Transposition of teeth & its management


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Transposition of teeth & its management

  1. 1. INDIAN DENTAL ACADEMY Leader in continuing dental education
  5. 5. INTRODUCTION :   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 eruptive position
  6. 6. . 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 cases.
  7. 7.   Its  correction  involves  treatment  risk  and  requires  a  great  deal  of  control  and  carefully applied mechanics.
  8. 8. HISTORY   Transposition of teeth has been observed and reported since the early 19th century.   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 teeth.
  9. 9.   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.
  10. 10. DEFINITION According  to  Mader and Joseph L.Konzelman  (JADA,  1979  :  98).    It  may  be defined as an interchange of position of  two teeth.    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  nonadjacent tooth.  
  11. 11. According  to  Y.Shapira and 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.  
  12. 12.
  13. 13. CLASSIFICATION Teeth transposition can be classified in a variety of ways. I. Given by Pertz B. and Arad A. Int. 1992 : 23) (Quintessence Complete : In complete transposition both crowns and entire roots of the involved teeth are found in their transposed position. Incomplete : In this crowns of the involved teeth may be transposed but the root apices still remain in their relatively normal position.
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  15. 15.
  16. 16. II. Given by Elizabeth C.Weeks (BDJ. 1996 : 181). Transposition True Unilateral False Bilateral
  17. 17.  True transposition : In true transposition the  both involved teeth ex. Central incisor and  canine do occupy each others respective  positions.  This again sub divided into ;      Unilateral : Transposition taking place  on one quadrant of the respective  arch. Bilateral : Transposition taking place  on  both sides of a arch.
  19. 19.  False Transposition:  In this the involved  teeth do not occupy each others normal  respective position.  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  forced distally.
  21. 21. TRANSPOSITION VS ECTOPIC ERUPTION Ectopic Eruption it is a broad category referring to any abnormal or aberrant eruptive position taken by a tooth. For example buccally placed maxillary canines. 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.
  24. 24. Transposition Vs Transmigration Transposition by definition is an interchange in the position of two adjacent permanent teeth within the same quadrant of the dental arch.   Transmigration It is referred as displacement of teeth from one quadrant across the midline to the other quadrant. Thus transmigration teeth should be considered ectopically erupted teeth not transposed teeth.
  27. 27.
  28. 28. Pseudo Transposition : (Peck et al AJO, 1995) Some reported variations of tooth sequence that mimic transpositions yet technically do not fit the definition of transposition. This category is known as pseudo transposition.
  29. 29. 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  molars.     The  cause  of  this  condition  is  probably  genetically  related,  like  most  types  of  hyperdontia.
  30. 30.
  31. 31. ETIOLOGY
  32. 32.  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  position.
  33. 33. 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 first premolar.
  34. 34. 2) Interchange in Position of Tooth Buds : 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  the anomaly.
  35. 35. 3) Trauma : The third possible explanation of etiology of transposition is that of trauma which presumably causes an exchange of germs imposed by an external force on the teeth.
  36. 36. 4) Genetic : Lastly genetic etiology has been strongly supported by “Nelson” from his study of prehistoric material from Santa Cruz Island, Calif, and also supported by Peck et al.
  37. 37. Following factors taken together point very  strongly towards a gene based etiology for  transposition 1.  Racial differences in frequency of transposition : 2. The higher frequency of associated dental anomalies such as peg shaped laterals and congenitally missing teeth.
  38. 38. 3. Frequent bilateral occurrence 4. Involvement of same type of teeth in bilateral cases on both sides.
  39. 39. .    These  observations  further  strengthen  considering  a  genetic  component  in  a  pre  eminent  position  in the etiology of transposition.
  41. 41.   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 cause of the transposition. Over retention is the effect rather than cause of transposition. the
  42. 42.     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  incisor.
  43. 43.   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.
  44. 44. 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.
  45. 45. .Thus  this  provides  the  antithesis  for  the  migration  and  deflection  theory  of  transposition.
  46. 46. 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.
