Al-Azhar University

Faculty of Dental Medicine

Orthodontic Department

Congenitally missing maxillary lateral incisor

By
Dr.Amal Magdy Fadle EL-Kareem

Supervisors
Dr.Mohammad Ahmed Mohammad Salim .
Assistant Professor of Orthodontics
Head of Orthodontic Department.

Dr. Wesam EL-Din Rafaat Ali Gouda

Lecturer of Orthodontics
Dr.Mostafa Mohamed Mahmoud Dawaba.
Lecturer of Orthodontics
Contents:
1-Introduction .
2-Diagnosis .
3-Treatment options
4-Space opening VS space closure .
5-Space closure .
6-orthodontic consideration during space closure
7-Esthetic consideration during space closure
8-space opening.
9-Orthodontic consideration during space opening
10-prosthetic placement .
11-Periorities in the treatment planning .
Introduction:

Congenitally missing tooth occurs due to disturbance in initial stages of

tooth formation.

Terms:

Anadontia : Total loss of the tooth number .

Oligodonita : Absence of many teeth but not all .

Hypodontia: Absence of only a few teeth .

Transmission and incidence:

Tooth agenesis (hypodontia) is an autosomal dominant ,
recessive or X linked condition .
It is common in females than male , Maxilla than mandible . with
the third molar being the highest in rate 20%, followed by
maxillary lateral incisor about 5 % and then mandibular second
premolar .
Tooth agenesis of maxillary lateral incisor :
They may be unilateral or bilateral missing . The unilateral
missing is usually associated with microdontia in the contra
lateral side .
Sequel of the missing lateral incisor :
When the lateral incisor is lost one of the 2 sequel may occur :
1-The erupting permanent canine resorbs the primary lateral
incisor and substitutes it , leaving the primary canine in place
that sheds later in time .
2-The primary lateral is retained and the canine erupts in it is
place ,this may lead to loss of space of lateral permanent incisor
and the left primary lateral incisor is unaesthetic .
Diagnosis :
The patient with missing lateral incisor usually seeks treatment at
early age due to the spaces found in the anterior area.
When the patient have a missing tooth , a careful evaluation
should be obtained to determine the treatment modalities . The
patient profile ,the incisor position , tooth shape and color ,
skeletal and dental development , the space available or the space
deficiency which is curricle in the treatment plan .
Radiographic examination , panorama is essential for evaluation
of the missing teeth , panorama may be obtained at the age of 7-8
years that show the tooth buds of all the teeth except for the 3 rd
molar tooth bud that is seen around 9-10 years old .
Clinical features :
-Midline diastema because the central incisor moves distally in
the missing space .
-Flaring of the central incisors .
-The canine may tilt mesially into the lateral space or it may be
impacted.
Correlation between missing lateral and canine impaction :
The role of the lateral incisor is considered critical for eruption of
the canine , it was found that absence of maxillary lateral incisor
may be associated with canine impaction as it lead to loss of
guidance for the canine eruption . Studies showed that up to 47 %
of palatally impacted canine have peg shaped , malformed or
congenitally missed lateral incisor. However it is not certain
whether the malformed shape of the tooth or the genetic
developmental disturbance is the main cause of canine impaction
.
Treatment :
The treatment of the congenitally missing lateral incisor is
challenging requiring a careful treatment plan , communication
with the patient , and often coordinated interdisciplinary team of
the orthodontist , the surgeon , periodontist , prosthodontist and
restorative to obtain optimum esthetic and functional results .
There are many factors that affect the treatment plane:
Occlusion , alignment of the teeth , patient age , the remaining
growth ,crowding or spaces , alveolar bone thickness , the facial
profile , shape ,form and color of the canine , lip length and
position , the gingival display , the smile line , the buccal corridor
, lip line and the relation with adjacent teeth .
Treatment options:
There are 2 main options available:
-Space opening and prosthetic replacement.
-Space closure with canine substitution.
The ideal option is the most conservative approach that satisfies
the patient esthetic and functional demand .

