Make the correct decision mutually.

I am excited to have you read this month’s PointCounterpoint feature. The topic is “Congenitally missing maxillary lateral incisors: Substitution vs restoration.” I invited 2 experienced teams to discuss this topic from 2 perspectives. Each team did an outstanding job in presenting their arguments favoring one approach or the other. And I am certain that, as you read the Point and then the Counterpoint, you will formulate your own opinion about how you would treat this clinical situation in your patients. But therein lies the problem. Who should make the decision of when to open space for an implant or a bridge, or to close the space and substitute the canines for the lateral incisors? This question is not fully addressed in either article. But this issue is perhaps the most important of all. Formany years, I presented interdisciplinary lectures to audiences around the world that typically included a mixture of orthodontists, primarily restorative dentists, and a few periodontists and oral and maxillofacial surgeons. When I discussed the management of missing maxillary lateral incisors, the restorative dentists, periodontists, and maxillofacial surgeons would often condemn canine substitution as a poor alternative that has no place in modern dentistry. After all, we are currently well into the third decade of the implant revolution that started in the late 1980s. Implants have completely changed the philosophy of general dentists regarding missing lateral incisors. Although implants are highly successful in their long-term stability, esthetic failures do occur. When orthodontists see these esthetic failures, they might become reluctant to choose the restorative option. Who should decide which method of treatment is most appropriate for maxillary lateral incisor agenesis? The patient’s general dentist might favor the restorative solution because it places the teeth in their correct relationship from both an esthetic standpoint and an occlusal perspective. The orthodontist might favor canine substitution because it could reduce the need for continued restorative replacement over the lifetime of the adolescent patient. If the parents were asked for their opinion, they would probably choose the least expensive alternative if the outcomes were equivalent.