Transcript of "Transposition of teeth & its management"
INDIAN DENTAL ACADEMY
Leader in continuing dental education
OF TEETH AND
5. TRANSPOSITION VS ECTOPIC ERUPTION
6. TRANSPOSITION VS TRANSMIGRATION
7. PSEUDO TRANSPOSITION
MIGRATION / DRIFT THEORY
INTERCHANGE IN POSITION OF
9. CONTROVERSIES REGARDING ETIOLOGY OF
10. CLINICAL FEATURES
11. WHY GREATEST INCIDENCE OF
MAXILLARY CANINE TRANSPOSITION
i. CANINE – FIRST PREMOLAR
ii. CANINE – LATERAL INCISOR
iii. CANINE – FIRST MOLAR
iv. LATERAL INCISOR – CENTRAL
v. CANINE - CENTRAL INCISOR
13. CLINICAL CONSIDERATIONS
Transposition of a tooth is a relatively
rare dental anomaly of unknown origin.
It can be basically said as a
phenomenon in which two teeth
in dental arch are in exchanged
position and is a disturbance of
. Orthodontists are usually forced with a
dilemma regarding the diagnosis and
treatment of patient with transposition
with the occurrence of transposition is
approximately 1 out of 300 orthodontic
Its correction involves treatment risk and
requires a great deal of control and
carefully applied mechanics.
Transposition of teeth has been
observed and reported since the early
In 1849 Harris in his first edition
of “A Dictionary of Dental Sciences,
Biography, Bibliography and Medical
Terminology” described transposition
as an aberration in the position of
A French dentist, E.M.Miel wrote in 1817
what is perhaps the earliest scientific
report of maxillary central and first
premolar transposition. He gives a detail
description of bilateral occurrence of this
dental positional anomaly in a 16 year old
girl. He noted that her father presented
with a unilateral left maxillary central
incisor and first premolar transposition.
According to Mader and Joseph
L.Konzelman (JADA, 1979 : 98). It may
be defined as an interchange of position of
According to Sheldon Peck (AJO.
1995 : 107). Tooth transposition is the
positional interchange of two adjacent
teeth, especially their roots, or the
development or eruption of a tooth in a
position occupied normally by a
M.M.Kuftinec (AJO, 2001 : 119). They
stated it as an interchange in the position
of two adjacent permanent teeth within the
same quadrant of the dental arch.
According to Elizabeth C.Weeks (BDJ,
1996: 181). It may be defined as the
migration of a tooth from its normal
developmental position, such that the
order of the teeth is changed.
Teeth transposition can be classified in a variety of ways.
I. Given by Pertz B. and Arad A.
Int. 1992 : 23)
Complete : In complete transposition both crowns and
entire roots of the involved teeth are found in their
Incomplete : In this crowns of the involved teeth may be
transposed but the root apices still remain in their relatively
II. Given by Elizabeth C.Weeks (BDJ. 1996 : 181).
True transposition : In true transposition the
both involved teeth ex. Central incisor and
canine do occupy each others respective
This again sub divided into ;
Unilateral : Transposition taking place
on one quadrant of the respective
Bilateral : Transposition taking place
on both sides of a arch.
False Transposition: In this the involved
teeth do not occupy each others normal
For example in case of canine and central
incisors transposition, the canine has
taken the position of central incisor by
migrating mesially and central incisor and
lateral incisor which are in normal
sequence have simply migrated or been
TRANSPOSITION VS ECTOPIC
it is a broad category
referring to any abnormal or aberrant eruptive position
taken by a tooth. For example buccally placed maxillary
In Transposition the teeth exchange their places
thereby reversing their sequence in the mouth.
Thus transposition must be considered a subdivision
of ectopic eruption.
All transpositions are examples of
ectopic eruption, but few ectopic
eruptions are transpositions.
Transposition Vs Transmigration
Transposition by definition is an interchange
position of two adjacent permanent
teeth within the
same quadrant of the dental
Transmigration It is referred as displacement
teeth from one quadrant across the midline
Thus transmigration teeth should be
ectopically erupted teeth not
transposed teeth. www.indiandentalacademy.com
Pseudo Transposition :
(Peck et al AJO, 1995)
Some reported variations of
tooth sequence that mimic
transpositions yet technically do
transposition. This category is
known as pseudo transposition.
