Resorption of maxillary lateral incisors caused by

ectopic eruption of the canines

A clinical and radiographic analysis of predisposing factors

Sune Ericson, DDS, Odont. Dr.,* and Jiiri Kurol, DDS, Odont. Dr.**
JSnkiiping, Sweden

Factors predisposing to resorption of adjacent permanent lateral incisors caused by ectopic eruption
of maxillary canines were evaluated. The subjects consisted of two groups: one with 40 lateral
incisors with resorption caused by ectopic eruption and a control group of 118 ectopic eruption cases
with no lateral incisor resorption. The mean age of the children in the two groups differed by only 0.7
of a year and ranged from 10.0 to 15.0 years, covering the normal eruption period of the maxillary
canine. Resorption of lateral incisors was three times as common in girls as in boys. The resorption
cases showed a more advanced dental development, a more medial canine position,in the dental
arch, and a slightly more mesial horizontal path of eruption (an average of 100) than that of the
control cases. Factors such as the width of the dental follicle and proclination or distal tilting of the
lateral incisor showed no correlation to the resorption. Potential resorption cases are always those in
which the canine cusp in periapical and panoramic films is positioned medially to the midline of the
lateral incisor. Such situations should be carefully investigated with polytomography if necessary.
The risk of resorption also will increase with a more mesial horizontal path of eruption. From 10
years of age or younger, annual clinical examination by palpation of the canine eruption path is
recommended. This clinical examination should be supplemented with a stepwise extended
radiographic procedure in cases in which ectopic eruption of the maxillary canines is suspected. (AM
J ORTHOD DENTOFAC ORTHOP 1988:94:503-l 3.)

T he permanent maxillary canine is fre-

quently misplaced in relation to other teeth in the max-
illa. The prevalence of noneruption and ectopic eruption
of this tooth has been reported to be 0.9% to 2.0% in
samples not previously selected for orthodontic treat-
ment.‘,’ The canine is most frequently found palatal to
the lateral incisor and buccally in only about 15% of
cases,2-4
Ectopic eruption of maxillary canines may lead to
impaction and/or resorption of neighboring permanent
teeth.‘*‘,” However, in most studies of the eruption of
the maxillary canines, the latter complication is sparsely
reported. This might give the impression that resorption
caused by the eruption of the maxillary canine is rare
and of minor clinical importance, however unfortunate
in the individual case. The lesions often are difficult to
diagnose with ordinary radiographic techniques because
most of the resorptions are located palatally or buccally
in the middle third of the root of the adjacent lateral
incisor. Often they are concealed by overlapping of the
canine in the periapical radiographs.”
In a recent epidemiologic study of maxillary canine
From the Departments of Maxilla-Facial Radiology* and Orthodontics.**
Institute for Postgraduate Dental Education.
eruption in which uninterpretable areas caused by over-
lapping on the intraoral radiographs were examined by
polytomography, it was found that resorption of lateral
incisors occurred in 12% of cases after ectopic eruption
of maxillary canines, suggesting a total prevalence of
0.7% for resorbed lateral incisors in the lo- to 13-year
age group.’
During eruption of the maxillary canines, these teeth
are in very close contact with the lateral incisors due
to the anatomy in this region,’ and it has been shown
in radiographs that the lamina dura often is missing.‘,6
Furthermore it is believed that in situations of resorp-
tion, there must be close contact between the canine
and lateral incisor, rather than mediation of the resorp-
tion by swelling of the dental follicle.‘.’ The importance
of the dental follicle in the tooth eruption process has
been shown in animal experiments.” However, it is not
clear what the predisposing causative factors in this
incisor resorption process are and in what positions and
situations an ectopically erupting or misplaced canine
is liable to resorb the adjacent teeth.
This investigation was undertaken in an attempt to
elucidate the role of various causative factors in the
The resorption of lateral incisors caused by ectopic eruption
of maxillary canines. A further aim was to evaluate the
503
504 Ericson and Kurol Am. J. Orthod. Dentofac. Orthop.
December 1988

Fig. 1. Records of female subject, aged 10 years 10 months. Lateral (A and B) and occlusal (C and
D) views of the dentition and dental arches show crowding and lack of space. Extraction of first premolars
was indicated and the patient was referred for orthodontic treatment. Note the buccal position of the
maxillary canines. E, Axial-vertex intraoral radiograph at 11 years 3 months of age shows the position
of the maxillary canines relative to the dental arch. In the Orthopantomograph F, the medial position
of the canine crowns and degree of mesial path of eruption are seen. In the periapical dental films (G
and H), an overlapping of the canine over the lateral incisor is seen together with an unbroken
mesiodistal root contour. The lamina dura is missing. Because of this and the close relation between
the canine and lateral incisor as seen in E, further radiographic investigation is indicated. (Which one
of the lateral incisors is resorbed?)

strength of various possible predisposing factors sin- eruption. The two groups were investigated in an iden-
gularly associated with the resorption of lateral incisors tical manner, both clinically and radiographically. In no
by comparing resorption cases with nonresorption cases case had the canine erupted into the oral cavity. The
after ectopic eruption of the maxillary canine. primary canine was missing in 30% of the subjects.

SUBJECTS Resorption group

The material for this study was derived from two
groups: a group with resorption of the maxillary per-
manent lateral incisor associated with ectopic eruption
of the maxillary canine and a control group in whom
the incisor was not resorbed because of the ectopic
This group comprised 40 consecutively collected
cases with resorbed lateral incisors with varying degrees
of resorption. No evidence of traumatic injuries to the
incisors was found. A detailed presentation of the lo-
cation and extent of resorption on the lateral incisors
Volume 94 Resorption of mcrrilla~ incisors 505
Number 6

Fig. 1 (Cont’d). The sagittal polytomograms (I and J) show that the girl’s right lateral incisor is buccally
in close relation to the canine crown and a resorption cavity ~&WOWS) is seen extending into the pulp.
On the left side, there is close contact between the lateral incisor root and canine crown but without
resorption. The girl showed a lack of interest and was reluctant to wear a visible fixed orthodontic
appliance. In K, the extracted lateral incisor on the right side shows a buccal resorption in the middle
third of the root and the radiograph L shows the full extent of buccal root resorpQon. Note the conformity
of information between the polytomogram (I) and the radiograph (L). For reasons of symmetry, both
lateral incisors were extracted, and in M and N the clinical and radiographic frontal views of both the
resorbed and normal lateral incisors are seen. The intraoral photograph (0) of the maxillary dental
arch shows the result 8 months after extraction at 12 years 0 months of age.

has been given previously.’ In 34 of the 40 lateral in-
cisors (85%), the erupting canine was found in an ec-
topic position lingually, distolingually, or buccally to
the resorbed incisor root. In six cases the canine position
was distal to the lateral incisor root. In 45% of the
lateral incisors, the resorption extended into the pulp.
Control group
The material for the control group was collected
from material presented earlie?.6.‘o in a series of studies
on normal and ectopic canine eruption. This group con-
sisted of 118 cases of nonerupted maxillary canines with
an ectopic path of eruption, but without causing re-
sorption of the lateral incisor roots. From the radio-
graphs it could be seen that the two materials were very
similar and comparable with regard to the position of
the canine crown relative to the adjacent teeth in the
dental arch. In 83% of cases, the canine crowns showed
lingual, distolingual, or buccal positions relative to the
incisor root. Buccal positions were noted for 15% of
the canines (as compared with 18% in the resorption
group).
Age
The age of the subjects ranged from 10.1 to 14.9
years in the resorption group and from 10.0 to 15 .O
years in the control group. The mean age in the re-
sorption group was 12.1 + 1.2 years; in the control
group, the mean age was 11.3 t 1.O years. This minor
difference in age (mean 0.7 years) between the two
groups was not statistically significant.
METHODS
Radiographic examination
The radiographic examination was performed ac-
cording to defined criteria and an earlier described step-
wise procedure.‘.‘” In addition to conventional intraoral
periapical films in different projections., an intraoral
occlusal film was exposed in an axial-vertex projection,
with the x-ray beam parallel to the long axis of the
incisors. An orthopantogram and lateral head film also
were obtained. In those cases in which the canines could
not be projected free from the lateral incisors and the
overlapping made it impossible to rule out resorption,
the lateral incisors were polytomographed (for a detailed
description, see Ericson and Kurol’.‘). A. complete ra-
diographic examination is illustrated in Fig. 1.
The panoramic image was obtained with a Siemens
Orthopantomograph (OP-3)” modified with a collimator
system and rotating anode. The patient was carefully
*Siemens Corporation, Icrlin, N I.
506 Ericson and Kurol Am. J. Orthod. Dent&c. Onhop.
December 1988

Table I. Analyzed factors and their statistical correlation to resorption of maxillary lateral incisors caused
by ectopic eruption of the canine in a group of 40 resorbed incisors (I) and a group of 118 nonresorption
cases (II) after ectopic eruption
I-II Level of Power
Variables test values significance (phi or Cramer’s V)

Sex x2 = 3.77 (DF 1) p 5 0.05 0.16

Degree of canine maturation x2 = 14.31 (DF 1) p 5 0.002 0.31
Canine position relative to the midline of the dental arch (trans- x2 = 1.80 (DF 3) NS -
verse plane)
Canine position relative to the lateral incisor root (transverse plane) x2 = 1.83 (DF 4) NS -
Medial position of the canine cusp:
-Panoramic image (frontal plane) x2 = 23.07 (DF 4) p 5 0.0001 0.39
-Axial projection (transverse plane) x2 = 24.67 (DF 4) p I 0.0002 0.40
Angle of canine mesial eruption to midline, (Y (panoramic image) t = 4.62 (DF 154) p~O.ooo 0.12
Angle of canine mesial eruption to long axis of lateral, p (pan- t = 2.93 (DF 154) p 5 0.004 0.05
oramic image)
Angle of canine eruption in sagittal plane, 6 (lateral head film) t = 0.13 (DF 156) NS -
Angle of canine mesial inclination to midline, y (axial projection) t = 3.89 (DF 156) p 5 0.000 0.09
Degree of vertical eruption:
-Panoramic image (d,) t = 2.10 (DF 154) p 5 0.04 0.02
-Lateral head film (d,) t = 1.23 (DF 156) NS
Distance from canine cusp to APg line (lateral head film) t = 2.03 (DF 156) p 5 0.04 0.02
Proclined lateral incisor x2 = 0.04 (DF 1) NS -
Distal tipping of lateral incisor x2 = 0.14 (DF I) NS -
Enlarged follicular width x* = 0.00 NS
Apical canine root deflection x2 = 1.90 (DF 1) NS -
Degree of resorption of primary canine x2 = 6.67 (DF 3) NS

KEY: x2 = Chi-square analysis; t = Student’s t test; DF = degrees of freedom; p = probability; NS = nonsignificant.

