July 30, 2014

Congenitally Missing Lateral Incisors – Treatment with Conservative Bonded Bridges

congenitally missing teeth implants bridges

Above, Allie with two conservative bonded lingual bridges. With this treatment none of the front surfaces of Allie’s teeth required any drilling or tooth preparation. Below, Allie before her bonded bridges were placed. Implants were ruled out as being an acceptable choice for her treatment.

Congenitally missing lateral incisors

Congenitally missing lateral incisors, both of them, Allie was faced with tackling a major cosmetic problem that affected her smile and her face.  Her orthodontist straightened her teeth and when her braces came off at age 14 he attached two “false teeth” to her retainer. Thus when she wore her retainer it appeared that she wasn’t missing any teeth, but that meant she also had to always wear her retainer. Her orthodontist’s strategy was that at an appropriate age Allie could get dental implants or bridges. Over the next three years Allie got very tired of wearing her retainer all the time.  The “false teeth”, although looking better than having no teeth there, didn’t look good.  It was obvious to those who looked at her that they weren’t her “real teeth.”

Finally, as a seventeen year old senior high school senior, Allie came to us to discuss what options she would have to give her some “permanent teeth” before she went away to college.  Along with her parents, Allie was thinking that dental implants would be the way to go to replace her congenitally missing lateral incisors. Unfortunately there were two reasons why dental implants would not work in Allie’s case.  First, there was not enough room in the bone to place a dental implant. The area between the adjacent teeth on both sides where the tooth was missing needed to be wide and thick enough for the implant.  It wasn’t!  The second reason is that her orthodontist could not confirm with certainty that all of her vertical facial growth had been completed. If an implant is placed and the patient is still growing, then the natural teeth and gums grow with the face, but the dental implant does not!  A horrible esthetic result could occur.  So dental implants was not the solution to correct Allie’s congenitally missing teeth problem.

congenitally missing teeth bonded bridge

Allie had beautiful looking teeth without any decay, fillings or defects. It would have been very hard to justify conventional bridges that require that the front of her anchor teeth be prepared to accept full crowns that anchor the false teeth. One of the main advantages of modern, bonded “lingually retained” bridges is that the fronts of her teeth do not require any tooth preparation (drilling).

Fortunately there was a permanent solution to Allie’s congenitally missing lateral incisors problem.  Since she was missing two teeth, she could have two dental bridges. The conventional type of dental bridge is a porcelain-fused-to-metal bridge, and this requires that her adjacent teeth be shaped to accept dental crowns that anchor the false tooth in place. Since Allie had beautiful teeth without any cavities, blemishes or flaws whatsoever, it would be very hard for both the patient and cosmetic dentist to justify shaping those teeth to accept crown coverings.

Conservative bonded winged bridges were the solution

But the great news is that in Allie’s case she did not have to have  conventional dental bridges!  She was a great candidate to take advantage of modern, ultra conservative bonded cosmetic dentistry.  Allie could get two bonded bridges that would not require that the fronts of the adjacent teeth be shaped or prepared in any way.  Other names for this conservative type of bonded bridge are “bonded winged bridges“, “non-metal Maryland-type bonded bridges” or “lingually retained bonded bridges“.

The main point here is that as an Orange County cosmetic dentist treating Allie with new techniques I did not need to drill any of the front surfaces of any of Allie’s teeth to accept the lingually retained bonded bridges.  These conservative types of bonded bridges can be done with just very minimal tooth preparation on the back sides (dental term “lingual”) of the adjacent teeth.  The new bonded bridges are made without any unsightly metal (as the old type of “Maryland bridges” were), and are fabricated completely from natural looking tooth colored materials which are bonded onto the back sides of the teeth with the dental curing laser.

congenitally missing teeth treatment

Allie’s beautiful smile with two conservative “lingually retained” bonded bridges. From the photo one can see that she got a superlative result and this was without drilling any of the front surfaces of her teeth.

Allie and her parents were excited that we could offer her this new strategy of conservative bonded cosmetic dentistry.  They absolutely loved the fact that her natural teeth didn’t have to be drilled (shaped) to accept crowns that covered the entire tooth. They also were thankful that we were able to give her a permanent solution and at the same time circumvent her treatment without the need for surgical dental implant treatment.

Just a note here: We are strong advocates of dental implants, use them often in our practice, as dental implants are in many situations the best treatment choice for the patient.  However,  most cosmetic dentists will agree with me that in Allie’s case it was not the best treatment choice.

And, the results for Allie congenitally missing later incisors treatment ?  Absolutely beautiful!  No description necessary, see the photos and see for yourself.  This beautiful young lady from Orange County is now away in college enjoying her freshman year without showing that she’s congenitally missing her lateral incisors.

Dr. Norman Huefner, Orange County Cosmetic Dentistry and Porcelain Veneers. Serving the surrounding cities of San Clemente, Laguna Niguel, Irvine, Newport Beach, Mission Viejo, Coto de Caza and Rancho Santa Margarita

Comments

  1. Hi , I’m 13 years old and I have the same problem than Allie , but only with one tooth. I am very exited to know that there may be a solution to my situation . I live in Argentina . Do you know dentists working with this sistem in my country ?
    Thanking you for the hope you give me !!
    Sofia.

    Hi Sofia,
    Nice to hear from you from such a great distance away. I’ve had patients come to me from as far away as Europe and Australia, but never anyone from South America.
    I know how frustrated you must be, as missing even one lateral incisor doesn’t give you as beautiful smile as you no doubt want. I don’t know if you knew this but 5% of the population are missing one or more permanent teeth. The most commonly missing tooth is the one you’re missing, the upper lateral incisor. The other commonly missing teeth are the lower second bicuspids and the third molars.
    Unfortunately I don’t know of any cosmetic dentists in Argentina. You might go to the American Academy of Cosmetic Dentistry website http://www.aacd.com and do a search for cosmetic dentists who are AACD members and practice dentistry in Argentina. I think it would be under “search for dentists” in the patient information section?
    I do know a world renown cosmetic dentist in Brazil, Dr. Newton Fahl. His website is http://www.fahl.com.br/
    You might contact Dr. Fahl, as he may know of a cosmetic dentist in Argentina for you.
    I wish you the best Sofia and thank you for your interest in cosmetic dentistry and commenting on my blog.
    Sincerely,
    Dr. Norman Huefner

  2. Dear Dr. Norman : Thank you for your answer !! . I was very happy to receive it , since i am so young and live so far away . I am still waiting for my canine tooth to come down and i was explained that until this happens nothing else can be done , so I have to be patient and hope this happens soon . Thank you again for the hope I have since I saw what you can do .
    Sincere regards,
    Sofia.

  3. Marilyn S. says:

    Hi, my name’s Marilyn, I’m actually a bit older than both these girls. I’m 32 and recently got braces because of the same problem. I have my upper left lateral incisor missing. And I assume that because the tooth is missing, the rest of my upper teeth shifted to the left, leaving with a misaligned smiled. I went to the orthodontist a month ago and got braces, kind of regret it because I feel very self conscious. I have my first f/u appt on Mon, I will ask if maybe invisalign can help. Do you know if it could? So the orthodontist’s plan was to move my canine to the lateral position, and the molar to the canine position to then reshape them. Does that make sense? Anyway I’m writing to ask if you think an implant would be a better choice. Thank you :)

    • Hi marylin, I just want to know what did you decide to do about your teeth. I think I have the same problem as you and don’t know which road to take. All I know is that I want to fix my smile aswell… Please let me know what they adviced you to do. :)

      Thank you!

  4. Hi Marilyn, It is difficult to give an intelligent response without having all the information that your orthodontist has (x-rays, models, photos and doing an exam). Saying that, if the space has already closed where your left lateral incisor should be and you don’t have any crowding, then your orthodontist is probably on the right track. However, if the space is open and there is a space 5mm or greater, then I might also consider just aligning your teeth (which could be done with invisalign) and then placing either a bridge or implant. Women definitely look better with six front teeth, not five….more symmetrical. However, if your spaces are closed (either after, or without orthodontics) you could have porcelain veneers that could accomplish that. With veneers you can make the cuspid look like a lateral incisor and a bicuspid look like a cuspid, end result it would appear as if you have the normal compliment of teeth. There are some examples of that on my blog. Sincerely, Dr. Norman Huefner

  5. Theresa says:

    My daughter is 12 years old and just finished orthodontic treatment for congenitally missing lateral incisors. The plan is to put implants in when she gets older. However, after having an implant specialist look at her, he informed me he would need to add some bone because her bone is concaved and gets thin. Do you know of any cosmetic dentists in the New York Area that are performing the procedure you describe? And how old does a child need to be before she can have this type of dental work done?
    Thank you for your advice.

