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Management of tooth agenesis in orthodontics

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Management of tooth agenesis in orthodontics

  2. 2. • Introduction • Incidence • Etiology • Diagnosis • Management Protocol
  3. 3. Tooth Agenesis/Hypodontia, which is characterized by the absence of one or more teeth, is one of the most common developmental anomalies of human dentition.
  4. 4. • 2.7 -12.2% In permanent dentition(excluding third molars) • Females > Males • Unilateral> Bilateral • Hypodontia(83%) : Oligodontia(7%) : Anodontia(1.4%) Gkantidis N, Katib H, Oeschger E, Karamolegkou M, Topouzelis N, Kanavakis G. Patterns of non-syndromic permanent tooth agenesis in a large orthodontic population. Archives of oral biology. 2017 Jul 1;79:42-7.
  5. 5. 1) GENETIC BASIS: Azzaldeen A, Watted N, Mai A, Borbély P, Abu-Hussein M. Tooth Agenesis; Aetiological Factors. Journal of Dental and Medical Sciences. 2017;16(1):75-85.
  6. 6. 2) TEETH INVOLVE: 25- 35% of all third molars 3% of all 5’s 2% of 2’s < 1% of mand inicisors
  7. 7. 3)SYNDROMES: • Down’s syndrome • Ectodermal dysplasia • Cleft lip and palate • Hemifacial microsomia 4)ENVIRONMENTAL FACTORS: • Radiation therapy • Chemotherapy • Drug(Thalidomide)
  8. 8. 5) HORMONAL FACTORS: • Hypoparathyrodism 7) INFECTIONS: • Rubella • Osteomyelitis 8)TRAUMA TO ANTERIOR REGION: • Fracture to anterior Maxilla
  9. 9. • Generalized reduction in crown and root size • Conical shape crowns • Enamel Hypoplasia • Delayed eruption of permanenet teeth • Prolonged retention of primary teeth • Tooth impaction (Maxillary Canine) • Ectopic eruption • Transposition
  10. 10.  MEDICAL AND DENTAL HISTORY • As as early as 3-4 years for missing deciduous teeth. • As early as 6 years for missing permanent teeth. • Family history for genetic basis. • Systemic History
  11. 11.  CLINICAL EXAMINATION • Missing teeth in upper/lower arch(incisors/ premolars) • Presence space in the arch (Localized/ Generalized) • Retained decidous teeth
  12. 12.  RADIOGRAPHIC EVALUATION • OPG- At 6 years or older, rarely indicated in age below 6. • Lateral Ceph- For Skeletal, Dental and Soft tissue facial components. • CBCT- Both for diagnosis and subsequent treatment to assess bone levels
  13. 13. • Effective counselling of patient and parents • Discussion with parents about: a) Dental, psychosocial, functional and financial implications of treatment b) Treatment options available c) Best treatment approach • Mutlidisciplinary approach
  14. 14. • No Active treatment • Interceptive treatment (Mixed Dentition) • Comprehensive treatment
  15. 15.  NO ACTIVE TREATMENT • Patient is satisfies with his/her condition • Unwilling to commit length of treatment • Financial issues with cost of treatment
  16. 16.  INTERCEPTIVE TREATMENT (MIXED DENTITION) • Extraction of primary lateral incisor or canine Allows eruption of permanent canine into lateral incisor position a)Space opening for prosthesis b)Space closure by orthodontics • Retention of primary incisor a)To allow bone preservation for implants
  17. 17. • COMPREHENSIVE TREATMENT Multidisciplinary Approach: Orthodontist Periodontists Prosthodontist Oral surgeon Restorative dentist
  18. 18. • Autotransplantation • Space closure of lateral incisor/ premolar a) Canine subsititution • Reopening of the space a)Tooth supported restoration b)Implant supported restoration c)Removable restroation
  19. 19. • AUTOTRANSPLANT • In growing children- Premolar can be transplant into Lateral incisor position • Transplanted tooth continue to erupt • Optimum esthetics when restored with porcelain venners/cronws
