She was born without her upper lateral incisors and had spent years hiding her smile. Her goal was simple — a smile that looked natural, not "done." Here is how we rebuilt it using the most conservative plan possible: no braces, and no implants in the front of her mouth.
When this 45-year-old patient came to our office, she had spent years hiding her smile. She was born with congenitally missing upper lateral incisors, leaving noticeable spaces between her front teeth. Over time, previous dental work attempted to compensate by making one of her canine teeth larger to fill the gap, but the result still appeared unbalanced and unnatural. She was also bothered by the spacing between her front teeth and the uneven appearance of her smile.
Although her primary concern was cosmetic, she also had missing first molars in all four quadrants, reducing her chewing efficiency and overall function. Her biggest wish was simple: "I just want a smile that looks natural."
Congenitally missing lateral incisors present one of the more complex smile-design challenges in cosmetic dentistry. When lateral incisors never develop, the neighboring teeth often drift into those spaces — the canines occupy the position where lateral incisors should be, while the premolars drift forward as well. Simply placing porcelain veneers on the front teeth rarely solves the problem, because the proportions of the entire smile have changed.
Many patients assume that replacing the missing teeth automatically requires braces followed by two dental implants. In reality, the best treatment depends on each patient's anatomy, goals, and priorities.
Orthodontics was carefully considered as one treatment option. However, after discussing the advantages and disadvantages together, we determined it was not the best solution for this particular patient. Several factors influenced that decision:
Rather than moving teeth simply because we could, our goal was to achieve the best esthetic result using the most conservative approach possible. That philosophy guided every step of her treatment.
Using Digital Smile Design, we first created a digital simulation and transferred that design into a physical mockup. This allowed the patient to "test drive" her new smile before any irreversible treatment was performed. The mockup demonstrated how carefully changing the proportions of each tooth could create balance, symmetry, and harmony throughout the smile. Once she approved the design, we proceeded with treatment.
To create her new smile, treatment included:
For function, guided dental implants were also placed at sites #3 and #19 to restore missing posterior chewing surfaces. Because adequate bone was already present, no bone grafting was required, and both implants healed uneventfully before restoration.
One of the most technically demanding aspects of this case was recreating the missing gum tissue around the replacement lateral incisor. Instead of performing anterior implant surgery and additional soft-tissue grafting, we used carefully layered pink porcelain as part of the bridge design. When properly designed, pink porcelain blends naturally with the surrounding tissues. Most people looking at her smile never realize it is there — and that's exactly the goal. The restoration disappears into the smile rather than drawing attention to itself.
Four appointments changed a smile that had caused years of self-consciousness into one that looks balanced, natural, and harmonious. The final photographs shown here were taken one year after treatment, demonstrating not only the esthetic outcome but also the long-term stability of the restorations and surrounding soft tissues.
Today, her smile appears as though she naturally developed all of her front teeth — the hallmark of successful smile makeover work: not creating teeth that look "done," but creating a smile that simply looks like it has always belonged.
What makes this case particularly rewarding isn't the number of restorations or the complexity of the procedures. It's that we resisted the temptation to pursue a more aggressive treatment simply because it was possible. Instead, we carefully evaluated every option and selected the approach that achieved the patient's goals while preserving healthy tooth structure, avoiding unnecessary surgery in the esthetic zone, and significantly shortening treatment time. Sometimes, the most sophisticated treatment plan isn't the one that does the most — it's the one that does exactly enough.
Written by Dr. Benjamin Wang, DMD — Cosmetic Dentist & Implant Specialist at Centerport Cosmetic & Implant Dentistry, Portland, OR. Reviewed for clinical accuracy.