    Theresa B

    • You’ve hit on a lot of things that could benefit from discussion. First, IF implants are to be considered it is extremely important that the implantologist wait until he/she can CONFIRM that all vertical facial growth has ceased! There is not a magic age, sometimes it is as early as 16 or as late as 22 or older. The only way this can be confirmed is two cephalometric tracings off of a lateral head plate x-ray one year apart. Your orthodontist should be involved in this determination and be the one doing this measurement. If the vertical facial height is the same on both cepts on year apart, that mean vertical grow is over and implants can be started. If there is a difference in the vertical facial height, then the implantologist must wait another year to repeat the verification process. IF implants are done before vertical facial growth has been completed, a horrible result may be seen after vertical growth has been completed because the gums, bone and implant teeth can all possibly be at a different level than the adjacent normal teeth. By the way, in dentistry poorly planned or executed implants will be the major area of dental malpractice in the next decade. Too many dentists, oral surgeons and periodontists doing them without proper training and/or planning.
      If the implantologist requires adding bone thickness that is not a major procedure and I would agree that oftentimes will be necessary to get a good implant result.
      One problem that oftentimes occurs with missing lateral incisors is that the space between the central incisor and canine teeth isn’t wide enough to place implants, or that the roots of those teeth angle into the area where the impants should be placed. Both of those problems often preclude being able to place implants.
      Regarding the lingually bonded winged dental bridge, there are many cosmetic dentists who do this procedure. I don’t anyone personally who does that procedure but you might try going to the American Academy of Cosmetic Dentistry website and doing a dentist search for cosmetic dentists in your area.
      I hope I’ve sufficiently answered your questions Theresa and good luck with your daughter’s treatment.
      Sincerely, Dr. Norman Huefner, Laguna Niguel, CA

  6. Theresa says:

    Dear Dr. Huefner,

    Thank you very much for your response. She is going for a consult with a recommended cosmetic dentist. The orthodontist recommended maryland bridges for her until she is older and timing is right for implants.

    Sincerely,

    Theresa B

    • I would absolutely disagree with your orthodontist about a traditional Maryland bridge, as they have metal wings, do not bond well to the backs of the adjacent teeth and actually inhibit light transmitting through the teeth, making them appear much darker than they would be before placing the Maryland bridge. I suggest better technology and esthetics that you can achieve for her with winged non-metal fiber supported bridges. They are in some ways similar to an actual Maryland bridge, but bond better to the adjacent teeth, are tooth colored (not black or silver metal) and will not darken the adjacent teeth. If your cosmetic dentists recommends a traditional Maryland bridge with metal I would strongly suggest you get a couple more opinions. Good luck.
      Dr. Huefner

  7. I agree with Dr.Huefner Maryland bridge is not a proper treatment. Please
    ask your orthodontist to create space between upper end lower front teeth so there is no need for reduction of the backs of teeth.I restored many congenitally missing teeth over 25 years and have great record. Please have a look at my website http://WWW.MK pontic.com
    Good luck.

  8. Hi. During a recent dental check up my dentist advised me that my daughter appears to be missing her lateral incisors. the baby teeth have fallen out, but he cannot feel any new teeth to replace them. He has advised that we wait 6 months to a year before taking an xray to confirm this. My daughter is 7 1/2, and I am also missing 2 teeth but not at the front (first upper molars), so it is quite likely that the dentist is correct. what I wanted to ask is at what age can she have a temporary solution to fill the gaps? i understand she will have to wait until she is an adult before she can have an implant (or permanent solution), but I am concerned that she will be picked on at school for having missing teeth and would like to do all we can to prevent that. Also, if she can have a temporary solution could this help prevent the need for braces later on to widen the gap, as they may prevent the gaps from closing?

  9. Hi Hazel,
    First, what benefit did your dentist say there was to wait 6 months to take an x-ray to confirm his suspicions? My opinion is find out now! The lateral incisors might be there and impacted, and if that were the case you would want to work with an orthodontist to make room and guide the tooth into place.
    If she has lost her baby lateral incisors and there is a space, you can have your dentist make a “flipper” with two teeth on it. It is like a retainer that has two teeth attached, but without a wire in the front. That should get her through school without walking around with obvious missing teeth.
    Under no circumstances should you allow any dentist to do implants until they can absolutely confirm that ALL VERTICAL FACIAL GROWTH has ceased! The way that is done is an orthodontist evaluates the x-ray of the side of the face two years in a row. If there is no difference, then implant can be done. If there is a vertical change, then you must wait another year, take an x-ray again, and confirm. For females, vertical facial growth can stop between the age of 15-20. So unfortunately, no magic age to do implant until adulthood is reached.
    The other approach is do lingual bonded winged bridges, as I have shown in several of my blog posts. This can be done anytime after the central incisors and canine teeth have erupted into their final position or after any planned orthodontics has been done.
    Good luck with your daughter’s cosmetic dental treatment Hazel.
    Dr. Norman Huefner

  10. theresa bonapace says:

    Dear Dr. Huefner,

    Thank you so much for your advice on my 12 year old daughter. I found an accredited cosmetic dentist on Long Island. He is using a resin bonded bridge for my daughter. The bridge does not contain any metal and looks exactly like yours.
    She is going to the lab first to obtain the right color. I would like to thank you very much for your informative website. Her orthodontist and regular dentist were only suggesting a removable retainer with teeth until she got older which I didn’t think was a great option.

  11. Dr. Huefner,
    Thank you so much for this information. My daughter just received a Maryland bridge for a missing lateral incisor, which we plan to keep until she is done growing and ready for an implant. Her treatment was coordinated with her orthodontist, so we could have adjusted spacing any way we wanted. As we developed her treatment plan, I asked the dentist about something tooth-colored instead of the metal, but he told me that it wasn’t an option in her case, and now I don’t recall why (perhaps spacing, but we could have worked that out with the orthodontist, I would have thought). Although this dentist is highly regarded and very expensive, I am now looking at her almost beautiful tooth – but with the dark edge along the gum, it looks so fake I want to cry. She got her braces off today, too, so maybe it’s the shock of this new look, but I am just feeling like we blew it, and with the braces off, our options to change spacing seem limited. Is there any recourse at this point? Thank you, Sarah

    • It would be very difficult to give an opinion on your daughter’s case without seeing her, or at least dental photos. The only comment I can make is that most cosmetic dentists stopped using metal Maryland Bridges years ago, being replaced by bonded resin retained winged bridges (absolutely no metal), which bond better to the adjacent teeth and also have improved esthetics by not having any dark metal substructure. My article illustrates the beautiful lifelike quality of this improved procedure. I’m sure the the metal Maryland bridge could be replaced with a resin retained winged bridge if at some time in the future you feel compelled to do so. Dr. Norm Huefner

  12. Faye Simpson says:

    Hi there, erm i have the same problem for quite a long while now, and im currently 19. I am also missing my top two lateral Incisors, however my gaps are not that big, but you can still tell im missing them, so i was wondering can i place any tooth in there or do i need to wear braces, Thank you

    • It depends on how large the spaces are where the missing lateral incisors were supposed to be? The normal width and space for the upper lateral incisors is about 60% of the width of the central incisor (front tooth). You might want to measure your central incisor, do the math, and then measure the space and see how the compare. With regards to orthodontics, orthodontists usually do two types of treatment. If the space is small, they generally try to close the spaces. If the space is normal, they open it up for the size of a normal lateral incisor so that an implant, bonded lingual bridge or conventional bridge can be done to the proper proportions. Faye, if your space is small then you might be able to get away with just some bonding on the central incisor and canine teeth. However the best result to close small spaces on front teeth will be achieved with porcelain veneers, as much better control over the size, shape and proportion can be achieved.
      Dr. Norm Huefner

  13. Christine says:

    This is the first blog that has made me feel better about missing my right lateral incisor! My quesiton stems from the bone grafting side of things…I am23 years old and currently I have a Maryland Bridge (i have had this since i went to college as well, noone even knew). I would like a more permanent solution now that i am getting older and now that i have graduated college and have an amazing job, I can finally afford the procedure. All set and ready to get the implant process started. I do however not have enough bone on the top to do the implant right now so we are starting with a bone graft. Question: how successful are implants after bone grafting is completed and healed properly? It makes me nervous seeing that my bone is concaved just where my missing tooth is and needs to be built outward in order for the implant to be placed in its proper position. Bone grafting sounds painful and sounds like a long healing process before the implant is placed…but is it successful?

