Bilateral congenital absence of maxillary

lateral incisors: A craniofacial and dental

cast analysis Dr. Woodworth

Don A. Woodworth, D.D.S., M.S.D.,* Peter M. Sinclair, B.D.S., M.S.D.,** and

Richard G. Alexander, D.D.S., M.S.D.***
Dallas, Texas

The dental casts and cephalometric records of forty-three patients exhibiting bilateral congenital absence of
maxillary lateral incisors were evaluated to determine the nature and extent of any concurrent craniofacial and
dental anomalies. The effects of bilateral orthodontic space closure were evaluated on a subsample of twenty-two
cases. The data revealed normal dental arch length, arch width, overjet, and overbite, while significant tooth
size discrepancies were found in several anterior and posterior teeth. Craniofacial deviations from normal included
smaller maxillary length, smaller mandibular length, smaller anterior cranial base, and nasal bone. Vertical facial
dimensions, both anterior and posterior, were significantly less, as was the mandibular plane angle. Soft-tissue
examination revealed a lo” greater nasiolabial angle, which was increased a further 5” as a result of a mean
incisor retraction of 1.5 mm during space closure. The craniofacial anomalies noted in the present sample were
similar to those seen in persons with clefts and may reflect a common etiology related to a developmental
disturbance during fusion of the facial processes in utero. In the treatment of patients with bilateral congenital
absence of maxillary incisors, mechanotherapy designed to open the mandibular plane, increase the vertical
dimension, and move the maxillary posterior teeth forward is recommended in order to prevent worsening the
Class Ill tendency and to minimize maxillary incisor and upper lip retraction. Most cases will require significant
mesiodistal reduction in tooth size in order to achieve an optimal occlusion.

Key words: Agenesis, tooth size discrepancy,craniofacial anomaly, treatment planning

P atients with bilateral congenital absence of

maxillary lateral incisors present challenging problems
with respect to treatment planning and mechanotherapy.
The decision has to be made whether to hold the spaces
left by the missing incisors open for future bridgework
or to attempt to close the spaces orthodontically. A
comprehensive treatment plan will have to consider the
potential effects of treatment upon the patient’s profile
as well as the need to estimate the amount and direction
of any future growth. Superimposed on these criteria
are such factors as the position of the maxillary canines,
their inclination, size, shape, and color, as well as the
need for extractions in the mandibular arch to provide
optimum occlusion and tooth size relationships.
The incidence of bilateral absence of maxillary lat-
eral incisors has been reported as being between 1%
From the Department of Orthodontics, Baylor College of Dentistry.
This article is based on research submitted by Dr. Woodwolth in partial ful-
fillment of the requirements for the Master of Science in Dentistry degree.
*Orthodontist in private practice, Arlington, Texas.
**Assistant Professor, Department of Orthodontics.
***Associate Professor, Department of Orthodontics.
and 2% in white persons of Northwest European ori-
gin.‘, * The vast majority of these patients seek ortho-
dontic care because of the unesthetic and socially un-
acceptable malocclusion that usually results when teeth
are missing.j
It has been suggested that the absence of maxillary
lateral incisors may be only one manifestation of a
complex, multifactorial, craniofacial anomaly.4-6 Fea-
tures that have been reported in association with the
absence of lateral incisors include a higher incidence
of absence of other teeth, more frequent impactions,
and tooth size discrepancies in both arches.4, 5. ‘, *
Two etiologic theories have been suggested. The
absence of maxillary lateral incisors may be an expres-
sion of an evolutionary trend of relaxed selection lead-
ing to the simplification of man’s dentition through a
reduction in tooth number43 5 Alternatively, a distur-
bance in the fusion of the embryonic facial processes
may result in the incomplete expression of a primary
cleft which is manifest as the absence of the maxillary
lateral incisors6. 9 At present, there is inadequate doc-
umentation to support either theory.

280
Volume 87 Bilateral congenital absence of maxillary lateral incisors 281
Number 4

Increased understanding of the cause and clinical

manifestations of cases with congenitally absent max-
illary lateral incisors would therefore aid in their di-
agnosis and treatment planning.
The purpose of this study was fourfold:
1. To determine the degree to which the cranio-
facial morphology of persons with bilateral congenital
absence of maxillary lateral incisors differs from
normal.
2. To evaluate the degree to which the dental arch,
tooth size, and occlusal relationships differ from
normal.
3. To analyze the effects of bilateral orthodontic
space closure on the facial profile.
4. To determine the optimum occlusal and tooth-
size relationships in cases treated with bilateral ortho-
dontic space closure.
MATERIALS AND METHODS
Patient data
The sample comprised forty-three patients (twenty-
eight females and fifteen males) of northwest European
origin exhibiting bilateral congenital absence of max-
illary lateral incisors. The cases were selected from the
private practice of one of the authors (R. G. A.). Sample
selection was based solely on the availability of ceph-
alometric and dental cast records. The mean age of the Fig. 1. Cephalometric points digitized.
patients was 13.5 years (range, 10.6 to 23.9 years).
Twenty-two of the forty-three patients were treated with sessed by a single investigator (D. A. W.). Twenty-
bilateral orthodontic space closure, and the posttreat- seven hard-tissue and twelve soft-tissue anatomic land-
ment records of this subgroup were used to assess the marks were located on each tracing (Fig. 1). The co-
effects of orthodontic treatment. Treatment time aver- ordinates of each landmark for each cephalogram were
aged 24.8 months. recorded by means of a Tektronix 4012* digitizer in-
There was a high incidence of tooth agenesis in the terfaced with a DEC system-lot computer. The output
sample. Twenty-four patients (55% of the sample) were values for each point were stored by coordinate rep-
missing one or more third molars, and seven of these resentation on a disk for computer analysis.
patients were also missing one or more second pre- Twenty-five linear and twenty-three angular mea-
molars. There was a 21% incidence of impaction, as surements were selected for quantitative cephalometric
compared with 14% to 18% in the general popula- evaluation.
tion. ‘o-‘2 Sixty percent of the sample demonstrated a
skeletal Class I relationship (ANB 2 to 4”), while 21% Dental cast analysis
had a skeletal Class II relationship (ANB 5” + ) and With Helios dial calipersS the following measure-
19% showed a Class III trend. In the general population ments were made by one investigator (D. A. W.) to the
most studies agree that the incidence of Class I is 60% nearest 0.1 mm for each set of casts:
to 70%; Class II, 25% to 30%; and Class III, 5% to Tooth size analysis. As described by Bolton,’ the
10%.‘3. I4 mesiodistal crown dimension of each maxillary and
mandibular tooth measured at the contact point (except
Cephalometric analysis third molars).
Standardized lateral cephalometric radiographs Overjet. The distance parallel to the occlusal plane
were obtained for all forty-three cases before treatment
*Tektronix, Inc., Beaverton, Ore.
and for the twenty-two completed cases after treatment. tDigita1 Equipment Corp., Marlboro, Mass.
The cephalometric headfilms were prepared and as- $Helios Dial Calipers, Schneider and Kern, Niedemhall. West Germany

