vances, orthodontics has also continued to advance. In acritical reevaluation of the article, one finds that, although thegingival index appears to be greater in the space-closedgroup, periodontal probing depths were not significantlydifferent between the groups when anterior and posteriorteeth were considered together. In addition, only 13 fixedpartial dentures were analyzed. It is doubtful that this articlewould pass the scrutiny needed to qualify it as a randomizedclinical trial, which is considered the highest ranking by moststatisticians today.

Our biggest concern, however, is that the paradigm forreplacing missing lateral incisors has changed since 1975.Specifically, in 2004, missing lateral incisors are optimallyrestored by using osseointegrated dental implants. Althoughpresenting all the evidence needed to substantiate this claim isinappropriate in this letter, we cite 2 meta-analysis studies onthe survivability of a 3-unit FPD compared with a singleosseointegrated dental implant.2,3 Although meta-analysesare not the most powerful, these studies clearly demonstratethat the longevity of implants far supersedes that of the 3-unitFPD. The biggest problem that we see in clinical practice isthat FPDs placed in the teenage years begin to fail when thepatients are in their 30s and 40s. Often the abutments fail withthe FPD, necessitating more extensive restorative measures.Failing implants, on the other hand, can simply be replacedwith no morbidity to the contiguous teeth.

If one is to treat by “ lateralizing” a canine to minimize theamount of dentistry needed, is it fair to say that the clinicianmust address the shape and form of the canine, the shade, andthe height of the gingival margin? Canines tend to be darker,thicker, and taller than incisors; thus facial veneers, bleach-ing, and gingival surgeries are all commonly used to addressthese issues. These procedures expose the tooth and theperiodontium to a lifetime of maintenance and care.

We have found that, once patients have sufficient informa-tion on all possible therapeutic outcomes to enable them toprovide informed consent, the overwhelming majority choosesimplants.

Thomas G. Wilson, Jr, DDSThomas A. Ding, DDS, MS

Dallas, Tex

0889-5406/$30.00doi:10.1016/j.ajodo.2004.01.001

REFERENCES

1. Norquist GG, McNeil RW. Orthodontic versus restorative treat-ment of the congenitally absent lateral incisor—long-term peri-odontal and occlusal evaluation. J Periodontol 1975;46:139-43.

2. Scurria MS, Bader JD, Shugars DA. A meta-analysis of fixedpartial denture survival: prostheses and abutments. J Prosthet Dent1998;79:459-64.

3. Lindh T, Gunne J, Tillberg A, Molin M. A meta-analysis in partialedentulism. Clin Oral Implants Res 1998;9:80-90.

Editor’s responseThank you for taking the time to respond in such a

thoughtful way to my editorial. I am sure we probably treatpatients with congenitally missing lateral incisors in much thesame way. The primary reason I took that stand in myeditorial was because we have very little evidence to provethat, when given a choice, space opening with prostheticreplacement for missing lateral incisors gives the patient abetter treatment result in the long term. We probably bothtreat patients this way and are usually pleased with theesthetics initially, but, over 10 to 20 years, the patient’sviewpoint and periodontal aspects must also be considered. Iam looking for a well-designed, long-term clinical studyconcluding that patients who are treated by space opening andprosthetic replacement have better long-term results. Ofcourse, I expect the study to look at esthetics, occlusalfunction, the periodontium, stability, cost, and patient accep-tance. When a patient has crowding, we tend to close space,substituting the canine for the missing lateral; when there isplenty of space, we would usually replace the lateral with apontic or an implant. But what should we advise when thereis truly a choice? There are no good studies to answer thisquestion, and that is my plea. We need more evidence beforewe can say that closing space and substituting the canine isnever acceptable.

David L. Turpin, DDS, MSDEditor-in-Chief

0889-5406/$30.00doi:10.1016/j.ajodo.2004.07.022

American Journal of Orthodontics and Dentofacial OrthopedicsVolume 126, Number 3

Readers’ forum 23A