Esthetic Substitution and Autotransplantationof Teeth in the Maxillary Anterior RegionRobert Tito Norris and R. Raymond Caesar

In the context of congenitally absent or traumatically avulsed teeth in the

maxillary anterior region of the dental arch of a preadolescent, the most

efficient, enduring, timely, and cost-effective solution is one and the same:

the use of natural dentition. In the previous 5 decades, extensive resources

have been allocated to the study of autotransplantation procedures, which

frequently reflect a high success rate. In addition, improvements in orth-

odontic positioning and restorations continue to enhance outcomes of den-

tal substitutions. Various studies have reviewed treatment alternatives for

individuals experiencing congenitally missing or traumatically lost maxillary

anterior teeth; however, reports discussing both substitution and autotrans-

plantation as viable treatment options in this region were not previously

available. The methodology and necessary considerations pertaining to

canine substitution for a maxillary lateral incisor, cuspid substitution for a

premolar, lateral substitution for a maxillary central incisor, and autotrans-

plantation of a mandibular premolar for a missing incisor are discussed in

detail. (Semin Orthod 2013;19:3-12.) © 2013 Elsevier Inc. All rights reserved.

O rthodontics blends biology, engineering,and art. Few situations require more har-

mony among these 3 disciplines than the re-placement of a missing tooth in the maxillaryanterior region, commonly called the estheticzone. Whether choosing orthodontic substitu-tion, an autotransplantation, a tooth-supportedrestoration, or a single-tooth implant, there are anumber of esthetic factors to consider in thefinal outcome of the treatment. These includesymmetry, morphology, shade, width, length, an-gulation, thickness, and gingival architecture ofthe replacement tooth or teeth. Other consider-ations that should influence the treatment plan-ning process include the age and dental/matu-rational development of the patient at the timeof diagnosis of agenesis or tooth loss, the

amount of time-lapse between the orthodontictreatment and the definitive restoration, as wellas the stability or longevity of the final result.There have been numerous advances in orth-odontic positioning,1 tooth reshaping,2,3 and re-storative treatment through hybrid composite orporcelain laminate veneers that make tooth sub-stitution or autotransplantation viable estheticoptions. In the context of a preteen patient, itbecomes apparent that replacement of a missingtooth in the esthetic zone with a natural tooththrough substitution or autotransplantation mostoften yields the best long-term solution.

Part 1: Canine Substitution in Casesof a Missing Maxillary Lateral Incisor

The maxillary lateral incisor is the second mostcommon congenitally missing tooth.4 The pa-tient’s age and dental development, malocclu-sion, canine color/morphology, and smile line,as well as the longevity and long-term periodon-tal health of treatment and financial resourcesof the patient, influence whether space closureor substitution should be the treatment plan ofchoice.

Diplomate, American Board of Orthodontics, San Antonio, TX;Dental Student, University of Texas Health Science Center, SanAntonio, TX.

Address correspondence to Robert Tito Norris, DDS, 18720 StoneOak Pkwy, #207, San Antonio, TX 78258. E-mail: tito@stoneoakortho.com

© 2013 Elsevier Inc. All rights reserved.1073-8746/13/1901-0$30.00/0http://dx.doi.org/10.1053/j.sodo.2012.10.003

3Seminars in Orthodontics, Vol 19, No 1 (March), 2013: pp 3-12

Age and Dental Development

Agenesis of a maxillary lateral incisor is oftendiagnosed by the patient’s pediatric or familydentist, and the patient is referred to an ortho-dontist before all the permanent dentition haserupted. One advantage of canine substitution isthat final restorative treatment can be com-pleted soon after orthodontics is finished in theearly teen years. Furthermore, the presence ofnatural tooth to induce alveolar bone formationduring these growing years is a great advantage.If space opening and a single-tooth implant areplanned, then a young patient is faced with thecumbersome challenge of esthetically maintain-ing the intercoronal as well as the inter-radicularspace through their growing years.5,6 Addition-ally, a bone graft is usually required before im-plant placement, introducing further morbidityand expense to the procedure.