Fig. 2. Dental cast measurements. A + 6 = Arch length.
C = Intercanine width. D = Intermolar width.
from the incisal edges of the most labial maxillary to
the most labial manidibular central incisors.
Overbite. The mean overlap of upper to lower cen-
tral incisors, perpendicular to the occlusal plane.
Intercanine width. The distance between mandib-
ular cusp tips or estimated cusp tips in cases of wear
facets.
lntermalar width. The distance between mandibular
mesiobuccal cusp tips or estimated cusp tips in cases
of wear facets.
Mandibular arch peripherylarch length. As sug-
gested by Nance,16 the “inside arch length” measured
as the sum of the right and left distances from me-
sial anatomic contact points of the first permanent mo-
lars to the contact point of the central incisors or to
the midpoint between the central incisors if spaced
(Fig. 2).
Thus, a total of thirty-one dental cast parame-
ters (twenty-six tooth size measurements and five linear
distances) were recorded for each patient. Each param-
eter was measured twice, and the mean was deter-
mined.
We used Bolton’s formula” in carrying out a
tooth size analysis comparing various combinations of
maxillary and mandibular anterior teeth to determine
which combinations produced the best occlusal rela-
tionship .
Statistical and error analysis
Statistical analysis was performed by standard
methods. I7 Groups were compared by Student’s t test
for independent groups, while the significance of
changes across time was determined by the Wilcoxon
signed rank test. Association between variables was
Am. J. Orthod.
April19x5
Fig. 3. Male hard-tissue composite, study group (- - - -) versus
normal (-)
evaluated by Spearman’s rank correlation coefficient
(r). Statistical significance was established at p d 0.01
and a correlation of r s 0.7 was considered of clinical
importance. Errors in landmark identification (tracing
error) and digitizing were statistically determined.
Cephalometric radiographs of five randomly selected
cases were remeasured to test within-day and between-
day examiner variability. Three sets of dental casts were
remeasured in similar fashion. Linear and angular mea-
surement error for the cephalometric radiographs av-
eraged 1.5% within days and 2.5% between days. Mea-
surement error for the dental cast parameters averaged
2% within days and 3% between days.
Hard-tissue craniofacial measurements were com-
pared by age and sex to normal data from the Michigan
Growth Study as described by Riolo and associates,‘8
and soft-tissue measurements were compared with ideal
profiles as described by Spradley and colleagues. I9
Tooth size relationships were evaluated by Bolton’s pa-
rameters. Is Mesiodistal tooth measurements were com-
pared with the standards of Moyers and his co-work-
ers,” and the other dental parameters were compared
with those of Sinclair and Little.*’
RESULTS
Dental cast dimensions
The sample showed no statistically significant dif-
ference from normal with regard to measurements of
Volume 81
Number 4
Table I. Significant mesiodistal tooth size differences
Dtferences
Tooth Males
Maxilla
Right second molar 0.59
Left second molar 0.0
Right first premolar 0.0
Mandible
Central incisor -0.23
Lateral incisor -0.37
First molar 0.0
Second molar 0.0
arch length/periphery, intercanine and intermolar
widths, overjet and overbite, suggesting relatively nor-
mal dental arch shape and size.
Statistically significant differences from normal
were found when comparisons were made of the me-
siodistal tooth size relationships of the sample (Table
I). In males, there was a small mandibular incisor di-
mension, while in females maxillary and mandibular
molars were larger.
Using Bolton’s formula,‘5 we compared the sum of
the mesiodistal tooth sizes of the maxillary central in-
cisors, canines, and first premolars to various combi-
nations of mandibular anterior teeth. In 86% of the cases
the extraction of lower first premolars (where warranted
by the malocclusion) should have provided the best
tooth size relationship. Eleven percent of the cases
should have been best treated by the extraction of both
mandibular central incisors, and only 3% gave a sat-
isfactory result where mandibular lateral incisors would
have been extracted.
In no case would the extraction of a single man-
dibular incisor have produced an acceptable tooth size
relationship. A mean maxillary tooth size excess of 0.7
mm was left in 70% of the cases treated with the most
successful option (mandibular first premolar extrac-
tion), while the remaining 30% of these cases were left
with a mean mandibular tooth size excess of 1.1 mm.
In the sample of twenty-two completed cases, nineteen
cases were treated without extractions in the mandibular
arch, in two cases first premolars were removed, and
in one case both central incisors were extracted because
of previous trauma to these teeth.
Cephalometric analysis
The cranial base. Both sexes showed an anterior
cranial base that was significantly shorter (p < 0.001)
than normal. In males the sella-to-nasion distance was
shorter on average, by 4.7 mm (x = 75.2 k 4.88 mm
Bilateral congenital absence of maxillary lateral incisors 283
in mesiodistal size from normal (mm)
P Females P
0.007 0.98 0.001
NS 1 .Ol 0.001
NS 0.27 0.002
0.01 0.0 NS
0.001 0.0 NS
NS 0.50 0.003
NS 0.66 0.001
versus 79.9 k 3.95 mm), while in females the differ-
ence was slightly less at 3.3 mm (x = 71.9 k 3.02
mm versus 75.2 k 2.12 mm). No significant differ-
ences were noted in posterior cranial base dimensions
or in the cranial base’s degree of Ilexure.
The shorter anterior cranial base was directly cor-