Space closure VS space opening

There has been an ongoing controversy in orthodontic and
restorative in treatment of agenesis cases especially the lateral
incisor in the aspect of occlusion , periodontal health ,esthetic .
Occlusion :
The restorative dentistry is against mesial movement of the
canine as it compromise the canine protected occlusion as it place
the canine in direct opposition to the lower lateral incisor Stuart
and Stallard advocate the canine protected occlusion . while
McNeill and Nordquist justify the mesial movement of the
canine into the space of lateral incisor as a rational option for
space closure they stated that no difference exist in adequency of
occlusal function between the canine protected group and the
space closure . and no difference in prevalence of
tempromandibular joint dysfunction.
Peridontal health :
McNeill and Nordquist stated that the treatment should aim at
eliminating the need for any prosthesis that contribute to plaque
accumulation , gingival irritation ,bone resorption in labile area
and bone loss in neighboring teeth .
Esthetic :
With the canine substitution reshaping of the canine usually
improves the esthetic but the dentoalveolar curvature cannot be
changed , in full smile the arch circumferential could be
diminished due to space closure and the canine alveolar
buttressing could be displayed anteriorly making the smile
unaccepted to patient . Henns study reported that when the
canine is moved to substitute the lateral incisor the canine
eminence is lost due to resorption but the resorption level does
not exceed 1.5 m.m making poor esthetic appearance of the
canine eminence .
Carlson have shown that after tooth is lost the alveolar bone
width is reduced by 23 % in the first 6 months and by 35% in the
followed 5 years so increasing the need for graft when prosthetic
is placed and it is highly liable to failure , but since tooth
movement in orthodontic brings bone with it , canine substitution
could be indicated to create natural alveolar bone in the anterior
area , and in cases where the canine erupted in place of lateral
incisor and prosthesis is to applied it is preferred to move the
canine to give enough bone for the implant placement as the
amount of bone loss over the time was about 1 % over the 4
years making the amount of resorption less.

Space closure Space opening

Prosthetic replacement Not required Required
Retention Long term Long term
Patient satisfaction Good Good
Periodontal health Good Fair
Profile May be flattened Support the lip
Midline May shift Coincide midline
Color and shape matching Concern Not a problem
of canine
Arch constriction Constricted arch and No constriction .
black buccal corridor .
Functional occlusion Loss of canine guidance Canine guidance
Cost Cheaper , only orthodontic Relatively expensive both
cost . orthodontic cost and
prosthetic cost .

1-Space closure with canine substitution :

In this cases the maxillary canine will substitute the lateral and
the premolar will replace the canine .