Malocclusion

Historically, those patients with missing lateralincisors who presented with maxillary dentoalve-olar protrusion and/or an Angle Class II molarrelationship and minimal crowding in the lowerarch were considered the best candidates forcanine substitution. This was owing to the re-duced orthodontic treatment needed to achievean occlusion in which the canine substitutes forthe missing lateral incisor and the premolar sub-stitutes for the canine. Another type of maloc-clusion that has historically lend itself favorablyto a substitution treatment plan is one in whichthere is a Class I molar occlusion with sufficientcrowding in the lower arch to justify extractionof mandibular premolars. However, temporaryanchorage devices have provided clinicians withthe necessary anchorage to predictably protractClass I molars into a Class II relationship,thereby allowing clinicians to comfortably offercanine substitution to patients with a widerrange of malocclusions. Critics of orthodonticsubstitution often claim that the inability toachieve canine guidance with this proceduremight cause occlusal problems. However, severalstudies have examined patients treated by sub-stitution versus prosthetic tooth replacementand found no significant difference in eitherocclusal function or temporomandibular dys-function.7-9 To exclude the dental implant from

the esthetic zone, many cases lend themselves toanterior space closure and canine substitution,leaving the implant space at the first or secondpremolar location, where there are lower es-thetic demands.

Size, Shape, and Color of the Canine

When substituting a canine for a lateral incisor,the anterior interarch tooth-size relationshipmust be considered, as canines are typicallywider than lateral incisors. Additionally, they arethicker faciolingually, which can also affect an-terior tooth-size relationships. Often, significantreduction of the lingual surface of the canine is

Figure 1. Proximal, facial, and occlusal view ofenamel reduction and composite addition suggestedto achieve ideal occlusion and esthetics.

4 Norris and Caesar

required to match the faciolingual thickness of alateral incisor (Fig 1). Subsequently, when thepremolar is substituted for the canine, the dif-ference in widths of these teeth should be con-sidered. The best way to ensure an esthetic andfunctional outcome is to perform a diagnosticwax setup.

Not all canines lend themselves equally tolateral substitution. Canines that are smaller,flatter facially, and lighter in color are moreideally suited than those that are large, faciallyconvex, and more saturated with color. How-ever, even the more challenging canines can bemade to look esthetically pleasing if proper tech-nique is followed. Large canines can be reducedin all dimensions, but reshaping the canine isnot without some risk. Possible complicationsinclude increased sensitivity and darkening ofcolor due to thinning of enamel. Zachrisson andMjör10 have shown that extensive reshaping ofteeth through grinding with an ample waterspray can be safely performed; however, themost conservative reshaping that will achieve anideal esthetic result is desired. Often, this re-

quires a combination of enamel grinding insome areas combined with the addition of com-posite resin in others. This technique involvesflattening the incisal edge of the canine. Ifneeded, the mesial and distal surfaces are re-duced (Figs 2-4), taking particular care not tointroduce an interproximal ledge that couldharbor plaque or irritate the interproximal tis-sue. Additionally, the convex facial surface of thecanine is flattened (Figs 5, 6), with particularcare taken not to darken the tooth due to exces-sive thinning of the enamel in this area. Themesioincisal and/or distoincisal corners arecommonly restored with composite resin (Figs 7,8), but equally important and often overlookedis the development of a mesiofacial line angle(Fig 9). Note that the conversion of a canine toa lateral incisor should be done before orth-odontic bracket placement (Figs 9, 10) whenpossible. This will allow the early establishmentof mesiodistal and faciolingual axial inclinationsas well as incisogingival position of the tooth that

Figure 2. Pretreatment photo of patient missing themaxillary right lateral incisor. (Color version of figureis available online.)

Figure 3. Before proximal reduction. (Color versionof figure is available online.)

Figure 4. After proximal reduction. (Color version offigure is available online.)

Figure 5. Before facial reduction. (Color version offigure is available online.)

5Esthetic Substitution and Autotransplantation of Teeth

most closely emulates a lateral incisor (Figs 11,12).

Longevity of Treatment

With a committed interdisciplinary approachfrom a talented team of specialists, a single-toothimplant in the anterior maxillary region can

Figure 6. After facial reduction. (Color version offigure is available online.)

Figure 7. Initial placement of composite on the me-sioincisal and distoincisal corners. (Color version offigure is available online.)

Figure 8. Completed composite restoration of maxil-lary lateral incisor. (Color version of figure is availableonline.)

Figure 9. Facial view of bracket placement after res-toration. (Color version of figure is available online.)

