ORIGINAL ARTICLE

Congenitally missing maxillary lateral incisors:

Long-term periodontal and functional evaluation
after orthodontic space closure with first premolar
intrusion and canine extrusion
Marco Rosa,a Patrizia Lucchi,b Simona Ferrari,c Bjørn U. Zachrisson,d and Alberto Caprioglioe
Varese and Cagliari, Italy, and Oslo, Norway

Introduction: The aims of this investigation were to evaluate associations between orthodontic space closure
(including first premolar intrusion and canine extrusion for esthetic reasons) and periodontal tissue deterioration
over a 10-year period in subjects with one or both missing maxillary lateral incisors and to investigate the
occurrence of signs or symptoms of temporomandibular disorder (TMD). Methods: This was a retrospective
cohort study comprising patients treated by the same orthodontist. The agenesis group included 26 consecutive
adolescent and young adult patients (9 male, 17 female) treated with space closure. The control group consisted
of 32 orthodontic patients (12 male, 20 female) with no missing teeth and no need for extractions. In the agenesis
group, full-mouth probing pocket depths and bleeding on probing were recorded at 6 locations for each of 657
teeth (3942 periodontal sites). In the control group, comparative data were collected for the maxillary first molars,
premolars, canines, and lateral incisors, a total of 264 teeth (1584 periodontal sites). Mobility and gingival
recession were also evaluated. Patients in both groups completed questionnaires concerning symptoms
related to TMD. Results: The full-mouth assessments in the agenesis group generally demonstrated
periodontally healthy conditions, with probing depths below 4 mm and few bleeding sites. Some slight
recessions were found, mostly on molars and second premolars, and there was normal mobility of first
premolars that substituted for canines. Comparisons between the agenesis and control groups showed no
statistically significant differences for the maxillary teeth regarding increased pocket depth ($4 mm) or
increased mobility. Interproximal sites in the agenesis group showed less bleeding on probing than in the
control group; this was statistically significant. Anterior teeth in the agenesis group did not show any more
recession than in the controls. In addition, we observed no difference in signs or symptoms between the 2
groups; this might be due to the limited sample size or the drawbacks of the surveys of TMD through
subjects' recall. Thus, the long-term periodontal tissue health and the incidence of dysfunction or TMD signs
were similar in the space-closure agenesis group and in the control group of nonextraction orthodontic
patients. Conclusions: Orthodontic space closure including first premolar intrusion and canine extrusion in pa-
tients with missing lateral incisors does not incur risks for periodontal tissue deterioration or TMD in the long term.
(Am J Orthod Dentofacial Orthop 2016;149:339-48)

a
Adjunct professor, Division of Orthodontics, Department of Surgical and
Morphological Sciences, University of Insubria, Varese, Italy.
b
Adjunct professor, Department of Orthodontics, University of Cagliari, Cagliari,
Italy.
c
Research fellow, Division of Orthodontics, Department of Surgical and Morpho-
logical Sciences, University of Insubria, Varese, Italy.
d
Professor emeritus, University of Oslo, Oslo, Norway.
e
Associate professor and chairman, Division of Orthodontics, Department of
Surgical and Morphological Sciences, University of Insubria, Varese, Italy.
All authors have completed and submitted the ICMJE Form for Disclosure of
Potential Conflicts of Interest, and none were reported.
Address correspondence to: Marco Rosa, Piazza della Mostra 19, Trento 38122,
Italy; e-mail, marco@marcorosa.it.
Submitted, March 2015; revised and accepted, August 2015.
0889-5406/$36.00
Copyright Ó 2016 by the American Association of Orthodontists.
http://dx.doi.org/10.1016/j.ajodo.2015.08.016
P
atients with congenitally missing maxillary lateral
incisors often need a challenging interdisciplinary
treatment, whether canine substitution, single
implants, or tooth-supported restorations are chosen.1-3
Ideally, each alternative should fulfill individual esthetic
concerns, functional requirements, and periodontal
tissue health, not only at the end of treatment but also
in the long term. When space closure is selected,1,4-8
premolar intrusion and canine extrusion can remodel
the gingival margins so that an optimal, natural-
looking result can be achieved.5-8 This means that the
labial gingival margin of the new canine (the intruded
first premolar) will be at the same level as that of the
339
340 Rosa et al