Indications :
-When all premolar extractions will be needed to relieve the
crowding or to replace the lateral incisor missed .
-Mild crowding and the space required can be filled with the
space of missed lateral .
-Class 2 molar with balanced facial profile and no mandibular
crowding .
-Class 1 molar with crowding in lower necessitating extraction
with good profile .
-Best when the incisors are protruded so the space could be used
for retraction .
-Canine and premolar of similar sizes .
Contra indications:
-Class 3 tendency and the retraction will have the possibility of
creating cross bite .
-Pronounced spaces in the maxillary arch .
-Patient who have no gingival display during smiling.
Advantages of canine substitution :
1-Natural compatible teeth with long term .
2-The finished results are permanent .
3-No need for future prosthetic replacement .
4-Studies showed that canine substitution and premolar
replacement maintain good occlusion and canine guidance .
Disadvantages :
1-Esthetic demands are compromised in the treatment plan.
2-The canine protected occlusion could be lost .
3-Need certain condition .
4-The facial alveolar bone could be unaesthetic due to canine
prominence.
5-Tendency for space reopening .
6-Very large , dark canine may be difficult to reshape and may
need restorative treatment .
Unilateral space closure in case of unilateral missed lateral
incisor:
In some instance unilateral loss of lateral incisor occur , in this
case it is not preferred to close unilateral space orthodontically .
In cases of unilateral loss of lateral incisor and the contra lateral
side is usually peg shaped , it may be better to extract this lateral
before eruption of canine and allow canine to drift bilaterally to
prepare for space closure .
Orthodontic consideration in space closure :
1-Before canine eruption . 2 -After canine eruption.
1-Before canine eruption :
In cases of missed lateral incisor large diastema is usually found
between the anterior teeth , it is preferred to close this diastema
befor eruption of the canine to allow maximum amount of drift of
canine into place of lateral incisor .
The primary canine could be extracted early to allow mesial drift
of the premolar in the area of the canine , this allows mesial
movement of the teeth and minimize the treatment time in the
following stage .
2-After canine eruption :
According to Nanda there are Six steps to be taken in
consideration for space closure :
1-Space closure with correction of malocclusion :
In cases of mandibular crowding extraction of lower premolars
could be performed according to soft tissue analysis but is better
not to expand the lower arch . in cases of gummy smile space
closure anteriorly can be made with skeletal anchorage mini
implant placed palatally and cl 3 elastics .
2-Orthodontic finishing in the anterior region :
Alignement to maxillary front teeth.
Canine extrusion and premolar intrusion .
Torque control during canine extrusion and premolar intrusion .
3- Gingivectomy :
In selected cases localized gingivectomy could be needed to
obtain proper gingival form .
4-Esthetic restoration :
At the end of orthodontic treatment , the canine and premolar will
need esthetic restoration .
The canine will need restoration to correct the shape and the
black triangles due to extrusion .
The premolar should be restored to the natural canine shape .
The goal is to obtain balanced , ideal smile both vertically and
transverse . The restoration can be made at the same day of
debonding , and whiter composite should be used to mask
yellowish color of canine .
5-vital bleaching :
Bleaching for the teeth specially the canine can be made but it is
better to adjust the bleach according to composite color not the
reverse .
6- Occlusal finishing , final restoration and long term stability :
Fundamental points should be taken into consideration for long
term stability :
-Do not expand the lower arch .
-Long term bonded retainer on the lower front teeth .
-Lip competence should be achieved .
-Stable occlusion in posterior teeth .
-Functional occlusion anterior without interferences .
-Since spaces may reopen again in the maxilla , fixed lingual
retainer is indicated .
-Esthetic restoration should be maintained with long term care
and careful hygiene .
Orthodontic consideration during space closure to improve
esthetic outcomes :
a)Bracket placement :
The lateral incisor bracket is placed over the canine , the canine
bracket is placed over the premolar .
The buccal surface of the canine should be reshaped before
bracket placement .
The orthodontist should place the bracket according to the