Figure 10. Occlusal view of bracket placement afterrestoration. (Color version of figure is available online.)

Figure 11. Occlusal view after completion of orth-odontic treatment. (Color version of figure is avail-able online.)

Figure 12. Facial view after completion of orthodontictreatment. (Color version of figure is available online.)

6 Norris and Caesar

have an esthetic result at the time the restorationis completed. In an agenesis patient, implantplacement and restoration most often occurs inthe late teens. However, maturational changes inhard and soft tissue can occur after the late teenyears, which can adversely affect the esthetics ofthe implant restoration relative to the surround-ing natural dentition. These changes include anatural uprighting of maxillary and mandibularincisors,11 as well as continued vertical changesof the maxillary anterior teeth.12-16 One studyfound blue coloring of the gingiva in �50% ofsingle-implant crowns at 4-year follow-up ap-pointments due to thinning of the facial alveolarbone overlying the gingiva.17 Gingival recessionand exposure of a dark crown margin or implanthead are also a possibility. A paramount advan-tage of having all-natural teeth in the estheticzone is that the substituted or autotransplantedteeth experience the same maturational soft-and hard-tissue changes as the adjacent naturalteeth. Robertsson and Mohlin9 compared finaloutcomes of 50 patients who had agenesis of alateral incisor. Of these, 30 patients had receivedorthodontic substitution and 20 had space open-ing for tooth-supported prosthetic replacement.The authors found that space-closure patientswere more satisfied with their treatment results,had less plaque and gingivitis, and better peri-odontal health around their natural tooth versusa tooth-supported prosthetic replacement.

Smile Line

Many patients display the gingival margins oftheir maxillary anterior teeth on a full smile, andsome have excessive gingival display. This can bedue to a hypermobile lip, vertical maxillary ex-cess, dentoalveolar extrusion, altered passiveeruption,18,19 or any combination thereof. Ow-ing to the highly visible nature of the gingivalmargins in the esthetic zone, the authors feelthat the placement of dental implants in theesthetic zone on young patients with high smilelines is contraindicated when other options suchas substitution, autotransplantation, and esthetictooth-supported restorations exist.

Financial Resources of the Patient

A number of patients seeking dental implantreplacement for a missing lateral incisor will firstrequire a bone graft. This procedure incurs a

substantial expense and has some morbidity.This cost, along with the expense of the dentalimplant and crown, can amount to thousands ofdollars per replacement tooth. Orthodontic ca-nine substitution for a missing lateral incisor cansave the patient a substantial amount of moneyper missing tooth, while providing a result thatis immediate, long-lasting, and adaptive to thebody’s natural maturational process.

Part 2: Substitutionof the Premolar for the Cuspid

One of the most commonly overlooked proce-dures in achieving an optimal result when sub-stituting a canine for a missing lateral incisor isto apply the same stringent esthetic require-ments when substituting a premolar for a ca-nine. The technique described by Rosa andZachrisson1,20 is a seminal contribution to thebody of knowledge on this subject. First, oneshould examine the gingival margins of the sub-stituted premolar tooth, the central incisors, andthe contralateral cuspid. These gingival marginsshould all be level with each other. The verticalgingival margin discrepancy and the amount ofintrusion necessary to achieve a symmetric gin-gival margin can then be measured (Fig 13).This measurement determines the amount ofthe occlusal offset in bracket position on thesubstituted premolar, and the occlusally offsetbracket can then be accurately bonded from theonset of orthodontic treatment. In this manner,the premolar can most efficiently be intrudedthroughout the leveling and aligning process(Figs 14, 15). The occlusal edge of the premo-lar can later be lengthened back into occlu-sion through a composite or porcelain resto-ration (Fig 16), thereby rendering a tooth thatmore closely resembles a canine in length,width, morphology, and gingival margin posi-tion(Figs 17, 18).

