Missing upper laterals can present with several challenges to the treating interdisciplinary team. At Study Club, this topic brings up discussions that attempts to answer several questions: What is the best treatment? Is it to replace the missing lateral with implants or to use canine substitution? What is the timing of treatment? Should we proceed when the canines have erupted or wait until closer to the age of implant placement?
When the replacement of the missing lateral(s) is the most ideal plan and accepted by the patient and family, then timing comes next. Creating the ideal bone to accept the future implant is the goal of the orthodontist and surgeon so the best possible site is prepared for the restorative dentist to do their best work. We know that when the canine crown and root fully erupt in the lateral position that we have the best bone development both vertically and buccal-lingually. When the canine is moved from the lateral site to the canine site the bone remains stable in the future implant site. The average age of the patient at the end of the orthodontic treatment is often around 14-15 years old. This patient has very high esthetic concerns especially as they approach the time for senior pictures. There are a variety of ways to manage the esthetic replacement of the missing lateral, both fixed and removable.
Removable flippers have been used for years. Maryland type bonded bridges have also been a nice esthetic restoration. Another option I have used is a fixed wire appliance for the stabilization of missing laterals. It is a lingual wire soldered to blank bands on the molars, with the pontics bonded to the wire. Advantages of this option include the low cost, the adjacent teeth do not require preparation and an Essix removable retainer can provide added support over this appliance. When custom made at the lab. the pontics can be adapted to the proximal sides of the centrals and canines to make sure there is no change in the prepared spacing for the future implant. The appliance seats like a bridge with “draw” so it is a tightly adapted fit. The glass ionomer used to cement the bands is very stable and rarely comes loose. When the time is ready for the implants this appliance can continue to be used until the final crown placement.
This is a viable option to consider when next planning the temporary replacement of missing laterals.
See images - U shaped lingual arch wire with pontics for #7 and 10, in final stages of orthodontic treatment. For final retention the Uarch will be soldered to blank bands with a removable Essix for night time wear.
Donna J. Stenberg D.D.S., M.S., P.A. Spear Visiting Faculty and Contributing Author www.stenbergorthodontics.com