    Thanks:)

    • First, to answer your questions, “properly done” implants are very successful after bone grafting. A few other things to think about. A maxillary lateral incisor is the smallest of all your upper teeth. Is there enough width to place a normal size tooth? Reason I ask is that many times when a tooth is missing the adjacent teeth drift, closing the space somewhat, and the resulting size isn’t wide enough for a normal size lateral incisor. Also, sometimes this also means there isn’t enough space for an implant between the roots of the adjacent teeth. If you measure the width of your central incisor (front tooth), the lateral incisor space should be about 60-70% of the size of the central incisor. Another consideration is how much bone height to bring up the gums to meet the adjacent teeth. Also, how much bone thickness is needed for adequate amount of bone for the implant. Achieving proper bone height on front teeth is more challenging for the dental surgeon doing the bone augmentation than achieving adequate bone thickness. Be very careful choosing your implant team, dentist doing the bone augmentation and implant placement, restorative/cosmetic dentist doing the actual crown over the implant abutment, and also the dental laboratory that will have to use materials and techniques to match your adjacent teeth. Although I am a strong proponent of dental implants, many dentists will agree with me that unfortunately there are dentists (often advertising “discount” implants) performing implant procedures without proper training and experience. Thus, we have been told at dental seminars that dental malpractice insurance carriers are expecting dental implants to be the major area of dental malpractice suits in the next ten years. Most recently I had a patient come to me to “redo” her dentistry after having SEVEN implants fail in less than a years time done by an inexperienced dentist. Regarding the post operative pain from the bone augmentation procedure, I think you’ll find that it will be much less than you anticipate and will be adequately controlled with oral medications. Most patients report that dental implant procedures including bone augmentation were much less painful than removal of impacted wisdom teeth. Good luck Christine. Sincerely, Dr. Norm Huefner
      PS I welcome other cosmetic dentists and implant dentists to give opinions on your topic and this blog.

  14. hi, i have the same kind of problem i am 12. i live in england do you know i there is anyone that can do what they did too allie because i hate the way my teeth look.

    kind regards,
    saleen

    • Norman Huefner says:

      Saleen, I would recommend you see Dr. Justin Glaister, cosmetic dentist trained at LVI (advanced cosmetic dental training at the Las Vegas Institute for Advanced Dental Studies). His dental office is in Umbrella, London.
      Good luck Saleen,
      Dr. Norm Huefner

  15. Hi there,
    I had the same problem as Allie with the same two teeth missing and had two porcelain bridges put in about 3 years ago. But this past week one of them has become loose, not enough to come out with pulled on but just enough to be a bother. My dentist says that the only options to replacing it with the same type of bridge, which I am happy with the appearance of, is to either wait until it falls off (embarrassing!!) or cut it off and remake a new one. I was under the impression that I wouldn’t have a problem with this for a LOT longer than a mere 3 years. Is that common? And I dread having to wear that silly retainer in the meantime. Isn’t there a way to get the whole thing redone in one day so I can go back to work without anything knowing about my condition? I am 21 and I think my teeth caused me enough embarrassment during junior and senior high to last a lifetime. Please help with any advice. (Implants were also not a possible choice for my teeth based on the lack of space in the jawbone.) Thanks so much.
    -Naomi

    • Norman Huefner says:

      You said you have two porcelain bridges. Are they lingual bonded bridges or bridges that have full crowns on both sides of the missing teeth? If they are lingual bridges, are the wings that are glued onto the backs of the adjacent teeth METAL or ceramic or tooth-colored fiber? If they are the type with metal wings, they are called Maryland Bridges, which have a short life-span due to the fact that the metal doesn’t bond (or glue) well to the teeth. Be careful about leaving a bridge loose, as you will eventually get decay under them bridges and may end up needing a root canal or possibly losing a tooth altogether. No, bridges cannot be done in one day! Sorry, it’s just reality. There is a lot of work that is necessary by the lab to make the bridge and do it correctly. Sometimes acrylic temporary type bridges can be fabricated quicker, but they have shorter lifespans and are certainly weaker. Good luck Naomi,
      Dr. Norm Huefner

  16. Rebecca Hernandez says:

    Hi,
    My name is Rebecca. I have been trying to research a problem that I have with my teeth and really have no idea what I can do to fix my problem….there are so many options. I am 32 years old and I am missing my two lateral inscissors which has cause some spacing between my two front teeth as well. I just want to fix my teeth already! Do you thing you can give me some advice as to what I can possibly to fix it? All of my other teeth have no gaps between its just my front teeth that are a big problem.
    Thank you

    • Hi Rebecca, before I can suggest possible treatment that could be used to correct your problem I need to know more information. First, you say there are spaces between your front two teeth, how wide are those spaces? Second, you say your are missing your lateral incisors. Are there spaces there? If so, how wide are those spaces? Did you ever have any braces on your upper teeth?
      Dr. Huefner

  17. Hi Dr Huefner,

    I am 24 years old and I have two missing lateral incisors just like Allie. My general dentist referred my to a orthodontist two years ago and recommended implants. My Ortho recommended them as well. I got braces and went for a consultation with an implant specialist. He told me to come back when it was closer to the time my braces were to be removed. Now is the time and I was told that nothing would be covered due to the “Missing tooth clause” with my insurance. I am devastated because now I have to pay for everything out of pocket. I found your blog and I was wondering how much does something like this cost (conservative bonded bridges). Also do you know any cosmetic dentists in the Houston, Texas area that you would recommend.
    Thank You!

    • Hi Monique, Yes, unfortunately dental insurance very rarely pays anything for implants. Bonded bridges might range between $2,000-$3,000 each, depending on the dentist, area practicing, years in practice, experience and ceramist used at the lab. I recommend two colleagues that I have known well for a long time and feel confidant that they could take care of your missing tooth problem and are in the Houston area. First is Dr. Arturo Garcia, http://www.smiletexas.com/ and the second is Dr. Kathy Frazar, http://www.cosmeticdentisthouston.net/. When you see either or both of them, make sure to let them know that I referred you and I’m certain they will take exceptional care of you! Good luck Monique!
      Sincerely, Dr. Norm Huefner, Laguna Niguel, CA

  18. I was pleased to come across your site. My daughter has just completed orthodontic treatment (braces), and space was left for eventual implant–we now realize this may not be possible. The interim plan was to have bridges installed. The difficulty is that we live in a town in Alaska that does not have a dental lab. The dentists here either refuse or are hesitant to use dental bridges both due to the lack of a local lab and to their experience being that the bridges come unbonded after a relatively short time. Both recommend a “flipper”. My daughter is currently wearing an Invisilign-type retainer with pontics. She is eating with the retainer in, so I know it won’t last long.

    Can you recommend anyone on the west coast (ideally Anchorage or Seattle) who could give us a good asthetic result similar to your work with Allie? My daughter was considerably cheered seeing your before/after.

    Thanks,
    Tracey

  19. Hello Dr Huefner,

    We live in England my 11yr old daughter is missing both of her upper lateral incisors. We have been referred to an orthodontist who, after x-raying her mouth, also confirmed that her upper canines (which are yet to break through as she still has her baby teeth) are growing at an angle towards her front two teeth. She has advised us that she will need to have her gums cut to encourage her canines to come down before anything can be done about the missing lateral incisors. We are having another meeting with the Orthodontist so I don’t fully understand what needs to happen and also a long term plan. After reading many of the blogs on your site, I would like to know what kind of questions I should be asking the Orthodontist so that I get the correct course of treatment for my daughter first time.

    Thanks in advance
    Sasha

    • Your orthodontist usually has two choices. One is to close the spaces completely, leaving the canines next to the central incisors. The second is to bring the canine down into position and leave a space the size of the missing lateral incisor, which can eventually be filled with either and implant, bonded bridge or conventional bridge. If you have means to eventually get a bonded bridge, implant or conventional bridge, that will give her a normal look of the natural front six teeth. If you have limited means just closing the spaces with orthodontics will eliminate needing to fill the space and is much easier and more simple to do. However, she won’t have the normal looking front six teeth. I have treated those cases many times with porcelain veneers, usually at least eight veneers, because the patient didn’t like the look of the abnormal combination of front teeth. By doing veneers we could disguise the teeth, giving the illusion that the six teeth were there. After having your consultation with the orthodontist and getting his/her recommendation, I would get a consultation from a cosmetic dentist (meaning a “real” cosmetic dentist, not just a dentist that says they do cosmetic dentistry, which in many areas of this country just means they do bleaching and white crowns). Don’t forget, the cosmetic dentist will be the one who has to finish off her treatment in the end, either with bridges, implants or veneers, with what the orthodontist left him with.
      Good luck with all of this Sasha.
      Sincerely,
      Dr. Norman Huefner
      http://www.drhuefner.com

  20. Hello Dr. Huefner!
    I’ve 2 sup congenitally missing lateral incisors… I’m 29 years old and I still have 2 “little teeth” in my mouth. I still have 1/3 of root in both, but they are very small and getting smaller of course… I’m afraid to loose them at anytime while biting something and also my smile it is not the same with these 2 little teeth.. I’d love to have more information about your technique. I’m afraid to do implants and if I don’t like the results… Can I send you a picture of my teeth than you can have a better idea of my situation?
    Currently I live in South Florida, but I’m often going to CA.
    I appreciate any information.
    Thanks a lot!