Part 3: Lateral Substitution in Casesof a Missing Maxillary Central Incisor

Most traumatic dental injuries occur in the pre-teen years, with the central incisor being themost commonly avulsed tooth.21,22 When an in-cisor is lost, its ability to induce growth of thesurrounding alveolar bone is also lost. There-fore, in the esthetic zone of a young and growing

7Esthetic Substitution and Autotransplantation of Teeth

patient, it is critical to replace a missing toothwith a natural tooth that can continue the pro-cess of bone induction through their teen years.In the case of a missing central incisor, onesolution is to transform the lateral incisor into acentral incisor with composite resin or porcelainlaminate veneer restoration and orthodonticallymove it into the central position (Figs 19-22).This orthodontic movement is best achieved bypushing the transformed lateral into the centralposition with a compressed open coil spring. By

careful use of push mechanics on a stopped archwire, a clinician can avoid the common error ofshifting of the maxillary midline toward the sideof the missing tooth. This unwanted shifting isoften observed when the diastema closure is at-tempted using pull mechanics with elastic chain.On closure of the central diastema, the case cannow be considered as missing a lateral incisor,and the aforementioned techniques on convert-ing a canine into a lateral incisor and transform-

Figure 13. Note gingival margin discrepancy betweenmaxillary central incisors and right first premolar sub-stituting as canine. This difference determines theamount of intrusion needed and, therefore, theamount of occlusal offset during initial bracket place-ment of the premolar. (Color version of figure isavailable online.)

Figure 14. Premolar was intruded during the levelingprocess owing to occlusal bracket position. (Colorversion of figure is available online.)

Figure 15. Note gingival margin of premolar is nowlevel with gingival margins of central incisors. (Colorversion of figure is available online.)

Figure 16. Occlusal edge of facial cusp of premolar isrestored with composite to emulate a canine. (Colorversion of figure is available online.)

Figure 17. Orthodontic bracket is rebonded in a pas-sive position. (Color version of figure is available on-line.)

Figure 18. Note the symmetry of the gingival marginsof the substituted premolar to the contralateral cus-pid and central incisors. (Color version of figure isavailable online.)

8 Norris and Caesar

ing a premolar into a canine can subsequentlybe followed.

Part 4: Autotransplantation in the Caseof a Traumatically Avulsed Central Incisor

Autogenous tooth transplantation, or dental au-totransplantation, is the extraction of a donortooth from its original erupted or impacted siteto a prepared recipient site or extraction socketin the same individual. One of the most success-ful and common applications of autotransplan-tation is the replacement of a missing maxillaryincisor with a premolar.23-27 As previously men-tioned, most traumatic dental injuries occur inthe preteen years, with the central incisor beingthe most commonly avulsed tooth. Unlike animplant, a successful autotransplantation ofone’s own tooth will induce growth of bone andsurrounding tissues and will re-establish a nor-mal alveolar process as the patient continues togrow and mature. If autotransplantation is cho-sen, orthodontic treatment will need to be timedsuch that the recipient site will be ready whenthe donor tooth has two-thirds to three-fourths

root development.25,27-29 Fortunately, this stageof root development usually occurs between theages of 9 and 13, which is the same age as mosttraumatic dental injuries resulting in loss of ananterior tooth (Figs 23, 24).

Donor tooth selection starts with measuringthe crown size of the contralateral incisor. Amandibular second premolar, owing to its crownsize, root shape, and root diameter, is often thebest donor tooth to replace a missing centralincisor. Although a case is ideal in which extrac-tions in the lower arch are beneficial to relievecrowding, not all cases require mandibular ex-tractions for orthodontic reasons. Donating amandibular second premolar makes for easierorthodontic mechanics during a temporary an-chorage device–assisted closure of the mandibu-lar space on an otherwise nonextraction case.

The autotransplantation procedure29 involvespreparation of the recipient site with surgicalburs, much like an implant site. Next, the donortooth is carefully harvested, patiently and metic-ulously, ensuring that the entire dental follicle isintact and undamaged. The donor tooth is thenplaced in the recipient site, paying particular

Figure 19. Maxillary left central incisor of a 12-year-old boy was traumatically avulsed. (Color version offigure is available online.)

Figure 20. Maxillary left lateral incisor restored withcomposite resin to emulate a central incisor. (Colorversion of figure is available online.)

Figure 21. Brackets placed on maxillary central “in-cisors.” (Color version of figure is available online.)

Figure 22. Central diastema closed with push me-chanics through an open coil spring. This is critical tonot shift the maxillary midline. Patient can now betreated as if he is missing a lateral incisor. (Colorversion of figure is available online.)