related with a decrease in both maxillary and mandib-
ular length (Ba-ANS, r = 0.75) (Art-B, r = 0.70) and
inversely correlated with the Y axis (r = -0.75) (Ta-
ble IV).
Maxillary length. A considerably shorter maxillary
length, as measured from ANS to PNS, was noted in
both sexes (Figs. 3 and 4). The maxilla was 8.9 mm
shorter than average in males (x = 49.2 k 1.85 mm
versus 58.1 + 3.61 mm, p ==c0.001) and 7.0 mm
shorter in females (x = 47.9 -+ 4.90 mm versus
54.9 + 3.55 mm, p < 0.001). Similar maxillary
shortness was noted when measurements were made
from PNS to point A as well as from the pterygomax-
illary fissure to point A or to the anterior nasal spine
(Tables II and III).
Maxillary position. In addition to being smaller in
size, the maxilla was also found to be retrusive in po-
sition (Figs. 3 and 4). The basion-to-ANS distance
was significantly smaller than normal in both sexes
(p < O.Ol), with that in males being 6.7 mm shorter
(x = 101.7 t 7.12 mm versus 108.4 + 5.5 mm)
while the female’s measurement was somewhat smaller
at 4.5 mm (98.1 k 7.32 mm versus 102.6 +- 5.58
mm) (Tables 11 and III). This maxillary retrusion was
directly correlated to a shorter anterior cranial base
(S-N, r = 0.75) (Table IV).
Angular measurements were less conclusive, for
SNA remained within normal limits as a result of both
nasion and point A being relatively retrusive (Figs. 3
and 4) while the SN-ANS angle was an average of 2.8”
(p < 0.01) smaller in males only (84.0 -+ 2.80” versus
86.8 + 3.63”). The angulation of the maxillary plane
284 Woodworth, Sinclair, and Alexander
Fig. 4. Female hard-tissue composite, study
sus normal (-).
relative to the cranial base was found to be reduced by
2.8” in females (5.1 +- 3.56” versus 7.9 + 2.52”,
p -=c0.001) because of a lack of upper anterior facial
height.
Mandibular length
Mandibular length (articulare to point B) was sig-
nificantly smaller (p < 0.01) in both sexes, with males
showing a mean difference of 6.8 mm (x =
98.6 + 8.42 mmversus 105.4 + 5.34 mm), while the
female difference was 3.1 mm (x = 97.3 t 8.42 mm
versus 100.4 + 5.54 mm). This shorter mandibular
length was strongly correlated to the maxilla’s reduced
size (PNS-point A, r = 0.92, PTM-point A, r = 0.74)
as well as to the size of the nose (nasion to nasal tip,
r = 0.78) and was inversely correlated to the Y axis
(r = -0.71) (Table IV).
Mandibular position
Neither SNB nor ANB showed any statistically sig-
nificant differences. This would be consistent with the
previously described retroposition relative to the cranial
base of nasion, point A, and point B, thus making the
normal SNA and SNB values inappropriate as cepha-
lometric standards for this sample.
Highly significant differences from normal were
found in parameters reflecting mandibular growth di-
rection. The mandibular plane angle (FH/Go-Gn) was
lower by 10.0” in males (x = 18.8 f 5.48” versus
28.8 * 5.3”, p < 0.001) and by 9.4” in females (X =
17.8 ? 3.94” versus 29.2 ? 4.73”, p < 0.001).
When measured to the SN plane, there were differences
of 4.6” less in males (X = 28.7 2 6.70” versus
33.3 ? 4.83”, p < 0.001) and 4.8” in females (X =-
28.9 k 4.09” versus 33.7 +- 5.24”, p < 0.001).
These changes were directly correlated with the
shorter maxilla (PTM-ANS, r = 0.72). the smaller na-
sal bone (nasion-rhinion, r = 0.70). the degree of up-
per incisor eruption (UI-PP: r = 0.86), and the Y axis
(r = 0.73) (Table IV).
The Y axis (FH/S-Gn) also reflected the tendency
for forward mandibular rotation, being smaller by 8. lo
in males (X = 54.3 t 3.69” versus 62.4 + 4.24”,
p < 0.001) and 5.6” in females (2 = 54.3 ? 3.57”
versus 59.9 t 3.56”, p < 0.001) (Tables II and III).
Facial height
Upper anterior face height, as measured from nasion
to anterior nasal spine, was significantly smaller in both
sexes (p < 0.001). Males showed a mean difference
of 3.8 mm (X = 52.9 t 3.95 mm versus 56.7 t
group (- - - -) ver-
4.29 mm) less than normal, while in females the dif-
ference was 2.4 mm (X = 51.5 +- 3.46 mm versus
53.9 2 3.5 1 mm). This reduction in midfacial vertical
development was correlated with the shorter antero-
posterior nasal length (r = 0.76).
Lower anterior face height, as measured from an-
terior nasal spine to menton, was significantly shorter
only in males, with a difference of 9.9 mm (2 =
63.4 k 3.55 mm versus 73.3 ? 6.27 mm for the nor-
mal, p < 0.001). In females a measure that was lesser
by 2.5 mm was not found to be statistically significant.
The shorter male lower face height (Fig. 3) was closely
correlated to the lack of anteroposterior maxillary de-
velopment (SN-ANS”, r = - 0.73) and reduced upper
incisor eruption (UI-PP mm, r = 0.84) (Table IV).
Incisor positions
The data showed the maxillary incisors to be in a
relatively normal position, both angularly and bodily,
with respect to their accompanying skeletal structures.
However, the distance of the maxillary incisor tip from
the palatal plane was measured shorter in males by 4.6
mm (x = 26.7 -+ 1.82 mm versus 31.3 -+ 2.53 mm
for the normal, p < O.OOl), suggesting a reduced de-
gree of dentoalveolar development in the anterior
maxilla.
The mandibular incisors in both sexes were found
to be bodily retrusive relative to the nasion to point B
line. In males this difference from normal was 2.3 mm
(x = 3.0 -+ 2.68 mm versus 5.3 rt 2.69 mm, p <
0,Ol) while in females the difference was 1.4 mm
(X = 3.2 + 2.10 mm versus 4.6 + 2.48 mm, p <
0.01). Mandibular incisor inclination in general ap-
peared to be normal, with only the inclination of the
lower incisor to the mandibular plane in females show-
Volume 87 Bilateral congenital absence of maxillary lateral incisors 285
Number 4