  21. Dr. Huefner: I am congenitally missing my right lateral incisor. I was informed by one prosthodontist I would need to have an “incision cut in my gum above where the pontic will go” . He states that if he doesn’t do this it will be very unhygenic as I will be unable to floss completely around the bridge. I am hesitant to proceed with this as my previous bond did not require this and I have never heard of any other’s (in my situation) requiring this nor could I locate info. on the internet about it. On a side note, I have completely healthy gum tissue. Please give me some direction! Does this sound like something commonly done. I am very anxious about going through with this and would love some guidance with your professional expertise. Thank you!!

    • Your prosthodontist (dental reconstruction specialist) is most likely planning on making an ovate pontic to replace your congenitally missing tooth. Yes, it is a more cleansable pontic than the typical ridgelap pontic. Also, it appears more natural and better looking, as ovate pontics appear to be growing out of the gums like a natural tooth instead of laying on top of the gum tissue. Ovate pontics have been used in advanced cosmetic dentistry for over a decade, but sadly are rarely used by most dentists. The reasons they aren’t can only be speculated, but most likely because the dentist hasn’t been trained to use ovate pontics or because they take more effort and expertise. A question to ask is how he is going to prepare the ovate pontic site? With a dental laser or will he be reflecting a flap and also reshaping the bone where the tooth is missing? If he just needs to reshape the gums and will be using a dental laser, that is a very conservative and common way of handling the ovate pontic site. Good luck with your treatment and be thankful that your dentist is going out of his way to try to give you the very best he can.
      Sincerely,
      Dr. Norm Huefner

  22. Thank you very much Dr. Huefner!

  23. Now I am torn between fixed bridge- adjacent teeth are healthy vs. Maryland bridge which wasn’t the prettiest result in the past! Very torn. Getting conflicting advice

    • Difficult decision, I know. Most likely the fixed bridge will be more stable, last longer and at least give you teeth that all will match the best. Downside is the dentist has to prepare the adjacent teeth for crowns. Hopefully he would make it in EMax porcelain. The bonded bridge preserves the adjacent teeth and only requires minimal preparation on the back side of the teeth. It should cost less but because of the marked reduction in surface area to bond onto the back side, it will most likely not last as long as the fixed bridge. Again, we are now using EMax porcelain for these, and the esthetics of them should look way better. I would in no way recommend a Maryland Bridge that has a metal support, they are really lacking in esthetics and do not bond nearly as well to the adjacent teeth. My suggestion is to find a dentist who you really trust and ask him/her how they would treat your problem if you were their sister. Also, to see photos of patients with both procedures. Truth is, many dentists have little experience in bonded lingually retained bridges. Good luck Sarah. Dr. Huefner

  24. Hello Dr. Huefner,
    Do you recommend a cosmetic dentist/ortho/oral surgeon in south and or central Florida. My grandchild will possibly need orthognathic surgery with ortho/ then followed by an implant. Because of a congenital missing front tooth at birth caused his jaw to be misaligned. Braces have been placed for 5 years however adequate spacing was not achieved. Getting ready for college, my grandchild does not want a removable flipper on a retainer however we are not sure if this is the best option due to lack of confirmation of vertical facial growth for surgery then implant.

    • I would refer you to Dr. Jill Morris or Dr. Burr Bakke in Sarasota, FL.
      They are both longtime colleagues of mine from both the American Academy of Cosmetic Dentistry and the Las Vegas Institute for Advanced Dental Studies. Their website is: http://www.sarasotadentist.com/
      I’m sure that they can get your grandchild on the right track and if they would not do the treatment themselves, can make sure he is referred to appropriate doctors.
      Good luck,
      Dr. Norman Huefner

  25. Debra Beyer says:

    Hello! I’m so happy to find you and the information you’re providing. I’m in glendale, CA, so not too far from Laguna Niguel. My 8-year-old daughter has been seeing an orthodontist up here at a Dental Group and I really want to get a 2nd opinion about her missing laterals. Both are definitely not there and she’s already lost her 2 teeth next to them on either side and the permanent ones are coming in. She has a space between her 2 front teeth and PLENTY of space between her front teeth and the 2 coming in, which i think are her canines, right? She’s an adorable girl and I’m just not sure if our orthodontist is taking the right approach! He says we might start braces in a year or so, whenever her permanent teeth are all in (she’s lost 12 of her baby teeth already), and he said we would leave a space where the laterals should be then when she’s an adult, do implants. And that maybe we could put temporary teeth in the braces? I’m not getting really clear answers, but she’s already had 2 of the xrays that go around the entire head and I don’t want to over-xray her, either! Thanks for your help…

    • Hello Debra,
      It sounds like your orthodontist is on the right tract. No need to go into braces too early if not necessary. The fact that he is wanting to retain the spaces for future implants or bridges is consistent with my recommendations. Yes, he can put false teeth (plastic pontics) onto the braces. When the braces are off he will no doubt put two onto her retainer as well. Then you can decide whether or not to do bonded bridges or wait until after all her vertical growth has finished (in her 20s) and have dental implants.
      Good luck,
      Dr. Norman Huefner

  26. Ryan Morgan says:

    Hi Dr. Norman Huefner,

    I am 37 and did not grow in my adult laterals. When I was around 17 I was fitted with Maryland bridges. I have always been very active and have knocked out many bridges over the years. In my mid twenties I had my Maryland Bridges replaced with the more modern bonded bridges that are white in color.
    Recently I knocked out one of my bonded bridges which lasted much longer than any of my Maryland bridges. When this bridge came out my dentist said that he could not remove any more material on the back side of my teeth to accommodate a new bridge. He said that my only option was to go the crown bridge route. I was very hesitant since my adjacent teeth were in great shape and I did not want to cut them down. I ended up going with the crown bridge and it looks great. However I am now very concerned that I will bread this one out and damage my newly shaved down teeth. And concerned about what I will do if either of the crowns fail since I am only 37.
    My other bridge has now come loose and I face the same issue. I wanted to ask you whether you agree with my dentist that the crown is the best option for me. After I had the first crown bridge done I just felt awful for weeks after knowing that I had perfectly good teeth shaved down. I also believe that I have the same issue of limited available bone in the lateral area for implants since I was born without the laterals.
    I am very interested in your opinion of my situation and any alternative solutions to shaving down my teeth.
    Best Regards,
    Ryan

    • Hi Ryan,
      First, “true” Maryland bridges (ones with metal wings) have been a huge disappointment to dentistry. As dentists we strive to always try more conservative options, like the Maryland bridges, when appropriate. The fact that your dentist at least “tried” to treat you with Maryland bridge was admirable on his/her part. But, a very active person, one who “clenches” or “grinds” their teeth will have a greater toll and higher failure rate for any type of bonded lingual bridge. With regard to your new bridge, I’m assuming it is a full-coverage (completely covers both abutment teeth) porcelain-fused-to-metal bridge. That would enable the back side of the bridge to be thin and strong, whereas more room is needed for bonded winged bridges. By the way, we have now switched materials for our bonded lingually retained bridges. My blog shows a lingual bonded bridge with the wings of fiber reinforced material. Our material of choice most recently is EMax porcelain, which is strong, looks great, is non-metal, can be bonded to the teeth…..we are very excited about this material. It looks very promising! I will post photos of this new type of conservative winged bridge soon.
      Getting back to the subject of your dentist recommending another conventional bridge on the other side, that may be the best choice for you since you’ve experienced so many failures with Maryland bridges.
      With regards to not having enough bone for implants, there are two issues here. If the space between the two adjacent roots is too small for an implant, then your choice is still a bridge. I might suggest your dentist look into utilizing EMax porcelain for your new bridge. BUT, if the problem is that the thickness of the bone is too thin, you may be in luck! Nowadays periodontists and oral surgeons are able to thicken the bone with some new bone augmentation procedures, and if that can be done for you an implant may be possible. Thus, I would suggest you consult with a periodontist/implantologist or oral surgeon who does many implants and get a second opinion.
      Good luck Ryan,
      Dr. Norm Huefner

  27. Debra Beyer says:

    Hello again, Thanks for your thorough reply! I emailed a few days ago about my 8-year-old daughter with both missing laterals. we saw an ortho up here in Glendale recently who said the missing laterals isn’t even the main problem, it’s her short frenum (I believe it’s called) causing a mild tongue-tied issue, and that she’s doing tongue thrust to enunciate correctly and her front teeth, which are quite spaced, too, are jutting outward. She suggested a frenectomy and then working on the tongue-thrust, etc. My daughter enunciates very well, actually, and the doctor said she’s very auditory and found ways to compensate for this tongue-tied-ness but it is only going to make her teeth worse. Besides the missing laterals and the above-mentioned issues, she has a v-shaped upper palate and a square lower…ugh! not sure what to do…and does your office take United Concordia dental insurance?!!

