A congenitally missing tooth means that one or more of the permanent teeth never formed (hypodontia). The teeth most often missing are the upper lateral incisors and the lower second premolars. The key question in treatment is whether the space will be closed with orthodontics or kept for a future implant or bridge. This decision is made according to age, which tooth is missing, the size of the jaws and teeth, the smile line and the bite, through a joint assessment by the orthodontist and the prosthodontist/implant dentist. This page focuses on missing teeth from birth; for a tooth that is missing because of a later extraction or loss, you can look at our page on clear aligners with a missing tooth.
This is general information; the decision for you is made after an examination.
What is a congenitally missing tooth, and why does it happen?
While tooth buds (the seeds of teeth that are not yet visible in the mouth) develop inside the jawbone, some may never form. Leaving wisdom teeth aside, this is reported to be seen in about one in twenty people in the population; the rate varies between populations. The causes are mostly genetic, and it can recur within a family. When many teeth are missing, or when there are differences in other tissues such as hair, nails and sweat glands, a genetic syndrome may be involved; in that case an assessment is made together with a pediatric dentist and, if needed, a geneticist.
The absence can be a single tooth or several teeth. How many teeth are missing is one of the most important factors that determine the scope of treatment.
Which teeth are most often missing?
Apart from wisdom teeth, the teeth most often missing are generally the following:
- Lower second premolars: In most studies this is the group of teeth most often missing.
- Upper lateral incisors: Because it directly affects aesthetics in the front teeth, this is the absence that is noticed most. Sometimes the tooth is not missing but develops smaller than normal, in a peg shape.
- Upper second premolars: These are seen less often.
The absence is often on both sides and symmetrical, but it can also be on one side. This difference affects the space plan and the alignment of the midline; the information on our page on midline shift may also be relevant.
When can you tell that a tooth is missing?
During the baby tooth stage, a missing tooth often goes unnoticed; the main sign is that a baby tooth stays in place at the age when it should have fallen out, or that the permanent tooth does not come in. A definite diagnosis is made with a panoramic X-ray. Because the buds of the second premolars form late, to say with confidence that one is missing you often have to wait until around age 8–10; for this reason a decision is not made from a single early X-ray, and the X-ray is repeated at certain intervals if needed. For baby teeth and the eruption timetable, you can read our article on baby teeth and the eruption timetable.
If a baby tooth in your child has not fallen out for a long time, if the neighboring teeth are leaning toward the space, or if the gap between two side-by-side teeth is wider than expected, a check by an orthodontist is useful. For the general framework, you can also look at our page on early orthodontic treatment.
Is the space closed or opened?
There are two main routes for a congenitally missing tooth. Both can be right; which one suits depends on the person.
- Closing the space with orthodontics: The neighboring teeth are brought closer together. For an upper lateral incisor, the canine is moved into the place of the lateral incisor and, if needed, its shape and color are adjusted; a permanent prosthesis may not be required.
- Keeping or redistributing the space: The teeth are aligned, and the site of the missing tooth is prepared for a future implant, bridge or bonded prosthesis.
In making the decision, the following are assessed: the type of the missing tooth, the width of the jaw and teeth, the color and shape of the canine, the gum line, the bite relationship (bite class), the amount of crowding, the profile and the patient's expectations. The advantage of closing the space is that it generally reduces the need for an additional prosthesis; the disadvantage is that it is not suitable in some bites and that additional adjustments may be needed for aesthetic harmony in the front area. The advantage of keeping the space is that the teeth can stay in their natural position; the disadvantage is that it creates a need for long-term maintenance with an implant or prosthesis.
How does the approach differ for an upper lateral incisor and a lower second premolar?
The table below summarizes the general picture; the actual plan is made with an examination, X-rays and measurements.
| Missing tooth | Possible approaches | Points considered |
|---|---|---|
| Upper lateral incisor | Closing the space and reshaping the canine like a lateral incisor; or opening the space and planning an implant or bridge | Smile line, color and shape of the canine, bite, gum level |
| Lower second premolar | Keeping the baby molar as long as possible; closing the space with orthodontics; or holding space for an implant | Root and bone condition of the baby tooth, tilt of the neighboring teeth, crowding |
| Upper second premolar | Space closure or space maintenance | Bite class, jaw width, relationship of the side teeth |
| Several missing teeth | A multidisciplinary plan; distributing the spaces and proceeding together with the prosthetic plan | Amount of bone, growth status, timing suited to age |
Can a baby tooth be used permanently?
