Managing Missing Lower Incisors with Significant Bolton Excess

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Managing Missing Lower Incisors with Significant Bolton Excess
Straight Talk draws its cases and discussions from the Orthotown message boards. Written by the editorial team with the assistance of AI, each article showcases how orthodontists tackle unusual and challenging scenarios.
Managing patients missing lower incisors can present a surprisingly complex treatment decision, particularly when a substantial Bolton discrepancy is involved. In a recent Orthotown message board discussion, clinicians debated options for a 28-year-old patient missing both lower lateral incisors and presenting with a Class I molar relationship.

Records showed oversized maxillary incisors, canines, and premolars, with a Bolton discrepancy of 13.4 mm excess in the upper anterior segment and 9.5 mm overall (Figs. 1–6). The original poster anticipated needing digital setup models and suspected upper premolar extractions might be required. The central question posed to the forum was straightforward: How should this case be treated?
Managing Missing Lower Incisors with Significant Bolton Excess
Fig. 1
Managing Missing Lower Incisors with Significant Bolton Excess
Fig. 2
Managing Missing Lower Incisors with Significant Bolton Excess
Fig. 3
Managing Missing Lower Incisors with Significant Bolton Excess
Fig. 4
Managing Missing Lower Incisors with Significant Bolton Excess
Fig. 5
Managing Missing Lower Incisors with Significant Bolton Excess
Fig. 6

Many contributors favored extraction of upper premolars, though opinions differed on whether first or second premolars would be more appropriate. One advantage noted for removing upper second premolars was the presence of an existing restoration. Several clinicians emphasized that with more than 10 mm of anterior maxillary excess, non-extraction treatment would likely result in significant overjet. As one member put it, it is difficult to “fit a large lid over a small cup.” Because the lower canines would effectively substitute for the missing lateral incisors, the upper canines were already functioning in a Class II relationship relative to the lower arch.

Others, however, advocated for a non-extraction approach. Aligning and broadening the upper arch while maintaining incisor position, potentially supported by TADs or fixed functional appliances, was proposed as a way to achieve an aesthetically pleasing smile despite the tooth-size discrepancy. After completing digital setups, the original poster concluded that non-extraction with upper interproximal reduction represented the lesser of two evils, believing that bicuspid extractions created as many challenges as they solved.

Timing of extractions also generated debate. Some suggested aligning first and postponing the irreversible decision, allowing the adult patient to evaluate alignment alone before committing to premolar removal. Others argued that delaying extractions could unnecessarily extend treatment time and increase anchorage demands because of incisor flaring, making bodily retraction more difficult later.

Mechanics entered the conversation as well. Lightwire philosophy was proposed as a way to allow distal tipping of canines and premolars into extraction space during leveling, potentially minimizing anchorage strain and simplifying space closure. Others anticipated the need for stronger anchorage control with appliances such as a Nance button or palatal TAD-supported transpalatal arch.

Beyond tooth-size discrepancy and mechanics, contributors advised evaluating condylar morphology and screening for temporomandibular symptoms before initiating treatment. The panoramic image suggested asymmetry, though the original poster clarified that the radiograph appeared distorted and the patient was asymptomatic.

Ultimately, the discussion highlighted the tension between mathematical Bolton analysis and clinical judgment. While the numbers strongly suggest upper premolar extractions may be necessary to achieve ideal overjet and occlusion, some clinicians remain comfortable accepting a controlled discrepancy if smile aesthetics and patient satisfaction are prioritized.

When managing patients missing lower incisors with more than 10 mm of maxillary Bolton excess, does the arithmetic dictate extraction—or is a carefully executed non-extraction compromise still reasonable? 

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