July, 2010
Esthetic Management of Missing Lateral Incisor
Dr Preeti Bhardwaj
Dentists often encounter patients with missing or malformed teeth. The maxillary lateral incisor is the second most common congenitally absent tooth. There are three treatment options that exist for replacing missing lateral incisors. They include canine substitution, a tooth-supported restoration, or a single-tooth implant. Selecting the appropriate option depends on the malocclusion, specific space requirements, tooth-size relationship, and size and shape of the canine. [1]
When treating patients with congenitally missing maxillary lateral incisors, the orthodontist must decide whether to close the spaces or open them and place fixed bridges. [2] Several authors have suggested that opening the spaces for prostheses and placing the canines in a Class I relationship results in a better occlusion and creates less flattening of the facial profile. [3,4] Woodworth found that little facial change occurs when the spaces are closed orthodontically, although resultant tooth size discrepancies frequently preclude the establishment of a canine-guided occlusion. [5]
Nordquist and McNeill [6] found that 89 percent of patients with prosthetic replacements exhibited a group function occlusion in lateral excursion.
Riding pontic
Riding pontics are temporary prostheses used during fixed orthodontic treatment in patients with missing teeth and can be used for any missing teeth. It is especially good when one or more anterior teeth are missing.
Benefits of using riding pontics
- Improvement of esthetics during orthodontic treatment.
- Development of abnormal habits such as tongue thrusting and defective speech can be prevented.
- Exact mesiodistal width of the missing tooth can be maintained.
- Midline matching along with riding pontic is easier when a unilateral incisor is missing.
- Psychosocial status of the patient can be improved.
Case Report
A 16-year-old female reported to the department of Orthodontics with a Chief Complaint of a gap in the region of her upper front teeth. She had no history of any tooth extraction and orthodontic treatment. She had a pleasing profile, Class-I molar relationship with missing maxillary lateral incisors, gap between maxillary anteriors, deviated maxillary dental midline (left, 2mm) and moderate crowding in the mandibular anterior region. Non-extraction treatment was planned. Treatment objectives were closure of midline diastema, regaining the space for prosthetic replacement of lateral incisors, correction of midline deviation, relieving the crowding and maintaining the existing Class-I molar relationship. The malocclusion was treated with fixed mechanotherapy (Roth, .022″). Maxillary and mandibular arches were aligned, leveled and space for the lateral incisors was created. The acrylic lateral incisor was selected to replace the missing lateral incisor. The color of the acrylic lateral incisor tooth was matched to the color of the adjacent natural tooth. The mesiodistal width of the pontic was determined by analyzing the space available and the dimensions of the remaining natural teeth. The height was determined – The cervical end of the pontic was touching the gingiva with a smooth contour. If the cervical end of the pontic does not touch to the gingiva, then the negative space between the pontic and the gingiva can affect the esthetics, especially in high smile line patients. The incisal edge of the pontic should be in harmony with the adjacent natural tooth for maximum esthetics. The bracket was bonded on the acrylic tooth. The pontic can be ligated to the archwire either by a ligature wire or elastomeric module. The esthetics and smile of the patient was improved after ligating the riding pontics. The space created was also maintained by the riding pontic.
Figure 1. Pretreatment extra oral photographs
Figure 2. Pretreatment intra oral photographs
Figure 3. Extra oral photographs during treatment
Figure 4. Intra oral photographs showing riding pontic
Problems With Riding Pontics
Labiopalatal rotational control of the riding pontic is difficult with round archwires, however, movement can be limited with rectangular archwires. Bond failure of the pontic may occur during treatment.
Conclusion
Riding pontics can be considered as an esthetic aid for the orthodontic patient with missing anterior teeth during orthodontic treatment. It helps to improve the patient’s esthetics and smile during orthodontic treatment and also maintains space until the permanent replacement of missing teeth.
References
1. Vincent O. Kokich JR, DMD, MSD*Greggory A. Kinzer, DDS, MSD† Managing Congenitally Missing Lateral Incisors,Part I: Canine Substitution J.Esthet.Restor Dent.17;202-210,2005
2. Peter M. Roth, DDS, John A. Gerling, DDS, MSD, Richard G. Alexander, DDS, M, Congenitally Missing Lateral Incisor Treatment.4:258-262, 1985.
3. D’Amico, A.: The canine teeth— normal functional relation of the natural teeth of man, J. So. Calif. Dent. Assoc. 26:200-204, 1958.
4. Stuart, C. and Stallard, H.: Diagnosis and treatment of occlusal relations of the teeth, Tex. Dent. J. 75:430-435, 1957.
5. Woodworth, D.A.: Bilateral congenitially missing maxillary lateral incisors— a craniofacial and dental cast analysis, Am. J. Orthod., in press, 1985.
6. Nordquist, G.G. and McNeill, R.W.: Orthodontics vs. restorative treatment of the congenitally missing lateral incisors— long term periodontal and occlusal evaluation, J. Periodont. 46:139-143, 1975.
Contributed by:
Dr Preeti Bhardwaj
Senior Lecturer, Kothiwal Dental College & Research Centre. Moradabad.