Table II. Distribution of the most medial position of the cusp of the ectopically erupting maxillary canine
(sectors l-5) as projected in the orthopantogram (%)
Canine position in sector (%)
Level of
Group 5 4 3 2 I Total (%) significance

Resorption (n = 40) 3 31 42 I9 5 100

p cc 0.001
Control (n = 118) 33 39 20 7 0.8 100

oriented to the x-ray machine and clinical measurements
of the mesiodistal width of the maxillary incisors were
made and compared with the orthopantograms to ensure
an optimal position of the x-rayed object within the
image-processing layer.
The lateral head films were obtained with a focus
distance of 155 cm and with the beam of the x ray
directed through the external auditory meatus.”
Analyzed factors
Twenty-four variables were analyzed. The data
were transferred to magnetic tape and analyzed by com-
puter. The SPSS computer program” was used. This
presentation focuses on the following factors:
Canine
-Degree of development (mineralization)
-Path of eruption in all three planes
-Position of the canine relative to the lateral incisor in all
three planes
The development (degree of maturation) of the maxillary
canine has been presented in two degrees:
1. The root is longer than the canine crown.
2. The root is shorter than the canine crown.
The positions, measured distances, and degrees can be
seen from Figs. 2 through 6.
Lateral incisor
The position of the lateral incisor within the dental arch
was clinically assessedand registered as normal or distally
tipped, proclined or not proclined.
Dental age was determined according to a method
developed by Gustafson and Koch.13 The tested vari-
ables are presented in Table I.
Space loss was measured with sliding calipers and
Volume 94 Resorption of mad/q incisors 507
Number 6

Fig. 3. Schematic illustration of the canine position in an axial-

Fig. 2. Schematic illustration of the projection of the canine in vertex intraoral radiograph and sectors (7 through 5) of the most
the panoramic image and sectors (7 through 5) of the most medial position of the canine cusp.
medial position of the crown.

amounted to 1 to 3 mm in three cases in the resorption

group.

Statistical methods
Conventional methods have been used for statistical
analysis.‘* Distributions have been studied by means of
the chi-square test with the Yates correction; differences
in means between two groups have been analyzed by
means of Student’s t test with n-2 degrees of freedom.
For those variables in which statistical significance
was found, the association was further analyzed, and
the strength of the statistical associations from obtained
differences was estimated and expressed with the co-
efficient phi and Cramer’s V for the chi-square tests”
and with the coefficient omega for Student’s t test.14
Any influence of sample size on statistical significance Fig. 4. Schematic illustration of the inclination of the maxillary
was hereby eliminated. The coefficients assumed canine to the midline (a) and long axis of the lateral incisor (p)
a value between 0 and 1, depending on the strength in the panoramic image.
of the statistical association (Table I), where 0 means
complete independence and 1.00 a complete as-
sociation . was 3 : 1 in the resorption group and 6: 5 in the control
The reliability of the radiographic methods was es- group. The factor related to sex accounts for about 16%
timated according to Guilford’s definitionI by studying (phi 0.16) of the variance of the score. Compared with
the variance between two determinations. No error ex- some of the other significant variables, sex was of com-
ists when the reliability coefficient is 1.OO. The coef- paratively little importance (Table I).
ficient varied between 0.92 and 0.94.
Canine tooth development
RESULTS The canine tooth development (measuring the length
The main results are presented in Table I, together of the root) was more advanced in the resorption group
with an estimate of the strength of the statistical as- than in the control group (Table I). In cases with re-
sociations of variables between the two groups. sorption, more than half of the root had developed in
nine of 10 cases as compared with a 6:5 ratio for con-
trols of the same age.
Resorption of maxillary lateral incisors was found Children in the resorption group had a dental age
to be more common in girls than in boys. The sex ratio close to the mean’* (mean k 1 year) in 97% of the
50% Ericson and Km-01 Am. J. Orthod. Dentofac. Orthop.
December 1988

0A
Lye
A
80.

80.

40.
NL
20-

Fig. 5. A, Schematic illustration of the maxillary canine incli-

nation lo the midline (y) in an intraoral axis-vertex projection.
B, Diagram showing median values (Md) of the eruption angles
(CXand p) in the resorption group (R) and control group (C), the
range for 50% of the observations, and the total range.

cases. For children in the control group, the corre-

sponding figure was 90%.
Position
Position of the canine crown relative to the dental
arch (transverse plane). The position of the cusp of the
maxillary canine crown in relation to the midline of the
dental arch or relative to the lateral incisor (both in
buccal and lingual positions) did not significantly differ
between the two groups (Table I).
Medial position of the canine cusp (transverse and
frontal planes). A detailed analysis showed that the
cusp of the maxillary canine was positioned more me-
sially in the resorption group than in the control group
(Tables I and II). This difference was statistically sig-
nificant. An estimate of this variable showed that it
accounts for approximately 40% of the variance of ob-
tained scores. The projection of the canine position in
the orthopantogram and in the axial-vertex projection
showed similar patterns. The distribution of the position
of the cusp of the maxillary canine in the orthopanto-
gram can be seen from Fig. 2 and TablebII.
Fig. 6. A, Degree of vertical eruption of the maxillary canine (6)
registered as a distance d, in the panoramic image. B, Degree
of vertical eruption of the maxillary canine registered as a dis-
tance d2 in the lateral head film. AU, Nasal line; OL, occlusal
line; Afg, line from the A point to the pogonion. Also shown is
the angle between NL and the long axis of the maxillary canine.
From Tables II and III, it can be seen that the num-
ber of resorbed lateral incisors increased as a result of
a more medial position of the canine cusp. The differ-
ence between the two groups in this respect is significant
and the strength of this relationship is high (Table I).
In the resorption group, canines in the most medial
sectors (1 through 3) in the orthopantogram comprised
65% of the material, whereas the corresponding figure
for the control material was 28% (Table II). The cor-
responding figures for the axial-vertex projection were
60% and 28%, respectively (Table III). It is worth not-
ing that when the cusp of the canine was positioned
mesially to the lateral incisor (in sectors 1 and 2), the
risk of complications increased three times, and every
Volume 94 Resorption of maxilluryviksors 509
Number 6

Table III. Distribution of the most medial position of the cusp of the ectopically erupting canine in an
axial-vertex projection (%)
Canine position in sectors (YG)
Level of
Group 5 4 3 2 I Total (o/o) srgnifcance

Resorption (n = 40) 0 41 33 18 8 100

F’ < 0.001
Control (n = 118) 31 40 20 7 1 100

Table IV. The vertical inclination (“) of the eruption path of the canine in the orthopantogram measured
to the midline (a) and to the long axis of the lateral incisor (@)-Mean, standard error, and
standard deviation