One type of pseudotransposition is in form
of hyperdontia best called supernumerary
distal maxillary premolars. Clinically it is
characterized by a premolar like extra
tooth developing or erupted between the
maxillary permanent first and second
The cause of this condition is probably
genetically related, like most types of
1) Migration / Deflection / Drift theory
This theory stated that over retained
deciduous teeth obstruct the eruption
path of permanent canine which
therefore gets deflected, it then
migrates and erupts in a transposed
The tooth most commonly
transposed is the maxillary canine,
starts its long pre eruptive migration
high above the premolars. It has
been suggested that it may change
its usual nearly straight downward
direction and migrate mesially to be
transposed with the lateral incisor
or distally to be transposed with the
2) Interchange in Position of
This theory put forward by Stafne
and Gibilsco stated interchange in
position of tooth buds during the
very early stages of tooth
development is responsible for
3) Trauma :
explanation of etiology of
transposition is that of
trauma which presumably
causes an exchange of germs
imposed by an external force
on the teeth.
4) Genetic :
Lastly genetic etiology has
been strongly supported by
“Nelson” from his study of
Santa Cruz Island, Calif, and
also supported by Peck et al.
Following factors taken together point very
strongly towards a gene based etiology for
1. Racial differences in frequency of
2. The higher frequency of associated
dental anomalies such as peg
shaped laterals and congenitally
3. Frequent bilateral occurrence
4. Involvement of same type of teeth in
bilateral cases on both sides.
strengthen considering a genetic
component in a pre eminent position
in the etiology of transposition.
REGARDING ETIOLOGY OF
1. Against Mesial Drift Theory:
Peck et al clearly assert that an
over retained deciduous canine is a
direct outcome of failure of
permanent canine to erupt below it
and not the
transposition. Over retention is
the effect rather than
cause of transposition.
This theory sounds plausible,
regarding transposition of the
canine and premolar as eruption
time of canine and premolar are
close to each other but theory fail
to explain the position of canine
with the early eruption of lateral
Normally eruption patterns of teeth are
generally constant 61245378 in upper
arch. The lateral incisor eruption
precedes the canine, by 2 to 3 years.
If the transposition of the canine with
lateral incisor is to explained through
migrating / drift theory then what
condition or situation makes the
earlier erupting lateral incisor occupy
the canines position.
At the same time mesio distal width of
lateral incisor is smaller than canine. If
canine has to force its way between
central incisor and lateral incisor, pushing
lateral incisor distally with an over retained
deciduous canine present distally, it is
bound to find very little space for precise
eruption in lateral incisor space. This
would lead to impaction or palatal eruption
of canine rather than transposition.
.Thus this provides the antithesis for the
migration and deflection theory of
2) Against inter change of tooth buds
It is important to remember that
transpositions affect the permanent
teeth but leave the deciduous teeth
normal. Since the deciduous germ and
its permanent successor are in same
bony crypt it is obvious that precise
exchange of germs of the permanent
teeth would not occur when the
deciduous teeth have not erupted.
In the phase following the eruption of
deciduous teeth, such precise exchanges
would be precluded due to obvious
3) Against the trauma:If trauma were to play a role one
would except displacement of the
dental elements rather than
precise exchanged position as in
Thus Peck et al suggested a polygenic,
transposition of teeth. However detailed
mechanism of origin of transposition is
matter for further research.
Usually both males and females are affected.
However some studies show higher male
predilection. According to study conducted at
Dharwad in 1993 showed higher male
predilection and Peck et al also cited higher
According to recent
studies done by Y.Shapira et al cited higher
Most transposition appear in maxillary
The five maxillary transposition types are
arranged in descending order according
to prevalence (AJO. 1995 : 107).
1. Canine to first premolar
2. Canine to lateral incisor
3. Canine to first molar
4. Lateral incisor to central incisor
5. Canine to lateral incisor
prevalent then bilateral ones.
