Canine substitution vs implant vs Maryland bridge

Canine substitution vs implant is a debate many orthodontists have internally with cases of missing laterals. Another solution is also the Maryland bridge, although many consider this more of a long term temporary solution.

Dental implant in a narrow missing lateral space. — A dental implant in a missing lateral space with no room to spare on either side. These are challenging cases because they must be done perfectly. This is another reason to consider canine substitution, because these are HARD to do well! Case by Dr. Bauer

When deciding between canine substitution and dental implants what should you consider?

When someone is missing lateral incisors, there are multiple factors that need to be taken into consideration. The management of adult patients that happen to have their lateral incisors and need them extracted is an entirely different process than patients with congenitally missing laterals. Single tooth implants are not suggested for young patients until they are completely done growing and new research shows the later the better. For these young patients that are congenitally missing their lateral incisors, canine substitution can be an excellent, esthetic treatment option. However, there are certain criteria that must be met to help guarantee this procedure will be a success and yield predictable results:

In the canine substitution vs implant debate the canine substitution can look good. — Canine substitution done by another local orthodontist with pretty bad result. Midline cant and off, uneven incisal edges and gumlines. The left canine was left way too high giving her a very toothy smile on that side. We made better with composite but need ortho again and 4 veneers to make perfect. Ortho done well the first time could have had excellent results. Need to choose a good orthodontist like Dr. Danielle and have a good dentist helping too.

Bite (occlusal) considerations that allow a canine substitution.

From an occlusal standpoint, there are two situations were canine substitution works well. The first situation is a Class II individual that does not have any mandibular crowding. When this is the case, the molars remain in Class II but the pre-molars are forward to act as a canine. The other situation is a Class I individual with enough mandibular anterior crowding that we need pre-molar extractions on the lower jaw.

Profile considerations for a canine substitution.

For a canine substitution we want someone to have a profile that is relatively flat or slightly convex. People without either of these characteristics would most likely benefit from treatment that manages the esthetic profile.

What is the canine shape and color?

If we move the canine to the lateral site then we must evaluate the canines shape and color. Canines are always larger than lateral incisors and so we want to see how much wider. We pay speacila attention to the width at the CEJ since this area can not be changed. The wider the tooth at the CEJ, the more difficult it will be to make them look like lateral incisors. Canines are the teeth with the most color and thus appear more yellow than a natural later would. We can deal with the color by whitening but it is something we look at before hand.

Smile line consideration for canine substitution.

Depending on how high the smile line is, the lip level may show the canine eminence. Large canines often have an obvious root prominence, and high lip levels may reveal that there is an unnatural eminence in the lateral sight. The gingival architecture will also be off as the canines have a higher gingival margin than the laterals, however this should be an easy fix with orthodontics. Overall dental implants are less favored in the gummy smile case.

So what is best canine substitution or implant?

The correct answer to the canine substitution vs implant debate, likely depends on who you ask. It is often best to go with what your orthodontist and dentist feel is best and what they prefer. They likely prefer what they are capable of best doing. Whether that is truly best or not is debatable, but it is likely the best treatment result you will get in their particular hands. Research might favor canine substitution but it’s not definitive. Most important is to choose the right docs though, as seen above. We can’t undo some things without spending a lot of time and money. Patient satisfaction tends to favor canine substitution and esthetics seem to be as good or better for canine substitution, especially to patients (Schneider AJO-DO 2016 references 23-28).

Canine subsitution vs implant tends to favor closing the space. — Nice article on canine space closing

What to do if only have one missing lateral, canine substitution vs implant?

In these cases the midline and crown shape, peg lateral or microdont, of solo lateral are paramount.

Extract the one lateral if

1. There was a peg-shaped lateral incisor. An alternative option in the presence of a normal lateral incisor could be to extract the contra-lateral second premolar.
2. Crowding on the contra-lateral arch.
3. A class II malocclusion.
4. Deviation of the center line towards the absent lateral incisor.

Open the space for an implant or Maryland bridge if

1. Class I buccal segment relationship bilaterally.
2. Inclination of the upper incisors is favorable to proclination.
3. Class III camouflage is appropriate.
4. Spaced upper arch.
5. Lack of alveolar bone.

Close the space for with canine substitution if

1. Class II buccal segment relationship on the side of the arch with the absent lateral incisor.
2. Class II canine relationship on the side of the arch with the absent lateral incisor.

Canine substitution vs implant research

I will be including studies and more info in this blog as time goes on.

The layperson does not notice a difference if do a canine substitution. BDJ 2015