Treatment of Missing Lateral Incisors in the Child Patient
Many dentists and parents are confronted with a major decision concerning a child's treatment when a child's permanent lateral incisors are not present. These teeth are very noticeable, being in the front of the mouth. In our society spaces in the anterior region of the mouth are simply not acceptable. We know a persons delicate developing psyche is very much affected by feedback from peers. If a child's smile is defective it can add to the difficulties of the many adolescent behavior adjustments.
I will attempt to lay out a simple cookbook to pattern decisions for the parent. I am using two assumptions as my fundamental branching points in my decision tree:
- The space necessary for the existing teeth to fit within the existing bone must be recognized and
- The least intrusive dental procedures are many times the best.
The most important fact to obtain and consider is how much space is present in the dental arch. If most of the space in the arch is filled even without the laterals present then the most prudent treatment is to somehow form the permanent canines to make them look more like lateral incisors and take the position of the missing laterals in the arch. This can be done with bonding, porcelain veneers, crowns, or the most conservative approach, selective shaping, of the existing canines.
Unfortunately, the most usual scenario seems to be the patient is not short of space and actually, has plenty of room for the missing lateral incisors. Treatment can take many forms in this situation. A super human effort can be launched to close the space by pulling all upper teeth past the central incisors forward thus closing the space left vacant by the missing lateral incisors. This path results in essentially the same restorative options mentioned above. However, this effort requires a great deal of tooth movement, time and perhaps not ideal results. Also, moving the canines into the spaces of the laterals does involve an important compromise, namely, the canine will not be the tooth that the bite rises upon when the patient moves his or her jaw to the side. The canines being one of the longest rooted teeth, and their shape allowing them to be guiding teeth, are normally, ideally placed at the guiding corners of the anterior of the mouth. When put in the position of the lateral incisors they no longer are able to function in that capacity. This trade off coupled with the fact that they are wider and thicker than the normal lateral incisors (our best efforts don't make them totally look like normal laterals) would lead me to consider some other alternatives in this situation.
I would probably recommend positioning the upper existing teeth as they normally would be positioned and consider placing implants with crowns to replace the missing lateral incisors. My second choice would be to place a bonded type bridge. My third choice would be to place a fixed bridge (crown both central incisors, splint them together, and cantilever both laterals from these teeth). Some patients will not do well with a bonded type bridge. They are not as strong as the implant or the regular fixed bridge. On patients who are not careful with them they will be a constant nuisance, falling off and needed repaired and rebonded.
I hope that this brief summary of thoughts will be helpful to parents considering a course of action for their children.