Transposition of teeth & its management

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TRANSPOSITION
OF TEETH AND
ITS
MANAGEMENT

CONTENTS

1. INTRODUCTION
2. HISTORY
3. DEFINITION
4. CLASSIFICATION
5. TRANSPOSITION VS ECTOPIC ERUPTION
6. TRANSPOSITION VS TRANSMIGRATION
7. PSEUDO TRANSPOSITION
8. ETIOLOGY
a
MIGRATION / DRIFT THEORY
b
INTERCHANGE IN POSITION OF
TOOTH BUDS
c
TRAUMA
d
GENETIC
9. CONTROVERSIES REGARDING ETIOLOGY OF
TRANSPOSITION

10. CLINICAL FEATURES
11. WHY GREATEST INCIDENCE OF
MAXILLARY CANINE TRANSPOSITION
12. MANAGEMENT
a.     INTERCEPTIVE
b.     DEFINITIVE
i.  CANINE – FIRST PREMOLAR

ii.  CANINE – LATERAL INCISOR
iii.  CANINE – FIRST MOLAR
iv.  LATERAL INCISOR – CENTRAL
INCISOR

v.   CANINE - CENTRAL INCISOR
13. CLINICAL CONSIDERATIONS
14. CONCLUSION
15. BIBLIOGRAPHY

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

. 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.


Its correction involves treatment risk and
requires a great deal of control and
carefully applied mechanics.


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.

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.

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.



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.



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.

II. Given by Elizabeth C.Weeks (BDJ. 1996 : 181).

Transposition
True
Unilateral

False

Bilateral


 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.

TRUE TRANSPOSITION


 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.

FALSE TRANSPOSITION


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.

ECTOPIC ERUPTION


TRANSPOSITION


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. www.indiandentalacademy.com

TRANSMIGRATION


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.

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.

ETIOLOGY


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.


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.


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.

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.

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.

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.

3. Frequent bilateral occurrence
4. Involvement of same type of teeth in
bilateral cases on both sides.


.

These
observations
further
strengthen considering a genetic
component in a pre eminent position
in the etiology of transposition.


CONTROVERSIES
REGARDING ETIOLOGY OF
TRANSPOSITION


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

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.

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
transposition.


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
anatomical, morphological
and
physiological reasons.

.


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.


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.


CLINICAL FEATURES


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.

-


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

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.
-    _


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
deciduous dentition.
 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
TRANSPOSITION


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.

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.

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.

MANAGEMENT


TREATMENT

INTERCEPTIVE
DEFINITIVE

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.

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

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.


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)


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
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.


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.


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
MAXILLARY TOOTH
TRANSPOSITION


11) Maxillary canine to First

premolar
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.

the
the

In cases of crowding or need for
overjet reduction correction of
transposition and malocclusion is
carried by extraction of the first
premolars.

.


 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
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.

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.


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.

 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.

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.

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.


No remedial treatment for this anoamly but
other than extraction of transposed canine


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.

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.

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.


 Then considerable restorative camouflage
to canine and central incisor will be carried
will reduction of the incisal corner


CLINICAL CONSIDERATIONS


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.


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.

2) Functional occlusion :
The
reshaping
and
recontouring
of
transposed teeth should be done in a
way that one can achieve good
functional occlusion.


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.


CASE
REPORTS

 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.

 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

CONCLUSION


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.

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.

BIBLIOGRAPHY


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


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.

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.

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.

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.


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Transposition of teeth & its management

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