Missing Teeth

The choice in these cases is usually to recreate space for the prosthetic replacement of missing teeth, or to close the space instead.

If an upper central incisor is missing then the usual choice is to open up the space and put in some form of prosthesis. If the space is closed and the lateral incisor is placed in the central incisor site, then camouflage is difficult because of the small width of the lateral that results in an unsightly emergence angle of the crown. In cases where an upper incisor is missing, the space may need to be re-distributed. The patient in Figure 1 had a partial upper denture, and it was difficult to restore the site with a bridge because of the inclination of the upper lateral incisor and the generalised spacing in the upper labial segment. Fixed appliances were therefore used to re-distribute the space in the upper arch. In order to maintain the appearance, a bracket was fitted to a denture tooth. At the completion of treatment the patient was fitted with an upper removable retainer carrying a denture tooth. Note the proximal metal stops on the upper right central and upper left lateral incisor, to prevent a space re-opening during retention. Finally a bonded bridge restored the site.

When lateral incisors are missing the choice is not so clear-cut, and often depends on the amount of spacing the patient has, the buccal occlusion and the shape and colour of the canines. Opening the space for prosthetic replacement produces optimal aesthetics but has the disadvantage of the maintenance involved with this type of restorative treatment. Closing the space obviates the need for false teeth but this may produce a less satisfactory appearance.

Where there is considerable space, the buccal occlusion is well inter-cuspated and the canine has a pointed cusp tip then the usual treatment is to open the spaces. Closing spaces will affect the buccal occlusion, and if it is a well interdigitated Class I then this may not be the best option. The shape of the canines is

Fig.1a,b A patient with a missing upper left central incisor, which has been replaced with an inadequate denture

Inter Treatment Impacted Canine

Fig. 1c A fixed appliance with a denture tooth to mask the space

Fig. 1d The space has been redistributed

Fig. 1e A retainer with a denture tooth. Note the proximal metal stops. If these are not used there is a risk of the teeth sliding past the denture tooth.

Fig. 1f A bonded bridge was placed 1 year after the removal of the fixed appliance important because if they are pointed they will look unsightly adjacent to the central incisor. Although the tips of the teeth can be trimmed to improve their appearance, this is not always the best choice. Figure 2 shows a case with spacing in the upper arch due to developmen-tally absent upper lateral incisors. The upper canines have very pointed tips and it would be difficult to modify the shape of these teeth to make them resemble lateral incisors. In addition, the buccal occlusion would make space closure very difficult. Therefore, space in the upper arch was recreated to allow prosthetic replacement. An upper fixed appliance with coil springs at the upper lateral incisor sites accomplished this task. At the completion of treatment, an upper retainer with denture teeth was used to restore the missing sites. This retainer was worn for a year prior to definitive restoration with adhesive bridgework.

If the canine teeth are more amenable to masking, and the buccal occlusion is not well inter-cuspated with less spacing in the upper arch, then consideration can be given to space closure. Figure 3 shows a case where this was accomplished, again using a fixed appliance and the tips of the canines subsequently trimmed. A good aesthetic appearance was achieved, but it is worth noting the slightly different colour of the canines in relation to the central incisors. If necessary, this can then be masked with veneers. Before the decision to open or close spaces is made, consultation with a restorative dentist or the patient's GDP is a pre-requisite.

Fig. 2c Following removal of the fixed appliance Fig. 2d A retainer with denture teeth was fitted and worn for one year prior to definitive restorative treatment

Fig. 2c Following removal of the fixed appliance Fig. 2d A retainer with denture teeth was fitted and worn for one year prior to definitive restorative treatment

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