Fig 1. Frontal views of a woman, aged 19 years, with 2 congenitally missing lateral incisors: A, before
treatment and B, at the end of treatment. Interdisciplinary treatment consisted of orthodontic space
closure and gingival margin remodeling, surgical correction of the skeletal discrepancy, followed by
composite restorations on the extruded canines replacing the lateral incisors and on the intruded first
premolars substituting for the canines.

central incisor, whereas that of the new lateral incisor
(the extruded canine) will be about 2 mm lower (Figs
1, B; 2, A; and 3, A). These vertical movements will
inevitably generate uneven vertical crestal bone septa,
particularly in the first premolar-canine region (Fig 4, A).
In adult patients with uncontrolled pathologic tooth
movements, osseous vertical defects including inter-
proximal craters and 1-, 2- or 3-wall defects may be
found around mesially tipped teeth or teeth that have
supraerupted. Vertical defects may compromise the pa-
tient's ability to clean his or her teeth adequately and
lead to attachment loss on the mesial and distal surfaces
of the adjacent roots. If the crater is mild to moderate
but the patient cannot maintain the area adequately, it
may require resective bone removal and recontour-
ing.9,10 However, the uneven vertical bone contours
(Fig 4, A) in well-performed orthodontic space closure
treatment (in which the teeth are aligned with proper
angulation and inclination) may not be comparable.
Also, the problem of maintaining adequate oral hygiene
should be lower in young and healthy patients.
Another potential problem is that the intruded and
restored first premolar might create later periodontal
problems or might not be able to provide a proper func-
tional occlusion, and therefore possibly predispose the
patient to temporomandibular disorder (TMD).
The aims of this investigation were to assess, over a
10-year period, (1) periodontal tissue conditions of
intruded first premolars and extruded canines in patients
with congenitally missing maxillary lateral incisors
compared with their full-mouth periodontal status, (2)
periodontal tissue conditions of intruded first premolars
and extruded canines in patients with congenitally
missing maxillary lateral incisors compared with the cor-
responding teeth (considering the position) in orthodon-
tic patients treated without extractions, and (3) the
functional and occlusal statuses and eventual TMD in
patients with congenitally missing maxillary lateral inci-
sors who were treated with space closure, premolar
intrusion, canine extrusion, and minimally invasive res-
torations, compared with a control group of orthodontic
patients treated without extractions.
MATERIAL AND METHODS
A retrospective cohort study was made of 2 groups of
patients consecutively treated by the same orthodontist
(M.R.), recruited from the files of his private office.
The inclusion criteria for the agenesis group (AG) were
(1) agenesis of at least 1 maxillary lateral incisor, (2) treat-
ment completed at least 60 months before follow-up,
and (3) patients who were treated consecutively. Patients
with cleft palate or syndromes were excluded.
All patients were consecutively treated by space
closure to replace the missing lateral incisors. Full fixed
appliances were used at the end of dental arch growth
in the permanent dentition by the same clinician
(M.R.). The clinical protocol was described previously
by Rosa and Zachrisson.5-8 It combines first premolar
intrusion and canine extrusion (Figs 2, A; 3, A; and 4,
A) to achieve optimal leveling of the labial gingival
margins. Minimally invasive supragingival restorations
may provide proper esthetics and functions (Figs 1, B;
2, B; and 3, B).5-8 Buildups on the intruded premolars
were made with porcelain veneers (4 patients) or
composite resin (22 patients). A posttreatment occlusal
equilibration was infrequently made to obtain optimal
occlusal function.8 A 0.019-in multibraided stainless
steel wire was bonded as a retainer in the maxillary
arch, a 0.019-in multibraided stainless steel wire was
bonded on the 6 front teeth and left in place for
24 months in 20 patients of the AG. In 6 patients, the
bonded retainer was still in place at follow-up
(0.0195-in Penta Twist retainer wire; Gold'n Braces,
Palm Harbor, Fla).

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Rosa et al 341

Fig 2. Frontal views of the same patient as in Figure 1: A, at the end of orthodontic treatment; B, after
composite buildups; and C, 7 years later. The overall appearance of the 6 front teeth is natural, with the
canines in place of the missing lateral incisors and the first premolars replacing the canines. The new
orthodontically created labial gingival margins remain stable at about the same levels as at the end of
treatment (compare A, B, and C).

