How good do Canine Substitutions look?

Subject comes up a lot!  Here is my take on it: 

NOT ANOTHER
NEWSLETTER (volume IV)



Since much of orthodontics
is still not “evidenced based”, and treatments are often influenced by the
prejudices (conscious and unconscious) of the practitioners, it is not
surprising that different orthodontists often seem to give very different
answers to the same problem…just ask a few: “how many months do you require
full time retainer wear after braces?” For what’s its worth, we would like to
use these letters to give you our philosophies of treatment to help you
with your referrals and to understanding the care of our mutual patients.



Missing Lateral Incisors



Some of the most
commonly congenitally missing teeth are the maxillary lateral incisors. Obviously there are only two ways to
orthodontically deal with this problem: open space for prosthetic replacement
or substitute the canines for the laterals.
When laterals are missing it is important to keep in mind that there is no
ideal solution, and different practioners can weigh the pros and cons of
the two options and differ on the best alternative.



In the past, when
the only “permanent” solution to missing laterals was a fixed bridge that
required cutting down virgin centrals and canines, we tried as hard as we could
to avoid opening space. Then when
Maryland bridges came along we eased off, only to find that the metal often
showed through the abutments and that Maryland bridges, as the joke goes, only
stay bonded in Maryland!



Of course now we
have implants – the latest breakthrough in dentistry. But again, over time,
these too have shown their limitations.
Some of the potential problems with implants are:



1.Often we must retain the missing tooth space(s) for
many years until the patient is old enough for the implants. Not only is the patient unhappy with fake
teeth on the retainer but sometimes the adjacent teeth “slip”, and when the
patient is finally ready, there is not enough room (especially apically) for
the implant. Of course a bonded
temporary bridge would help solve these problems but these are expensive, very
prone to coming loose, and can keep the abutment teeth from moving to adjust
for facial growth. 

2.Although far better than any traditional prosthetic
replacement, implant supported crowns may become less esthetic over the years
as the gums recede, teeth change shade and the labial bone becomes thinner. For
someone getting implants at age 20 no one knows the prognosis for the next 65
years!

3.Often, just the fact that the laterals are missing
results in a less developed maxilla. It
can be very difficult to open sufficient space for a well-positioned implant in
this situation. Other times the patient
is just very crowded and would normally require premolar extractions … its hard
to justify the extraction of more teeth and leave them with implants when we
could avoid both problems by substitution.

4.Finally, for class II patients opening space for the
laterals just makes the overjet worse while closing the spaces and leaving the
molars class II makes for a much easier orthodontic correction.

Canine substitutions can be tricky to make look natural. There are a lot of reasons why. One alternative is to the orthodontics now and wear a removable appliance until you can save the money for implants in the future. Another option is to have a Maryland Bridge done. This is a much more esthetic alternative than canine substitution and allows you to place implants in the future. I would suggest discussing other restorative options with your dentist before proceeding.