Group x SE SD x SE SD

Resorption (n = 40) 29.5 t 2.5 15.4 39.1 -c 2.5 15.5

Control (n = 118) 18.6 2 I.0 Il.5 31.1 2 1.3 14.2
Level of significance p < 0.001 p < 0.01

second lateral incisor was found to be resorbed with
canines in this medial position.
Inclination
Vertical inclination of the canine path of eruption.
The vertical inclination of the canine was analyzed both
from the orthopantogram and from the lateral head film
(Figs. 4 and 6).
Inclination of the canine in the frontal plane. In the
orthopantogram, the inclinations of the eruption path to
the midline (a) and to the long axis of the lateral incisor
(p) were measured. The mean values and standard de-
viations for these two angles are shown in Table IV.
When measured to the midline ((-u-29.5” and 18.6”,
respectively) and also to the long axis of the laterals (p
39.1” and 31. l”, respectively), the inclination of the
erupting canine was more horizontal (average 10”) than
that of the control group. This difference between the
two groups was statistically significant and more pro-
nounced for the inclination to the midline (CL).The range
in individual variation was considerable, however, and
the strength of the association was thus found to be
fairly low-5% to 12% (Table I).
For the vertical inclination angles a and p, the me-
dians and the 50% quartiles were calculated (diagram
shown in Fig. 5, B). The inclination angle (Y ranged
from 8” to 80” in the resorption group and from 0” to
59” in the control group, the median values being 28”
and 17”, respectively. It was found that 25% to 75%
of the observations could be found between 18” and
40” and between 10” and 25”, respectively. This indi-
cates that the risk of resorption increases by 50% when
the eruption inclination exceeds 25” as compared with
the controls. The corresponding value for the vertical
eruption inclination to the lateral incisor (p) is 28”. This
is valid for the positions (buccolingually) as expressed
in the orthopantograms.
Inclination of the canine in the sagittal plane. The
sagittal inclination of the path of eruption (6) was mea-
sured in lateral head films (Fig. 6); no statistically sig-
nificant differences were found between the two groups.
Inclination of the canine in the horizontal plane.
The degree of mesial orientation of the canine was
analyzed by measuring the angle (y) between the pro-
jections of the long axis of the canine and the midline
of the maxilla in the axial-vertex occlusal film (Fig.
5). The values are presented in Table V. In the resorption
group, the mesial inclination of the canine to the midline
in the horizontal plane was more pronounced (34.5”)
than in the control group (16.4”). This difference be-
tween the groups was statistically significant.
Canine eruption in the vertical dimension
The degree of vertical canine eruption was analyzed
by measuring the distance (d,) from the canine cusp to
the occlusal plane in the orthopantogram (Fig. 6). The
results can be seen in Table VI; they show a statistically
significant but small difference between the two groups.
However, the strength of the statistically significant as-
sociation is low. When calculating means and 50%
quartiles, no definite difference could be found between
the two groups.
510 Ericson and Kurol Am. J. Orthod. Dentofac. Orthop.
December 1988

Table V. The mesial inclination of the canine to the midline (6) of the canine in an axial-vertex
projection-Mean, standard error, and standard deviation
6
Level of
Group x SE SD significance

Resorption (n = 40) 34.5 k 4.5 29

p < 0.001
Control (n = 118) 16.4 ” 2.2 24

Table Vi. The distance from the canine cusp to the occlusal line in orthopantograms (d,) and lateral head
films (d,)-Mean, standard error, and standard deviation
d, (orthopantogram) dz (lateral headjlm)

Group x SE SD x SE SD

Resorption (n = 40) 14.1 t 0.6 4.5 10.7 * 0.5 3.6

Control (n = 118) 15.6 2 0.3 3.8 11.4 -t 0.3 3.4
Level of significance p < 0.05 NS

Tabts WI. Distribution of the degree of root resorption of the primary canine (1 and 2) or absence (3)
(0 denotes no resorption)
.53”163” of resorption (%)
Level of
Group 0 1 2 3 Total (%) significance

Resorption (n = 40) 35 17.5 17.5 30 100

NS
Control (n = 118) 34 34 18 14 100

Canine position in the sagittai plane
The canine position in the sagittal plane was mea-
sured as the distance between the cusp and the line APg
(A point to pogonion) in lateral head films (Fig. 6). A
small but not statistically significant difference was
found between the two groups.
The width of the dental follicle
The influence of the dental follicular width (mea-
sured in intraoral periapical radiographs with calipers)
was analyzed by comparing two groups, one with a
maximum width of 3 mm or more and another with a
maximum width less than 3 mm. The distributions were
then tested between the resorption group and the control
group and no difference was found. In intraoral radio-
graphs, the dental follicles exceeded 3 mm in 23% and
24% of the subjects in the resorption and control groups,
respectively.
No such association was found (Fig. 7, Table VII). In
one third of the resorption cases, normal resorption of
the primary canine root was found.
The position of the lateral incisor relative to the
dental arch
When compared to adjacent incisors clinically, in
the axial-vertex projection, and in the orthopantogram,
the position of the lateral incisor relative to the dental
arch was registered as (1) proclined or normal and (2)
distal tipping or normal for the two groups (Table I).
No association was found between the position of the
lateral incisor and the lateral incisor root resorption. In
the resorption group, 16% of the lateral incisors were
proclined and 27% were distally tilted; the correspond-
ing figures for the control group were 18% and 23%,
respectively. Most proclinations were associated with
buccal positions of the canine.

Resorption of the primary canine root DISCUSSION

The association between lateral incisor resorption Root resorption of permanent incisors caused by an
and the degree of the so-called physiologic root re- erupting maxillary canine is an underestimated prob-
sorption or absence of the primary canine was tested. 1em.6 Immediate therapeutic measures often are needed
Volume 94
Numhcr 6
to avoid worsening of the situation and subsequent pro-
longed and expensive orthodontic treatment. Several
predisposing and singularly associated factors involved
in the resorption of incisors due to canine ectopic erup-
tion have been identified in this study and their impor-
tance evaluated. The possibility of any covariation of
the analyzed factors has not been assessed and needs
further study.
The subjects in this study were younger than those
in other reports because of the screening procedure
used.” The age ranges of the resorption and control
groups (10 to 15 years) cover the entire normal eruption
period of the canine and differ on average only 0.7 of
a year. Furthermore the number of subjects is large for
this uncommon complication. This material therefore
may be considered representative for identification of
factors associated with resorption of lateral incisors
caused by ectopic eruption of maxillary canines.
The conventional clinical and radiographic methods
used are representative of an everyday clinical situation
and have been used to present an analysis that facilitates
the everyday use of the results. Of the radiographic
methods used, the intraoral periapical and axial-vertex
projections in occlusal films and the panoramic image
were the most efficient in identifying differences in
position between the resorption and control groups.
Used together, these three methods describe the dis-
placed canine in three dimensions and can be expected
to have a sufficient degree of accuracy in describing
the relationship of the canine to the adjacent incisor
and to other anatomic structures. The detailed analysis
of the results also showed good agreement among these
methods (Tables III through V). The lateral head tilm
was less efficient in this respect because of the over-
lapping of the two sides, which made identification of
the specific canine difficult. The curve of the dental
arch in the canine region was also a factor.
The posterior-anterior (PA) skull radiograph was not
used in this study since it has been shown by Coup-
land,” that this radiograph is comparable to the ortho-
pantogram in the presentation of the position of the
canine. The orthopantogram was chosen because it bet-
ter describes the dental situation in the anterior region
without disturbing the overlap and can be obtained at
many orthodontic departments, whereas the PA skull
radiograph is not as available. Most panographic ma-
chines give approximately comparable images in the
central part of the cut, provided that the orientation of
the patient is correct.”
In all radiographic techniques, there is some degree
of distortion. Comparing the position of the canine in
two series of observations in this study, the distortion
factor did not influence the main results in a decisive
way because the same methods were used and the two
groups showed similar locations of the canine relative
Rt~sorption of maxillary incisors 511
DEGREE OF RESORPTION
TOOTH 53/63
--____--__
__________
0
---____
_ _-_-_-__-_
1
~ -- - ____-_--_
__-____ 2
--_---_ - --------3 (missing)
Fig. 7. Schematic illustration of the degree of root resorption of
the primary canines.
to the dental arch. Guilford’s coefficient of reliabilityI
was high for all measurements of both inclination and
distance in the panoramic and vertex images, indicating
that the errors of the methods were low as compared
with the total variance of the measured variables.
The results show that ectopic eruption per se does
not increase the risk of resorption unless accompanied
by other factors. The factors that most increased the
risk were a more medially positioned canine crown, a
more advanced degree of canine development, and an
increased mesial inclination of the path of eruption. Of
the angles of eruption, (Yand y had greater power than
p, which would indicate that tipping of the lateral in-
cisors to a certain extent moderates the risk of resorp-
tion. Townend” has reported that canines causing re-
sorption appeared to be more vertical, which is contrary
to the findings of this study. Female sex also was as-
sociated with the occurrence of resorption as indicated
earlier by Howard’ and Sasakura and associates.‘” The
estimates of the strength of the statistical associations
do not give much consideration to mutual relationship
and covariations. It may well be that a discriminant
analysis could better explain the strength of these as-
sociations.
Of the clinical factors that may influence resorption
during ectopic eruption of the canines, we gave partic-
ular attention to the lateral incisor’s proclination and
tipping, the width of the canine’s dental follicle, and
the degree of primary canine root resorption. No sig-
nificant associations could be demonstrated in this
study. This is in contrast to earlier observations and
opinions in which such factors have been stated to be
associated with resorption, -namely, tipping of lateral
incisors,2o an enlarged canine follicle in some resorption
cases,’ and delayed resorption and exfoliation of the
primary canine.“‘.”
512 Ericson and Kurol Am. J. Orthod. Dentofac. Orthop.
December 1988