Fig 3. Lateral views of the same patient as in Figures 1 and 2: A, near the end of treatment; B, after
bracket removal and composite buildups; and C and D, 7 years postoperation during the clinical
assessment of probing depth. Intrusion of the first premolar and extrusion of the canine were
obtained by bracket positioning (note the incisal placement of the bracket on the first premolar and
the gingival placement on the canine) and archwire bending (A). “Natural” overall appearance and
gingival margins were obtained after treatment.

Thirty-two consecutively treated patients were con-
tacted by telephone and invited to participate in the
study; 4 declined for private reasons, 1 had moved
away from the area, and 1 could not participate for pro-
fessional reasons. Thus, the final AG sample consisted of
26 patients (9 male, 17 female). The mean age at the end
of orthodontic treatment was 23 years 7 months (SD,
10 years 7 months). The mean time after the completion
of treatment was 9 years 9 months (SD, 4 years
2 months). The mean age at follow-up was 33 years
5 months (SD, 10 years 3 months). Nineteen patients
had bilateral agenesis, and 7 had unilateral agenesis.
Among those 7 subjects, 1 was treated with unilateral
space closure, and the others were treated with bilateral
space closure after extraction of the contralateral inci-
sors. The total number of teeth analyzed in the AG
was 657.
The inclusion criteria for the control group (CG) were
(1) no congenitally missing maxillary teeth (except for
third molars), (2) no need for extractions and less than
4 mm of crowding, (3) orthodontic treatment finished
at least 60 months before follow-up, and (4) no fixed
retention on the maxillary teeth at the follow-up.
Patients with cleft palate or syndromes were excluded.
The CG consisted of 32 orthodontic patients (12
male, 20 female). The mean age at the end of orthodon-
tic treatment was 17 years 7 months (SD, 5 years
6 months). The mean time after completion of treatment

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342 Rosa et al

Fig 4. Intraoral radiographs of the right first premolar-canine area: A, in the last stage of orthodontic
treatment; B, immediately after treatment; and C, 6 years later. In the same patient as in Figures 1
through 3, the bonded lingual retainer wire is still in place. The interproximal vertical bone contours
between the intruded first premolar and the extruded canine apparently have undergone some
remodeling (compare the mesial aspects of the first premolar in B and C).

was 9 years 11 months (SD, 3 years 5 months). The mean
age at follow-up was 27 years 6 months (SD, 6 years
11 months). The t test was applied regarding the age dif-
ferences between the 2 groups, with a P value of 0.061.
The ratios between the male and female subjects
were 35% to 65% in the AG and 38% to 62% in the CG.
The purposes of this investigation were to (1) assess
the periodontal health of all maxillary and mandibular
teeth in the AG by recording tissue data at 6 locations
on each of the 657 teeth: mesiofacial, facial, distofacial,
distolingual, lingual, and mesiolingual (3942 sites alto-
gether); and (2) compare the periodontal status of the
maxillary teeth that were moved mesially in the AG with
the homologous data in the CG. The comparison sites
were the central incisors in both groups, canines replacing
lateral incisors in the AG compared with lateral incisors in
the CG, first premolars replacing canines in the AG
compared with canines in the CG, second premolars in
the AG compared with first premolars in the CG, and first
molars in both groups, for a total of 8 teeth and 48 sites
for each subject (264 teeth, 1584 sites). Any additional
data were inserted in the data set for the AG.
All interviews and clinical examinations were per-
formed by 1 examiner (S.F.), who was not involved in
the treatment.
Periodontal tissue examination included evaluations
of probing pocket depth (distance from the free gingival
margin to the bottom of the sulcus or periodontal
pocket), bleeding on probing, plaque accumulation,
gingival recession (distance between the free gingival
margin and the cementoenamel junction), and
mobility.11 Mobility was assessed according to a stan-
dard classification, indicating that increased mobility
was more than that attributable to physiologic tooth
movement (\0.2 mm).12 Mobility was recorded for all
teeth. The mobility of the first premolars in the AG was
also compared with that of the first premolars in the
CG. This comparison was made to check whether the
mobility of the first premolars in the canine position
was different from the mobility of the first premolars
in the normal position. Six patients of the AG still had
a bonded retainer in place at the follow-up and were
therefore excluded from the mobility tests. Thus, only
20 patients in the AG (40 first premolars) were consid-
ered in the statistical analysis and compared with the
CG. Probing pocket depth, bleeding on probing, plaque
accumulation, and gingival recession were measured at
6 sites per tooth (mesiobuccal, midbuccal, and distobuc-
cal; mesiolingual, midlingual, and distolingual). Mea-
surements at each site were made using a periodontal
probe (PCP 15/11.5B screening probe; Hu-Friedy, Chi-
cago, Ill) along the root surface and angulating it in a
mesiodistal direction but parallel to the long axis of
the tooth to avoid a buccolingual angulation (Fig 3, C
and D). Each measurement was rounded to the lower
whole millimeter. Data were recorded directly on a peri-
odontal chart developed by the Department of Peri-
odontology, University of Bern, in Bern, Switzerland,
that instantly calculated attachment loss as the differ-
ence between probing depth and recession.13 A pocket
of 4 mm or greater was considered to be “deepened”
(at risk of attachment loss).11 Bleeding on probing was
registered when bleeding occurred within 15 seconds af-
ter probing.14,15 Plaque accumulation was registered if
residuals were present on passing the probe along the
gingival margin of each tooth.16 Plaque index and
bleeding index scores were calculated according to the
method of L€ oe and Silness.17 Gingival margin recessions
were registered on each tooth as present or absent.18
When an apical displacement of the free gingival margin