A baby tooth with no permanent successor beneath it stays in the mouth and functions for years in some people. If the baby tooth is sound and its root and the surrounding bone are suitable, it is often not extracted unnecessarily. However, its root structures are thinner than those of permanent teeth; over time the root may resorb, the tooth may sit lower than the teeth around it (infraocclusion), or it may be lost. For this reason a baby tooth is monitored with regular X-rays. The doctor may recommend keeping the tooth or extracting it in a planned way and closing the space. The decision on whether to keep the baby tooth is made together with the long-term plan for the space. For measures that prevent space loss in children, our page on space maintainers and our article on space maintainers may be useful.
How do the orthodontist and the prosthodontist/implant dentist work together?
Treatment of a congenitally missing tooth is often teamwork. The orthodontist brings the teeth into the right position and adjusts the width and direction of the space; the implant or prosthodontic dentist plans the solution suited to that space. A good plan is made together from the start: if the space ends up narrower or wider than it should be, the later restoration becomes difficult. Root position matters too: if an implant is to be placed, the roots of the neighboring teeth must be far enough from the space.
To compare the options, our articles on implant or bridge and dental bridges give general information. If there is a crown, implant or bridge during or after orthodontics, you can also look at our page on clear aligners with implants and crowns for the process.
What age should you wait for an implant?
An implant does not grow with the jawbone the way teeth do; an implant placed while growth continues may in time end up lower than the neighboring teeth. For this reason, an implant is considered after jaw growth has generally been completed. When growth is complete varies from person to person; the doctor assesses it from age, development and, if needed, additional tests. During the growth period, the space can be kept with orthodontic appliances or removable temporary solutions. In the meantime, removable temporary prostheses or bonded temporary solutions can be used for aesthetics. For the general process of an implant, you can read our article on implant treatment.
Can congenitally missing teeth be treated with clear aligners?
In many cases yes, but not in every case. With clear aligners the teeth can be aligned and the spaces redistributed or closed; if the space is to be kept, the aligner plan can proceed in a way that avoids loss of space. In some plans it is also possible to give a temporary look that fills the space inside the aligner. However, in complex cases where root movement is required, where teeth will be moved a large distance, or where many teeth are missing, clear aligners alone may not be enough and fixed wires/brackets may be recommended; additional auxiliary parts (attachments) can be used. For teenage patients you can look at our page on Invisalign for teens, for children our page on Invisalign First, and for adults our page on Invisalign for adults. Our page on who clear aligners are suitable for is also useful for general suitability.
Treatment duration and afterward
The duration varies with the number of missing teeth and the method chosen. Alignment and space arrangement alone can range from a few months to two years; if a prosthesis/implant and waiting for growth are needed, the total follow-up can stretch over years. At the end of treatment, wearing a retainer is especially important so that the teeth do not shift; in areas where the space is kept, the retainer can also act as a space holder. For details, see our page on retainers after clear aligners.
What should you prepare before seeing the dentist?
- Any earlier panoramic X-rays and photos of the inside of the mouth
- Whether there is a family history of missing teeth
- When the baby teeth fell out, and which baby tooth is still in place
- Writing down your questions; our orthodontic consultation question list can be used for this
Assessment at our clinic
The Invisalign system is offered at the Funda Sarıkaya Oral and Dental Health Polyclinic. At the examination, Funda Pekyılmaz Sarıkaya, specialist orthodontist (Uzm. Dt.), assesses the missing tooth and the jaw-tooth relationship through a clinical examination and X-rays/digital records; where needed, a referral is made so that a joint plan can be drawn up with a prosthodontist or implant dentist. The clinic is in Park Oran Ofis in Oran, Çankaya; service languages are Turkish, English, German and Russian. You can make an appointment Monday–Saturday, 09:00–20:00, on 0312 911 60 36.