Among possible causative factors in ectopic erup- ods should be based on individual indications according
tion and impaction of maxillary canines, lack of space to our previously suggested clinical and radiographic
and crowding in the canine region have been proposed procedures. *.I0
to influence ectopic eruption.‘~3~5~20~22 It has been sug- It is customary in scientific articles to express as-
gested, however, that most such patients have sufficient sociations with some sort of statistical significance, usu-
space. 6~2’~23-25 In this study of resorbed lateral incisors, ally in the form of certain previously chosen levels
lack of space was found in only three of the 40 cases of statistical significance-for example, *** = p <
and was apparently of minor importance. 0.001. However, the occurrence of such a significant
For diagnostic awareness, it is important to note result discloses nothing about the strength of the as-
that the relative prevalence of the most common site of sociation among the tested variables.‘4 For this reason
resorption was not greater in palatal positions (which we have performed an analysis of the statistical power
is a far more common ectopic position compared with of the associations to evaluate the most important single
buccal ones). However, it is interesting that resorption factors that are easily recognized by the clinician.
was far more common in the middle third of the root It is also our opinion that it is very important, es-
than in the cervical and apical thirds, which is contrary pecially when studying causative factors, to analyze the
to Kettle,” who believed apical resorption to be more strength of the associations in addition to the signifi-
common. Thus this midroot location of resorption in cance. This study could in this respect point out three
the sagittal and vertical dimensions means that, because powerful factors-namely, more advanced canine de-
of overlapping, diagnosis from intraoral or even pan- velopment, a more medial position of the canine cusp,
oramic films is not always reliable. and mesial inclination of the canine to the midline ex-
The importance of polytomography in diagnosing ceeding 25” as measured on the orthopantogram.
resorption in these cases has been evaluated earlier by
Ericson and Kurol.6 Polytomography, which is gaining CONCLUSION
increasing use for localizing unerupted teeth,2.6.8.26 In general, the results show that the typical candi-
should be considered when resorptions cannot be ruled date for resorption of the lateral incisors during ectopic
out from routine intraoral films. Another possible tool eruption is a girl approximately 11 to 12 years of age,
is computed tomography.*’ with (1) a well-developed canine root, (2) the canine
An advanced canine root development was signif- cusp erupted medially to the long axis of the adjacent
icantly correlated to resorption on adjacent incisors as lateral incisor, and (3) the canine in a mesial angle of
was a more medial position of the canine crown. Both eruption to the midline exceeding 25”. However, be-
of these factors may be assumed to be age-related. cause the pattern is not uniform and resorption also may
It may therefore be concluded that early diagnosis occur in apparently normal eruption situations, the risk
of ectopic eruption and potential resorptive situations of resorption in children with displaced canines must
should reduce the number of complications. Annual not be neglected.
clinical investigation, including palpation of the canine
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dental maturity, may show cause for a radiographic illary canines. Acta Odontol Stand 1968;26:145-68.
investigation of the canine position starting at 10 years 2. Ericson S, Kurol J. Radiographic assessment of maxillary canine
of age at the latest,*.” and may help to reduce the eruption in children with clinical signs of eruption disturbance.
Eur J Orthod 1986;8:133-40.
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3. Hitchin AD. The impacted maxillary canine. Br Dent J
bances. This is especially important because it has been 1956;100:1-14.
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and rapid.5.20.29.31 It is noteworthy that in the resorption 19:194-204.
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physiologic root resorption. Thus the discovery of such
1970-1;57:149-57.
normal primary root resorption is no guarantee that the 6. Ericson S, Kurol J. Radiographic examination of ectopically
canine is free from complications. erupting maxillary canines. AM J ORTHOD DENTOFAC ORTHOP
Resorption may occur as early as 10 years of age 1987;91:483-92.
but the prevalence of such unfortunate resorption and 7. van der Linden FPGM, Dutterloo HS. Development of the human
dentition. An atlas. Hagerstown, Maryland: Harper & Row,
the degree of resorption seem to be 10w.~ Therefore
1976.
general radiographic screening at this age is not rec- 8. Ericson S, Kurol J. Resorption of permanent incisors due to
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Numhrr 6

9. Marks SC Jr, Cahill DR. Regional control by the dental follicle 21. Dewel BF. The upper cuspid. Its development and impaction.
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J Oral Path01 1987:16:164-9. 22. Bass TB. Observations on the misplaced upper canine tooth.
10. Ericson S, Kurol J. Longitudinal study and analysis of clinical Dent Pratt 1967;18:25-33.
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Epidemiol 1986;14:172-6. schlingung retinierter oberer Schneide- und Eckzlhne. Dtsch
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cephalostat and its performance. Dentomaxillofac Radio1 1975: 24. Richardson A, McKay C. Delayed eruption of maxillary canine
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12. Nie N, Hull CH, Jenkins JG, Steinbrenner K, Bent DH. Statis- 1982;12:15-25.
tical package for the social sciences. 2nd ed. New York: 25. Jacoby H. The etiology of maxillary canine impactions. t\M J
McGraw-Hill, 1975. ORTHOD 198384: 125-32.
13. Gustafson G, Koch G. Age estimation up to 16 years of age 26. Cugat Femandez de la CA, Asensi CC, Gascon MF. Aplicacion
based on dental development. Odontol Revy 1974;25:297-306. de la tomogralia multidirectional al estudio de piezas dentarias
14. Hays WL. Statistics for the social sciences. 2nd ed. New York: incluidas. Acta Estomatokjgica Valenciana 1986; I :3- 10.
Holt, Rinehart & Winston, 1973:414-24. 27. Ericson S, Kurol J. CT diagnosis of ectopicaily erupting max-
15. Guilford JP. Introduction to analysis of variance. In: Funda- illary canines. A case report. Eur J Orthod 1988: 10: 115-2 1.
mental statistics in psychology and education. 4th ed. New York: 28. Hotz R. Orthodontics in daily practice. Bern, Switzerland: Hans
McGraw-Hill, 1965:268-303. Huber, 1974:340-53.
16. Coupland MA. Localisation of misplaced maxillary canines. Or- 29. Moss JP. The unerupted canine. Dent Pratt 1972:22:241-8.
thopantomograph and P.A. skull views compared. Br J Orthod 30. Kisling E, Ravn E. Two cases of marked pressure resorption in
1984:11:27-32. maxillary incisors. Tandlaegebladet 1977;81: 153-5.
17. McDavid WD. Tronje G, Welander U, Morris CR, Nummikoski 3 1. Brown ID, Matthews RW. Apical resorption of a maxillary lateral
P. Imaging characteristics of seven panoramic X-ray units. J Int incisor from a misplaced canine in 17-year old. A case report.
Assoc Dent Maxillofac Radio1 1985[suppl 81. Br J Orthod 1981;8:3-5.
18. Townend PI. Resorption of the roots of upper incisor teeth due
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to misplaced canine teeth. Trans Br Sot Study Orthod 1967:
Dr. Jiiri Kurol
74-7.
Department of Orthodontics
19. Sasakura H. Yoshida T, Murayama S, Hanada K, Nakajima T.
The Institute for Postgraduate Dental Education
Root resorption of upper pennanent incisor caused by impacted
Jimvagsgatan 9
canine. An analysis of 23 cases. Int J Oral Surg 1984;13:299-
S-552 55 Jijnkoping
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Sweden
20. Kettle MA. Treatment of the unerupted maxillary canine. Trans
Br Sot Study Orthod 1957:74-84.
 Original Article

Dentoskeletal Features Associated with Unilateral or Bilateral

Palatal Displacement of Maxillary Canines
Raffaele Sacerdoti, DDS, PhDa; Tiziano Baccetti, DDS, PhDb

Abstract: The aim of the present study was to analyze the prevalence and distribution of palatally
displaced maxillary canines (PDC) in a large orthodontic population, and to investigate the associations
between PDC, craniofacial features, and other dental anomalies such as aplasia or small-sized upper lateral
incisors. An initial sample of 5000 subjects was evaluated. The reference values were calculated in a
control group of 1000 subjects that was extracted from the initial sample. Chi-squared tests were used for
statistical comparisons. The prevalence rate of PDC was 2.4%, with a male-to-female ratio of 1:3. PDC
subjects with low angle vertical relationships showed a significantly high prevalence rate (60.2%). Uni-
lateral PDC was significantly associated with aplasia of upper lateral incisors, whereas bilateral PDC was
associated with aplasia of third molars. PDC showed reciprocal significant associations with bilateral small-
sized upper lateral incisors. None of the three hypotheses offered in support of the ‘‘guidance theory’’ in
the etiology of PDC were corroborated by the findings of the present study. The occurrence of other dental
anomalies concurrent with PDC, sex differences, and the bilateral expression of PDC, all confirm the
genetic component in the etiology of this tooth disturbance. (Angle Orthod 2004;74:723–730.)
Key Words: Palatally displaced canine, Impacted canine, Dental anomalies, Aplasia of upper lateral
incisors, Small-sized upper lateral incisors, Hypodivergency