gingival line not the incisal or cusp tip as it will be reshaped .
To make the canine appear less curved and more like the lateral
incisor the bracket should be placed more distally in the center
rather than on the height of contour .
The canine bracket to be placed on the premolar in amore distal
position to replace the canine .
The bracket level at the canine should be slightly heigher to
allow some extrusion that will help in reshaping and enhance the
gingival level .
The premolar should be intruded to enhance the gingival level
During premolar intrusion the crown tend to move bucally which
impair the smile esthetic to avoid this problem high steel wire
should be used and inset bend is needed mesial to second
premolar and distal to canine .Regarding the torque , the canine
needs positive torque to decrease the appearance of canine
eminence .
To improve the contact between the central and the canine ,
offset bend (in-out) bend may be needed between the 2 teeth .
b) Reshaping of the canine and premolar :
To the maxillary canine :
It needs reshaping to the cusp , the height of contour , the
proximal surface , the incisal edges to mimic the lateral incisor
shape and composite work on the labile surface .
To the premolar :
Reshaping to the slopes and reduction of the lingual cusp to give
functional contact with mandibular canine .
Recontouring of both the canine and premolar is important to
eliminate the traumatic occlusion of mandibular lateral incisor
and maxillary canine and establish balanced occlusion .
After reshaping , the canine may need restorative treatment to
give color matching and ideal contour resembles the lateral
incisor .
Steps of canine reshaping :
1-Inter proximal reduction .
2-Cusp tip flattening .
3-Facial surface flattening .
4-Reduction of cingulum thickness .
5-Rounding to the corners of the flattened crwons.
Esthetic consideration for space closure :
When examining the esthetic of the anterior teeth and the smile,
the orthodontist should be aware of tooth contact , morphology of
gingival contour , tooth size problems and black triangles .
1-Tooth proportions :
The proportions of teeth are seen in relation in each other and
each individual tooth in both height width relation.
Width relationship (Golden proportion) :
According to the golden proportions , when the teeth are viewed
form the frontal view the width of the lateral incisor should be 62
% of the central incisor , the width of the canine should be 62 %
of the lateral incisor , the first premolar should be of 62 % of the
canine and so on . With golden proportions of 1.6:1:0.6 .
Height width relationship :
The width of the tooth should be 80 % of it is height , so in
reshaping this parameters should be put into consideration .
The gingival height , shape and contour :
The gingival margin of the anterior should coincide with the
upper lip line having the canine and the central gingival margin
at the same level and the lateral incisor gingival margin is
inferior by 1-2mm.
The gingival shape :
The curvature of the gingiva at the margin of the tooth .the
gingival shape of the lateral incisor should be half circle or half
oval .the central and the canine should have gingival shape to be
more elliptical and oriented distally to the long axis of the tooth .
The gingival zenith , the most apical point of the gingival tissue
should be located distal to the long axis of the tooth in both the
central and the canine , while the maxillary lateral should
coincide with their long axis .
The connectors and embrasure :
The contact point between the teeth moves gingivally from the
central to the premolars , so there is large embrasure in incisal
area .Short connectors lead to black triangles and unaesthetic
facial appearance .
Tooth shade and color :
The teeth appear lighter in younger age and gets dull during
aging .
Normal shade change from midline to posterior making the smile
more attractive , the central incisor tend to be the brightest in the
smile , the lateral less in brightness and the canine being the least
.The premolars are being brighter than the canine with the color
resembles the lateral incisor making the canine need bleaching or
composite resin to enhance the color and the smile .
Smile symmetry:
The smile should be symmetry at the two sides and the tooth
level should be the same at the two quadrant , so care should be
obtained during smile creation at the two sides .
Lip projection :
In case of missed lateral with protruded incisor it is better to use
this space to treat the protrusion rather than prosthetic
replacement .