    • Hi Debra,
      We do laser frenectomies in our dental practice, which is much more accurate and heals faster than those done with a bladed instrument that most oral surgeons use. I would be happy to do your daughter’s frenectomy if you would like that. Regarding fees and dental insurance, please call our office M-Th and speak with Pam. She can better answer those questions for you.
      Sincerely,
      Dr. Norm Huefner

  28. Hi y name is Korina. I’m 13 years old and i lost my upper Left and Right Lateral Incisors before the summer ended and they have not grown back yet. Also my Upper right First Molar has another tooth growing over it and the new tooth has both its pointed bottoms sticking out of each side of the tooth and I am not able to get it out. What do I do? Thanks.

    • Hi Korina, it should be obvious that you need to see a dentist, have x-rays taken, and find out what is going on. I’m unable to answer your questions and direct you without adequate information. You need to find out if there are lateral incisors present or not? If so, are they impacted. You might end up needing an orthodontist to correct the problem. If they are not there, then you might ultimately need a “flipper” with two teeth, two bridges or implants to solve your “missing lateral incisor” problem.
      Regarding your first molar, are you referring to your permanent molar (often called six year molar) or your primary (deciduous, baby tooth) molar, which should have permanent bicuspid under it and coming in around this time? If you haven’t gone to a dentist in a few years, then you are way behind and need to see one anyway. Good luck. Sincerely, Dr. Norm Huefner

  29. Hi,
    I’m 33 years old and missing my lateral incisors, at 13 had my two my molars taken out
    so now the bottom are spread out and with the molars on both side leaves a gap and bottom front teeth moving to the gaps.
    Please any suggestion on what to do, as this is really making be very self conscious and really feel bad about my smile and teeth.
    Thankx

    • If you’re missing teeth then you would most likely need to have either braces, bridges or implants, or possibly a combination of those treatments. Luna, you don’t give me enough information to give me a more detailed opinion as to your treatment options. I would need to see you personally or else see photos and models of your teeth. If you’re in Southern California I invite you to schedule an appointment with me for a cosmetic consultation. If you are not in our part of the country, suggest getting at least two opinions, seeing both an orthodontist and cosmetic dentist. Good luck Luna, Dr. Norm Huefner

  30. I am in a similar situation where traditional implants are not an option as there is not enough space between the teeth. I’ve had a Maryland bridge that has held strong for 17 years (I’m now 32) and still is aesthetically very pleasing, however x-rays have showed it’s started to decay under one wing.

    My dentist has suggested mini implants which are comparable in price to a traditional fixed bridge. I am leaning towards them as I do not want to damage any other teeth if it’s not necessary, but I have read very negative things online in relation to mini implants in the upper jaw.

    Has anyone had success with mini implants?

  31. I have been struggling with the same problem for years. My right lateral incisor never grew up but my canine moved half way over towards my front 2 teeth. I am not sure what to do, I am so insecure because I have a gap in my front 2 teeth and now my canine has moved over into the middle of where my lateral incisor should be and part where my canine should be, so a total of 3 spaces on my right side. It is so embarrising. What should I do?

    • Hello Sarah,
      Sorry to hear you are having this problem with your teeth. Unfortunately I can’t give you accurate information regarding what type of treatment would serve you best without seeing at least photos and models of your teeth, and sometimes even x-rays. My guess base on the limited information you have provided me with is that braces and/or cosmetic dentistry with veneers or bridges would be the two areas that you should looking into. Start with a consultation with an orthodontist and then one with a SKILLED AND EXPERIENCED cosmetic dentist. The reason I say SKILLED AND EXPERIENCED is that almost every dentist advertises that they are either a “cosmetic dentist” or offer cosmetic dentistry. There is a huge difference in skill level between a general dentist who occasionally does some cosmetic dentistry or a few veneers a year and someone who has years of training and experience in cosmetic dentistry and that is the main focus of their dental practice. If you are in Southern California I would be happy to see you for a cosmetic dentistry consultation. Good luck, Dr. Norm Huefner

  32. Hello,
    Just wondering if Mini-Implants would be a viable cosmetic alternative. Also, do they require the same prep, ie. bone grafting that conventional implants do? Any info is appreciated.
    Thanks!

    • Mini implants, because they are smaller than conventional implants, require less bone, so they can be used in places where bone is minimal. However, by no means do all or most implants, mini or otherwise, need bone grafting. That being said, larger and/or longer implants are usually more stable and can be restored better with custom tooth colored zirconia abutments, which are more esthetic for missing teeth in the front of the mouth. Bone grafts are usually used for three different reasons: to give the implant more support or to be utilized if there isn’t enough bone for the implants and thirdly, to give better esthetics if the implant without bone graft would appear too long and the gum side. The most important advice I can give you is not to choose the specifics of the treatment (i.e. mini or conventional size implants) and then find a dentist who will utilize that. Better is to find a cosmetic dentist and implantologist who are experts in their field and will work together to choose the type of implant and bone surgery if necessary, insuring that you will get the most stable and long lasting implant, and one that will look “real” and natural to match your adjacent teeth.
      Sincerely,
      Dr. Norm Huefner

  33. Stephanie says:

    Hello Dr. Huefner,

    I have a long family history of missing lateral incisors. Now sadly, it appears 3 of my 4 children have inherited this problem. I had the treatment you described above, braces followed by implants. The result is good but I was very self-conscious in my teen years and hate to think of my kids getting all the same teasing about being a “vampire” etc.

    My 11 year old son has not lost his baby canines and has his adult canines tracking in to take the place of his baby lateral incisors which have fallen out. An OPG x-ray revealed my 9 year old daughter has the same problem but her adult canines are still positioned above her baby canines and she still has her baby lateral incisors. An orthodontist has suggested we pull her baby canines so that the adult canines track down into the proper space- meaning less work to do moving the canines to the rear with braces. Is this a sensible idea? Would it work? I am concerned that if no adult teeth come down into that lateral incisor spot, then the bone won’t be dense enough for implants in the future. It is very hard because I have to make this huge decision now, before the adult canines turn and take the path of least resistance like my sons did.

    Any advice would be helpful.

    Sincerely,

    Stephanie (a very desperate mother)

    • Your orthodontist’s solution is probably a good one. However, make sure that it is followed and x-rays taken at least quarterly to see the progress. What causes eruption of the tooth into the mouth is the growth of the root. If the root is fully grown to its full length, then expect no movement of the tooth after that unless your orthodontist attaches a braces or wire onto it to move it down and into the desired space.
      You still may need some bone augmentation prior to implant. A tooth helps build up the bone. No tooth, definitely less bone. In the lateral incisor are you not only need thickness of bone with width of a space to put an implant into. You need to work closely with both the orthodontist and implantologist, and they should be communicating throughout orthodontic treatment. I’d be happy to have you consult with me if you want another opinion. I know your frustration, you want the best for your children. You’re doing the right thing, early planning and proactive treatment rather than after the fact attempts at correction.
      Sincerely, Dr. Norm Huefner, Orange County Cosmetic Dentist, http://www.drhuefner.com

  34. Hello Dr. Huefner,

    I have the same problem as above, braces as a teen moved the teeth enough to allow implants later. I had two “fake” teeth attached to a retainer for years. I am now 31 years old and implants are not an option (not enough space for the post to fit between the roots of the adjacent teeth) The dentist suggested putting braces back on and shifting the roots but at this point in my life, braces are not something I want to do. I am now working with my dentist to get a bridge. However, a bonded bridge was never suggested, never even heard of it until I read your article. I am really nervous about a traditional bridge, my teeth are very healthy and filing down my front teeth is very worrisome. I was so relieved to read your article, to finally see someone with the identical issue as me and have a successful result is amazing. My only concern is the strength, can you bite an apple or eat a burger without worrying about cracking? Daily flossing with a threader and good brushing would be enough to keep clean and healthy? Do they last as long as a traditional bridge (which I am told is 10-12 years)
    Thank you doctor, sorry for all the questions, I have been searching for years for a solution that would work for me and I hope this will bring me closer…..Amy (Ontario, Canada)