Table II. Male cephalometric data

No_rmal group S&dJ group Level of sign$cance
Measurement (X 2 S.D.) (X 2 S.D.) fP)

Cranial base
S-N (mm) 79.9 k 3.59 75.2 2 4.88 **
CBR-N (mm) 51.8 2 3.27 51.6 k 4.06 NS
N-S-Ba (“) 129.1 -c 5.12 129.8 + 5.80 NS
SN-FH (“) 4.4 2 3.84 9.9 k 4.28 **
Maxilla
ANS-PNS (mm) 58.1 k 3.61 49.2 2 1.85 **
PNS-A (mm) 53.0 ” 3.27 45.6 + 2.21 **
PTM-ANS (mm) 61.4 k 3.48 56.4 t 3.89 **
PTM-A (mm) 57.0 k 3.43 53.9 2 3.84 **
Ba-ANS (mm) 108.4 ” 4.50 101.7 2 7.12 **
SNA (“) 81.0 t 6.34 80.2 2 2.50 NS
S-N-ANS (“) 86.8 k 3.63 84.0 ” 2.80 *
SN-PP (“) 6.9 k 3.17 5.6 ” 5.04 NS
Mandible
Art-B (mm) 105.4 + 5.34 98.6 k 8.42 *
SNB (“) 77.3 2 3.00 78.0 2 4.87 NS
ANB (“) 3.6 ” 2.06 2.2 2 4.68 NS
SN-MP (“) 33.3 f 4.83 28.7 5 6.70 NS
FH-MP (“) 28.8 -c 5.31 18.8 2 5.48 **
Y-axis (mm) 62.4 2 4.24 54.3 2 3.69 **
Vertical dimensions
N-ANS (mm) 56.7 2 4.29 52.8 2 3.95 **
CBR-PNS (mm) 51.6 + 4.13 48.3 t 4.36 *
ANS-Me (mm) 73.3 k 6.27 63.4 i 3.55 **
N-Me (mm) 127.7 + 8.69 115.2 2 6.44 **
OR-PP (mm) 25.4 k 3.02 23.0 2 3.08 *
Upper incisors
UI-SN (“) 103.7 k 5.85 105.0 k 10.32 NS
UI-FH (“, 108.9 + 7.44 114.9 of- 9.92 *
UI-NA (“) 22.7 f 5.80 24.8 i 10.51 NS
UI-NA (mm) 4.5 L 2.67 3.9 AI 4.12 NS
UI-PP (mm) 31.3 2 2.53 26.6 k 1.82 **
UI-LI (0) 127.4 t 10.14 129.1 ” 11.74 NS
Lower incisors
LI-MP (“) 95.6 2 6.38 97.3 t 6.39 NS
LI-NB (mm) 5.3 ‘- 2.69 3.0 5 2.68 *
LI-NB (“) 26.1 e 6.68 24.0 k 6.52 NS
Occlusal plane
SN-OP (“) 15.5 IT 3.97 12.5 _’ 5.81 NS
FH-OP (“) 10.8 k 4.26 2.6 k 5.44 **
PP-OP (“) 8.7 2 3.21 6.9 i- 3.43 NS
Nasal dimensions
N-rhinion (mm) 24.9 -+ 3.19 21.3 k 3.41 *
NA line-rhinion (mm) N.D. 10.5 k I.98 -
NA line-nasal tip (mm) N.D. 30.7 2 3.03
G-Pg to nasal dorsum (“) N.D. 38.3 t 3.06
Soft tissues
A-SLS (mm) 17.8 t 1.79 15.6 f 2.89 NS
SLS-subnasale vertical (mm) -1.8 2 0.79 -1.9 k 1.04 NS
UL-subnasale vertical (mm) 1.6 2 1.72 0.9 2 2.24 NS
LL-subnasale vertical (mm) -0.2 2 2.07 -1.7 L 5.15 NS
ILS-subnasale vertical (mm) -7.9 2 2.43 -9.3 t 5.89 NS
PgS-subnasale vertical (mm) -3.4 I 3.64 -6.0 k 7.08 NS
Nasiolabial angle (“) 105.0 5 10.2 116.4 2 11.15 *
FH-subnasale vertical (“) 99.6 t 2.30 101.5 k 2.35 NS
Maxillary depth (SNIUL-FH) 96.4 rt 6.00 93.3 2 8.19 NS

*Indicates a statistically significant difference (p < 0.01) between groups.