INTRODUCTION genetic origin of PDC, ie, familial occurrence,8 bilateral oc-

The palatal eruption or the impaction of the maxillary
permanent canine is an important chapter of oral pathology
and represents frequently faced problems in clinical ortho-
dontics. Two major theories have been proposed to explain
the occurrence of palatally displaced maxillary canines
(PDC), ie, the ‘‘guidance’’ theory and the ‘‘genetic’’ theory.
According to the guidance theory, local conditions are re-
sponsible for the displacement of the canine.1–6 While erupt-
ing, the canine lacks the guide that, in normal conditions,
would be provided by the root of the lateral incisor because
of hypoplasia or aplasia of this tooth. The genetic theory
assigns the eruption anomaly of the upper permanent canine
to a multifactorial complex that controls the expression of
other, possibly concurrent, tooth anomalies.7 Peck et al7
have also indicated multiple evidential categories for the
a
Research Associate, Department of Orthodontics, The University
of Florence, Florence, Italy.
b
Assistant Professor, Department of Orthodontics, The University
of Florence, Florence, Italy and Thomas M. Graber Visiting Scholar,
Department of Orthodontics and Pediatric Dentistry, School of Den-
tistry, The University of Michigan, Ann Arbor, MI.
Corresponding author: Tiziano Baccetti, DDS, PhD, Department of
Orthodontics, The University of Florence, Via del Ponte di Mezzo,
46-48, 50127 Florence, Italy (e-mail: tbacc@tiscali.it).
Accepted: December 2003. Submitted: October 2003.
! 2004 by The EH Angle Education and Research Foundation, Inc.
currence (17–45%), sex differences (indicating involvement
of the sexual chromosomes), differences in prevalence rates
among different populations, and increased occurrence of
other concomitant dental anomalies.
The search for associated dental anomalies is one of the
most relevant methods to investigate into the genetic de-
terminants of PDC.7,9 The spectrum of possible associations
among tooth anomalies had been studied by Hoffmeister
between 1975 and 1985.10 The following manifestations
were found over three generations of a family: multiple
missing teeth (aplasia of upper lateral incisors included),
peg-shaped incisors, ectopic eruption of maxillary first per-
manent molars, and intraosseous displacement of maxillary
canines.
In 1992 Bjerklin et al11 investigated the associations
among four tooth and eruption disturbances (ectopic erup-
tion of first molars and of maxillary canines, infraocclusion
of primary molars, and aplasia of premolars). The findings
indicated the presence of significant reciprocal associations.
These results were interpreted supporting the hypothesis of
a common, presumably hereditary, etiology for the studied
tooth disturbances, each disturbance having incomplete
penetrance. A very high prevalence of associated tooth
anomalies (70%) was calculated by Baccetti in 1993 in a
sample of 169 inherited syndromes presenting with tooth
disturbances, strongly suggesting the possibility of genetic

723 Angle Orthodontist, Vol 74, No 6, 2004

724 SACERDOTI, BACCETTI

relationships between tooth number, size, shape, and struc-

ture characteristics.12 These relationships have been con-
firmed further in the studies by Baccetti13 in 1998 and by
Leifert and Jonas14 in 2003. The existence of associations
between different tooth anomalies is not only important
from an etiologic point of view but also relevant clinically
because the early diagnosis of one anomaly may indicate
an increased risk for later appearance of others. However,
information is not definitive about the differential role
played by aplasia or small-sized upper lateral incisors (SSI)
in subjects with PDC, especially with reference to a pos-
sible evaluation of the guidance theory.
Canine malpositions and agenesis of at least one tooth
are abnormalities known to occur together frequently. Peck
et al15,16 evaluated the site specificity of tooth agenesis as-
sociated with the occurrence of different categories of ca-
nine malpositions. PDC appeared to be associated with a FIGURE 1. Description of study groups (numbers refer to subjects).
significantly increased prevalence for aplasia of at least one
third molar. This type of dental anomaly could be ascribed
to the so-called posterior orofacial field, ie, a condition of (Figure 1). All subjects were observed before any ortho-
increased susceptibility to developmental defects in the dis- dontic treatment. Dental casts, intraoral photographs, and
tal elements of a dental series.17,18 radiographic material (panoramic X-ray, lateral cephalo-
The correlations between PDC and dentoskeletal char- grams) of all subjects were examined. A group of 150 sub-
acteristics in the sagittal plane (molar relationships and sag- jects was excluded from the initial sample because of the
ittal maxillomandibular discrepancy) have been described presence of complex craniofacial malformations, cleft lip
in the past.19–21 No significant associations with any class or palate (or both), sequelae of traumatic injuries to the
I, II, or III craniofacial patterns have been reported. The teeth, odontomas, or cysts. Another 230 subjects were ex-
literature does not provide information regarding the ver- cluded because of incomplete or inadequate records, racial
tical skeletal relationships in association with PDC. How- diversity (only Caucasian subjects were included in the
ever, an increased prevalence of an occlusal deep bite char- study), familial relationships with other examined subjects,
acteristic has been described in PDC subjects.14 and severe tooth crowding within the dental arches.
The aim of the present study was to analyze the preva- The remaining sample of 4620 subjects was divided ran-
lence and the distribution of palatal displacement of the domly into two groups. The first group of 1000 subjects
maxillary canine in a large orthodontic population to pro- contained 468 males and 532 females and was used as a
vide evidence concerning the existence of significant recip- control group. The ‘‘reference’’ prevalence rates for the ex-
rocal associations between PDC, skeletal features, and other amined parameters were calculated for this group. The re-
dental anomalies such as aplasia or small-sized upper lateral maining 3620 subjects comprised the sample from which
incisors and to indicate the etiological and clinical rele- the experimental groups were derived.
vance of such associations. In addition to sex distribution and age, the following den-
The specific objectives of the present study were to: tal and craniofacial parameters were examined. Palatal dis-
placement of maxillary canines (Figure 2): the intraosseous
• determine the prevalence and the sex distribution of PDC
palatal position of the upper permanent canines, unilaterally
in a large orthodontic population;
or bilaterally, was evaluated on the basis of panoramic and
• analyze site-specificity of tooth aplasia concurrent with
periapical radiographs. Small-sized maxillary lateral inci-
PDC, as well as the craniofacial skeletal characteristics
sors: unilaterally or bilaterally (Figure 2), defined as a se-
associated with PDC;
vere crown-size reduction of the lateral incisors, in some
• evaluate the guidance theory in the etiology of PDC;
cases associated with a certain degree of narrowing in di-
• assess the significance and reciprocity of the associations
ameter from the cervix to the incisal edge (peg-shaped lat-
between PDC and other types of tooth disturbances in-
eral incisors).22 A milder version of the latter form was
volving the upper lateral incisor primarily.
considered as well in those cases showing a slight tapering
of the crown from gingival to incisal (‘‘screwdriver-head’’
MATERIALS AND METHODS
crown of the maxillary lateral incisor). Aplasia of maxillary
An initial sample of 5000 subjects (2347 males and 2653 lateral incisors, second premolars, and third molars (Figure
females), 7 to 17 years old, from the files of the Department 2): the diagnosis, unilaterally or bilaterally, was made on
of Orthodontics of the University of Florence was examined dental casts and panoramic radiographs. Craniofacial skel-

Angle Orthodontist, Vol 74, No 6, 2004

DENTOSKELETAL FEATURES AND PDC
FIGURE 2. Bilateral palatally displaced maxillary canines, bilateral small-sized upper lateral incisors, and aplasia of lower left second premolar
in a 9-year-old female subject.
FIGURE 3. Cephalometric measurements for sagittal and vertical
skeletal relationships.
etal relationships (Figure 3): the evaluation of the skeletal
relationships was performed on the lateral cephalograms
using the angular measure A-N-B for the sagittal relation-
725
ships and the angular measure S-N/Go-Gn for the vertical
relationships.
Reproducibility of the diagnosis was assessed by reex-
amining the records of 100 subjects one month after the
first examination by one single operator (Dr Sacerdoti). Re-
producibility was 100% for all dental anomalies except for
small-sized maxillary lateral incisors (94%). Accuracy of
cephalometric measurements was tested by means of Kappa
test, and it was 0.96. Measurement error for the cephalo-
metric angles was smaller than 1!.
The study was divided into the following three sections
with respect to the three specific aims of the research de-
sign.
Prevalence and distribution study
The objective of this section of the study was the as-
sessment of: prevalence rate of PDC; unilateral-bilateral ra-
tio of PDC; male-female ratio of PDC; sagittal skeletal re-
lationships in PDC subjects, defined as skeletal class I when
A-N-B values ranged between 0! and 4!, skeletal class II
when they were greater than 4!, and skeletal class III when
they were smaller than 0!; vertical skeletal relationships in
PDC subjects, defined as normodivergent when S-N/Go-Gn
values ranged between 27! and 37!, hypodivergent when
they were smaller than 27!, hyperdivergent when they were
greater than 37!; prevalence rates of aplasia of third molars,
second premolars, and upper lateral incisors in PDC sub-
jects. This ratio was calculated by taking into consideration
first, the total number of the PDC cases, then the unilateral
ones and, finally, the bilateral ones with the goal of testing
how PDC associates with the specific expression of ‘‘pos-
terior-field hypodontia.’’16
Angle Orthodontist, Vol 74, No 6, 2004
726 SACERDOTI, BACCETTI