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Rosa et al 343

Table I. Probing pocket depth (PD) evaluation in the AG and the CG

PD 5 4 mm PD .4 mm

Teeth (n) Sites (n) n % n %

AG
Full mouth 657 3942 96 2.4 18 0.5
Maxilla 206 1236 35 2,8 9 0.7
First molars 51 306 10 3.3 5 1.6
Second premolars 52 312 7 2.2 3 1.0
First premolars 51 306 9 3.0 1 0.3
Canines 52 312 9 2.9 0 0
CG
Maxilla 256 1536 60 3.9 11 0.7
First molars 64 384 27 7.0 6 1.6
First premolars 64 384 22 5.7 3 0.8
Canines 64 384 8 2.1 2 0.5
Lateral incisors 64 384 3 0.8 0 0
t test P 5 0.162 P 5 0.856
NS NS

Full mouth, All maxillary and mandibular teeth and sites assessed in the AG; maxilla, the number of teeth and sites assessed for teeth moved mesi-
ally in the AG and homologous teeth and sites in the nonextraction CG; NS, not significant. Compare canines in the AG with lateral incisors in the
CG, and so on.

from the cementoenamel junction occurred, recession
was recorded, with the final aim of rating its prevalence.
A clinical chart was used in both groups to evaluate peri-
odontal risk factors, such as current and former cigarette
smoking, history of diabetes, frequency of visits to a
dentist, and familial predisposition.13
Occlusal and functional examinations were made in-
traorally in both groups. Discrepancies between centric
relation and centric occlusion of more than 1 mm were
registered.19 Tooth contacts were recorded using thin
articulation paper (Articheck 40; Bausch, Koln,
Germany), as well as occlusal function in lateral excur-
sions (canine-protected or group function) and the pres-
ence of balancing contacts. A questionnaire concerning
symptoms related to TMD, such as pain, noises, locking,
and parafunctions, was completed by all patients of both
groups. They were asked to provide answers to 10 ques-
tions, including “Do you ever (1) hear a click from the
temporomandibular joint (TMJ); (2) feel crepitation
sounds from the TMJ; (3) get pain around the TMJ; (4)
get pain in the facial muscles; (5) get pain when chewing
or opening your mouth; (6) get headaches; (7) have dif-
ficulty opening your mouth; (8) grind your teeth; (9)
clench your teeth or hold them tightly together when
you are not eating; and (10) bite your tongue, lips, nails,
or something else?” The possible answers were 0, no,
never; 1, in the past; 2, sometimes; or 3, often.
Statistical analysis
Descriptive statistics were used to summarize the per-
centages and distributions of the measurements. Normal
distributions for the values of all variables were verified
in both groups with the Shapiro-Wilk test.20
A power analysis was done, and the alpha level was
fixed at 0.05. Three tests gave a power over 80%, and
only one was underpowered (probing .4 mm). Howev-
er, in this last statistical analysis, the difference in the
frequency was low and had no clinical relevance. There-
fore, the risk of a beta error would not influence the final
conclusion.
The 2 groups comprised different subjects. As a
consequence of this, the 2 samples were independent.
An independent t test was used to analyze the outcomes;
specifically, a comparison was made between the 2 sam-
ples and not within the samples. An unpaired t test was
performed to detect any significant changes between
data in the AG and the CG. Significance was set at
P \0.05. The error of the method of each considered
variable was calculated by double measurements in
20% of the sample with Dahlberg's formula.20 The ob-
tained value was 0.032, considerably lower than the
maximum limit of 0.25.
All data were statistically analyzed with Stata 12 soft-
ware (StataCorp, College Station, Tex).
RESULTS
In the probing depth evaluation (Table I), of the 3942
sites probed in the full-mouth evaluation in the AG, only
18 (0.5%) had a pocket depth greater than 4 mm, and 96
(2.4%) sites were 4 mm deep. The sites with deeper prob-
ing depths were mainly in the posterior teeth. Among the
1536 sites probed in the CG, 11 (0.7%) had a depth