Esthetic restoration between now and then :

With the increase in esthetic demands and high durability
expectation , the question was whether the composite restoration
will be enough as an option to reshape and mask the canine and
premolars for achieving final good esthetics, which lead to
introduction of ceramic veneers as substitution for composite
veneers . Composite veneers have a number of advantages over
ceramics, chief among which is cost , composites can typically
be fabricated while you wait, making it a same-day treatment.
Direct composite veneers (also referred to as composite bonding)
are actually sculpted on your teeth rather than in an offsite lab .
Arguably the biggest advantage that composite veneers have over
ceramics is reversibility. ceramics require reshaping of your
natural teeth in order to fit the veneer. When it comes to
composites, minimal prep work is required on your natural teeth,
meaning that they are not permanently altered to such an extent
that the composite material cannot be removed and replaced as
needed.
Although composite veneers have a number of advantages, there
is one area in which they cannot compete with ceramics:
durability. ceramics are far stronger material than composite
resin (even with the improvements in resin materials over the
years). Well-maintained ceramic veneers can last 10 to 15 years,
compared to the five- to seven-year average lifespan of
composites. It’s important to consider this tradeoff if you’re
thinking of having veneers placed. That is, while composites may
cost half as much as ceramic, they last only half as long. So
which is the better value?
Most dentists agree that ceramic veneers offer the most natural, tooth-
like aesthetics. ceramics has a translucent quality that is quite similar to
tooth enamel and it adhere to tooth by trasnopaque cement masking the
discolorations under it . It is also highly resistant to staining and
chipping due to the strength of the material and the glaze that is applied
after treatment. On the other hand, composite veneers are more porous
and therefore susceptible to staining, meaning that you may need to
adjust your diet in order to avoid certain stain-causing foods. Composite
also needs to be polished in order to achieve a tooth-like esthetic. And
even then it doesn’t quite compare.
The ceramic veneer procedure is more involved, and often
requires temporaries be worn while you wait for the veneers to be
sculpted in a lab. However more and more dentists are embracing
chairside CAD/CAM technologies that help to speed up the
process by allowing for on-site fabrication. If you are looking for
a ceramic veneers solution, it’s important to evaluate the sort of
technologies that your dentist has available. You could end up
drastically reducing the overall treatment time. Lastly, ceramic
veneers offer a viable treatment solution for all cases of worn
enamel, wear and tear, genetic defects, uneven teeth, etc.
Composites may not be a viable option for severe concerns. For
example, significant discoloration or spacing issues may not be
adequately treatable with composite veneers, making ceramics
your only option.
2-Space opening and prosthetic replacement :
Indications :
-Class 1 molar with normal profile and large spaces .
-Class 3 with retrognathic profile .
Contraindications :
In cases where canine was severely moved mesially and sever
distallization is needed to open space for pontic .
Prosthetic replacement options:
-Auto transplantation -Implant
-Fixed prosthesis. –Removable partial denture
Treatment sequence:
1-Orthodontic treatment :
The orthodontic treatment is usually required before restorative
treatment to evaluate the space and redistribute it .
It is better to have a consultation from the restorative specialist
before the orthodontic treatment start and at the finishing stages ,
some modifications could be implied during the orthodontic
treatment to facilitate the restoration placement .
The biomechanics in space opening :
The canine bracket is bonded normally with the normal position ,
no grinding to the canine is required , the premolar normal
bracket is bonded .
Determination of the appropriate space : 4 methods
-The golden proportions : as stated earlier each tooth should
represent 62% of previous one .
-The contralateral incisor: not reliable method since the other
lateral could be missed or pegged shape .
-Bolton analysis : sum of mandibular six anterior /sum of
maxillary six anterior =77.2 %
-Waxing up :The most predicted method , a cast with a wax set
up is made when the anterior and the posterior teeth are placed
in their normal functional position , the remaining space should
be ideal for the lateral incisor , it should be about 6-7 mm .
The digitalized CAD cast is the new alternative now .
Orthodontic consideration during space opening :
1-Midline :
When creating a space for the lateral incisor , it is important to
place the maxillary central incisor to be coincide with the facial
midline and the lower incisor to be coincide with the maxillary
midline .
2-Root position :
Panoramic radiograph should be taken to ensure the root
parallism and their proper position specially before prosthesis
placement.20
3-Soft tissue consideration in pontic area :
The ideal gingival contour is important for placement of the
