Today there is in increasing demand for pleasing aesthetics. This is not only in regard to the finished product from an aesthetic procedure (plastic surgery, orthodontics, aesthetic dentistry), but is often preferred while the procedure itself is being performed. Thus in the field of orthodontics aesthetic appliances have become in demand. The forms of those aesthetic appliances are as followed; invisalign, porcelain or clear brackets, veneers or crowns, and lingual braces.

            As with all things there are pros and cons to each one of these procedures.  I will attempt to provide a clear view of what they might be:


Pros: Very well marketed, simple,less visible than traditional braces

Cons: Must be worn 24 hours a day with attachments necessary to move teeth, can hardly be considered invisible, has been proven to achieve the predicted result 41% of the time, requires a high degree od patient cooperation

Veneers and Crowns

Pros:  Allows for aesthetic correction in a relatively short period of time (3 to 5 weeks)

Cons: Invasive, requiring some requiring some reduction of the natural tooth in order to correct tooth position, encroachment on periodontium often occurs leading to potential problems down the road

Porcelain or clear brackets

Pros: Not as visible as metal brackets, provides greater control for tooth movement for the orthodontist

Cons: Visible

 Lingual Braces

Pros: Invisible appliance, as brackets are located behind the teeth, eliminates the possibility of white marks on the facial surface of the teeth, provides complete control for the orthodontist in treating the malocclusion

Cons: Some irritation to the tongue, accommodated with two to three weeks, requires slightly more meticulous care and cleaning

Its been my experience, that in the right circumstances, lingual braces provides the best treatment appliance available in orthodontics today. This is in terms of both the ending aesthetics, tooth position, appearance, as well as treatment mechanics superior to the traditional braces used today. It was with this thought in mind that I felt it incumbent upon me to introduce the use of lingual braces to the Tufts orthodontic residency. The use of that appliance in this program has been ongoing now for a three-year period.


When missing upper lateral incisors, there are two options for their replacement.  The first is referred to as cuspid substitution; this is done when the eye tooth or cuspid is placed in the position of the lateral incisor. The cuspid is then modified in size and shape to mimic the lateral incisor. The other option is to replace the lateral incisor with some form of prosthesis. This form can either be a bridge or a single tooth implant.  There are advantages and disadvantages to both of these options.

When providing the cuspid substitution, there can be problems in both shade and tooth shape.  Often a veneer (or porcelain covering), is used to mask the discrepancies. There is also the problem of the root configuration for a cuspid. The root is often more prominent. The advantages of cuspid substitution, is a natural tooth is replacing the lateral incisor. This eliminates the problem of gingival architecture, bone heights changing during later growth periods and development, and possible implant show through in the bone and gums.

When providing prosthetic replacement, either with an implant or a bridge, one needs to look at a different set of problems. The first is the necessity to place an implant with a crown, at a cost of approximately $5000 to $6000. An additional problem is implant show through at the gum level.  A third problem is an alteration in gingival  and bone height later in the person’s development. This has created an interesting problem reading timing for implant placement. It was once believed the best placement time was ages 17 or 18. This has been altered to later in the early 20s. It has always been my advice that once the space is created and the root positions are appropriate.  The patient should place a semi-permanent replacement. This in the form of a Maryland bridge, a false tooth bonded in place with  metal tie wings to the proximal teeth. This should provide a reasonable aesthetic result that will address the patients need until thet decide to proceed with an implant.