9Esthetic Substitution and Autotransplantation of Teeth

attention that there is no binding, impinging, orcompression of the periodontal ligament andthe tooth should be out of contact with theopposing dentition. It is then sutured into placeand stabilized with a light wire splint to allowonly physiological movement. Ideally, the recip-ient site should be slightly wider than the donortooth (Figs 25, 26), and the remaining proximalspace should be distributed such that one-thirdof the space lies mesially and two-thirds of thespace lies distally (Fig 27). The facial surface ofthe donor tooth should also be placed approxi-mately 0.5 mm lingual to the facial surfaces ofthe adjacent teeth to allow space for composite

restoration (Figs 28, 29). The patient is placedon a chlorhexidine rinse and soft diet for 6weeks as a precautionary measure, and in-structed to gently clean the area with a cottonswab rather than a toothbrush. While it is theposition of some authors to recommend healingfor 3-4 months before restoration or applicationof orthodontic forces, the composite build-upand application of extremely light orthodonticforces can be successfully begun as early as 6

Figure 23. Maxillary right lateral incisor of a 9-year-old boy was traumatically avulsed. (Color version offigure is available online.)

Figure 24. Panoramic radiograph on initial examina-tion.

Figure 25. Space was opened at the recipient site andmaintained until the donor tooth achieved two-thirdsroot development. (Color version of figure is availableonline.)

Figure 26. Panoramic radiograph showing two-thirdsroot development of the mandibular left second pre-molar donor tooth.

Figure 27. Mandibular left second premolar was au-totransplanted into the recipient site. (Color versionof figure is available online.)

Figure 28. On the same day as the autotransplanta-tion surgery, the donor tooth was splinted to adjacentteeth with a thin coaxial cable wire to allow physio-logical movement. (Color version of figure is availableonline.)

10 Norris and Caesar

weeks if necessary due to scheduling constraints(Figs 30-35).

The risks of autotransplantation include an-kylosis and pulpal necrosis with either inflamma-tory resorption or replacement resorption. Mostlikely, these complications are a result of dam-age to the periodontal ligament of the donortooth during extraction. Even in the event of anunsuccessful autotransplantation, the donortooth will have facilitated alveolar bone induc-tion necessary for an osseointegrated implantonce the child’s growth has been completed.

Figure 29. Facial view of the splinted donor tooth.(Color version of figure is available online.)

Figure 30. Six weeks of healing allowed the soft tissueto mature and the tooth to stabilize. (Color version offigure is available online.)

Figure 31. Stabilizing wire was removed. (Color ver-sion of figure is available online.)

Figure 32. Donor tooth was built up with compositeresin to emulate a maxillary right central incisor.(Color version of figure is available online.)

Figure 33. Bracket was placed on the new tooth and0.014” � 0.025” NiTi orthodontic wire engaged.(Color version of figure is available online.)

Figure 34. Final alignment of donor tooth. Furthertissue maturation will occur over time with good oralhygiene. (Color version of figure is available online.)

Figure 35. Panoramic radiograph 12 months afterautotransplantation.

11Esthetic Substitution and Autotransplantation of Teeth

However, when fastidious care is taken duringthe surgical technique, long-term survival ratesof 98%-100% have been reported.27,29,30 Withsuch high success rates and predictable estheticresults, autotransplantation of a mandibular pre-molar should be one of the primary methodsused to replace a maxillary anterior tooth.

References

1. Zachrisson BU: Improving the esthetic outcome of ca-nine substitution for missing maxillary lateral incisors.World J Orthod 8:72-79, 2007

2. Tuverson DL: Orthodontic treatment using canines inplace of missing maxillary lateral incisors. Am J Orthod58:109-127, 1970

3. Thordarson A, Zachrisson BU, Mjör IA: Remodeling ofcanines to the shape of lateral incisors by grinding: along-term clinical and radiographic evaluation. Am JOrthod Dentofacial Orthop 100:123-132, 1991

4. Zilberman Y, Cohen B, Becker A: Familial trends inpalatal canines, anomalous lateral incisors, and relatedphenomena. Eur J Orthod 12:135-139, 1990

5. Sabri R: Management of missing maxillary lateral inci-sors. J Am Dent Assoc 130:80-84, 1999

6. Olsen TM, Kokich VG Sr: Postorthodontic root approx-imation after opening space for maxillary lateral incisorimplants. Am J Orthod Dentofacial Orthop 137:158.e1-8, 2010

