1.
DR. MUHAMMAD SHARIQ SOHAIL
PGR ORTHODONTICS
FMH COLLEGE OF MEDICINE AND
DENTISTRY

2.
• Introduction
• Incidence
• Etiology
• Diagnosis
• Management Protocol

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.
• 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.
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.
2) TEETH INVOLVE:
25- 35% of all third molars
3% of all 5’s
2% of 2’s
< 1% of mand inicisors

7.
3)SYNDROMES:
• Down’s syndrome
• Ectodermal dysplasia
• Cleft lip and palate
• Hemifacial microsomia
4)ENVIRONMENTAL FACTORS:
• Radiation therapy
• Chemotherapy
• Drug(Thalidomide)

8.
5) HORMONAL FACTORS:
• Hypoparathyrodism
7) INFECTIONS:
• Rubella
• Osteomyelitis
8)TRAUMA TO ANTERIOR REGION:
• Fracture to anterior Maxilla

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.
 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.
 CLINICAL EXAMINATION
• Missing teeth in upper/lower arch(incisors/ premolars)
• Presence space in the arch (Localized/ Generalized)
• Retained decidous teeth

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.
• 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.
• No Active treatment
• Interceptive treatment (Mixed Dentition)
• Comprehensive treatment

15.
 NO ACTIVE TREATMENT
• Patient is satisfies with his/her condition
• Unwilling to commit length of treatment
• Financial issues with cost of treatment

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.
• COMPREHENSIVE TREATMENT
Multidisciplinary Approach:
Orthodontist
Periodontists
Prosthodontist
Oral surgeon
Restorative dentist

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.
• 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.
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.
• 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.
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.
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.
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.
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.
• 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.
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.
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.
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.
• 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.
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.
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.
B) Mandibular second premolar
C)Other treatment options(Replacement)
• Tooth borne bridge
• Autotransplantation
• Prosthetic implant

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.
Radiographic evaluation shows multiple
missing teeth
7862 7 8
8 8

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.
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.
Radiographic evaluation:
Retained b b
Impacted 3 3

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.
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.
Radiographic Evaluation
• Missing 5 2
5
• Peg shaped 2

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.
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.
Radiographic evaluation confirmed aganesis of bilateral
maxillary lateral incisors

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.
• 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.
• 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.

48.
THANKYOU
FOR YOUR ATTENTION !!