  47. 47.     In  the  phase  following  the  eruption  of  deciduous  teeth,  such  precise  exchanges  would  be  precluded  due  to  obvious  anatomical, morphological   and  physiological reasons.    .
  48. 48. 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  transposition.
  49. 49. Thus Peck et al suggested a polygenic, multifactorial inheritance for transposition of teeth. However detailed mechanism of origin of transposition is matter for further research.
  51. 51.   SSex : 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 male predilection. According to recent studies done by Y.Shapira et al cited higher female predilection.   -
  52. 52. Site : Most  transposition  appear  in  maxillary  arch.  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
  53. 53. Unilateral transposition are more 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 2:1. -    _       The preponderance of left sided expression of transposition remains unexplained at present. -    _
  54. 54.   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. -
  55. 55.       Transposition has never been reported in  deciduous dentition.   In a recent study of individuals with Down  syndrome a tooth transposition prevalence  of 15% was found. (ANGLE 0 2000,70)
  57. 57. The maxillary canines are important key stone in the dental arch both for good esthetics and normal masticatory function.   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 eruption.
  58. 58. 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. It starts to calcify at about four to five months after parturition and erupts into the mouth at the age of approximately 12-13 years.
  59. 59. 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 first premolar.
  60. 60. MANAGEMENT
  62. 62. Interceptive : 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.
  63. 63. 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 canine which has prevented transposition process from continuing. the
  64. 64. 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.
  65. 65. DDefinitive : BBefore deciding any definitive treatment strategy, certain factors need to be considered ; 11)  Position and condition of root apices. Whether it is complete or incomplete transposition. 22)  Dental and facial esthetics. 33)  Occlusion (both static and dynamic)
  66. 66. 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
  67. 67. vVarious treatment options are : 11)    Alignment in the transposed position followed by recontouring and reshaping of transposed teeth. 22)  Extraction of the transposed tooth 33) Orthodontic movement of transposed teeth into the normal arch positions.
  68. 68. In case of incomplete 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 arch.
  69. 69. 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
  70. 70. 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.
  72. 72. 11)   Maxillary canine to First premolar MMaxillary canine and first premolar transposition appears to be the most commonest transposition in man.
  73. 73. 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. the the
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  75. 75.
  76. 76.
  77. 77. In cases of crowding or need for overjet reduction correction of transposition and malocclusion is carried by extraction of the first premolars.   .
  78. 78.  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
  79. 79. Orthodontic correction of transposed teeth involves complex fixed appliance mechanics. The transposed teeth are moved 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.
  80. 80. 22)Maxillary canine to lateral incisor transposition : 1.Retained deciduous canines. 22.Labially blocked out and often rotated canine and lateral incisor. 33.  Small lateral incisors and missing second premolars. 44.Impaction of the canine or central incisor most often on the transposition side.
  81. 81.
  82. 82.
  83. 83. In this situation there are two problems a) Ability of the lateral incisor to function as canine. b) The ability to disguise the canine and lateral incisor as each other.
  84. 84.  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.
  85. 85. Last option is to correct transposition orthodontically.. The correction may be achieved by moving lateral incisor palatally by bodily movement.Then canine 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.
  86. 86. 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 mesiopalataly with slight palatal displacement.
  87. 87.
  88. 88.
  89. 89. No remedial treatment for this anoamly but other than extraction of transposed canine
  90. 90. 4) Maxillary lateral to central incisor transposition : 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 crowns. But then residual gingival triangular space may look cosmetically poor for patients with high smile line.
  91. 91. 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 results.
  92. 92.
  93. 93.
  94. 94. 5) Maxillary canine to central incisor transposition : 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. The 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.
  95. 95.  Then considerable restorative camouflage to canine and central incisor will be carried will reduction of the incisal corner
  96. 96.
  97. 97.
  99. 99. 1) Bracket placement : 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.
  100. 100. For example, canine and central incisor transposition. The 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.
  101. 101. 2) Functional occlusion : The reshaping and recontouring of transposed teeth should be done in a way that one can achieve good functional occlusion.