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344 Rosa et al

For the evaluation of gingival recession (Table III) in

Table II. Bleeding on probing (BoP) in the AG and the
the AG, 26.6% of all 657 teeth examined had slight reces-
CG
sions, mostly on the first molars and second premolars,
Sites with BoP but less than a third (24.7%) of these were found in teeth
Sites (n) n %
selected for the intergroup comparisons. In the CG, 43 of
AG the 256 analyzed teeth (16.8%) showed recessions.
Full mouth 3942 339 8.6 No statistically significant differences between the 2
Maxilla 1236 114 9.2 groups were observed, except for more recessions (statis-
First molars 306 39 12.7 tically significant, P \0.02) in the maxillary first molars
Second premolars 312 26 8.3
in the AG (power test, 100%).
First premolars 306 24 7.8
Canines 312 25 8.0 For tooth mobility (Table III) in the AG, 95.6% of all
CG maxillary and mandibular teeth had no increased
Maxilla 1536 271 17.6 mobility, and similar findings were made for the maxil-
First molars 384 74 19.3 lary teeth in the CG (93.7%); 4.4% of the teeth in the
First premolars 384 78 20.3 AG had degree 1 mobility. When we compared the AG
Canines 384 60 15.6
Lateral incisors 384 59 15.4 and CG, we found no statistically significant differences.
t test P \0.001 No measured teeth showed mobility greater than 1.
Probings were made at 6 locations around each tooth.
Among the 40 first premolars replacing canines, only 2
Full mouth, All maxillary and mandibular sites assessed in the AG; (5%) showed degree 1 mobility; in the CG, 11 first pre-
maxilla, number of sites assessed for teeth moved mesially in the molars (17.2%) showed degree 1 mobility. The differ-
AG and homologous sites in the nonextraction CG. Compare canines ence in mobility between the first premolars in the AG
in the AG with lateral incisors in the CG, and so on. and the CG was not statistically significant (P 5 0.11;
power test, 80%).
greater than 4 mm, and 60 (3.9%) sites had a depth of For occlusal function and TMD, the results of the
4 mm. TMD questionnaire completed by the patients in both
When the maxillary segments in the 2 groups were groups are listed in Table IV. Most patients in the AG
compared, no statistically significant differences were had a group function occlusion in lateral excursions
found (power test, 81% for probing pocket depth of (92.3%). A canine-raised occlusion was found in 7.7%
4 mm; power test, 12% for probing pocket of these patients, in contrast to about 32% in the CG.
depth .4 mm), either for sites with probing pocket A minimal (\1 mm) centric occlusion–centric relation
depths greater than 4 mm or for sites with probing discrepancy was found in only 7% of the patients in
pocket depths of 4 mm. Notably, 97.1% of the probing the AG and in no subjects in the CG. The signs and symp-
pocket depths around the intruded premolars and toms were equally distributed in the 2 groups. Tooth
extruded canines were within normal limits, and almost grinding was reported to be more frequent by the pa-
identical to the probing pocket depths around the intact tients in the CG than in the AG, but the sample size
canines and lateral incisors in the CG. was too small to run a regression model.
For bleeding on probing (Table II) in the AG, bleeding For other parameters, no significant differences were
was observed in 339 (8.6%) of the 3942 examined sites. observed between the AG and the CG with regard to
Most bleeding sites were registered at the first molars cigarette smoking, previous dental care, incidence of
(12.7%), followed by the second premolars (8.3%). In diabetes, parental predisposition to periodontal tissue
the CG, 271 of the 1536 recorded sites (17.6%) had breakdown, or periodontal tissue biotype. The sample
bleeding on probing. Again, most bleeding sites were size was too small to run a regression model, which
observed at the first molars and first premolars. No sta- would have computed the most relevant exposures for
tistically significant differences between the maxillary periodontal problems (age, sex, treatment, cigarette
teeth in the AG and the CG were observed on the labial smoking, plaque accumulation).
and lingual sites, whereas the comparisons of the mesial
and distal interproximal sites demonstrated more DISCUSSION
bleeding that was statistically significant in the CG The results of this study demonstrated that in pa-
(P \0.05), as shown in Table II (power test, 100%). tients with agenesis of the maxillary lateral incisors,
The bleeding sites around the intruded first premolars carefully performed orthodontic space closure treatment
and the extruded canines were few and less frequent with fixed appliances including first premolar intrusion
than around the intact canines and lateral incisors in and canine extrusion did not cause a risk for periodontal
the CG. tissue deterioration and TMD. Our specific study design