These prevalence and distribution rates were compared TABLE 1. Prevalence Rates of Examined Tooth Anomalies and
Other Features in the Control Group (n " 1000)
statistically with those assessed in the control group.
Aplasia of lateral incisors 4.4%
Aplasia of lateral incisors (unilateral) 2.4%
Evaluation of the guidance theory Aplasia of lateral incisors (bilateral) 2.0%
Aplasia of second premolars 3.6%
This section was aimed at testing the guidance etiologic Aplasia of third molars 20.7%
theory proposed by Becker and coworkers2–6 by means of Small size of lateral incisors 3.8%
a study of the associations between PDC and upper lateral Small size of lateral incisors (unilateral) 2.4%
incisor features. From the experimental sample of 3620 Small size of lateral incisors (bilateral) 1.4%
Palatally displaced maxillary canines 2.4%
subjects, a group of 138 subjects was selected who pre- Palatally displaced maxillary canines (unilateral) 1.8%
sented at least one or more of the following anomalies: Palatally displaced maxillary canines (bilateral) 0.6%
PDC, aplasia of the upper lateral incisors (AI), and small Males 46.8%
size of upper lateral incisors (SSI). A clinical substantiation Females 53.2%
of the guidance theory would have fulfilled the following Hypodivergent 33.0%
Hyperdivergent 21.0%
requirements: prevalence rate for homolateral unilateral Normodivergent 39.0%
small-sized lateral incisors (SSIu) significantly higher than Skeletal class I 48.0%
the prevalence rate for bilateral small-sized lateral incisors Skeletal class II 32.0%
(SSIb) in subjects who presented with unilateral PDC Skeletal class III 20.0%
(PDCu); prevalence rate for bilateral AI (AIb) significantly
higher in subjects with bilateral PDC (PDCb) than PDCu;
and prevalence rate of homolateral unilateral AI (AIu) sig- eral expression of the anomaly; and reciprocal associations
nificantly higher than contralateral unilateral aplasia in sub- between PDC and AIu, AIb, SSIu, SSIb.
jects with PDCu.
Statistical analysis
Significance and reciprocity of the associations All comparisons of prevalence rates were carried out by
between PDC and other developmental means of chi-squared tests (SAS 6.12, Statistic Analysis
disturbances of the upper lateral incisors System Institute, Cary, NC). Yates’ correction was applied
when appropriate. Level of significance was set at P # .05.
The aim of the third section of the study was to evaluate
the existence of significant reciprocal associations between RESULTS
PDC and different types of dental anomalies, with special
The prevalence rates of tooth anomalies and other fea-
emphasis on the features of the upper lateral incisors, and
tures of the control group are shown in Table 1.
to side specificity of the anomaly.
Six types of dental anomalies were considered: PDCu;
Prevalence and distribution study
PDCb; AIu; AIb; SSI—unilateral (SSIu); and SSI—bilat-
eral (SSIb). The prevalence of PDC in the experimental group was
Six groups of 20 subjects with one primarily diagnosed 88 subjects (2.43%). Unilateral-bilateral ratio of PDC was
type of tooth anomaly each were extracted from the exper- 58:30 subjects. Therefore, the prevalence rate for PDCb
imental group (3620 subjects). The individuals belonging was 34%. The M-F ratio in PDC subjects was 23:65, which
to one of the six groups were not concomitantly present in approximates a M-F ratio of 1:3.
any of the other five groups. The prevalence rates of the The prevalence rates for sagittal skeletal relationships in
five other types of dental anomalies in association with the PDC subjects were 15 class III subjects (17%), 27 class II
primarily diagnosed dental anomaly were calculated for subjects (31%), and 46 class I subjects (52%) (Table 2).
each of the six groups (according to the method of Bjerklin These data reproduce closely the standard prevalence rates
et al10 and Baccetti11). The prevalence rates of dental anom- for the three sagittal skeletal classes in orthodontic popu-
alies associated with the primarily diagnosed anomaly in lations, as shown by the rates in the control group (Table
the six groups of 20 subjects each were compared statisti- 1).
cally with the prevalence rates in the control group of 1000 The prevalence rates for vertical skeletal relationships in
subjects. Associations between anomalies that were recip- PDC subjects were 53 hypodivergent subjects (60.2%), 13
rocally exclusive were not considered (eg, bilateral SSIu in hyperdivergent subjects (14.8%), and 22 normodivergent
the group with AIb). subjects (25%) (Table 2). The prevalence rate for hypodiv-
To investigate further into the specific role played by ergent subjects in the control group was significantly small-
aplasia or SSIu in subjects with PDC, other associations er (33%) (Table 1).
and prevalences were calculated: reciprocal associations be- The prevalence rate for aplasia of third molars was sig-
tween PDC, SSI, and AI, regardless of the unilateral-bilat- nificantly greater in PDCb subjects than in the control

Angle Orthodontist, Vol 74, No 6, 2004

DENTOSKELETAL FEATURES AND PDC 727

TABLE 2. Prevalence and Distribution Study (n " 88). Statistical Analysis

Primarily
Diagnosed Associated Dental Prevalence in the
Dental Anomaly Anomaly/Feature Prevalence (%) Control Group (%) $2
PDCa Third molars aplasia 21.5 20.7 0.03
PDC Second premolars aplasia 7.9 3.6 2.97
PDC Upper lateral incisor aplasia 11.9 4.4 2.75
PDCb Third molars aplasia 36.6 20.7 4.4*
PDCb Second premolars aplasia 10 3.6 1.75
PDCb Upper lateral incisor aplasia 6.6 4.4 0.02
PDCu Third molars aplasia 13.7 20.7 1.61
PDCu Second premolars aplasia 6.8 3.6 0.86
PDCu Upper lateral incisor aplasia 18.9 4.4 20.7*
PDC Female sex 73.8 53.2 13.1*
PDC Hypodivergence 60.2 33 26.2*
a
PDC indicates palatal displacement of maxillary canines; PDCb, PDC bilateral; and PDCu, PDC unilateral.
* Significant comparisons with control group (P # .05).

group (Tables 1 and 2). The prevalence rate for AI was

significantly greater in PDCu subjects than in the control
group (Tables 1 and 2). The occurrence of aplasia of second
premolars was similar in PDCu and PDCb subjects and in
the control group (Tables 1 and 2).

Evaluation of the guidance theory

The prevalence rate for homolateral unilateral small-

sized upper lateral incisors was not significantly higher than
the prevalence rate for bilateral small-sized upper lateral
incisors in subjects with PDCu. On the contrary, the bilat-
eral presence of small-sized upper lateral incisors in PDCu
cases was significantly more prevalent than the unilateral
presence of the tooth size anomaly. A total of 35 subjects
showed the association between PDCu and unilateral or bi-
lateral small-sized maxillary lateral incisors. Of these, six
subjects (17%) presented with homolateral unilateral small-
sized upper lateral incisors, 26 subjects (74%) with bilateral
small-sized upper lateral incisors, and three subjects (9%)
with contralateral unilateral small-sized upper lateral inci-
sors.
The prevalence rate for AIb was not higher in PDCb as
compared with PDCu subjects. The prevalence rate for the
two groups was identical with 2 of 30 (6.6%) PDCb sub-
jects showing bilateral aplasia of lateral incisors and 2 of
30 (6.6%) PDCb subjects showing unilateral aplasia of lat-
eral incisors.
The prevalence rate for homolateral AIu was not higher
than contralateral unilateral aplasia in PDCu subjects. Once
again, the prevalence rate for the two groups was identical:
5 of 58 (8.6%) PDCu subjects showing homolateral unilat-
eral aplasia of upper lateral incisors, 5 of 58 (8.6%) PDCu
subjects showing contralateral unilateral aplasia of upper
lateral incisors. None of the three proposed hypotheses in
support of the guidance theory was corroborated by the
findings of the present study.
FIGURE 4. Graphical representation of the associations between
unilateral and bilateral forms of examined dental anomalies.
Significance and reciprocity of the associations
between PDC and other developmental
disturbances of the upper lateral incisor
The results of the comparisons between the prevalence
rates for the dental anomalies associated with the primarily
diagnosed anomaly in the six subgroups of 20 subjects each
and the prevalence rate of dental anomalies in the control
group are shown in Figure 4 and Table 3.
The groups with PDCu and PDCb showed significant
reciprocal associations with bilateral small-sized lateral in-
cisors (SSIb). On the other hand, no significant association
with unilateral small-sized upper lateral incisors (SSIu) was
found with the exception of a significantly higher preva-
lence rate of PDCu in subjects with SSIu. The groups with
PDCu and PDCb did not show any significant reciprocal
associations with lateral incisors aplasia with the exception
of a significantly higher prevalence rate of PDCu in sub-
jects with AIu. AIu on one side of the upper arch presented

Angle Orthodontist, Vol 74, No 6, 2004

728 SACERDOTI, BACCETTI

TABLE 3. Prevalence Rate and $2 Test for The Analysis of Associations Between Tooth Anomaliesa
Primarily
PDCu PDCb AIu AIb SSIu SSIb
Diagnosed
Dental Anomaly Prev. $2
Prev. $
2
Prev. $2
Prev. $2
Prev. $
2
Prev. $2
PDCu — —b 2/20 2.01 0/20 0.49 0/20 0.49 8/20 79.3*
PDCb — — 1/20 0.98 0/20 0.12 0/20 0.12 12/20 365.5*
AIu 6/20 43.10* 0/20 0.00 — — 6/20 43.10* — —
AIb 0/20 0.40 2/20 2.75 — — — — — —
SSIu 5/20 28.5* 1/20 0.55 18/20 381.1* — — — —
SSIb 12/20 271.1* 8/20 120.8* — — — — — —
a
PDCu indicates palatally displaced maxillary canines, unilateral; PDCb, PDC bilateral; AIU, aplasia of upper lateral incisors, unilateral; AIb,
AI bilateral; SSIu, small-sized upper lateral incisor, unilateral; and SSIu, SSI, bilateral.
b
— indicates reciprocally exclusive.
* Significant comparisons with control group (P # .05).

FIGURE 6. Graphical representation of the associations between

FIGURE 5. Graphical representation of the associations between palatally displaced maxillary canines and unilateral or bilateral forms
palatally displaced maxillary canines, aplasia of upper lateral incisors of aplasia of upper lateral incisors and small-sized upper lateral in-
and small-sized upper lateral incisors. cisors.