  20. 20. Criteria for Autotransplantation • Roots of donor tooth should be less than ¾ formed • Adequate space at recipient site • Atraumatic extraction of donor tooth- PDL intact • Skill of the surgeon • No jiggling contacts with opposing tooth after transplant
  21. 21. • SPACE CLOSURE OF MISSING TEETH A)Maxillary Lateral Incisor a)Canines are subsitututed with Lateral incisors b)First premolars subsituted for Canines c)Second premolars for first premolars d)Finishing molar in full Cusp Class II relationship e)Recountouring of subsituted teeth
  22. 22. A)Maxillary Lateral incisor Prerequisites for space closure: • Patient is commited to undergo fixed orthodontic treatment • Well balanced facial profile • Class II malocclusion with minimal overjet and minimal incisor crowding • Dentoalveolar protusion
  23. 23. A)Maxillary Lateral incisor How to achieve Optimal esthetic space closure? • Marginal level of relocated canine and first premolar a)Extrusion of canine and intrusion of first premolar • Crown Torque of relocated canine and premolar a)Palatal root torque of the canine and palatal crown torque of first premolar
  24. 24. A)Maxillary Lateral incisor Recountouring of relocated canine: • Recontour: a)Mesiodistally b)Incisal edge c)Labial Contour d)Cingulum • Extrusion to level ginigival margin • Resin or Ceramic buildup
  25. 25. A)Maxillary Lateral incisor Recountouring of relocated First premolar: • Recontour a)Palatal cusp • Rotate mesially • Intrude to level gingival margin • Resin or ceramic buildup
  26. 26. • A)Maxillary Lateral incisor • Vital Bleaching of relocated teeth: • Young patients- a)Nocturnal use of 10% H2PO2 in Essix type retainer preferable. b)Start at canine and move to remaining teeth • Adult Patients- a)In office bleaching with 35-37% H2P02 if preferable
  27. 27. A)Maxillary Lateral incisor Long term stability: • Bonded retainer for long term stability • Donot expand the lower arch • Group function occlusion anteriorly preferable to canine protected occlusion • Lip competence should be achieved • No Co Cr discrepancy
  28. 28. A)Maxillary Lateral incisor Prerequisites for space reopening: • Well aligned Class I malocclusion • Normal intercuspation of posterior teeth • Pronounced spacing in maxillary dentition • Straight to concave profile • Large size discrepancy between canine and first premolar • Significant difference of shade of central incisor and canine
  29. 29. A)Maxillary Lateral incisor Points to consider in space reopening • Not recommend before 13 years of age a)To prevent alveolar bone atrophy and relapse • After reopening of space orthdontically: a)Orthodontic implant site preparation b)Interim restoration- to maintain space to future implant placement c)Retention
  30. 30. • A)Maxillary Lateral incisor Tooth supported: a)Resin bonded bridge b)Fiber reinforced bridge c)Porcelain fused to metal bridge Implant supported: a)Preferable- must be done after completion of growth Removable: a)If patient cannot afford fix prosthesis
  31. 31. B) Mandibular second premolar Treatment Deicision making factors: • Age • Facial Typology (Hypo/Hyperdivergent) • Skeletal and dental disorders (Bialveoler protusion/ crowding) • Number of dental agenesis • Decidous molar integrity • Extraction of ankylosed decidous teeth • Motivation of patients and parents
  32. 32. B) Mandibular second premolar Treatment options A)Space closure: Extraction and spontanous closure Hemisection of decidous molar Extraction and Orthodontic closure B)Retaining/ preserving decidous second molar To preserve bone integrity for later prosthetic replacement
  33. 33. B) Mandibular second premolar C)Other treatment options(Replacement) • Tooth borne bridge • Autotransplantation • Prosthetic implant
