The Missing Lateral Incisor Dilemma

One of the most common interdisciplinary treatment decisions in orthodontics is determining whether a congenitally missing maxillary lateral incisor should be replaced with an implant or whether the canine should be substituted into the lateral position. There is no one-size-fits-all solution—the ideal treatment depends on the patient’s smile esthetics, occlusion, tooth anatomy, and long-term restorative goals.

Option 1: Open Space for a Future Dental Implant

Opening space for a future implant is often the preferred treatment when preserving ideal tooth proportions and smile esthetics is the primary goal.

Clinical situations that favor implant space opening:

• Unilateral missing lateral incisor – Maintaining symmetry is often more predictable when the contralateral lateral incisor is present.
• One peg-shaped lateral and one missing lateral – Orthodontic space opening allows the peg lateral to be restored while replacing the missing lateral, creating a more harmonious smile.
• High smile line – Patients with greater gingival display often benefit from preserving natural tooth anatomy and gingival architecture. The gingival margins of the canines are naturally positioned more coronally, often matching the central incisors. This can result in an unbalanced gingival architecture when canines are substituted for lateral incisors.
• Large, pointed, or darker-colored canines – Prominent canines are often difficult to disguise as lateral incisors, even with enamel recontouring and restorative enhancement.
• Class I or Class III malocclusions – These occlusal relationships generally allow ideal canine guidance to be maintained while replacing the missing lateral incisor.

Advantages

• Preserves natural canine anatomy and function.
• Maintains canine guidance and ideal occlusal relationships.
• Produces the most anatomically accurate tooth proportions.
• Often provides the most ideal esthetic outcome in appropriately selected patients.

Considerations

• Dental implants should not be placed until craniofacial growth is complete, often requiring several years of interim space maintenance after orthodontic treatment.
• Patients and parents should understand the commitment to future restorative treatment and the lifelong maintenance associated with implant-supported restorations.
• My preferred interim solution is a bonded pontic (Maryland bridge) to maintain space and esthetics, combined with a clear overlay retainer for additional stability until implant placement is appropriate. The bonded pontic aids in holding root divergence for future implant placement as well as increases patient confidence throughout their adolescent years.
• Collaboration is extremely important during the space preparation phase for implants. It’s my job to ensure that adequate overbite, overjet, and root divergence of adjacent teeth are achieved to support a long-lasting interim and permanent restoration. 

Case Reports:

Addison

Meet Addison, a teenager with missing maxillary right canine (#7), peg maxillary left canine (#10) and impacted maxillary left canine (#11). The referring dentist restored #10 prior to orthodontic treatment to ideal size so I could match the site for #7 to that of #10. A bonded pontic was placed after braces removal. I plan to monitor growth and an implant will be placed once cessation of growth is confirmed. Gingival contouring should also be considered prior to final restorations. 

Kimberlie

Meet Kimberlie, an adult with bilateral missing lateral incisors. Treatment included removal of maxillary primary canines, distalization of permanent canines and implants in the maxillary lateral incisor sites. This provided the optimal cosmetic outcome.

Adalyn

Meet Adalyn, a teenager with Class III tendency and retroclined incisors. The best cosmetic outcome for her malocclusion was determined to be implants. Bonded pontics were placed to help maintain root angulation and space. Gingival recontouring should be considered before final restorations done

Option 2: Canine Substitution

In the right patient, canine substitution is a conservative treatment option that creates a functional and esthetic smile while avoiding future implant therapy.

Clinical situations that favor canine substitution:

• Class II malocclusions – Space closure often complements the desired orthodontic correction.
• Low smile line – Differences in canine anatomy and gingival contours are less noticeable during smiling.
• Bilateral missing lateral incisors – Symmetrical canine substitution can sometimes produce harmonious smile esthetics.
• Smaller, lighter-colored canines – Canines that naturally resemble lateral incisors require minimal reshaping and restorative modification.

Advantages

• Eliminates the need for future dental implant placement.
• Reduces long-term restorative treatment and maintenance.
• Avoids years of interim space maintenance during adolescence.
• Utilizes the patient’s natural dentition, creating a biologic, lifelong solution.
• Can provide acceptable esthetic outcomes with selective enamel recontouring and, when needed, conservative restorative reshaping.

Case Report: 

Maddy

Meet Maddy, a unique case of unilateral canine substitution. She was missing her maxillary right second premolar (#4) and maxillary left lateral incisor (#10)

Due to small size of maxillary left canine (#11) and low smile line, it was determined to treat her with canine substitution and closing the space for the missing #4. Recontouring of #11 was done to improve esthetics to better match the anatomy of contralateral #7. 

The Bottom Line

There is no universally correct treatment for a congenitally missing maxillary lateral incisor. Both implant space opening and canine substitution can produce outstanding long-term esthetic and functional outcomes. The best treatment results from thoughtful interdisciplinary planning between the orthodontist, restorative dentist, and, when indicated, the implant surgeon—tailored to each patient’s occlusion, smile characteristics, and long-term restorative goals.