    • What you get with the bonded non-metal lingual bridge is maximum esthetics with minimal tooth preparation, thus very conservative type of treatment. Although we do not have long term studies using these all-porcelain lingually retained bonded bridges I believe that for strength and longevity that a traditional bridge with full coverage of the adjacent teeth will be stronger and last longer. Neither one is right or better, each having its own advantages and disadvantages. And for you, not having a dentist who has been trained and has experience doing these new types of conservative bridges may produce a less successful treatment result for you. The safe bet for you is probably a full coverage bridge, but ask your dentist if he/she will utilize EMax all-porcelain non-metal bridge rather than the old fashioned porcelain-fused-to-metal. This is a good choice for missing maxillary lateral incisors, requires minimal tooth preparation and by virtue of having no metal substructure has great esthetics. And, this is actually the material we are currently using for our lingually retained bonded bridges.
      Sincerely, Dr. Norm Huefner, Orange County Cosmetic Dentist, http://www.drhuefner.com

  35. I’ve read through your blog and it is clear you are very knowledgeable. I got two implants for congentially missing lateral incisors. The crowns no longer look good and my upper front two teeth have shifted slightly to the left from the axis. I would like to replace the crowns to update them to look more natural but my orthodontist told me that the posts are old and that the crowns for them are no longer being made. Secondly, the bone density has decreased over the last several years (I’m 31 and got the implants in my early twenties). Originally I had to have graphs to grow the bone. So, a replacement of the implant posts is not possible. What do you recommend in my case to improve the appearance of my posts? Thank you.

    • Hello Susan,
      First, I’m a little confused. If the implant is still good, then oftentimes all that is necessary is removing the old crowns on the implants and replacing them with new crowns. This is done all the time.
      If the abutments (more appropriate term than post) need to be redone, but the implant itself is of the older type then oftentimes the old abutment can be removed and a new abutment placed into it. You would need to speak with an actual implant specialist who is familiar with many of the older types of implants.
      However, it sounds to me that you’re implying that the bone has receded and the implant itself won’t do the job even if new abutments and crowns can be made. In this case you might consider having an implant specialist remove the old implant, “regrow” the bone and place new implants. Susan, I can’t even begin to tell you how many amazing improvements in implant and bone regeneration techniques have developed over the past few years. It’s a completely different world. New bone building techniques…incredible. New implants…changing the whole world of dentistry. New abutments…now tooth colored instead of metal, allowing all ceramic restorations instead of porcelain fused to metal crowns.
      You’re a young lady and it sounds like your appearance is important to you. I suggest you find a really good implantologist and cosmetic dentist who can work as a team to give you the incredible smile you deserve. Today just because you were born missing your lateral incisors you don’t have to settle.
      However, saying all of that, if you’re not willing to go through the new procedures you could just have the implants removed and 3-unit porcelain bridges made instead.
      If you’re in the Southern California area I would be happy to offer you a consult and discuss your options.
      Please check back with my blog, as I will be posting two incredible cases I recently completed where the patients were missing front teeth and we restored their smile to the level that you would never guess that they were missing front teeth or had dental implants.
      Sincerely, Dr. Norm Huefner

  36. I am missing both of my laterial incisors. My dentist said that an option would be braces in form or train tracks, my only worry is that for the duration I have braces I will end up with 2 even bigger gaps while they are trying to widen them for implants. Is there any other options?

    • Your orthodontist can put two false teeth on the braces when the spaces are wide enough. This is commonly done by most orthodontists, just tell him that you want him to do it.
      And make sure that the orthodontist takes x-rays periodically, at least every six months, to make sure that he moves the roots wide enough to accommodate an implant. If the roots aren’t separated enough then implants may not be possible, so the orthodontist must accomplish that.

  37. Hello,
    First I’d like to say that I wish I would have seen this blog a year ago! My 10 year old daughter is also missing both of her lateral incisors. After MUCH debate and research one year ago we decided to go with her orthodontist’s advice and pull the 3 teeth on each side of her front teeth. The plan is to let the adult teeth come in as “forward” as they can then move the canines into place next to the front teeth substituting them for the lateral incisors then file them down to look like lateral incisors.

    I have never been fully comfortable with this but it sounded right to keep her own teeth and not mess with implants which she could possibly not be a candidate for.

    So, last week we went to our new dentist who I like very much. She saw my daughter and asked me what our plans were. She then told me “Don’t do that” then proceeded to show me her teeth. She said that is a “very old fashioned” way to go. She said she has problems with TMJ and now has to have crowns on all of her molars b/c of her bite being “off” and the abnormal wear on her teeth. She showed me her molars and the bases were brown.

    By the way, at the time of the discussion I am in the dental chair having my teeth cleaned. On the other side of me the hygenist (who does not normally work with this Dr.) said “I had the same problem.” She said she just recently got implants and wouldn’t have gone any other way. The dentist then said…”yes, go that way, not this way.”

    My daughter of couse is afraid of the implant proceedure. I’m sure by the time she’s 22 she’ll be ok. I am very very happy to hear about the non metal bridges. I did ask our orthodontist about bridges and he said that was not the way to go that her own teeth in those spots were better.

    I feel HORRIBLE that we pulled all of those teeth when there was a better option that didn’t include implants and that seems to be a decent solution. I also feel HORRIBLE that we didn’t seek more of an opinion at the time besides our dentist (at the time) and the orthodontist. From all the reading we did it seemed like most orthodontist recommeded moving the canines foreward and most oral surgeons recommeded implants.

    What do you think about the canine substitutes for laterals? Have we caused her to have more work b/c of removing all those teeth and now the adult teeth are coming down so that they absorb that space? By the way, only one of those adult teeth is just now starting to break the gum.

    We live in the Omaha, NE area if you have any recommedations.

    Thank you for all of the information!!!!

    • Kim,
      It would really be difficult to give appropriate recommendations without seeing your daughter and current x-rays. However, here are some general recommendations. First, I would almost always prefer that the orthodontist NOT move the canines into the position normally occupied by the lateral incisors, especially for a female. There are many reasons why I support this position, but esthetically it almost never looks good without later having porcelain veneers and as many as eight porcelain veneers might be needed to create a normal proportion of teeth that shows when she smiles. The problem here is that the lateral incisor is the smallest of all upper teeth and the canine is the largest rooted single-root tooth. Also, the gums on the canine are almost always much higher than on the lateral incisor. So although you can veneer the teeth to look normal, the canine may look very much longer at the gumline than would a normal lateral incisor. This is another reason why a bride or implant will look more normal. Second, today implants done by a good implantologist and cosmetic dentist can look fantastic and most likely a superior approach to a bonded bridge provided that the patient has stopped all facial growth. I would never recommend implants in anyone under the age of 20. Most of the bonded bridges I place are in teenagers. Third, if in doubt, get more consultations. Also, you will oftentimes get very different opinions from orthodontists than oral surgeons, implantologists, general dentists and cosmetic dentists. Choose a team of dentists that will work TOGETHER, that is your checks and balances. Make sure that the team is all on the same page. Fourth, unfortunately I don’t know anyone in your area.
      I wish you and your daughter well.
      Sincerely, Dr. Norm Huefner

  38. Hi Dr. Huefner,
    I am so happy I found your website. My son was born without his lateral incisors, and after my initial consultation with an orthodonist today, I left feeling sick to my stomach. All that I learned today was incorrect and your information here has helped immensely. I feel like had I not found your information I may have made a huge mistake with regards to implants, as they assured me 18 would be old enough, The issue is my son is 5’10 at 12 years old and his father is 6’5 and did not finish growing til much later. I am planning to set up another consult with a different orthodonis,t but as far as dentist in my area that provide a conservative bonded bridge, they are far and few between. I read all of your posts and noticed you have referenced 2 doctors in Sarasota Fl. I live 3 hours north from there and if I have to I will travel, but if you know of anyone near or north of Tampa it would be greatly appreciated. You really made me feel more at ease with the decision process in my sons case. I now can make a educated decision in his care.