**Indicates a statistically significant difference (p < 0.001) between groups.
ND indicates no control data available.
288 Woodworth, Sinclair, and Alexander

Table III. Female cephalometric data

Cranial base
Measurement
I Normal group
(X -f SD) I
Stxdy group
(X i SD)
I
Level of sign$cance
(pi

S-N (mm) 15.2 t 3.12 71.9 k 3.02 1’ *

CBR-N (mm) 41.9 2 3.11 49.0 k 3.02 NS

N-S-Ba (“) 130.2 +- 4.61 130.0 t 6.42 NS
SN-FH (“) 5.9 ” 3.72 11.1 ” 2.71 **
Maxilla
ANS-PNS (mm) 54.9 2 3.55 47.9 e 4.90 **
PNS-A (mm) 50.2 t 3.30 44.0 t 4.40 **
PTM-ANS (mm) 58.6 2 3.69 54.2 t 4.70 **
PTM-A (mm) 54.9 -+ 3.48 51.3 ” 4.34 **
Ba-ANS (mm) 102.6 + 5.58 98.1 t 7.32 *
SNA (“) 81.2 k 7.12 81.1 k 3.18 NS
SN-ANS (“) 86.4 2 3.94 85.4 +- 3.80 NS
SN-PP (“) 7.9 -c 2.52 5.1 -+ 3.56 **
Mandible
Art-B (mm) 100.4 ” 5.54 97.3 ” 8.42 **
SNB (“) 71.5 i- 3.61 18.7 i 3.25 NS
ANB (“) 3.6 i 2.41 2.4 2 2.33 NS
SN-MP (“) 33.1 2 5.24 28.9 ” 4.09 **
FH-MP (“) 27.2 + 4.13 17.8 i 3.94 **
Y-axis (“) 59.9 ‘- 3.56 54.3 ” 3.51 **
Vertical dimensions
N-ANS (mm) 53.9 k 3.51 51.6 2 3.46 **
CBR-PNS (mm) 48.6 2 3.21 48.4 t 4.38 NS
ANS-Me (mm) 67.3 k 4.90 64.7 k 6.19 NS
N-Me (mm) 119.0 i- 6.77 115.0 i- 8.65 NS
OR-PP (mm) 24.8 t 2.33 23.0 2 2.65 **
Upper incisors
UI-SN (“) 104.6 ‘- 6.49 104.0 -+ 6.13 NS
UI-FH (“) 112.2 2 5.86 115.0 IT 5.80 NS
UI-Na (“) 23.5 ? 6.28 22.9 ? 6.33 NS
UI-Na (mm) 4.0 k 2.55 3.7 ir 2.64 NS
UI-PP (mm) 28.2 2 2.72 27.0 t 2.73 NS
UI-LI (“) 127.7 t 9.65 130.0 k 7.84 NS
Lower incisors
LI-MP (“) 93.7 2 6.49 97.1 -r- 5.87 *
LI-NB (mm) 25.3 lr- 6.60 24.1 + 4.90 NS
LI-NB (“) 4.6 2 2.48 3.2 z!z 2.10
Occlusal plane
SN-OP (“) 16.0 2 3.70 13.5 2 3.71 **
FH-OP (“) 9.2 2 3.28 2.4 k 4.31 **
PP-OP (0) 8.1 2 3.24 8.4 k 4.14 NS
Nasal dimensions
N-rhinion (mm) 23.7 2 3.98 20.8 t 2.13
NA line-rhinion (mm) N.D. 9.7 ? 1.99
NA line-nasal tip (mm) N.D. 29.7 2 3.39
G-Pg to nasal dorsum (“) N.D. 39.2 ” 4.11
Soft tissues
A-SLS (mm) 14.4 ” 1.33 14.7 k 1.80 NS
SLS-subnasale vertical (mm) - 1.2 t 0.77 - 1.7 ? 1.37 NS
UL-subnasale vertical (mm) 2.2 2 1.2 1.0 2 2.47 NS
LL-subnasale vertical (mm) 0.6 it 1.69 -0.7 k 4.09 NS
ILS-subnasale vertical (mm) -5.8 t 2.41 -7.8 -r- 3.96 NS
Pgs-subnasale vertical (mm) -2.6 t 2.75 -4.7 t 5.71 NS
Nasiolabial angle (“) 105.3 k 7.90 115.7 2 11.29 **
FHsubnasale vertical 100.5 k 2.7 102.9 2 4.25 NS
Maxillary depth (SNIUL-FH) 98.8 t 4.1 93.6 k 8.29 *

*Indicates a statistically significant difference (p < 0.01) between groups.

**Indicates a statistically significant difference (p < 0.001) between groups
ND indicates no control data available.
Volume 81 Bilateral congenital absence of maxillary lateral incisors 287
Number 4

/
.’

Fig. 5. Soft-tissuecomposite. A, Males. 8, Females. Study group (- - - -) versus normal (-).