TABLE 4. Prevalence Rate and $2 Test for the Analysis of Asso-

ciations Between PDC, AI, SSI Groupsa
associations between PDC and bilateral size anomaly of the
upper lateral incisor, in the absence of any association with
Primarily
PDC AI SSI the bilateral aplasia of the same tooth (Figure 6; Table 5).
Diagnosed
Dental Anomaly Prev. $
2
Prev. $2
Prev. $2
DISCUSSION
PDC 3/40 2.2 20/40 203.5*
AI 9/40 22.4* — —b The aim of the present study was to analyze the preva-
SSI 26/40 238.9* — — lence and distribution of PDC in an orthodontic sample.
a
PDC indicates palatally displaced maxillary canine; AI, aplasia of PDC was examined also with regard to possible associa-
upper lateral incisors; and SSI, small-sized upper lateral incisors. tions with other dental and craniofacial features. In partic-
b
— Reciprocally exclusive.
ular, the associations between PDC and third molar aplasia,
* Significant comparisons with control group (P # .05).
second premolar aplasia, upper lateral incisor aplasia, and
small size of upper lateral incisors were studied. The prev-
with a significant reciprocal association with small-sized alence rate of PDC was 2.4%, in agreement with previous
upper lateral incisor (SSIu) on the other side. studies on orthodontic populations.7,8,13 However, the prev-
Considering the groups regardless of the unilateral or bi- alence rates of dental anomalies in the present study do not
lateral expression of the anomaly, significant reciprocal as- necessarily reflect the prevalence rate of these anomalies in
sociations between canine displacement and the size anom- the general population because of the fact that the examined
aly of the upper lateral incisor were found (Figure 5; Table subjects had been referred to an orthodontic department.
4). The study of the associations between PDC and AIu, PDC was bilateral in more than one-third of the sample,
AIb, SSIu, SSIb revealed statistically significant reciprocal and the M-F ratio was 1:3. These data confirm a genetic

Angle Orthodontist, Vol 74, No 6, 2004

DENTOSKELETAL FEATURES AND PDC
TABLE 5. Prevalence Rate and $2 Test for the Analysis of Associations Between PDC, AIu, AIb, SSIu, SSIb Groupsa
Primarily
PDC AIu
Diagnosed
Dental Anomaly Prev. $ 2
Prev.
PDC 3/40
AIu 6/20 43.10*
AIb 2/20 2.32
SSIu 6/20 43.11*
SSIb 20/20 561.4*
a
PDC indicates palatally displaced maxillary canines; AIu, aplasia of upper lateral incisors, unilateral; AIb, bilateral; SSIu, small-sized upper
lateral incisor, unilateral; and SSIb, SSI bilateral.
* Significant comparisons with control group (P # .05).
component in the etiology of this tooth malposition with a
possible involvement of the sexual chromosomes.7
A section of the present investigation was dedicated to
the analysis of the prevalence rates for tooth agenesis in
PDC subjects. Peck et al15,16 had suggested site specificity
of tooth agenesis in PDC subjects, with the maxillary ca-
nine malposition associated with third molar agenesis in the
absence of an increased prevalence rate for aplasia of upper
lateral incisors. The present study analyzed these issues in
a more detailed manner and revealed the existence of the
association indicated by Peck and coworkers in subjects
with PDCb, whereas PDCu was associated with AI. Dif-
ferent orofacial genetic fields appear to be linked to the
PDCu or PDCb. The genetic mechanisms underlying PDC
deserve to be elucidated further regarding the role of site
specificity of associated dental anomalies vs the PDCu or
PDCb phenotype of PDC.
One of the aims of the present study was to verify clin-
ically the possible role of the size anomaly or aplasia of
the upper lateral incisors as a local factor in the etiopatho-
genesis of PDC according to the so-called guidance theo-
ry.2–6 The investigation model of the study of associated
dental anomalies allowed the testing of three hypotheses
offered to support the theory. According to the present find-
ings, none of the three hypotheses was corroborated. PDCu
was associated with unilateral small-sized lateral incisors
on the PDC side of the dental arch in a very limited per-
centage of the cases (17%). In the vast majority of the cases
(about three-quarters), PDCu was associated with bilateral
small-sized lateral incisors. In 9% of the cases, unilateral
small-sized lateral incisors were found opposite to the
PDCu side of the dental arch. The prevalence rate for ho-
molateral AIu was not significantly greater than the prev-
alence for contralateral unilateral aplasia in PDCu subjects.
The percentage of subjects with AIu on the PDC side of
the dental arch was only 8.6%.
Reciprocal associations between PDC and aplasia or SSI
were investigated according to the methodology proposed
by Bjerklin et al11 and by Baccetti12 for the identification
of a shared genetic component in the etiology of these tooth
disturbances. Specific attention was devoted to the unilat-
eral or bilateral expression of the dental anomaly.
729
AIb SSIu SSIb
$2
Prev. $2
Prev. $2
Prev. $2
1.85 0/40 0.22 0/40 0.22 20/40 203.4*
Both PDCu and PDCb demonstrated significant reciprocal
associations with bilateral small-sized upper lateral incisors.
On the contrary, no significant association was found be-
tween PDCu and PDCb and aplasia of the lateral incisors,
with the exception of a significantly greater prevalence rate
for PDCu in subjects with unilateral aplasia. When the three
dental anomalies were taken into account regardless of uni-
lateral or bilateral expression, both the presence of a signif-
icant reciprocal association between PDC and small-sized
upper lateral incisors and the absence of a significant recip-
rocal association between PDC and aplasia of upper lateral
incisors were confirmed. Finally, the existence of a signifi-
cant reciprocal association between aplasia of the lateral in-
cisor on one side of the upper dental arch and small-sized
lateral incisor on the opposite side of the arch in the same
subjects was corroborated.12,23–25
The relationship between PDC and craniofacial skeletal
characteristics in the anteroposterior plane (sagittal maxil-
lomandibular discrepancy) has been investigated in the past,
with no significant associations with any specific craniofa-
cial pattern (class I, II, or III) being described.19–21 The re-
sults of the present study confirm that the distribution of
categories of sagittal skeletal relationship in subjects with
intraosseous malposition of the maxillary canines is very
similar to standard orthodontic populations. Evidence has
been gathered here, for the first time, that reveals a signif-
icant association between vertical craniofacial features and
PDC. The prevalence rate for hypodivergent cases in the
PDC subjects was three times greater than in control sub-
jects.
To summarize, three of the five categories of clinical ev-
idence proposed by Peck and coworkers7 in support of a
genetic component in the etiology of PDC have been con-
firmed by the results of the present study. In particular, the
canine malposition is significantly associated with a size
defect of the upper lateral incisor, especially in bilateral
forms. Bilateral expression of PDC occurs frequently, and
the prevalence of PDC is significantly greater in females
than in males. According to the parameters investigated
here, a triad of signs appear to be linked with PDC ex-
pression in growing subjects. More than 25% of PDC sub-
jects examined in this study presented with: (1) female sex,
Angle Orthodontist, Vol 74, No 6, 2004
730
(2) hypodivergent vertical skeletal relationships, and (3)
SSIb. The early recognition of the concurrence of these
three characteristics may aid in the identification of those
subjects who will develop a palatal displacement of the
maxillary canine.
CONCLUSIONS
The PDC has shown a significant reciprocal association
with SSI. Both PDCb and PDCu are significantly associated
with bilateral small-sized upper lateral incisors.
PDCu exhibited a significant association with AI. PDCb
was significantly associated with aplasia of third molars.
The concurrence of other dental anomalies with PDC,
significant differences in sex distribution, and the high
prevalence rate for PDCb confirm the genetic component
in the etiology for this tooth disturbance, at least for its
bilateral form.
ACKNOWLEDGMENT
The authors wish to thank Professor Isabella Tollaro, Head of the
Department of Orthodontics, University of Florence, for providing
access to the Department of Orthodontics’ files.
REFERENCES
1. Miller BH. The influence of congenitally missing teeth on the
eruption of the upper canine. Dent Pract Dent Rec. 1963;13:497–
504.
2. Becker A, Smith P, Behar R. The incidence of anomalous max-
illary lateral incisors in relation to palatally-displaced cuspids.
Angle Orthod. 1981;51:24–29.
3. Becker A, Zilberman Y, Tsur B. Root length of lateral incisors
adjacent to palatally-displaced maxillary cuspids. Angle Orthod.
1984;54:218–225.
4. Brin I, Becker A, Shalhav M. Position of the maxillary permanent
canine in relation to anomalous or missing lateral incisors: a pop-
ulation study. Eur J Orthod. 1986;8:12–16.
5. Zilberman Y, Cohen B, Becker A. Familial trends in palatal ca-
nines, anomalous lateral incisors, and related phenomena. Eur J
Orthod. 1990;12:135–139.
6. Becker A, Sharabi S, Chaushu S. Maxillary tooth size variation
in dentitions with palatal canine displacement. Eur J Orthod.
2002;24:313–318.
7. Peck S, Peck L, Kataja M. The palatally displaced canine as a
dental anomaly of genetic origin. Angle Orthod. 1994;64:249–
256.
8. Pirinen S, Arte S, Apajalahti S. Palatal displacement of canine is
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genetic and related to congenital absence of teeth. J Dent Res.
1996;75:1742–1746.
9. Baccetti T. A controlled study of associated dental anomalies.
Angle Orthod. 1998;68:267–274.
10. Hoffmeister H. Die unterminierende Resorption der zweiten
Milchmolaren als Mikrosymptom der vererbten Störanfälligkeit
der Gebissbildung. Schweiz Mschr Zahnmed 1985:151–154.
11. Bjerklin K, Kurol J, Valentin J. Ectopic eruption of maxillary first
permanent molars and association with other tooth and develop-
mental disturbances. Eur J Orthod. 1992;14:369–375.
12. Baccetti T. Analisi della prevalenza di anomalie dentali isolate ed
associate nelle sindromi ereditarie: modello per la valutazione del
controllo genetico sulle caratteristiche della dentatura. Minerva
Stomatol. 1993;42:281–294.
13. Baccetti T. A clinical and statistical study of etiologic aspects
related to associated tooth anomalies in number size and position.
Minerva Stomatol. 1998;47:655–663.
14. Leifert S, Jonas IE. Dental anomalies as a microsymptom of pal-
atal canine displacement. J Orofac Orthop. 2003;64:108–120.
15. Peck S, Peck L, Kataja M. Site-specificity of tooth agenesis in
subjects with maxillary canine malpositions. Angle Orthod. 1996;
66:473–476.
16. Peck S, Peck L, Kataja M. Concomitant occurrence of canine
malposition and tooth agenesis: evidence of orofacial genetic
fields. Am J Orthod Dentofacial Orthop. 2002;122:657–660.
17. Butler PM. Studies of the mammalian dentition, differentiation of
the post-canine dentition. Proc Zool Soc Lond Ser B. 1939;109:
1–36.
18. Garn SM. Genetics of dental development. In: McNamara JA Jr,
ed. The Biology of Occlusal Development. Monograph 7, Cranio-
facial Growth Series, Ann Arbor, Mich: Center for Human
Growth and Development, University of Michigan; 1977:61–88.
19. Basdra EK, Kiokpasoglou MN, Komposch G. Congenital tooth
anomalies and malocclusion: a genetic link? Eur J Orthod. 2001;
23:145–151.
20. Mossey PA, Campell HM, Luffingham JK. The palatal canine and
the adjacent lateral incisor: a study of a west of Scotland popu-
lation. Br J Orthod. 1994;21:169–174.
21. Franchi L, Vichi M, Defraia E, Gigli G. Indagine epidemiologica
sulla inclusione dei canini superiori. Proceedings 10th S.I.D.O.
Meeting, 1989.
22. Le Bot P, Salmon D. Congenital defects of the upper lateral in-
cisors (ULI): condition and measurements of the other teeth, mea-
surements of the superior arch, head and face. Am J Phys Anthrop.
1977;46:231–244.
23. Alvesalo L, Portin P. The inheritance pattern of missing, peg-
shaped and strongly mesio-distally reduced upper lateral incisors.
Acta Odontol Scand. 1969;27:563–575.
24. Garn SM, Lewis AB. Effect of agenesis on the crown-size profile
pattern. J Dent Res. 1969;48:1314.
25. Lai PY, Seow WK. A controlled study of the association of var-
ious dental anomalies with hypodontia of permanent teeth. Pe-
diatr Dent. 1989;11:291–296.
 J Appl Oral Sci. 2005;13(4):431-6
www.fob.usp.br/revista or www.scielo.br/jaos