pontic , the amount of the remaining hard and soft tissue in
pontic area should be evaluated .
Soft tissue recontouring can be with one of the following :
-Surgical gingivoplasty .
-Non surgical gingivoplasty with temporary restoration.
The pontic could be placed in the retention appliance until the
final prosthesis is applied .
Prosthetic replacement :
The prosthetic may be one of the following
1-Removable partial denture :
It is more conservative than the fixed but it is bulky , hard to
achieve high esthetic demands and patient dislike to wear them .
2-Autotransplantation :
Tooth with single root can be suitable for transplantation in
anterior region like the lower premolar or upper second premolar.
Studies have showed the long term stability and durability of this
treatment .
3-Tooth supported restoration :
a-Bonded single tooth replacement
The bonded bridge became acceptable as a semi permanent
procedure , it is cheap , simple but has high failure rate .
b-Resin bonded fixed partial denture (Maryland bridge) :
It is minimally invasive , very conservative but compromise the
esthetic due to this metal wing showing through translucent
enamel , it has high failure rate specially in deep bite cases
c-Fiber reinforced resin bonded bridge (encore bridge ):
Resembles the Maryland bridge instead of the metal junction part
, this design incorporates composite resin fiber reinforced lingual
frame work to ensure long term esthetic stability but it needs
mere tooth preparation on the lingual side and high failure rate
specially to lateral forces .
d-Cantilevered fixed partial denture .
e-Conventional full coverage fixed bridges (PFM , all ceramic) :
It require significant amount of tooth reduction but it is more
esthetic than removable partial denture and good functional
perspective .
It is contra indicated in young children due to large pulp , it also
require careful preparation from the orthodontist to ensure
parallism in the long axis between the canine and labile surface
of the central otherwise one tooth will go under severe reduction
to give parallism for bridge placement .
4-Implant supported restoration :
Single tooth implant is the most currently used treatment option .
It has long term success rate , the tooth next to it is healthy and
no reduction , bone preservation with high esthetic and functional
stability .
Disadvantages :
Require very careful case selection .
Require multidisciplinary approach .
Space requirement, site preparation and age restrictions.
The potential for esthetic failure due to gingival darkening or
exposure to gingival margin due to recession .
Incisal edge and vertical discrepancies due to vertical movement
of the tooth .
The ridge may need augmentation .
The need for careful root alignment.
When the choosing the implant option several factors should be
taken into consideration :
1-Growth :
The implant must be placed when the growth of the patient has
stopped as the implant usually act as ankylosed tooth so any
vertical alveolar growth or tooth eruption will cause
discrepancies between the gingival margin and the implant crown
.
2-Space requirement :
-The tooth width requirement for the mesial distal placement :
It should be determined before the orthodontic treatment end , the
restorative specialist should decide the amount of space needed .
-The amount of space between the roots :
The inter radicular space available , the root uprighting and the
angulation between roots , this can be monitored by periapical
radiograph .
-The alveolar width :
The alveolar width in buccolingual direction must be adequate
for implant placement . It is necessary to augment the ridge or
place graft before implant placement . It has been suggested to
allow eruption of canine more mesially then moving it back to it
is natural position to allow more alveolar thickness .
-Root angulation :
Following space opening or space closure , the root angulation
change , so it is important to place the apices away from each
other to ensure perfect implant placement .
In cases where the crowns of the teeth are proclined that created
root approximity , the roots tend to converge toward one another
resulting in a wagon wheel effect .
Interim tooth replacement after orthodontic treatment :
If the implant or the final restoration cannot be placed
immediately after the orthodontic treatment due to growth issues
, then a temporary restoration can be placed in the retainer to
maintain the space of the pontic , this type of restoration keeps
the pressure away from papilla and maintain healthy gingiva ,
after the growth has stopped the final restoration can be placed .
Another option is placement of alveolar mini anchor screw and
crown supported to it .
Priorities in the treatment plan :
It is important to understand the patient expects and their
motivations.
-Predictability :
The ability to achieve the desired treatment with long term
stability from both biological , periodontal and esthetic point of
view .
-Over all esthetic :
The over all esthetic idea is ideal alignment of tooth with intact
gingiva display and attractive smile and face .
-Age :
Most cases of congenitally missed lateral come at very young age
, these patients need only a smile , but adolescent people usually
seek attractive smile that became fundamental issue in their life .
Refrences :