Table IV. Significant correlation coefficients

(r > 0.7)
Criterion Correlates ’ ‘r” Value

Cranial base
S-N(mm) Ba-ANS(mm) 0.75
Art-B (mm) 0.70
Y-axis(") -0.75
Maxilla
Ba-ANS(mm) S-N(mm) 0.75
PNS-A(mm) Art-B (mm) 0.92
PTM-A(mm) Art-B (mm) 0.74
PTM-ANS(mm) SN-MP(") 0.72
SN-ANS(") ANS-Me(mm) -0.73
UI-PP(mm) ANS-Me(mm) 0.84
Mandible
Fig. 6. Treatment-related changes. A, Males. B, Females.
Art-B (mm) PNS-A(mm) 0.92
PTM-A(mm) 0.74 3.70”, p < 0.001) while the males showed no signifi-
Nasion-nasal
tip (mm) 0.78
Y-axis(") -0.71 cant change. When measured to Frankfort horizontal,
SN-MP(") PTM-ANS(mm) 0.72 however, both the males and the females appeared to
Nasion-rhinion(mm) 0.70 show a much smaller occlusal plane angle (Tables II
UI-PP(mm) 0.86 and III). These measurements should be considered
Y-axis(") 0.73 with considerable caution as previous data have sug-
gested a considerable canting of the Frankfort plane
(Figs. 3 and 4).
ing a small but statistically significant degree of pro-
clination (x = 93.7 2 6.49” versus 97.1 ? 5.87”, Nasal size
p < 0.01). The interincisal angle was not significantly The length of the nasal bone (nasion to rhinion) was
altered (Tables II and III). found to be significantly shorter than normal in_both
sexes. In males the difference was 3.6 mm (X =
Occlusal plane 21.3 t 3.41 mm versus 24.9 + 3.19 mm, p < 0.01)
When measured relative to the palatal plane there while in females it was 2.9 mm less (X = 20.8 + 2.13
was no statistically significant difference in the occlu- versus 23.7 ? 3.98 mm, p < 0.01). Other measure-
sal plane’s position from normal. Relative to the S-N ments of hard- and soft-tissue dimensions were made
plane, the females Eclusal plane was shown to be 2.5” (Tables II and III) and although a clinical impression
less than normal (X = 13.5 ? 3.71” versus 16.0 & was gained of relatively small nasal dimensions, no
288 Woodworth, Sinclair, and Alexander
.._~-.I .._- ^..-. --
Fig. 7. A to C, Pretreatment
lateral incisors.
statistical results can be presented because of the lack
of normative data for comparison.
Soft-tissue profile
The most significant soft-tissue difference noted
was the larger nasiolabial_angle seen in both sexes. In
malesitwas 11.4”larger(X = 116.4 ? 11.15”versus
105.00 t 10.2”, p < 0.91) while in females the angle
was greater by 10.4” (X = 115.7 + 11.27” versus
105.3 + 7.90”, p < 0.001). The thickness of the up-
per lip was not found to differ significantly from normal;
however, the upper lip drape (the angulation of the
upper lip to Frankfort horizontal) showed a relative
retropositioning of the upper lip in males (X =
93.6 2 8.29” versus 98.8 + 4.10”, p < 0.01). No
significant changes from normal were noted in the rel-
ative anteroposterior positions of the upper and lower
lips or the chin when measured relative to the true
vertical reference line described by Spradley and co-
authors” (subnasale vertical plane) (Fig. 5).
Changes occurring during treatment
When measured on pre- and posttreatment head-
films relative to the NA line, the maxillary incisors were
facial photographs of a patient with bilateral congenital absence of maxillary
retracted bodily during space closure ( Fig. 6). In males
this change was 1.5 mm (UI-Na mm: 3.9 + 4.12 mm
versus 2.4 + 1.99 mm, p < 0.01) while in females a
smaller degree (0.5 mm) of retraction occurred (UI-Na
mm:3.7 t 2.64 mm versus 3.2 2 2.52 mm, p =
NS). The greater change seen in males was attributed
to the need to overcome a larger initial overjet (Figs.
3 and 4). No significant changes in incisor angulation
occurred (Fig. 6). There appeared to be a compensating
increase of 1.1 mm in upper lip thickness in males (point
A to SLS: 16.7 5 1.50 mm versus 15.6 t 2.89 mm,
p = NS). This compensation tended to mask a signif-
icant 1.4 mm of upper lip retraction (UL-subnasale
vertical: -0.3 k 2.1 mm versus 0.9 -+ 2.2 mm,
p < 0.01) noted in relation to the subnasale vertical
reference line. In males, therefore, there was very little
overall change in lip position. In females, however, a
retraction of 1.6 mm (UL-subnasale vertical: - 0.6 +
2.7 mm versus 1.0 +- 2.5 mm, p = NS) was noted,
with little compensatory lip thickness, resulting in a
more retrusive upper lip. Overall, there was a tendency
for the nasiolabial angle to increase with treatment.
However, because of the wide standard deviation seen,
this change was not statistically significant. Lower in-
Volume 87 Bilateral congenital absence of maxillary lateral incisors 299
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Fig. 7 (Cont’d). D to F, Intraoral photographs showing bilateral absence of maxillary lateral incisors.
290 Woodworth, Sinclair, and Alexander
Fig. 8. A to C, Posttreatment facial photographs
and selective grinding of maxillary canines
cisor retraction was effected primarily by tipping (Fig.
6) without increasing intercanine width and with min-
imal effects on the lower lip.
DISCUSSION
The precise cause of congenital absence of maxil-
lary lateral incisors has yet to be determined. Environ-
mental influences, such as trauma, ionizing radiation,
and hormonal influences, have been suggested as pre-
disposing factors. ” Pedigrees have been elucidated,
linking agenesis traits with several patterns of inheri-
tance,‘. 23 while disturbances in the embryonic fusion
of the midfacial process have also been implicated as
potential etiologic agents in the agenesis of maxillary
lateral incisors.6, 24
On the basis of extensive data showing decreased
tooth size and increased frequency of missing teeth,
LeBot and Salmon4, 5 proposed a model for the mor-
phologic simplification of man’s dentition. Their theory
suggested a generalized evolutionary trend toward a
decrease in tooth size and dental arch dimensions. Ini-
tially, a delay in tooth eruption resulted in a simplifi-
cation of dental morphology. Next, a reduction in both
cusp number and tooth size occurred. The final stage
of patient treated nonextraction with space closure
to resemble lateral incisors.
of this model was represented by the agenesis of in-
dividual teeth.
The data from the present study showed little de-
viation from normal with regard to arch length and
width. Other investigations of patients with agenesis
have also found few changes in arch dimensions.“. Lb
The present study, as well as work by Rune and Sar-
nas2’ also tends to contradict the findings of LeBot and