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Rosa et al 345

Table III. Labial gingival recessions (REC1) and increased tooth mobility (MOB1) in the AG and the CG
REC 1 MOB 1

Teeth (n) REC 1 (n) % Teeth (n) MOB 1 (n) %

AG
Full mouth 657 175 26.6 657 29 4.4
Maxilla 206 51 24.8 206 4.9
First molars 51 24 47.1
Second premolars 52 9 17.3
First premolars 51 9 17.6 40 2 5
Canines 52 9 17.3
CG
Maxilla 256 43 16.8 256 6.3
First molars 64 13 20.3
First premolars 64 14 21.9 64 11 17.2
Canines 64 10 15.6
Lateral incisors 64 6 9.4
t test P 5 0.062 P 5 0.110
NS NS

Full mouth, All maxillary and mandibular teeth assessed in the AG; maxilla, number of mesially moved teeth assessed in the maxilla in the AG and
homologous assessments in the nonextraction CG; NS, not significant. Compare canines in the AG with lateral incisors in the CG, and so on.

Table IV. Occlusal functional pattern registrations in the AG and the CG (percentages)
Often Sometimes In the past No, never

n % n % n % n %
AG
TMJ clicking 3 12 2 8 1 4 20 76
TMJ crepitation 3 12 0 0 0 0 23 88
Pain around TMJ 2 8 1 4 0 0 23 88
Pain in jaw muscles 2 8 0 0 0 0 24 92
Pain on mouth opening 2 8 1 4 1 4 22 84
Headhache 5 19 2 8 4 15 15 58
Mouth opening 3 12 1 4 4 15 18 69
Tooth grinding 0 0 0 0 0 0 26 100
Tooth clenching 6 23 3 12 2 8 15 57
Biting habits 4 15 1 4 0 0 21 81
CG
TMJ clicking 3 9 9 28 2 6 18 56
TMJ crepitation 2 6 4 13 0 0 26 81
Pain around TMJ 0 0 7 22 2 6 23 72
Pain in jaw muscles 0 0 2 6 1 3 29 91
Pain on mouth opening 0 0 7 22 3 9 22 69
Headhache 3 9 10 31 3 9 16 50
Mouth opening 0 0 4 13 2 6 26 81
Tooth grinding 2 6 8 25 3 9 19 59
Tooth clenching 2 6 7 22 0 0 23 72
Biting habits 7 22 8 25 2 6 15 47

made it possible to compare the periodontal statuses of
mesially and vertically moved teeth (canines and first
premolars) in the patients of the AG with the corre-
sponding maxillary anterior and posterior teeth in the
nonextraction CG.
These encouraging findings agree with previous
studies regarding periodontal condition and TMJ
function with space closure treatment performed by
other authors.21,22 In 1975, Nordquist and McNeill21
compared 2 groups of patients and found that agenesis
patients treated with orthodontic space closure were
significantly healthier periodontally than those with
prosthetic lateral incisors. Moreover, the 2 groups did
not differ in adequacy of occlusal function or

