CASE REPORT

Techniques for improving orthodontic results in the

treatment of missing maxillary lateral incisors
A case report with literature review
tvangeios Mrgyropoulos, LJMIJ,

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Pittsburgh, Pa.

congenital absence of one or both of the

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of tooth agenesis)2 The incidence of bilateral

absence of maxillary lateral incisors has been reported
as be tween 1% and 2% in white persons of northwest
Eu ropean origin.23 A developmental disturbance in
the process of embryonic fusion in the area of the
median nasal process, similar to that seen in clefts,
has been implicated as the cause of bilateral congenital
absence of maxillary lateral incisors.4623
Treatment planning and mechanotherapy present the
most frequent problems in cases requiring orthodontic
treatment of bilateral absence of maxillary lateral in
cisors. This absence creates an imbalance in potential
maxillary and mandibular dental arch lengths in the
pennanent dentition. After complete eruption of the
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balance can be achieved through the application of a

comprehensive treatment plan that includes the follow
ing alternatives with respect to the aforementioned
cases: (1) maintaining or recovering the missing incisor
space followed by prosthetic reconstruction, (2) closing
space and establishing Class II posterior relationships,
and (3) closing space and extracting two mandibular
teeth, either the premolars or lateral incisors, and es
tablishing Class I posterior relationships.
In the choice among these modes of treatment, the
patients profile, the amount and direction of future
growth, and the presence or absence of major maloc
clusion symptoms must be taken into consideration.
15,17,23
of cases with miss
Long-term follow-up
ing lateral incisors have shown that prosthetic replace
ment is usually a less desirable treatment alternative
than orthodontic space closure from both esthetic and
periodontal considerations.

FIg. 1. Pretreatment fu!! face view.

The case report that follows describes the ortho

dontic treatment of a patient with bilateral congenital
absence of maxillary lateral incisors. Tne approach used
combines interesting clinical procedures and methods
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onstrates treatment techniques that may significantly

improve the treatment results when orthodontic space
closure and correction of deep overbite are performed
simultaneously.
EXAMINATION

*A recently graduated resident of orthodontics, School of Dental Medicine,

University of Pittsburgh, and presently in private orthodontic practice.
**Associate Professor of Orthodontics, School of Dental Medicine, University
of Pittsburgh.

150

M.M., a female patient aged 13 years 5 months (Fig. 1),

had a Class II occlusion (molars relationship) with the max
illary right and left lateral incisors not visible clinically
(Fig. 2). The deciduous maxillary left canine was still r e

Volume 94
Number 2

Case report

151

FIg. 2. Pretreatment intraoral view (maxilla).

tamed. The m axi l l ary canines had erupted mesially to their

normal positions with resultant spacing on each side of the
canines and diastema between the two central incisors. In
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(Figs. 3 and 4). The maxillary right first and second

premolars were in a buccal crossbite relationship (Fig. 5).
Intraorally. there was 7 mm of overjet and 6 mm of
overbite (Fig. 6). The mandibular arch was symmetrically
ovoid in form with a generalized spacing of all the lower
teeth (Fig. 7):
good, with no
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clinically
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tissues appeared healthy.

The intraoral radiographs confirmed the absence of both
the maxillary lateral incisors (Fig. 8). There was no history
of permanent teeth being extracted. Maxillary lateral incisors
were congenitally absent in both the patients father and pa
ternal grandmother. The cause of the tooth agenesis was
thought to be genetic.
The facia evaluation presented a symmetric, almost
square facial type and a slightly convex facial profile
(Fig. 9). The maxillary lip was protrusive; the lower lip
presented a deep labiomental groove. The lower facial profile
was slightly retrusive with a prominent soft-tissue pogonion.
The cephalometric evaluation (Fig. 10, Table I) indicated
a slightly retrcgnathic skeletal pattern (NPo to FH =
81.5, Pog 3 mm posterior to ANS arc) with a severe
skeletal deep bite (Palatal-mandibular angle =
15, LAFH
50%).
8mm <UAFH, ANS-Me/NA-Me =
An analysis of the dental pattern showed a severe pro
lu
trusion or the tnaxiiiary central incisors (!to Iwo =
mm,
11.5 mm) with a retrusion of point B
I to NPo =
relative
7). Also,
4, A-B to NPo =
to point A (ANB =
the angulation of the maxillary central incisors ( j to SN =
107,
I to palatal plane = 62) and the mandibular incisors (1

47) was beyond the normal

112, I t o FH =
MP =
stan dards. However, the cant of the occlusal plane (OP to
FH) was 9, which suggested a satisfactory inclination.
DIAGNOSIS

The patient had a Class H, deep bite dental malocclusion

characterized by maxillary and mandibular dental protrusion,
congenital absence of the maxillary lateral incisors, spacing
in the upper and lower teeth, and a slightly retrusive skeletal
pattern.
P LA N OF

TREATMENT

The main objectives of orthodontic therapy for this case

were to: (1) position the maxillary canines in the place of the
missing lateral incisors as esthetically as possible, (2) retract
the maxillary incisors and upright the lower incisors, (3) close
the maxillary and mandibular spaces, (4) reduce the ovei-jet
and decrease the overbite, (5) harmonize the maxillary and
mandibular apical bases, (6) shift the maxillary dental midline
to the left side to coincide with the midfacial one, (7) improve
the contour and balance of the lips, (8) establish harmony of
dentition to the existing facial pattern, and (9) slightly advance
the mandible and increase the lower skeletal height.
Since the patients growth was almost complete, the treat
ment was limited by the impossibility of correcting the skeletal
Class H deep bite. Therefore, the compromise objectives were
to stabilize rather than to increase the vertical dimension, and
to decrease the deep dental overbite by genuine intrusion of
the anterior teeth.
BoRons method and diagnostic set-up were used to
assess the problem of tooth size caused by the substitution of
canines for lateral incisors.
To accomplish all of the above treatment goals, the treat
ment of choice was maxillary space closure and maintenance