  34. 34. 22 years old female came with the complain of spaces in upper teeth Facial and intraoral evaluation showed: • Straight profile • Competent lips • Class II subdivision left relationship • Competent lips • 2mm overjet and 60% overbite
  35. 35. Radiographic evaluation shows multiple missing teeth 7862 7 8 8 8
  36. 36. After diagnosis, the proposed treatment plan was: • Fixed comprehensive extraction orthodontic plan: • Cross-bite relieving with bite blocks (arch wire expansion • De-rotations of teeth (levelling and alignment) • Open space at the region of right lateral incisor (push-pull mechanics) • Midline correction of upper • Prosthetic replacement of 6 ,2 . • Extraction of right lower 7
  37. 37. A 17 yeard old female came with the complain of that my baby teeth are carious Facial and intraoral evaluation showed: • Symmetric face • Competent lips • Convex profile • Class I molar Relationship • 0mm overjet, 30% overbite
  38. 38. Radiographic evaluation: Retained b b Impacted 3 3
  39. 39. After diagnosis, the proposed treatment plan was: • Fixed comprehensve orthodontic treatment plan with extraction of 2 2 4 4 • Deimpaction of canine followed by subsitution of canine into laterals and premolar into canine • Finishing would be in class I molar, canine and incisor relationship
  40. 40. 21 years old female came with the complain of irregular teeth Facial and intraoral evaluation showed: • Mild convex profile • Competent lips • Class II molar Relationship • Peg shaped and missing laterals • Impacted canines • 1mm overjet , 20% overbite
  41. 41. Radiographic Evaluation • Missing 5 2 5 • Peg shaped 2
  42. 42. After diagnosis, the proposed treatment plan was: • Periodontal management • Restoration of pits and fissure caries • Fixed comprehensive orthodontic extraction treatment plan of 2 2 5 5 • Deimpaction of canines and bring in the arch • Later on subsititution of canine into laterals and premolar into canines • Prosthetic replacement of 5
  43. 43. A 12 year old female presented with chief complain of Spacing in upper front teeth Facial and Intraoral evaluation: • Propotional face • Competent lips • Convex profile • Class II molars and canines • Normal Overjet and Overbite Almeida RR, Morandini AC, Castro RC et al. J.Appl.Oral Sci. 2014; 22(5): 465-71.
  44. 44. Radiographic evaluation confirmed aganesis of bilateral maxillary lateral incisors
  45. 45. After diagnosis, the proposed treatment plan was: • Space closure with mesial movement of canines and posterior teeth. • 3M Unitek 0.022 X 0.028 inch MBT prescription brackets used. • Reshaping of canines into laterals and first premolars into canines. • Lower fixed bonded retainers.
  46. 46. • Treatment progression included: • Initial upper levelling and alignment was carried out using round NiTi archwires. • Space closure carried out on Stainless stell 0.018 X 0.025 rectangular archwires. • Extrusion of canines and intrusion of premolars carried out during space closure. • Finishing with 0.019 X 0.025 SS archwires
  47. 47. • REEFERENCES: • Kokich VO Jr, Kinzer GA, Janakievski J. Congenitally missing maxillary lateral incisors. Am J Orthod Dentofacial Orthop. 2011; 139: 434-445. • Beyer A, Tausche E, Boening k. Orthodontic space opening in patients with congenitally missing lateral incisors. Angle Orthod. 2007; 77: 404-409. • Zachrisson BU, Rosa M, Toreskog S. Congenitally mising maxillary lateral incisors: canine substitution. Am J Orthod Dentofacial Orthop. 2011;139: 434-436. • Almeida RR, Morandini AC, Castro RC et al. J.Appl.Oral Sci. 2014; 22(5): 465-471. • Zochrowska EM, Stenvik A, Bjercke B. Outcome of tooth transplantations. Survival and success rates. Am j Orthod Dentofacial Orthop. 2002; 121: 110-119.