7. Nordquist GG, McNeill RW: Orthodontic vs. restorativetreatment of the congenitally absent lateral incisor—long term periodontal and occlusal evaluation. J Peri-odontol 46:139-143, 1975

8. Senty EL: The maxillary cuspid and missing lateral inci-sors: esthetics and occlusion. Angle Orthod 46:365-371,1976

9. Robertsson S, Mohlin B: The congenitally missing upperlateral incisor. A retrospective study of orthodonticspace closure versus restorative treatment. Eur J Orthod22:697-710, 2000

10. Zachrisson BU, Mjör IA: Remodeling of teeth by grind-ing. Am J Orthod 68:545-553, 1975

11. Bjork A, Palling M: Adoslecent age changes in sagittaljaw relation, alveolar prognathy, and incisal inclination.Acta Odontol Scand 12:201-232, 1955

12. Bernard JP, Schatz JP, Christou P, et al: Long-term ver-tical changes of the anterior maxillary teeth adjacent tosingle implants in young and mature adults. A retrospec-tive study. J Clin Periodontol 31:1024-1028, 2004

13. Thilander B, Odman J, Lekholm U: Orthodontic aspectsof the use of oral implants in adolescents: a 10-yearfollow-up study. Eur J Orthod 23:715-731, 2001

14. Jemt T: Measurements of tooth movements in relation tosingle-implant restorations during 16 years: a case re-port. Clin Implant Dent Relat Res 7:200-208, 2005

15. Zachrisson BU: Single implant-supported crowns in theanterior maxilla: potential esthetic long-term (�5 years)problems. World J Orthod 7:306-312, 2006

16. Covani U, Crespi R, Cornelini R, et al: Immediate im-plants supporting single crown restoration: a 4 year pro-spective study. J Periodontol 75:982-988, 2004

17. Garber DA, Salama MA, Salama H: Immediate totaltooth replacement. Compend Contin Educ Dent 22:210-218, 2001

18. Robbins JW: Differential diagnosis and treatment of ex-cess gingival display. Pract Periodontics Aesthet Dent11:265-272, 1999

19. Dolt AH, Robbins JW: Altered passive eruption: an eti-ology of short clinical crowns. Quintessence Int 28:363-372, 1997

20. Rosa M, Zachrisson BU: Integrating esthetic dentistryand space closure in patients with missing maxillarylateral incisors. J Clin Orthod 35:221-234, 2001

21. Gassner R, Bösch R, Tuli T, et al: Prevalence of dentaltrauma in 6000 patients with facial injuries: implicationsfor prevention. Oral Surg Oral Med Oral Pathol OralRadiol Endod 87:27-33, 1999

22. Andreasen JO, Ravn JJ: Epidemiology of traumatic den-tal injuries to primary and permanent teeth in a Danishpopulation sample. Int J Oral Surg 1:235-239, 1972

23. Kristerson L: Autotransplantation of human premolars.A clinical and radiographic study of 100 teeth. Int J OralSurg 14:200-213, 1985

24. Czochrowska EM, Stenvik A, Bjercke B, et al: Outcomeof tooth transplantation: survival and success rates 17-41years post-treatment. Am J Orthod Dentofacial Orthop121:110-119, 2002

25. Czochrowska EM, Stenvik A, Album B, et al: Autotrans-plantation of premolars to replace maxillary incisors. Acomparison with natural incisors. Am J Orthod Dento-facial Orthop 118:592-600, 2000

26. Czochrowska EM, Stenvik A, Zachrisson B: The estheticoutcome of autotransplanted premolars replacing max-illary incisors. Dent Traumol 35:221-234, 2002

27. Kvint S, Lindsten R, Magnusson A, et al: Autotransplan-tation of teeth in 215 patients. Angle Orthod 80:446-451,2010

28. Slagsvold O, Bjercke B: Applicability of autotransplanta-tion in cases of missing upper anterior teeth. Am JOrthod 74:410-421, 1978

29. Slagsvold O, Bjercke B: Autotransplantation of premo-lars with partly formed roots. A radiographic study ofroot growth. Am J Orthod 66:355-366, 1974

30. Andreasen JO, Paulsen HU, Yu Z, et al: A long-termstudy of 370 autotransplanted premolars. part II. Toothsurvival and pulp healing subsequent to transplantation.Eur J Orthod 12:14-24, 1990

12 Norris and Caesar