    • Hi Denine,
      As orthodontists very well know, males can grow facially up to age 25. This is an indisputable fact, as many males with class III occlusions get worse between the ages of 18 and 25. Females stop growing much sooner. But the only way an orthodontist can tell with any certainty is not by the age, but by taking two facial radiographs (x-rays) 12 months apart, measuring the bone, and if there has been no vertical change it is probably OK to go through the implants. By age 25 there is little chance that either males or females are still growing.
      As far as referrals, I refer you to Drs. Bakke and Morris in Sarasota. Dr. Bakke is an excellent implantologist, so his opinion is well worth taking into consideration.
      Bonded bridges are a great solution, especially with younger people. However for adults who have stopped all vertical facial growth and there is sufficient room and bone, a properly done implant may be the best choice. Many times a bone augmentation procedure is necessary to place an implant into an area of a congenitally missing tooth. This is not a big deal nowadays and helps produce very predictable and esthetic results.
      Good luck Denine,
      Dr. Norm Huefner, Laguna Niguel, CA

  39. hi doc =) i lost both my central incisor when i was young & now i wearing a denture. a month ago i decided to have braces. now my dentist told me to move my lateral incisors to replace my central incisors & my canine to the lateral incisors so that i will not have a denture or bridges in the future . honestly im having a second thought about it. i heard that there are some risks moving your canine to your lateral space. is there any alternative like conservative bonded bridge or fix bridge so that i will not use my denture while im having my braces so my teeth will move freely. i hope you can help me. thank you so much ^_^

    • Sounds like your choices are bridges or implants or doing what your dentist recommends (i.e. moving the lateral incisors and canines towards the center). How old are you? If the space is large bodily moving those teeth to completely close the space may take a number of years or completely impossible (i.e. leaving some spaces still). Also, your orthodontist should inform you of possible complications, like root shortening, which can happen when orthodontically moving teeth large distances.
      My suggestion, get a number of opinions from cosmetic dentists and orthodontists and implant dentists before making your “final decision” on the treatment. The two front teeth and cosmetically the most important of all your teeth, and each of the aforementioned treatments would yield very different results.
      Good luck,
      Dr. Norm Huefner

  40. Hello Dr. Huefner,

    Id first like to say I am shocked to see that congenitally missing lateral incisors is so common! Im 26 years old and had braces followed by a clear plastic retainer with teeth glued to the inside which Im still currently wearing (10+ years now). I am desperate for a more permanent solution. Unfortunately, I do not have enough bone on the top of teeth 7 and 10 so they want to start with a bone graft and tissue regeneration. I am a little waery of the procedure seeing as I am uninsured and am having to finance the surgery. Also, what are the possible dangers of bone grafting? I saw your blog and had asked if a Marilyn Bridge would be an option for me, he said that is not a permanent option and would not recommend it. I am not sold on doing a traditional bridge as my teeth surrounding 7 &10 are perfectly healthy. The quote from my dentist was upwards of $7,000. My question would be is there a more permanent solution other than implants that would be closer to the $5,000 range? Also, do you recommend any dentists in the Vestal, NY area that I could possibly go for a second opinion. Im completely torn on what would be the best option for me (most permanent and cost efficient) at this point.

    • Hi Lauren,
      In practicing dentistry for over three decades I would say that roughly 5% of my patients are congenitally missing one or more permanent teeth. Most common is the lateral incisors, second is the lower second bicuspids and third are wisdom teeth. If one is congenitally missing a lateral incisor it is common that there won’t be enough bone for the implant and a bone augmentation procedure would be necessary to have a successful implant placed. There is very little danger of bone grafting. Implants are the most permanent solution. Regarding cost, there are no consistent fees regarding implants. Fees will depend on the amount of treatment with the bone augmentation procedure, the cost of the implant and of placing the implant, the type and cost of abutment placed into the dental implant, and the type and cost of the crown that will ultimately be placed on top of the abutment. If you want the most permanent and best outcome I highly suggest you wait until you can afford the best dental treatment for your implants and not shop for the “lowest” implant dentist. Implant “clinics” that offer “bargain” low cost implants are popping up all over the country. I recently had a patient who went to one of those and had seven implants. Two were OK, two fell out, two are unrestorable with crowns and will need to be redone and one had an very badly fitting crown placed on it. Instead of looking for “best” in her area, the patient shopped for “the cheapest” and it certainly backfired.
      I’m sorry, I don’t know anyone in your area that I could refer you to. I suggest you find a great cosmetic dentist for the crown and go to the oral surgeon or periodontist (both specialists) that he/she refer you too for your implant. This is a “team approach” and often yields very good results.
      Good luck Lauren,
      Dr. Norman Huefner

  41. My thirteen year old son is missing both lateral incisors. He is getting braces in August. His permanent canines came in in the lateral incisor position. His orthodontist recommends pulling them back and making room for implants but says that canine substitution is also an option. Functionally and aesthetically she says his bite will be fine but that implants will be more aesthetically pleasing than trying to shape his canines. She also says veneers will not be as functional as implants and will require more maintenance. I have done some research and I am not sure if that is a universally accepted opinion. I also have several concerns about moving his canines to make room for implants. First, I have read that by the time he is ready for implants the roots of his other teeth could get in the way or other problems could arise making implants not a good option. Second, I have read that if implants are out in so young (early 20′s) that as his face matures and teeth and jaw naturally shift as he ages, it could look unnatural. I am interested in your thoughts any any possible recommendations in the Chicago area for cosmetic dentists or implantologists that you would recommend that I could consult about this decision and the possibility of the type of bridge you discuss on your blog as an alternative to implants if the patient doesn’t want to wait until their early 20′s (or longer) to get implants.
    Sincerely,
    Debbie (Glenview IL)

    • Sounds like you are right on track with your research and thinking Debbie! One question, are the spaces completely closed now? If some spacing, where and how much?
      If you open up the spaces it is important that the orthodontist bodily move the teeth, NOT JUST TIP THE CROWNS LEAVING THE ROOT TIPS CLOSE TOGETHER! I just restored a young patient where that happened and implants were impossible. There must be enough room for the implant, and if you read some of my other posts you realize that he may not be full grown to have implants until in his 20s when vertical facial growth has been completed. Also, if the orthodontist opens up the site for the missing lateral incisors bone grafts/augmentation procedure(s) may also be necessary. So it is not an easy decision as many things need to be taken into consideration.
      The orthodontist is right that implants will require less maintenance than veneers in the long run, however that doesn’t mean that veneers may not be the most appropriate choice for him based on his situation. If you search my blog you can see several patients that had the canines in the lateral position and that I successfully treated with porcelain veneers. In an ideal world teeth wouldn’t be missing, and implants and porcelain veneers wouldn’t be needed, but we all know that’s not the case.
      I’m sorry I can’t give you anything other than generalities, and you both living in the Chicago area would make coming to me for my opinion very difficult. Sorry, don’t know a cosmetic dentist personally that I can refer you too. You might look at the American Academy of Cosmetic Dentistry website, or the Las Vegas Institute for Advanced Dental Studies website, for referrals. Both good sources for dentist with keen interest in cosmetic dentistry.
      Good luck Debbie to you and your son.
      Sincerely,
      Dr. Norm Huefner

    • Debbie i am 14 and i have been having orthodontic work for 7 years, i am missing both of my lateral incisors and my orthodontist is going to move my canine 3 teeth into where the lateral incisor teeth should be and after he will fill all the gaps with braces and then shave the canine 3 teeth into what my lateral incisor teeth should look like. He said that it will be easier later in life and will cut the pain out of fake teeth and other implants.

      • It may be “easier”, but by no means will that look the very best, especially since you are a female. Your lateral incisors are the smallest and shortest of all your upper teeth, and your orthodontist is going “try” to move the canines, which are the longest (and considerably wider than the lateral incisors) of your upper teeth. Implants or bridges today can look very natural. I have had many patients who have had the canines moved into the lateral position and they have come to me to do eight porcelain veneers to try to “get the look and proportion” right. Also, because your canines are the longest teeth it will be a more difficult orthodontic movement to move them next to the central incisors without overly tipping them. And, if you weren’t crowded to begin with, sometimes that dishes in the profile of a full smile. I suggest you get a couple opinions from cosmetic dentist and implantologist, and have their input. Sometimes “easiest” is not best.
        Good luck Clare.
        Dr. Norm Huefner

  42. I was just wondering about my 8 year old son. He lost his baby right lateral incisor almost 9 months ago. The left one grew in about a year ago. I never really thought anything about it until today when my ex and I were talking about our 12 1/2 year old son who is in the process of getting braces and has to have 4 teeth removed as his teeth are crowded. My ex told me today that he never got one of his adult lateral incisors and because the dentist waited so long to deal with it, my ex’s canine tooth moved in it’s place and a bridge was put in the empty space. Anyway while reading all of these stories, it appears that even though my ex is 44 years old now, this still might be the way that my son has to go. I am a little premature as I just found this out tonight and tomorrow will contact my son’s pediatric dentist to see if they can see by his x-rays if he has that right lateral incisor and it just hasn’t come down yet or if it is missing due to this being hereditary. Then I will follow the next steps. However, my question is that my ex feels that if he could do it all over again, he wouldn’t have let that canine tooth move into place of the missing tooth, but he would have the bridge put in that spot. I know that you are just going on what you are reading here, but just wondering what your thoughts are? In the end, I think that my 8 year old will need braces at some point, as his bottom front teeth are not curved(oval), they are more like they should be, it is almost as if he has four front teeth that are all straight across and then the rest of the teeth go back, almost in a square like style.
    Just wondering if you could offer you opinion to me.
    Thanks so much for your time.