Salmon4. 5 in that, although there was a decrease in
mandibular incisor size, there was also a concurrent
increase in molar size.
Gam and Lewis,28 studying patients with general-
ized hypodontia, suggested an explanation for these
findings based on the presence of an anteroposterior
gradient for the alteration of tooth size. The greatest
decrease in tooth size was found to occur anteriorly,
with no change (or even an increase) in tooth size oc-
curring posteriorly.* A certain degree of sexual di-
morphism in tooth size changes was noted by Rune and
Sarnas2’ as well as in the present study.
Thus, the present study confirmed the trend of a
gradation in tooth size decrease from posterior to an-
terior with the involvement of a degree of sexual di-
morphism but does not support the theory suggesting
Volume 87 Bilateral congenital absence of maxillary lateral incisors 291
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Fig. 8 (Cont’d). D to F, Intraoral photographs showing results of space closure and selective grinding
to make maxillary canines resemble lateral incisors.
292 Woodworth, Sinclair, and Alexander
a generalized evolutionary trend toward a decrease in
arch size.
An alternative theory concerning the cause of con-
genital absence of maxillary lateral incisors is related
to a disturbance in the fusion of the median nasal pro-
cess with the maxillary process in the 7- to g-week-old
embryo. Patients with cleft lip and palate frequently
have lateral incisors missing’ and it has been suggested
that congenital absence of maxillary lateral incisors may
represent the incomplete expression of a cleft or part
of a larger craniofacial anomaly.6. 24Comparison of data
from the present study and Dahl’? report on patients
with cleft lip reveals several similarities. Findings in
common include a small but relatively normally posi-
tioned maxilla, decreased upper anterior face height,
shorter posterior face height, and decreased mandibular
length. However, the smaller mandibular plane angle
seen in the present study was not noted in the cleft
patients.
Further support for the possibility that the congenital
absence of maxillary lateral incisors may be related to
developmental disturbances comes from the evaluation
of patients with general hypodontia who do not dem-
onstrate craniofacial anomalies of a similar nature or
extent.24, *’
The fact that in the present study few correlations
could be found between measurements representing
craniofacial morphology suggests that the individual
parameters acted independently and tended to be af-
fected to different degrees, with the females being less
severely affected overall. Overall, the data from the
present study seemed to support the developmental dis-
turbance theory and suggested that there might be a
connection between bilateral congenital absence of
maxillary lateral incisors and disturbances in the process
of embryologic fusion in the midface.
Considerable controversy surrounds the question as
to whether it is better to orthodontically close the spaces
left by the missing lateral incisors or to maintain the
spaces for future bridgework.30”2 Advocates of main-
taining the space suggest that a better occlusion and
less flattening of the facial profile will result if the
canines are left in a Class I relationship.“. 34The present
study suggests that little facial change occurs with or-
thodontic space closure and that the presence of tooth
size discrepancies will often preclude the establishment
of a canine-guided occlusion. Indeed, Nordquist and
McNeiP5 found that 89% of the patients who had re-
ceived bridges exhibited a group function occlusion in
lateral excursions. With the current sophistication of
restorative techniques using selective grinding of the
incisal edges (Figs. 7 and 8), as well as composite
materials where indicated, excellent cosmetic results
can now be achieved routinely in reshaping maxillary
canines to resemble lateral incisors. ” ‘I’
In treating patients in whom maxillary incisors arc
congenitally absent, the clinician should be aware of
the greater than normal predisposition of these patients
toward a Class III skeletal relationship as well as an
increase in the incidence of impactions and the absence
of other teeth. Mechanotherapy should be directed to-
ward opening the mandibular plane and increasing ver-
tical facial proportions where indicated. Space closure
should be attempted from the posterior to avoid incisor
retraction with subsequent lip retraction and increase in
the nasolabial angle. The judicious use of a facial mask
or reverse-pull headgear may be an excellent treatment
modality for this problem.40 Extraction decisions should
be based on individual wax setups, and significant in-
terdental enamel reduction may be necessary in order
to overcome tooth size discrepancies that might other-
wise prevent the establishment of a satisfactory static
and functional occlusion.
SUMMARY
On the basis of cephalometric and dental cast rec-
ords of forty-three persons with bilateral congenital ab-
sence of maxillary lateral incisors, twenty-two of whom
were treated by orthodontic space closure, the following
conclusions were drawn:
1. The sample showed a Class III tendency, with
a 55% incidence of absence of other missing teeth and
a 2 1% impaction rate.
2. Arch length, arch width, overjet, and overbite
were normal.
3. Significant tooth size discrepancies were present
in several additional teeth. Males demonstrated smaller
mandibular incisors and females demonstrated larger
than normal molars.
4. Bolton’s tooth size analysis revealed that in cases
requiring mandibular extractions the extraction of first
premolars should produce optimal occlusion in 85% of
the cases.
5. The maxilla, the mandible, the nasal bone, and
the anterior cranial base were significantly shorter in
both sexes.
6. Upper anterior face height, lower anterior face
height, and posterior face height were all significantly
less than normal.
7. The mandibular plane angle was less than av-
erage by a mean of 5”.
8. The nasiolabial angle was 10” more as compared
to untreated normals.
9. Orthodontic space closure resulted in a mean
incisor retraction of 1.5 mm in males along with a
further 5” increase in the nasiolabial angle.
Volume 81 Bilateral congenital absence of muxillary lateral incisors 293
Number 4