  102. 102. 3) Periodontal tissue consideration : 1]the width of the alveolus is usually in sufficient for the roots of the teeth to pass labio-palatally. 2) Root resorption may then occur as a result of compression and friction during the correction. 3) Thinning of the labial alveolus and mucosa may result in clefting and recession of the gingiva.
  103. 103. CASE REPORTS
  104. 104.  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 side.  Radiographic Finding – – Complete transposition of canine and the lateral incisor on right side.  Treated By – – Non extraction standard edgewise.
  105. 105.
  106. 106.
  107. 107.  Francisco A.M. (Angle 2000)  Age/Sex – 10 yrs 10 mnths / female.  Clinical Findings – – Clinical transposition of upper left lateral incisor and canine. – 5 mm deviation of upper midline towards left. – Posterior lateral open bite  Radiographic Finding – – Complete transposition of upper left lateral incisor and canine.  Treated By – – 4 4 extraction P.E.A. mechanotherapy
  108. 108.
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  112. 112. CONCLUSION
  113. 113. 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 interplay in the formation of malocclusion. 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.  
  114. 114.  What 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 teeth and may not come complaining about transposition. In fact, he will be amused by the interest his teeth has aroused among the dentist.
  115. 115. BIBLIOGRAPHY
  116. 116. D1. Dayal P.K. : Transposition of canine with traumatic etiology. J Ind Dent Assoc. 55 : 283-285, 1983. 22. Mohendra L. : An unusual transposition of maxillary lateral incisor. J Ind Dent Assoc. 55 : 115-117, 1983. 33. Loptook T. and Siling G. : Canine transposition approaches to treatment. J Am Dent Assoc. 107 : 746, 748, 1983. 4
  117. 117. 4. Joshi M.R. and Bhatt N.A. : Canine transposition. Oral Surg. 31 : 49-53, 1971. 5. Mader C. and Konzelmon J.L. : Transposition of teeth. J Am Dent Assoc. 98 : 412-413, 1979. 6. Shopira Y. and Kuftinec M.M. : Orthodontic management of mandibular canine incisor transposition. Am J Orthod. 83 : 271-76, 1983. 7. Chottapadhayay A. and Srinivas K. : Transposition of teeth and genetic etiology. Angle Orthod. 66 : 147-152, 1996.
  118. 118. 8. Shopira Y. and Kulftinec M.M. : Tooth transpositions – a review of the literature and treatment considerations. Angle Orthod. 59 : 271-275, 1989. 9. Elizabeth C.Weeks : The presentations and management of transposed teeth. Br Dent J. 181 : 421-424, 1996. 10. Peck S., Peck L. : Classification of maxillary tooth transpositions. Am J Orthod. 107 : 505517, 1995.
  119. 119. 11. Shopira y. and Kuftinec M.M. : A unique treatment approach for maxillary canine lateral incisor transposition. Am J Orthod. 119 : 540545, 2001. 12. Shapira Y. and Kuffinec M.M. : Maxillary tooth transpositions : Characteristic features and accompanying dental anomalies. Am J Orthod. 119 :127-134, 2001. 13. Francisco A.M.: Orthodontic correction of a transposed maxillary canine and lateral incisor. Angle Orthod. 70 :339, 348, 2000. 14. Parker W.S. : Transposed premolars, canines and lateral incisors. Am J Orthod. 97 ; 431-487, 1990.
  120. 120. 115.     Mitchell L. : Canines, in an introduction to orthodontics, Ed.. L.Mitchell, Oxford University Press, Oxford, England 1996, Pg.137. 616.     Peretz B. and Arad A. : Bilateral transposition of maxillary canines and first premolars : Case Report. Quintessence Int. 23 : 345-348, 1992. 717.     Shapira J. and Chaushu S. : Prevalence of tooth transposition, Third molar agencies, and maxillary canine impaction in individuals with Down syndrome. Angle Orthod. 70 : 290-295, 2000. 818.     Patel J.R. : Transposition and microdontia. Oral Surg Oral Med Oral Pathol. 76 ; 129, 1993.
  121. 121. THANK YOU