American Journal of Orthodontics and Dentofacial Orthopedics March 2016  Vol 149  Issue 3
346
prevalence of TMD. They concluded that “the presence
or absence of a canine rise was not related to peri-
odontal status.” In 2000, Robertsson and Mohlin22
found less plaque and gingival inflammation (statisti-
cally significant) in space-closure patients than in pa-
tients treated with prosthetic means, and concluded
that “orthodontic space closure will produce results
that are well accepted by the patients, does not impair
temporo-mandibular joint function, and encourages
periodontal health.”
Most patients with lateral agenesis are treated at a
young age. The replacement of the missing lateral
incisor, whether by orthodontic closure or insertion of
an osseointegrated single implant, must be viewed in a
lifelong perspective. Recent reports have claimed that
periodontal and esthetic problems may occur in the
long term around lateral incisor implants.23-28
These problems include mucosal discoloration and
retraction, infraocclusion of the implant crown, and
reduction of the marginal bone level at the teeth adja-
cent to the implant. Therefore, to determine what is
optimal for patients, we need more research and clinical
follow-up studies of implants (5-10 years or longer) in
large samples with varying craniofacial morphology
and at different ages.23 Such a study comparing the
long-term periodontal and esthetic assessments after or-
thodontic space closure and opening up for implants is
in progress at our clinic.
The intrusion of the first premolars in the AG was
made to obtain an improved marginal gingival level
and a larger “canine” by a buildup (Figs 1-3) of the
generally short and small first premolars in the
“normal” canine position.5-8 Periodontal changes
immediately after selective intrusion were investigated
on healthy incisors. Murakami et al29 found, in monkeys,
that during intrusion of the maxillary incisors the
gingivae moved in the same direction about 60% as
far, and the epithelium was always attached at the ce-
mentoenamel junction. The clinical crowns shortened,
and the gingival sulci deepened, about 40% as much,
not because of inflammation or swelling but because
of the accumulation of gingival tissue. For intrusions
less than 5 mm, the epithelium was always attached to
the cementoenamel junction. In humans, Erkan et al30
evaluated the gingival response to intrusion of healthy
mandibular incisors. They observed that the gingival
margin and the mucogingival junction moved in the
same direction as the teeth by 79% and 62%, respec-
tively. Bellamy et al31 demonstrated that intrusion of
healthy incisors in adults moved the dentogingival com-
plex apically, whereas alveolar bone loss and root resorp-
tion were minimal and comparable with other
orthodontic movements.
March 2016  Vol 149  Issue 3 American Journal of Orthodontics and Dentofacial Orthopedics
Rosa et al
A relevant issue to be discussed here is the long-term
appearance and influence on the periodontium of the
labial gingival margins and the vertical bone crests,
which developed interproximally on the intruded first
premolars and extruded canines. Orthodontic vertical
movements of some teeth will change the position of
the periodontal supporting apparatus. Thus, after first
premolar intrusion and canine extrusion, not only the
gingival margins (Figs 2, A; and 3, A) but also the
mesial and distal bone crests follow and become
vertical or angular. Consequently, the probing pocket
depths will deepen, and a radiologic vertical “defect”
will appear (Fig 4, A and B), with a potential risk for peri-
odontal tissue breakdown. It has been demonstrated that
without systematic periodontal therapy, the presence of
vertical defects entails an increased risk for further loss
of supporting alveolar bone.32,33 The hypothesis is that
the vertical bony defect comprises a locus minoris
resistentiae for recurrent periodontitis.
However, because the periodontal tissues were intact
and healthy, the vertical bone crests produced by premo-
lar intrusion and canine extrusion in the patients studied
in this investigation must be different from the hemisep-
tal defects (where half of a septum remains on 1 tooth)
that occur in case of periodontal tissue destruction
with attachment loss.9,10,32,33 Our patients were
regarded as dentally aware with high standards of oral
hygiene and regular dental care habits. At the start,
they all had intact healthy periodontia with the
epithelial attachment located at the cementoenamel
junction. The partial deepening of the sulcus
immediately after intrusion was predictable. What was
created by the orthodontic vertical movements is
therefore not a “defect” but merely a discrepancy in the
normal interproximal crestal attachment levels between
2 teeth. Mesially and distally, these vertical bone crests
can be effectively maintained by proper oral hygiene
procedures, so that the risk for future attachment loss
is most likely negligible. Our results confirmed that
even in the long term, the uneven mesial and distal
bone crests did not result in attachment loss.
Another question may be that even if the periodontal
tissues remain healthy, how will the bone peaks, gingival
margins, and papillae remodel after treatment? In
several of our patients, it appeared on radiographs taken
at irregular intervals that the uneven bone crests around
the intruded and extruded teeth tended to remodel and
level off.8 Even with a bonded retainer in place, we
noticed apparent remodeling of the mesial and distal