10. Mechanotherapy designed to open the mandib- of craniofacial growth, Ann Arbor, 1979, University of Michigan
Press.
ular plane, increase the vertical dimension, and move
19. Spradley FL, Jacobs JD, Crowe DL: Assessment of the an-
posterior teeth forward is recommended. teroposterior soft-tissue contour of the lower facial third in the
11. Mesiodistal tooth reduction will be required in ideal young adult. AM J ORTHOD 79: 316-325, 1981.
most cases to achieve normal tooth size relationships 20. Moyers RE, Van der Linden FPGM, Riolo ML, McNamara JA
and optimal occlusion. Jr: Standards of human occlusal development, ed. 3, Ann Arbor,
1976, University of Michigan Press.
12. A developmental disturbance in the process of
21. Sinclair PM, Little RM: Maturation of untreated normal occlu-
fusion in the area of the median nasal process, similar
sions. AM J ORTHOD 83: 14-123, 1983.
to that seen in clefts, may represent the cause of bilateral 22. Arya BS, Savara BS: Familial partial anodontia: report of a case.
congenital absence of maxillary lateral incisors. J Dent Child 41: 47, 1974.
23. Woolf CM: Missing maxillary lateral incisors: a genetic study.
The authors would like to thank Drs. C. Moody Alexander Am J Hum Genet 23: 280-296, 1971.
and Martin Wagner for their assistance,Kent Dana for his 24. Wisth PJ, Thunold K, Boe OE: The craniofacial morphology of
statistical advice, Chris Barreiro for drawing the figures, and individuals and hypodontia. Acta Odontol Stand 32: 293-302,
Sharon Cepak for typing the manuscript. This study was sup- 1974.
ported in part by Baylor College of Dentistry Research Funds. 25. Wisth PJ, Thunold K, Boe OE: Frequency of hypodontia in
relation to tooth size and dental arch width. Acta Odontol Stand
32: 201-206, 1974.
REFERENCES 26. Bailit HL, Thomson LA, Niswander JD: Dental eruption and
1. Montagu MFA: The significance of the variability of the upper hypodontia. J Dent Res 47: 699, 1968.
lateral incisor teeth in man. Hum Biol 12: 358-373, 1940. 27. Rune B, Samas KV: Tooth size and tooth formation in children
2. Meskin LH, Gorlin RJ: Agenesis and peg-shaped permanent with advanced hypodontia. Angle Orthod 44: 316-321, 1974.
maxillary lateral incisors. J Dent Res 42: 1476-1479, 1963. 28. Gam SM, Lewis AB: The gradient and the pattern of crown size
3. Shaw WC: The influence of children’s dentofacial appearance reduction in simple hypodontia. Angle Orthod 40: 5 l-58, 1970.
on their social attractiveness as judged by peers and by adults. 29. Jamsa T, Alvesalo L: Size of the mandible related to hypodontia.
AM J ORTHOD 79: 399-415, 1981. Proc Finn Dent Sot 76: 214-218, 1980.
4. LeBot P, Salmon D: Congenital defects of the upper lateral in- 30. Carlsson H: Suggested treatment for missing lateral incisors.
cisors (ULI): Condition and measurements of the other teeth, Angle Orthod 22: 205-216, 1952.
measurements of the superior arch, head and face. Am J Phys 31. Strang RW, Thompson WM: Textbook on orthodontia, ed. 4,
Anthropol 46: 213-243, 1977. Philadelphia, 1985, Lea & Febiger.
5. LeBot P, Gueguen A, Salmon D: Congenital defects of the upper 32. Zachrisson BU, Mj#r IA: Remodeling of teeth by grinding. AM
lateral incisors (ULI) and the morphology of other teeth in man. J ORTHOD 68: 545-553, 1975.
Am J Phys Anthropol 53: 479-486, 1980. 33. D’Amico A: The canine teeth-normal functional relation of the
6. Dahl E: Craniofacial morphology in congenital clefts of the lip natural teeth of man. J S Calif Dent Assoc 26: 200, 1958.
and palate. Acta Odontol Stand 28: Suppl. 57, 1970. 34. Stuart C, Stallard H: Diagnosis and treatment of occlusal rela-
7. Baum BJ, Cohen MM: Agenesis and tooth size in the permanent tions of the teeth. Tex Dent J 75: 430, 1957.
dentition. Angle Orthod 41: 100-102, 1971. 35. Nordquist GG, McNeil1 RW: Orthodontic vs. restorative treat-
8. Baum BJ, Cohen MM: Patterns of size reduction in hypodontia. ment of the congenitally absent lateral incisors-long-term peri-
J Dent Res 50: 799, 1971. odontal and occlusal evaluation. J Periodont 46: 139- 143,
9. Graber LW: Congenital absence of teeth: a review with emphasis 1975.
on inheritance patterns. J Am Dent Assoc 96: 266-275, 1978. 36. Yankelson M: Altering canines to resemble lateral incisors: a
10. Dachi SF, Howell FV: A survey of 3,874 routine full mouth new technique. J Int Assoc Dent Child 42: 39-40, 1973.
radiographs-a study of impacted teeth. Oral Surg Oral Med 37. Zachrisson BU: Improving orthodontic results in cases with max-
Oral Pathol 14: 1165-1169, 1961. illary incisors missing. AM J ORTHOD 73: 274-289, 1978.
11. Kramer RM, Williams AC: The incidence of impacted teeth. 38. Tuverson DL: Orthodontic treatment using canines in place of
Oral Surg Oral Med Oral Path01 29: 237-241, 1970. missing maxillary lateral incisors. AM J ORTHOD 58: 109-127,
12. Aitasalo K, Lehtinen R, Oksala F: An orthopantomographic 1970.
study of impacted teeth. Int J Oral Surg 1: 117-124, 1972. 39. Tuverson DL: Anterior interocclusal relations. Part II. AM J
13. Massler M, Frankel JM: Prevalence of malocclusion in children ORTHOD 78: 371-393, 1980.
aged 14-18 years. AM J ORTHOD 37: 751-768, 1951. 40. Petit H: Adaptation following accelerated facial-mask therapy.
14. Bjijrk A: Variability and age changes in overjet and overbite: In McNamara JA Jr (editor): Clinical alteration of the growing
report from a follow-up study of individuals from 12 to 20 years face, Ann Arbor, 1983, Center for Human Growth and Devel-
of age. AM J ORTHOD 39: 799-801, 1953. opment, University of Michigan.
15. Bolton WA: Disharmony in tooth size and its relation to the
Reprint requests to:
analysis and treatment of malocclusion. Angle Orthod 28: 113-
Dr. Peter Sinclair
130, 1958.
Department of Orthodontics
16. Nance H: The limitations of orthodontic treatment. AM J ORTHOD
Baylor College of Dentistry
ORAL SURG 33: 177-223, 1947.
3302 Gaston St.
17. Snedecor GW, Co&ran WG: Statistical methods, Ames, 1967,
Dallas, TX 75246
Iowa State University Press.
18. Riolo ML, Moyers RE, McNamara JA Jr, Hunter WS: An atlas