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Q U I N T E S S E N C E I N T E R N AT I O N A L

Congenital agenesis of premolars associated

with submerged primary molars and a
peg-shaped lateral incisor: A case report
Carolina Steiner-Oliveira, DDS, MSc1/
Maria Beatriz Duarte Gavião, DDS, MSc, PhD2/
Marines Nobre dos Santos, DDS, MSc, PhD2

The combination of infraoccluded primary molars and agenesis of the permanent succes-
sors is rare. This condition progresses with increased severity since the primary teeth do
not usually exfoliate spontaneously. The clinical examination of an 11-year-old girl revealed
4 submerged primary second molars, agenesis of all second premolars, and a peg-
shaped maxillary lateral incisor. Treatment in this case was surgical extraction of the sub-
merged teeth and placement of removable appliances to maintain space and vertical
dimension. (Quintessence Int 2007;38:435–438)

Key words: agenesis, ankylosis, infraocclusion, peg-shaped tooth, primary teeth,

removable appliance, surgical treatment

Tooth agenesis of permanent teeth is the
most common developmental dental anom-
aly. It is genetically determined with autoso-
mal-dominant transmission and is associated
with several other dental abnormalities.1,2
The prevalence of agenesis varies from 5%
to 10%, excluding third molars, and it occurs
mostly in second premolars and maxillary
lateral incisors.1,3–5 Researchers have indi-
cated a relationship of 17% between agene-
sis and infraocclusion of primary molars6,7 as
well as a relationship between agenesis and
peg-shaped maxillary lateral incisors.8
Ankylosis is a well-established condition
associated with infraocclusion of primary
molars.9,10 It involves fusion of cementum to
alveolar bone, affects almost all infraoccluded
1
Graduate student, Department of Pediatric Dentistry, Piracicaba
Dental School, State University of Campinas (UNICAMP), Brazil.
2
Professor, Department of Pediatric Dentistry, Piracicaba Dental
School, State University of Campinas (UNICAMP), Brazil.
Reprint requests: Dr M. B. D. Gavião, Avenida Limeira, 901,
Piracicaba–SP, 13414-918, Brazil. E-mail: mbgavião@fop.unicamp.br
primary molars, and may subsequently
develop into infraocclusion, often at a micro-
scopic level; any obliteration of the periodon-
tal ligament may remain undetected in con-
ventional radiographs.11 The mechanism of
ankylosis initiation is unknown,12 but it is
probably due to developmental disturbances
in the periodontium.10 Furthermore, changes
in the distribution of epithelial cell rests of
Malassez in the periodontium of ankylosed
primary molars are etiologically relevant to
subsequent root resorption and ankylosis.13
The combination of the absence of a perma-
nent successor and infraocclusion of pri-
mary molars might affect not only alveolar
bone growth, which stops in the submerged
area, but also occlusal disturbances such as
mesial tipping of the permanent first molar.7,11
Thus, whenever a tooth is congenitally miss-
ing, an early diagnosis is vital to provide ade-
quate treatment and to prevent malocclu-
sion, particularly if agenesis occurs in asso-
ciation with another dental defect.2
The following report describes the man-
agement of a patient with agenesis, ankylo-
sis, infraocclusion, and a peg-shaped tooth.