    • First, have your pediatric dentist check the x-rays. Most likely the lateral is slow to erupt and that is why he never mentioned that your son was missing a tooth. If the lateral incisor is not there, then the dentist was not doing his job, reading the x-ray and informing you of the problem. That is his responsibility, not wait for you to ask if a tooth is missing.
      Regarding moving the canine into the lateral position, and then doing a bridge to fill the gap between the canine and bicuspid…..NO, NO, NO. Go back and read my posts, I touch on this a lot. Yes, your son will be able to eat and chew, but his smile will never look as good as it could. Easy orthodontic treatment is not always the best. If the lateral is missing, then would suggest a “flipper” or bonded bridge until he is older, and then an implant is ideal. However the orthodontist has to make sure there is enough room for the implant, and it probably can’t be done until he is 21 years old when the dentists are sure that all his vertical facial growth has been completed. I’m in agreement with your ex if you choose not to do an implant or bonded bridge. Again strongly, I do not recommend the orthodontist move the canine into the lateral incisor position and then make a bridge to fill the newly created space! The is my general position for most instances, although there are certain situations where that might be acceptable or the only way to go. Another word of advice, if you are getting different opinions, then get several different consultations. You will be amazed that many dentists will not agree on your son’s treatment. Preferably, seek out a highly skilled cosmetic dentist who will oversee the choices of treatment done by the orthodontist and any other dentists that your son might need (implantologist or restorative dentist).
      Good luck, and let me know if the lateral incisor is missing or if the pediatric dentist missed it on the x-ray or just chose not to tell you. It is probably there, but if the lateral is missing why didn’t the dentist tell you? This would greatly concern me. After all, the purpose of x-rays is not just to look for cavities. We look for development of the dentition (teeth below the gums that will/should eventually erupt), infections, tumors, aberrations in the jaws, etc.
      Sincerely,
      Dr. Norm Huefner

  43. Hi Dr. Huefner,

    My Daughter who is 12 has her upper lateral incisers missing. Her NHS (free) ortho dentist will not open the gaps for future implants or bridge because he said that he would have to remove two healthy teeth to achieve this. I took my daughter to a private dentist for a second opinion who said that he had never heard that before and that he could not see any reason why the gap could not be opened ready for whatever we decide on when my daughter has finished growing. Im confused could you please give me any advice on this.

    Thank you

    • Donna, without seeing your daughter or models or dental photos I don’t have enough information to comment. I do suggest that you get a couple more opinions. IF (and that’s a big “if”) the orthodontist would have to extract two bicuspids to open the spaces for the two lateral incisors (assuming that the canines have already moved into the spaces and closed the off), I wouldn’t recommend the trade off, two extractions to enable two implants to be placed later on.
      Your daughter will need 6.0mm-7.0mm of space per lateral incisor for enough space to place an implant.
      However if the orthodontist can expand her arches and open the spaces that much, that only gets you part way there. In addition to waiting for adulthood to do her implants, many if not most areas where the lateral incisors are congenitally missing will also require some bone grafting. That is no big thing, just something that the implantologist will need to go over with you first.
      Good luck, Dr. Norm Huefner

  44. Hello!

    Yes I have a missing lateral incisor on my top right. It was knocked out when I was younger and i never bothered to get it fixed because it didn’t matter to me when I was younger, now that I’m 25, I’m self conscience about it. It has caused my teeth in front to shift, the gap that was there isn’t fully closed but closed a little. After finding this forum I wanted to ask is it possible to fix? And what would my options be if there was even any?

    Thanks in advance

    • Depending on the size of the space remaining you have a few options Larry. A normal maxillary (upper) lateral incisor has a width of 6.5mm. If the space has closed much an implant is probably out of the question unless you would want to have orthodontics to open back the space. If the space has closed to 5.0mm a porcelain bridge is an option. If closed more than that you might consider porcelain veneering. Check my blog for examples of all of these, especially doing porcelain veneers when there are only five of the upper front six teeth present.
      Larry, if you are in Southern California I would be happy to offer you a complimentary cosmetic dentistry evaluation and consultation.
      Sincerely, Dr. Norm Huefner

  45. Dr. Huefner,

    Thanks sooo much for all this information! I really appreciate the time you put into helping people. My 14 year old sons is missing both canines on top and another tooth on the bottom. He’s had ortho work done over the past several years and now we’re ready to move into final braces. We’ve seen 5 orthodontist and every one had given us different advice. We are leaning toward moving his teeth together to close the spaces and reshaping the teeth. I understand it won’t look perfect, but it will certainly be better than what he has now. Our main concern with making spaces and using implants or bridges is saddling him with the cost of having to replace them periodically for the rest of his life. Can you give me estimates about how often bridges and implants have to be replaced?

    Regards,
    Erin

    • Esthetically doing implants or bridges will look much more “normal” than just closing the spaces and trying to reshape the teeth. If space closure is what you have done for your son then porcelain veneers would be the best way to try to make the teeth look normal. I have had to do that for several patients who weren’t happy with the appearance of space closure. Examples are posted here on this blog.
      Saying all that, if space can be made for implants, it is my opinion that implants would be the ultimate choice if you want the longest lasting restorations. Porcelain bridges and bonded winged bridges are other alternatives, the former probably lasting longer than the latter, but the latter being the most conservative of all treatments.
      As to “how often bridges or implants would need to be replaced”, it would be impossible to predict the future. If he gets the bridges or implants at age 20 or so, and lives to be 80-90, we would be talking about 60-70 years, right? At least one replacement on the implant crowns or a couple on the bridges minimum would be my estimate.
      Hope this helps Erin,
      Dr. Norm Huefner

      • Thank you so much for your information. I thought implants and bridges had to be replaced more often – every 15 years or so – but we haven’t found a cosmetic dentist who wants to discuss much without an orthodontist’s instructions. (The 2 we’ve had consults have just told us that they’ll do whatever the orthodontist says.)

        A couple more questions…
        If we close space and go with veneers, how long do they typically last? Would they create problems as he grows?
        If we do bridges, we don’t have to wait until he’s grown, right? They could be done as soon as the space was created?
        What is your opinion on closing space on bottom and opening spaces on top?

        We really want to do what is best for our son long-term, but when we get so many different opinions it is hard to decide!

        Again, thank you for your time,
        Erin

        • I suggest you find an experienced cosmetic dentist who will lead, or work as a team with the orthodontist.
          There is no average as to the longevity of any dental restoration, crowns, bridges or veneers. Properly done veneers might last 15-20 years. I had one patient who I treated back in the late 80s when porcelain veneers came out who still had them after 19 years. She chose to replace them because she wanted a whiter, more youthful color.
          No, veneers should no create any problem whatsoever as he grows!
          Yes, bridges could be done soon. If you choose implants, it is imperative that you wait for all facial growth to cease, at least age twenty.
          In general, when there is a lot of spacing you may be faced with orthodontic relapse, the spaces opening back up after the braces have close them up. I couldn’t comment on the lower teeth without seeing the situation.
          If you see five different dentists/orthodontists, you will no doubt get at least three different opinions. And more confusing than that, even if two agree on one course of treatment it doesn’t mean that treatment will yield the best results.
          Good luck Erin,
          Dr. Norm Huefner

  46. Hi there, I’m trying to make the decision for my 10 year old daughter’s ortho treatment. She is missing her lateral incisors and has plenty of space. My ortho wants to pull all the maxillary teeth forward and reshape her canines. My boss (an Oralmaxillofacial Surgeon) disagrees and says we should allow her canines to come in naturally, using braces to pull them to their normal position and maintain spaces for implants after growth has ceased. Ive tried to research this myself but end up very confused as to which treatment is best. I would appreciate your opinion, understanding that without films etc its not easy for you to form an opinion.

    Thanks so much!

    Cheryl white R.N.

    • Based on the information you provided I agree strongly with “your boss” the oral and maxillofacial surgeon, don’t close the spaces and reshape the teeth. However, your orthodontist has the advantage of actually examining your daughter, which I haven’t done. Since this treatment varies so much among orthodontists and other dentists (cosmetic dentists, oral surgeons, etc) I suggest that you get a couple other opinions from orthodontists.
      Good luck Cheryl with your daughter.
      Sincerely,
      Dr. Norm Huefner

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