- _ In mandible it is found to occur in the
site off lateral incisor to canine.
- _ Among unilateral left side is more
frequently involved then right side in ratio of
- _ The preponderance of left sided
unexplained at present.
Other dental anomalies associated with
tooth transposition are :
1) Developmentally missing or peg shaped,
upper lateral incisor.
2) Retention of deciduous teeth.
3) Malpositioned adjacent teeth.
4) Rotation of transposed teeth.
Transposition has never been reported in
In a recent study of individuals with Down
syndrome a tooth transposition prevalence
of 15% was found. (ANGLE 0 2000,70)
WHY GREATEST INCIDENCE
OF MAXILLARY CANINE
important key stone in the dental arch
both for good esthetics and normal
The maxillary canine is the most
common tooth to get transposed. In
case of canines, the preeruptive position
of the permanent maxillary canines
increases its potential for ectopic
The maxillary permanent canine has the
longest period of development and the
longest way to travel from the point of
its early formational stage, just under
the orbit to its complete eruption.
starts to calcify at about four to five
months after parturition and erupts into
the mouth at the age of approximately
Any bony obstruction, insufficient
bone development and crowding for
other reasons, or resistance of the
neighbouring teeth such as a
retained deciduous canine may
deflect the permanent canine from
its normal eruptive path. It may be
displaced mesially and become
transposed with lateral incisor or
distally to become transposed with
This is carried out before the
complete transposition have occurred.
When incipient transposition is detected
early enough interceptive modality of
orthodontic treatment can be initiated.
This is made possible by changing
eruptive path of permanent tooth by
removal of retained primary tooth.
For example in mandibular arch the
retained deciduous lateral incisor and
canines are removed and the ectopically
erupted lateral incisor are uprighted and
aligned in their normal positions in the
arch before the eruption of permanent
transposition process from continuing.
Here is another example; A case with severe
distal angulation of the lateral incisor. Uprighting
of 41, 42, 31, 32 with a sectional fixed appliance
was done, before the eruption of permanent
mandibular canine which has prevented the
transposition process from continuing.
treatment strategy, certain factors need
to be considered ;
11) Position and condition of root
Whether it is complete or
22) Dental and facial esthetics.
33) Occlusion (both static and dynamic)
4) The underlying malocclusion and
degree of crowding.
5) Clinical crown height and shape
should be evaluate in case of
reshaping the transposed teeth.
6) Patient motivation
vVarious treatment options are :
11) Alignment in the transposed
followed by recontouring
22) Extraction of the transposed tooth
teeth into the normal
transposition where the crowns are
transposed but the root apices are
in their relatively normal positions,
uprighting and rotating the involved
teeth is the procedure to place them
in their normal position, provided
enough space is available in the
In cases of complete transposition,
with root apices in their transposed
positions, repositioning the teeth to
their normal relationship in the arch is
complex and may be damaging to the
teeth and supporting structures. So
one should align them in the
transposed position and then go for
reshaping and recontouring of them
Or otherwise treatment option
include the attempt to move
transposed teeth to their normal
positions in the arch providing
alignment in the transposed
positions would be esthetically
and functionally unacceptable.
TREATMENT OPTIONS FOR
DIFFERENT TYPES OF
11) Maxillary canine to First
MMaxillary canine and first premolar
transposition appears to be the most
commonest transposition in man.
1. Retained deciduous canines.
2. The permanent canine, which is positioned
between the adjacent first and second
premolars, is usually blocked out bucally, and is
often mesiolabially rotated.
3. The transposed first premolar is nearly always
rotated mesiopalatally upto 90o ; occasionally
also blocked palatally.
4. Transitional crowding is present in
transposition area, especially when
deciduous canine been retained.
