I am excited to have you read this month’s Point-Counterpoint feature. The topic is “Congenitally missing maxillary lateral incisors: Substitution vs restoration.” I invited 2 experienced teams to discuss this topic from 2 perspectives. Each team did an outstanding job in presenting their arguments favoring one approach or the other. And I am certain that, as you read the Point and then the Counterpoint, you will formulate your own opinion about how you would treat this clinical situation in your patients.
But therein lies the problem. Who should make the decision of when to open space for an implant or a bridge, or to close the space and substitute the canines for the lateral incisors? This question is not fully addressed in either article. But this issue is perhaps the most important of all.
For many years, I presented interdisciplinary lectures to audiences around the world that typically included a mixture of orthodontists, primarily restorative dentists, and a few periodontists and oral and maxillofacial surgeons. When I discussed the management of missing maxillary lateral incisors, the restorative dentists, periodontists, and maxillofacial surgeons would often condemn canine substitution as a poor alternative that has no place in modern dentistry. After all, we are currently well into the third decade of the implant revolution that started in the late 1980s. Implants have completely changed the philosophy of general dentists regarding missing lateral incisors. Although implants are highly successful in their long-term stability, esthetic failures do occur. When orthodontists see these esthetic failures, they might become reluctant to choose the restorative option.
Who should decide which method of treatment is most appropriate for maxillary lateral incisor agenesis? The patient’s general dentist might favor the restorative solution because it places the teeth in their correct relationship from both an esthetic standpoint and an occlusal perspective. The orthodontist might favor canine substitution because it could reduce the need for continued restorative replacement over the lifetime of the adolescent patient. If the parents were asked for their opinion, they would probably choose the least expensive alternative if the outcomes were equivalent.
Here is the real problem. The mistake is made when 1 person unilaterally makes the decision without consulting with the others involved. And since the orthodontist is the one planning the treatment, he or she often makes the unilateral treatment decisions in these situations. I do not agree with this philosophy. I never make the decision myself about canine substitution vs space opening and restoration.
When I am referred a patient who is missing lateral incisors, I gather the records and meet with the restorative dentist before my consultation with the parents. I present the 2 options for treatment as well as the advantages and disadvantages of each treatment approach. Then I ask the dentist which option seems most appropriate to him or her. After all, these adolescents with missing teeth are not our patients in the long term. They are the patients of the general dentist. We simply intervene with our treatment early on, and whatever we produce the general dentist must maintain for many years to come.
But some would say that general dentists simply do not understand the option of canine substitution and only want to place and restore implants for missing lateral incisors. I agree that this is a common perception among general dentists. But why? Could it be a lack of knowledge about the other options for treatment? Some orthodontists might only favor canine substitution. But why? Could it be that they know little about the restorative options for replacing missing lateral incisors?
That is the reason that I invited these 2 teams to present their philosophies in this Point-Counterpoint format. The information in these articles is incredibly valuable. How will I use this information? I plan to make copies of this Point-Counterpoint piece and send it to all of my referral sources. In fact, this would be good information for parents to read when they are considering the options for treatment of their adolescent child. If the orthodontist, general dentist, and parents are all aware of the issues, then perhaps they can “make the correct decision mutually.”