in three increments to reduce discomfort for the patient and assure a stable papilla formation prior to impression for the final restoration (Figure 5). A purple dot was placed to locate the center of the edentulous area with a color transfer applicator stick (Dr. Thompson’s, Great Plains Dental Products, 6). Using gentle pressure, the pontic was delivered (Figure 7 and Figure 8).

After 3 weeks, the patient presented for the final impression. In keeping with the goal of delivering conservative dentistry, no preparation was done prior to taking the final impression.

A lithium disilicate material (IPS e.max®, Ivoclar Vivadent, was chosen for the fabrication of the all-ceramic unit with proximal wings that extended lingually onto the adjacent teeth to help with retention (Figure 9).

The surface area was etched using 35% phosphoric acid (Ultra-Etch®, Ultradent Products, Inc., for 15 seconds, assuring that the chalky white surface was uniform after thoroughly rinsing with water for 15 seconds.

The light-cured bonding agent (Clearfil™ SE Protect, Kuraray America Inc.) was thoroughly applied to the surface areas for 20 seconds, and then air-dried for 5 seconds.

The fabricated restorations were cemented using dual-cure adhesive cement (Clearfil Esthetic Cement EX, Kuraray America, Inc.) The excess cement was cleaned with a microbrush and flossed under the pontic prior to curing. The restoration were held in place with a gentle touch and light cured for 5 seconds (radii Plus, SDI, on the buccual and lingual (Figure 10 and Figure 11). A #12 stainless steel blade (Pearson Dental, was used to remove the excess cement prior to final curing for an additional 30 seconds on both the buccual and lingual.

Final occlusion was checked to make sure the patient was following the golden rules of occlusion, which include ensuring bilateral and even occlusal contact (Figure 12 and Figure 13). Immediately post-treatment, the maxillary lateral pontics had light contacts with the opposing teeth. The only contacts were on the cingulum with no contact on the proximal wings, staying true with the third golden rule of occlusion, unobstructed envelope of function. At 2-years post cementation, the patient presented for follow-up and was satisfied both with the short-term solution that addressed her esthetic concerns as well as the long-term plan for restoration (Figure 14 and Figure 15).


Congenital edentulism in pediatric patients presents a unique challenge for practitioners. While each case should be treatment planned on its merit, from a dentist’s perspective, higher consideration should be given to conservative restorations to satisfy the patient’s expectations as well as to maximize the benefits of the new materials available in dentistry today.


1. Thompson GW, Popovich F. Probability of congenitally missing teeth: result in 1,191 children in the Burlington Growth centre in Toronto. Community Dent Oral Epidemiol. 1974;2(1):26-32.

2. Rose JS. A survey of congenitally missing teeth, excluding third molars, in 6000 orthodontic patients. Dent Pract Dent Rec. 1966;17(3):107-114.

3. Trushkowskey RD. Replacement of congenitally missing lateral incisors with ceramic resin-bonded fixed partial dentures. J Prosthet Dent. 1995;73(1):12-16.

4. Kokich VO Jr., Kinzer GA, Janakievski J. Congenitally missing maxillary lateral incisors: restorative replacement. Counterpoint. Am J Orthod Dentofacial Orthop. 2011;139(4):435-445.

5. Kinzer GA, Kokich VO Jr. Managing congenitally missing lateral incisors. Part I: Canine Substitution. J Esthet Restor Dent. 2005;17(1):5-10.

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7. Kinzer GA, Kokich VO Jr, Managing congenitally missing lateral incisors. Part III: Single-tooth implants. J Esthet Restor Dent. 2005;17(4):202-210.

8. Kokich VO Jr. Maxillary lateral incisor implants: planning with the aid of orthodontics. J Oral Maxillofac Surg. 2004;62(9 suppl 2):S48-S56

9. Richardson G, Russell KA. Congenitally missing lateral incisors and orthodontic treatment considerations for the single-tooth implants. J Can Dent Assoc. 2001;67(1):25-28.

10. Ruiz JL. Achieving predictable, beautiful smiles using a dento-facial esthetic diagnosis system. Compend Contin Educ Dent. 2007;28(1):50-55.

11. Ruiz JL, Christensen GJ. Rationale for the utilization of bonded nonmetal onlays as an alternative to PFM crowns. Dent Today. 2006;25(9):80-83.

12. Esfandiari AN. Supragingival dentistry: a practical paradigm shift. Dent Today. 2011;30(8):106-107.

13. Sadan A, Blatz MB, Salinas TJ, Block MS. Single-implant restoration: a contemporary approach for achieving a predictable outcome. J Oral Maxillofac Surg. 2004;62(9 suppl 2):S73-S81.

14. Romeo E, Chiapasco M, Ghisolfi M, Vogel G. Long-term clinical effectiveness of oral implants in the treatment of partial edentulism. Seven-year life table analysis of a prospective study ITI dental implants system used for single-tooth restorations. Clin Oral Implants Res. 2002;13(2):133-143.

15. Grunder U, Gracis S, Capelli M. Influence of 3-D bone-to-implant relationship on esthetics. Int J Periodontics Restorative Dent. 2005;25(2):113-119.

16. Thilander B, Odman J, Lekholm U. Orthodontic aspects of the use of oral implant in adolescents: a 10 year follow-up study. Eur J Orthod. 2001;23(6):715-731.

17. Bolton WA. Disharmony in tooth size and its relationship to the analysis and treatment of malocclusion. Angle Orthodontist. 1958;28(3):113-130.

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20. Fudalej P, Kokich VG, Leroux B. Determining the cessation for vertical growth of the craniofacial structures to facilitate placement of single-tooth implants. Am J Orthod Dentofacial Orthop. 2007;131(4 suppl):S59-S67.

About the Author

Faculty and Course Instructor
The Los Angeles Institute of Clinical Dentistry
Los Angeles, California

Faculty, Clinical Associate Professor
USC School of Dentistry
Los Angeles, California

OC Center for Advanced Cosmetic Dentistry
Santa Ana, California

Emergency Care Panel
OC Dental Society
Santa Ana, California

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Image Gallery

Figure 1 Pre-orthodontic anterior view.

Figure 1

Figure 2 Post-orthodontic treatment; note the clear brackets on the mandibular first molars.

Figure 2

Figure 3 Post-orthodontic full face view.

Figure 3

figure 4 Post-orthodontic anterior view.

Figure 4

Figure 5 The last Invisalign tray shown with the marking transferred to the composite to fabricate the ovate pontic.

Figure 5

Figure 6 A color transfer applicator stick was used to mark the center of the edentulous area.

Figure 6

Figure 7 Delivering Invisalign modified temporary to develop the gingival contour.

Figure 7

Figure 8 When gentle delivering the pontic, slight benching is desirable.

Figure 8

Figure 9 Laboratory design for the no-prep pontic, showing the proximal wings.

Figure 9

Figure 10 Restoration held in place with gentle pressure to clean excess cement.

Figure 10

Figure 11 Restoration post-cementation left lateral view.

Figure 11

Figure 12 Restoration post-cementation anterior view.

Figure 12

Figure 13 Smile view post-cementation of the conservative restorations to replace congenitally missing lateral incisors.

Figure 13

Figure 14 Smile view at 2-year follow-up visit.

Figure 14

Figure 15 Full facial view at 2-year follow-up visit.

Figure 15