1- Anurag Nand Amitab. Interdisciplinary management of congenitally missing

maxillary lateral incisors. J Oral Biol Craniofac Res. 2020 ;10: 184–8.

2-Smaragda K. Sofia P . Ioannis P . Agenesis of maxillary lateral incisors: A

global overview of the clinical problem. Orthodontics : the art and practice of
dentofacial enhancement . 2011 ;12:296-317.

3- Eustaquio A. Dauro O. Monica A. Diagnostic protocol in cases of congenitally

missing maxillary lateral incisors . World journal of orthodontics.2006 :7:376-88.

4- George L and Ahu A.A Review of Early Displaced Maxillary Canines:

Etiology, Diagnosis and Interceptive Treatment. Open Dent J. 2011; 5: 39–47.

5- Kokich Jr. Early management of congenitally missing teeth. Semin Orthod.

2005; 11(3):146-51.

6- Stuart C. Stallard H. Diagnosis and treatment of occlusal relations of the teeth.

Texas Dent J. 1957;75:430.

7- McNeill R. Joondeph D. Congenitally absent maxillary lateral incisors:

treatment planning consideration. Angle Orthod .1973;43:24-9.

8- Ricardo A.Girlaine N. Juliana M.Raildo C . Perception of attractiveness of

missing maxillary lateral incisors replaced by canines. Dental Press J Orthod. 2018
; 23: 65–74.

9- Kokich V, Kinzer G. Managing congenitally missing lateral incisors. Part I:

Canine Substitution. J Esthet Restor Dent. 2005;17:5-10.

10- Mota A, Pinho T. Esthetic perception of maxillary lateral incisors agenesis

treatment by canine mesialization. Int Orthod. 2016;14:95-107.

11-Ravindra Nanda. Esthetics and biomechanics in orthodontics .2015 2nd

edition.ch 25:p530-45.

12- Gerson L and Helder B. Understanding the basis of space closure in

Orthodontics for a more efficient orthodontic treatment. Dental Press J Orthod.
2016; 21: 115–25.
13- Zachrisson B. Improving the esthetic outcome of canine substitution for
missing maxillary lateral incisors. World J Orthod. 2007 ;8:72-9.

14-Sarver. D. The importance of incisor positioning in the esthetic smile: The

smile arc, Am. J. Orthod;129:96-111, 2001.

15-Brandão R. Brandão L. Finishing procedures in orthodontics: Dental

dimensions and proportions (microesthetics) .Dental Press J Orthod. 2013;18:147-
74.

16- Davis N. Smile Design. Dent Clin N Am. 2007;51:299–318.

17- Fradeani M, Redemagni M, Corrado M. Porcelain laminate veneers: 6- to

12-year clinical evaluation – a retrospective study. Int J Periodontics Restor Dent.
2005;25:9–17.

18- Seydler B, Schimitter M. Esthetic restoration of maxillary incisors using

CAD/CAM chairside technology – a case report. Quintessence Int. 2011;42:533–7.

19- Kinzer G. Kokich Jr . Managing congenitally missing lateral incisors. Part II:
tooth-supported restorations. J Esthet Restor Dent. 2005;17:76-84.

20- Bosio J. Bradley T. Hefti A. Moving an incisor across the midline: A

treatment alternative in an adolescent patient. Am J Orthod Dentofacial Orthop.
2011;139:533-43

21- Nakada T, Motoyoshi M, Horinuki E, Shimizu N. Cone-beam computed

tomography evaluation of the association of cortical plate proximity and apical root
resorption after orthodontic treatment. J Oral Sci. 2016;58:231-6.

22- Kuijs A. Dalen J. Roeters, and Wismeijer D. “The resin-bonded fixed partial
denture as the first treatment consideration to replace a missing tooth,” The
International Journal of Prosthodontics. 2016; 29: 337–9.

23- Augusti. G. and D. Re .“Prosthetic restoration in the single-tooth gap: patient

preferences and analysis of the WTP index,” Clinical Oral Implants
Research.2014; 25: 1257–64,.

24-Schneider U, Moser L, Fornasetti M, Piattella M, Siciliani G. Esthetic

evaluation of implants vs canine substitution in patients with congenitally missing
maxillary lateral incisors: are there any new insights? Am J Orthod Dentofacial
Orthop. 2016;150:416-24.

25- Kermanshah H. and Motevasselian F. Immediate tooth replacement using

fiber-reinforced composite and natural tooth pontic, Operative
Dentistry.2010;35:238–45.

26- Odilon G.Cristiano M.Angela G.Orlando M. Ricardo K. Prosthetic,

orthodontic and implant-supported rehabilitation of five maxillary anterior teeth
with alveolar bone loss. Dental Press J Orthod. 2018; 23: 87–96.