In cases of crowding or need for
overjet reduction correction of
transposition and malocclusion is
carried by extraction of the first
In non-extraction cases, transposition can
be accepted with reasonable esthetic
result by restorative camouflage
procedures. The roots of upper first
premolars are usually acceptable for
canine guidance. Partial reduction of the
palatal cups may assist in providing a
smoothly cuspally guided occlusion
Orthodontic correction of transposed
simultaneously, one buccally and
other palatally while also being
moved distally or mesially as
required. Palatal as well as buccal
archwires may be required in order to
control the tooth movements.
canine to lateral incisor
1.Retained deciduous canines.
22.Labially blocked out and often rotated canine
and lateral incisor.
33. Small lateral incisors and missing second
44.Impaction of the canine or central incisor most often on
the transposition side.
In this situation there are two
a) Ability of the lateral incisor to
function as canine.
b) The ability to disguise the canine
and lateral incisor as each other.
The upper lateral incisor is less favourable
for canine guidance since its roots is
usually thin and small in length.
If the color, shape or bulbosity of the
upper canine be infavourable for
restorative camouflage, consideration
should be given to extraction of lateral
incisor. The upper canine can then be
retracted into its correct position and the
lateral incisor can be replaced by a
cantilever adhesive bridge or an implant.
The correction may be achieved by
moving lateral incisor palatally by
retraction is carried avoiding any
major root interferences . After
canine retraction the lateral
incisor is moved labially to its
normal position in the arch,
aligned next to central incisor.
3) Canine to First molar site :
This transposition is characterized by
presence of maxillary canine in the
space of the same side permanent first
molar which had been lost earlier. The
canine usually is observed rotated
No remedial treatment for this anoamly but
other than extraction of transposed canine
4) Maxillary lateral to central
In this type of transposition esthetically
symmetry is the main difficulty since the
gingival contour of the lateral incisor is
lower and narrower than that of central
incisor. Aesthetics can be improved with
restorative procedures using veneers and
But then residual gingival
triangular space may look cosmetically
poor for patients with high smile line.
Other alternative is to selectively
extract the lateral incisor, followed
by alignment of the central incisor
into its correct position followed
with prosthetic replacement of the
lateral incisor. This procedure
would provide a more aesthetic
5) Maxillary canine to central incisor
In this type of transposition, it is often decided
to retain the canine in the central incisor site and to
keep central incisor into canine position.
brackets on the 11,13 are inverted in order to assist
palatal root torque on 13 and labial root torque on
11. The upper central incisor root is adequate to
withstand cuspid guidance, however aesthetics will
not be ideal.
Then considerable restorative camouflage
to canine and central incisor will be carried
will reduction of the incisal corner
Regarding the bracket placement
one has too first decide whether
one is aligning the transposed
teeth in the same way or whether
he is bringing the transposed teeth
to its normal position in the arch.
For example, canine and central
treatment procedure was decided
to align them in a transposed
position. The brackets on both of
them are inverted in order to
assist palatal root torque on the
canine and labial root torque on
the central incisor.
2) Functional occlusion :
transposed teeth should be done in a
way that one can achieve good
3) Periodontal tissue consideration :
1]the width of the alveolus is usually in
sufficient for the roots of the teeth to pass
2) Root resorption may then occur as a
result of compression and friction during the
3) Thinning of the labial alveolus and
mucosa may result in clefting and recession
of the gingiva.
Y. Shapira and M.M. Kuftinec (AJO 1989)
Age/Sex - 12.5 yrs /female.
Clinical Findings –
Bilateral end on molar relationship.
Crowding in the maxillary right anterior region.
Rotation of right lateral incisor and first premolar.
Transposition of canine and the lateral incisor on right
Radiographic Finding –
– Complete transposition of canine and the lateral
incisor on right side.
Treated By –
– Non extraction standard edgewise.
Transposition can be considered a
small part of the phenomena of tooth
malposition permitting identification and
discrimination of some of the genetic and
adventitious factors that seem to
Once transposition has
occurred careful orthodontic assessment
must be carried out in order to correct
the malocclusion in order to get best
aesthetics and functional results.
may seem to be an
anomaly in the dentists eyes,
sometimes may not be unusual in
the patients eye. The patient is
interested in the health of his
complaining about transposition.
In fact, he will be amused by the
interest his teeth has aroused
among the dentist.
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