Show Your Work: Replacing Missing Upper Lateral Incisors by Dr Andy Toy

The patient in this case was a male in his mid-20s who was a trainee when he first attended the practice. His upper lateral incisors were congenitally absent, for which he (rightly) blamed his parents. He had been offered fixed appliances as a teenager but he had refused at the time. This meant that he now had to fund his own orthodontics, for which he (wrongly) blamed his parents for not forcing him into orthodontics 10 years previously.

There are generally two ways of dealing with missing upper lateral incisors:

1. Close the spaces and reshape the canines (a relatively cheap option).
2. Open up the spaces and restore with an implant, bridge or denture (a great deal more expensive option).

The patient was also very keen on the idea of long-term restoration with implants, using his actuarial skills to determine that this would be a much better quality result that would also work out cheaper over his expected lifetime.

He used these figures and a degree of coercion to gain funding from the ‘Bank of Mum and Dad’.

There are a number of issues to consider when choosing the best of these two options:

• How much room is required to open the spaces between UR1–UR3 and UL1–UL3? His mild Class III skeletal pattern and low upper lip line meant that he did not show a lot of tooth when he smiled.
• He also had a crossbite at UR1 LR2. Some space could be gained by proclining the upper central incisors, which would also make them more prominent in the smile and correct the crossbite.
• If we wish to restore with implants, can we create sufficient space between the whole length of the crowns and roots of UR1–UR3 and UL1–UL3?

Initial radiographs indicated that the roots of these teeth were relatively upright already. When creating further space, it was important to ensure that tipping of the adjacent teeth was avoided. ‘SmartForce’ attachments mean that some bodily movement is possible with Invisalign aligners.

The ClinCheck treatment plan was a great aid to communication with the patient’s implant dentist, and also with the patient himself. The implant dentist could dictate how much space was required to provide enough room for an implant, as well as the most appropriate crown width at the end of the treatment. This can be programmed into the ClinCheck treatment plan, making it much easier to achieve than with fixed appliances, in my experience.

Using the ClinCheck’s Tooth Movement Assessment Tool provided us with a measure of how challenging the tooth movements were likely to be. In this case, movement of UR43 and UL34 were deemed to be moderately predictable (see blue dots on Fig. 2, p. 11). This tool was used to help the patient understand some of the complexities of his case.

Consequently, he consented to the use of supplementary techniques, such as ‘power bars’ and elastics in combination with the aligners, if they were needed to apply more root torque to these teeth. (In the end, however, this was unnecessary.)

As the spaces between UR3–UR1 and UL1–UL3 increased, we were able to place pontics into the aligners. These proved invaluable after first-stage surgery, providing the patient with a prosthetic replacement that was easy to clean and wear but did not impinge on the surgery site.

The patient required 24 upper and 25 lower aligners in the first phase of treatment. A second phase of aligners included 11 upper and five lower aligners. There was a slight posterior open bite at the end of this second phase; this is not unusual with aligner treatment. To correct this, the last lower aligner was trimmed with scissors distal to the lower canines to enable it to act as a Dahl appliance.

Firm, balanced posterior contacts were obtained after 6 weeks of wearing this appliance.

Implants and crowns in this case were provided by Dr Nilesh Shah, MMedSci, BDS, MFGDP(UK)

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  Fig. 1. Preorthodontic treatment.

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  Fig. 2. Preorthodontic treatment ClinCheck.

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  Fig. 3 Postorthodontic Phase 1 treatment

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  Fig. 4. ClinCheck, postorthodontic Phase 1.

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  Fig. 5. ClinCheck, start of Phase 2.

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  Fig. 6. ClinCheck, end of Phase 2.

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  Fig. 7. Post-Phase 2, implant placement and restoration.

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  UL2: restored implant

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  UR2: restored implant