# Aesthetic Adjustments for Missing Teeth 🦷

## Question:

Hoping to get your insight on a treatment plan here. Patient is missing upper and lower laterals and has a very large Bolton discrepancy!  
Would you extract the 34? Is there a way to make this a camouflage case to improve esthetics without 2.5+years of treatment? Curious to hear your thoughts. Thanks!  
(I have not worked on this clincheck - just posting it so you have access to move the model around)

<https://shub.invisalign.com/cc-cloud/latest/index.html?locale=en_US&user=user&ccModIntegrity=false&configUrl=%2Fconfig%2Fscsl_cc_cloud&ccId=604437>


## Answer:

[https://www.loom.com/share/57b799336ae9473284e45af3d2568cfd?sid=bbf2dbb3-5308-48d9-abca-6b9c1efe7b16](https://www.loom.com/share/57b799336ae9473284e45af3d2568cfd?sid=bbf2dbb3-5308-48d9-abca-6b9c1efe7b16)


### Orthodontic Treatment Planning in the Presence of Missing Lateral Incisors and Class II Molar Relationship

#### Clinical Context

In orthodontic cases where a patient is missing two lower lateral incisors, it is essential to recognize that the Bolton tooth size discrepancy is altered. This is particularly relevant when there is a concurrent Class II molar relationship, such as an upper first molar occluding in a full Class II position. This anatomical imbalance must be carefully assessed when developing a comprehensive treatment plan.

#### Treatment Goals and Initial Assessment

The primary goal in such cases, especially when upper lateral incisors are also missing, often revolves around improving dental aesthetics and achieving harmonious arch coordination. In situations where no significant anterior-posterior adjustment is planned, the first step is to assess the existing overjet.

Even in the absence of certain teeth, such as both upper and lower lateral incisors, the remaining dentition can often result in a naturally balanced occlusion. If the posterior occlusion is deemed acceptable and the arches coordinate well, then significant anterior-posterior modifications may not be necessary. In such cases, simple proclination of the incisors may suffice.

The Bolton analysis, commonly used to evaluate tooth size discrepancies, becomes less relevant in these cases due to the absence of multiple teeth, rendering the typical measurements inapplicable.

#### Aesthetic and Functional Considerations

One of the key challenges in these patients is the morphological discrepancy between the remaining teeth and the role they must assume. For example, canines, which are typically pointed and larger, may need to be reshaped to function as lateral incisors. These canines often appear disproportionate relative to the central incisors.

To address this, aesthetic re-contouring of the canines is recommended. This can involve:

* **Gingival Adjustment**: Lowering the gum lines to better match the profile of lateral incisors.
* **Mesiodistal Reduction**: Narrowing the width of the canines using interproximal reduction (IPR) or direct enameloplasty.
* **Incisal Modification**: Shortening the incisal edge to harmonize with adjacent teeth.
* **Black Triangle Closure**: Performing IPR on the lower teeth to close gingival embrasures and create more overjet if needed.

These steps allow the canines to more closely resemble lateral incisors in both form and function.

#### Substitution and Restorative Planning

In previous cases, canine substitution has been successfully implemented to address missing lateral incisors. The process includes:


1. **Extruding the Canines**: Slight extrusion ensures the gingival contour of the canine matches that of a natural lateral incisor, which typically has a more upright gum line.
2. **Enameloplasty**: Using burs to reshape the tooth’s mesial and distal surfaces to create a more appropriate lateral incisor form.
3. **Premolar Modification**: Increasing the clinical crown height of the first premolars to match adjacent incisors, followed by restorative work such as veneers to give them the appearance and function of canines.

These esthetic reconfigurations require precise planning and execution, usually performed after orthodontic alignment has been achieved.

#### Clinical Adjustments and Considerations

Rather than relying solely on IPR within digital treatment planning software (e.g., ClinCheck), clinicians are encouraged to perform enamel reduction manually, guided by clinical judgment. The goal is to establish ideal tooth proportions and close spaces in a controlled manner.

Attention must also be given to occlusal relationships. Adjustments may be required to prevent improper contact between reshaped canines (now functioning as lateral incisors) and opposing upper canines. This may include:

* **Occlusal Reduction**: Selective grinding of cusp tips to prevent interferences.
* **Functional Recontouring**: Ensuring that new contact points do not compromise occlusion or the integrity of any restorative work.

#### Conclusion

In such complex orthodontic cases involving multiple congenitally missing teeth and a Class II molar relationship, extraction is typically unnecessary. With careful planning and techniques like IPR, enameloplasty, and prosthetic augmentation, both functional and aesthetic objectives can be achieved. This approach allows for preservation of natural dentition while still providing a harmonious and esthetically pleasing outcome.