alveolar bone peaks with resultant flattening (Fig 4, C).
This phenomenon apparently occurred with individual
variability, and further investigations are necessary
before more definite conclusions can be drawn.
Rosa et al
On the other hand, the “new” gingival margins and
interdental papillae were stable at the desired level
(Figs 2, C; and 3, C and D). On the labial side of the
intruded first premolars, immediately after the
orthodontic treatment, we observed in a few young
patients a sulcus deeper than 4 mm caused by the
intrusion and the altered passive eruption. A simple
gingivectomy can, if necessary, take care of this
problem, but no patient in the AG was treated with a
gingivectomy.34,35 At the long-term observation, the
probing pocket depth on the labial sites was less than
4 mm.
Tooth mobility was compared for the first premolars
in both groups. A common doubt regarding canine sub-
stitution is that the maxillary first premolars cannot sup-
port the occlusal forces of the canines and will display
increased mobility. The roots of the first premolars
may be thought to be too short and thin. In addition,
in the AG of this study, the first premolars were intruded
and the crown elongated, with a resulting worsened
crown-root ratio. As mentioned, the mobility tests in
the AG were restricted to teeth that were not stabilized
with a bonded retainer. Therefore, when the mobility
of the first premolars in the AG was compared with
that of the first premolars in the CG (in a normal posi-
tion), there was no statistically significant difference.
This agrees with previous studies showing that posi-
tioning a first premolar in the place of a canine can pro-
vide an adequate functional occlusion.21,22 Also, 92% of
the patients in the AG showed group function in lateral
excursions, whereas 32% of the CG patients had a
canine-protected occlusion.
The previous studies also demonstrated that patients
with maxillary first premolars in the place of canines
have the same (or better) periodontal health and TMJ re-
actions as do patients treated with prosthetic lateral in-
cisors, and this was confirmed in our investigation.21,22
The agenesis patients treated with space closure,
premolar intrusion (and buildups with supragingivally
placed restorations), and canine extrusion had
comparable periodontal health and TMJ reactions to
the reactions of the patients in CG with an intact
dentition and an optimal orthodontically produced
normal occlusion. However, TMD may not occur often,
surveys of subjects' TMD symptoms through follow-up
interviews have drawbacks, and a larger sample size
would be required to more thoroughly investigate
whether TMJ problems occur with orthodontic space
closure. The limitations of our study are not only the
small number of patients examined for TMD signs and
symptoms, but also that they were analyzed only at
the long-term recall. To be able to draw more definite
conclusions regarding TMD status after space closure
American Journal of Orthodontics and Dentofacial Orthopedics
347
treatment, it would have been preferable to compare
signs and symptoms before and after orthodontic treat-
ment, in addition to the statuses 10 years later. There-
fore, this report on TMD should be considered as an
incidental finding. However, our observation agrees
with recent concepts that occlusal factors have a fairly
small influence on the development of dysfunction in
young adults.36-38 It may be optimal to provide a
group function occlusion at the end of treatment, and
a proper functional balance should, if necessary, be
secured by posttreatment occlusal equilibration, but
this was rarely needed in the patients of both the AG
and the CG. Because of the complex etiology of TMD,
the authors of one study cannot consider all potential
operative factors. Since our patients were selected only
on the basis of availability of long-term records, it may
be assumed that noncontrolled potentially causative
factors had a similar influence in both treatment groups.
Some other limitations of this study were the small
number of patients in the groups and the retrospective
nonrandomized design. It would be preferable in coming
years to make a prospective randomized clinical trial
with a larger patient sample, in which the long-term
periodontal condition, frequency and severity of TMD,
and esthetic appearance and smile line are compared be-
tween patients treated with space closure and with
single-tooth implants.
CONCLUSIONS
Our results validated the following conclusions.
1. Patients with congenitally missing maxillary lateral
incisors treated with space closure, first premolar
intrusion, and canine extrusion are periodontally
healthy 10 years after treatment. Their overall peri-
odontal status is comparable with the condition of
patients without missing teeth who have received
similar orthodontic treatment. The intrusion of the
first premolar and the extrusion of the canine did
not increase the risk of periodontal tissue destruc-
tion and attachment loss in the long term.
2. No significant difference with regard to occlusal
function was found between the patients whose
premolars and canines were moved mesially and
vertically to close spaces and the orthodontically
treated patients with intact dentitions.
ACKNOWLEDGMENTS
We thank Sabrina Mutinelli for her contribution in
the statistical analysis and Jim Janakievsky for his advice
regarding the interpretation of the periodontal tissue
data.
March 2016  Vol 149  Issue 3
348
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