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Fig 1a Infraoccluded maxillary and mandibular right primary second
molars.
CASE REPORT
A healthy 11-year-old girl came to the
Department of Pediatric Dentistry at
Piracicaba Dental School with 4 submerged
primary second molars. Her medical history
was noncontributory and within normal lim-
its. The patient had been under the care of a
general dentist since the age of 3 years with-
out a reported problem, except for delayed
exfoliation of the primary molars and their
infraocclusal position.
Clinical examination revealed a symmetric
face. The patient presented an Angle Class 2
molar relationship, right and left maxillary pri-
mary second molars, right and left mandibu-
lar primary second molars severely sub-
merged (Figs 1a and 1b), and a lingually posi-
tioned peg-shaped maxillary right lateral inci-
sor (see Fig 1a). A slight mesial tipping of the
right and left mandibular permanent first
molars was also observed.
Periapical radiographs (Figs 2 and 3)
revealed the absence of the maxillary and
mandibular right and left second premolars.
The mandibular left primary second molar
was ankylosed, while the maxillary right and
left primary second molars were only sub-
merged with some degree of root resorption.
The mandibular right primary second molar
presented total root resorption accompanied
by a bone lesion.
436
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Fig 1b Infraoccluded maxillary left primary second molar
and ankylosed mandibular left primary second molar.
Dental casts were made and analyzed. In
view of the degree of root resorption of the
retained primary teeth, presence of bone
lesion, severity of the infraocclusion, and the
risk of increasing loss of bone support of the
adjacent permanent teeth, it was decided to
extract all of the retained primary molars.
These surgical procedures were conducted
under local anesthesia.
At this stage, removable appliances with
artificial teeth, to maintain space and vertical
dimension, were planned until the patient
could obtain definitive orthodontic treat-
ment. Even though the removable appli-
ances could not solve the child’s orthodontic
needs at that time, they remained the treat-
ment of choice. Impressions were made of
both arches for study casts. Maxillary and
mandibular removable appliances were con-
structed to maintain space and prevent
mesial drift of the permanent first molars
(Figs 4a and 4b).
For the lingually positioned peg-shaped
maxillary right lateral incisor, orthodontic ther-
apy would first be necessary to bring it to an
adequate position, followed by reshaping to
ideal contours with an esthetic bonding pro-
cedure. Because the family decided to post-
pone definitive orthodontic treatment, this
esthetic procedure could not be performed.
Therefore, only removable appliances were
inserted. The family was strongly encouraged,
however, to seek the continuation of treatment
at a time more appropriate for them.
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Steiner-Oliveira et al

Figs 2a and 2b Periapical radiographs showing the submerged maxillary right and left primary second molars.

Fig 3a Periapical radiograph showing the submerged Fig 3b Periapical radiograph showing the ankylosed mandibular left
mandibular right primary second molar with total root primary second molar.
resorption and bone lesion.

Figs 4a and 4b Clinical views after surgical therapy and insertion of the removable appliances with artificial teeth.

VOLUME 38 • NUMBER 5 • MAY 2007 437

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DISCUSSION
The combination of infraocclusion of pri-
mary molars and agenesis of the permanent
successor is rare.12 Diagnostic considera-
tions include the age of the patient, occlusal
status, condition of the infraoccluded tooth
including the degree of infraocclusion and
root resorption, as well as adjacent alveolar
bone levels.11
Delaying extraction increases the risk of
additional alveolar bone loss, and 1 of the con-
sequences of long-standing and untreated
infraocclusion of the primary molar is over-
eruption of the opposing teeth.14 In this case,
removable appliances with artificial teeth
were placed to provide esthetic, phonetic,
and masticatory improvements and to pre-
vent psychologic trauma, development of
incorrect oral habits, and mesial tipping of
the permanent first molars.15 If this therapy
were not performed, the patient would expe-
rience future problems with the definitive
orthodontic treatment. In addition, in previ-
ous research it was found that no primary
molars in infraocclusion with agenesis of the
successor exfoliated spontaneously, in con-
trast to primary molars for which the succes-
sor was present.12
Based on genetic studies, it is evident that
agenesis is a heterogeneous trait and that
several mutated genes are responsible for
this anomaly. Studies of odontogenesis at
the molecular level, mostly with mouse teeth
as models, indicate that the development of
teeth is under strict genetic control, which
determines the position, number, and shape
of different teeth.1 Once agenesis of perma-
nent teeth is detected, it is necessary to con-
firm the congenital absence of other perma-
nent teeth and examine the dentition for any
associated anomaly, such as a peg-shaped
maxillary lateral incisor, as found in this
case.2
438
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