ASSOCIATED DENTAL ANOMALIES: CASE REPORT

MÚLTIPLAS ANOMALIAS DENTÁRIAS ASSOCIADAS: CASO CLÍNICO

Daniela Gamba GARIB1, Nildiceli Leite Melo ZANELLA2, Sheldon PECK3

1- DDS, MSc, PhD, Associate Professor of Orthodontics, UNICID, São Paulo, Brazil; Research Fellow, Department of Developmental Biology,
Harvard School of Dental Medicine, Boston, USA.
2- DDS. MSc, PhD, Department of Pedodontics, FOB/USP, São Paulo; Dentist of Health Municipal Secretary of Bauru, São Paulo, Brazil.
3- DDS, MScD, Associate Clinical Professor, Department of Developmental Biology, Harvard School of Dental Medicine, Boston, USA.

Corresponding address: R: Rio Branco no 19-18 - Cep.: 17014480 - Bauru - São Paulo - Brazil - E-mail: dgarib@uol.com.br

Received: June 9, 2005 - Modification: September 26, 2005 - Accepted: September 30, 2005

ABSTRACT
C ertain human dental anomalies frequently occur together, supporting the accumulated evidence of the shared genetic
control of dental developmental disturbances. The present study reports a rare and interesting case of a 12-year-old girl with
an association of multiple dental abnormalities, including agenesis, tooth malposition and delayed development. The etiology
and treatment planning are discussed with reference to the literature. The clinical implications of genetically controlled patterns
of dental anomalies are important in the establishment of early diagnosis and appropriate orthodontic intervention.
Uniterms: Agenesis; Dental anomalies; Orthodontics.

RESUMO
C ertas anomalias dentárias humanas freqüentemente ocorrem concomitantemente, contribuindo para validar as evidências
do controle genético nos distúrbios de desenvolvimento. O presente estudo relata um caso raro e interessante de uma jovem
de 12 anos de idade, com associação de anormalidades dentárias múltiplas, incluindo agenesia, ectopia e atraso no
desenvolvimento dentário. A etiologia e tratamento planejados são discutidos com referência à literatura. As implicações
clínicas do padrão de anomalias dentárias geneticamente controladas são importantes no estabelecimento do diagnóstico
precoce e de adequada intervenção ortodôntica.
Unitermos: Agenesia; Anomalias dentárias, Ortodontia.

INTRODUCTION 3y7m)7, its development can be suppressed until 6 years8,

Tooth agenesis is the most common developmental
anomaly of the human dentition, occurring in 25% of the
population1. The third molar (M3) represents the tooth most
affected with agenesis2, 3, having a prevalence rate of 20.7%2.
In contrast, permanent second molar (M2) agenesis is a rare
occurrence, found in only 2 of 6,000 consecutive orthodontic
patients (0.03%)4.
Excluding the third molars, the prevalence rate of tooth
agenesis is reported as 4.3 to 7.8%4, 5. The mandibular second
premolar (MnP2) is the tooth most often absent, with a
relative frequency of 2.2 to 4.1%4, 5. In fact, the MnP2 is
highly variable developmentally. Besides the high
prevalence of agenesis, the MnP2 often shows significantly
retarded development, especially when there is agenesis of
other permanent teeth6. Despite the fact that the mean initial
calcification age for MnP2 is 3 years (varying from 2y3m to
and some published reports show radiographic appearance
of the MnP2 after the age of 9 and even at 13 years old9, 10. In
addition, the MnP2 accounts for approximately 24% of all
impacted teeth, excluding the third molars11. The most
frequent malposition reported for the unerupted MnP2 is
distoangular development, with a prevalence rate of 0.2% in
dental clinic patients12. This malposition was found to be
associated with agenesis of the contralateral MnP213.
Several investigations suggest a genetic and hereditary
basis for the etiology of dental anomalies of number, size,
position, shape and timing of eruption3, 6, 13-27. Such evidence
is based on family and monozygotic twin studies, and on
observation of associations between certain dental
anomalies. This article aims at presenting a case report of a
non-syndromic young girl with several dental anomalies,
contributing evidence to an understanding of genetically
controlled dental anomaly patterns.

431
 ASSOCIATED DENTAL ANOMALIES: CASE REPORT

Case report
A girl aged 12.1 years was referred to orthodontic
treatment by her pediatric dentist, due to retention of the
mandibular left permanent lateral incisor (32). At diagnosis,
the patient presented with a Class I facial pattern and Class
I malocclusion in the late mixed dentition, with retention of
the mandibular left deciduous lateral incisor and well-aligned
arches. The mandibular dental midline was deviated to the
left (Figure 1).
Initial panoramic dental radiograph (Figure 1f) showed a
cystic formation at the dental follicle of the unerupted 32,
suggesting a dentigerous cyst, which besides leading to its
retention seemed to negatively influence formation of the
mandibular left permanent canine (33), whose eruption was
delayed compared to the fully erupted contralateral canine.
However, retention of the 32 was not the only irregularity
observed. Other notable radiographic features were tooth
agenesis of the mandibular left second premolar,
distoangular position and delayed development of its
unerupted antimere, agenesis of the mandibular right
permanent second molar, and absence of all third molars.

a b

c d

e
FIGURE 1- (a-f) Initial intraoral photographs and panoramic radiograph

432
GARIB D G, ZANELLA N L M, PECK S
The M3 agenesis were confirmed using the later panoramic
radiographs taken after age 14, because that appears to be a
critical age for M3 formation23, 28. The dental age was delayed
as observed in the majority of cases with dental agenesis6,
14
. case report, along with microdontia. Published evidence also
Treatment was initiated by placement of a lingual arch,
extraction of the mandibular left deciduous lateral incisor
and canine, and surgical exposure followed by orthodontic
traction of 32 with closed-eruption technique and cantilever
springs. Extraction of the deciduous mandibular right second
molar was also requested in an attempt to stimulate
spontaneous correction of the eruption pathway of the
mandibular right second premolar10, 29. The post-surgical
histopathological report confirmed the initial assumption of
dentigerous cyst on the mandibular left lateral incisor.
After 6 months of treatment, the mandibular left lateral
incisor reached the oral cavity, and a pre-adjusted mandibular
fixed partial appliance was then bonded for midline
correction and simultaneous space recovery for 33, which
was still able to erupt due to its incomplete root formation.
Eighteen months after deciduous mandibular right
second molar extraction, the succeeding permanent tooth
still displayed the same magnitude of distoangular position
and delayed development, and thus its orthodontic traction
was performed. After 3 months of traction, the mandibular
right second premolar was upright, and after 5 months it
erupted in the oral cavity. In fact, a minor periodontal surgery
was required at completion of orthodontic traction to expose
the crown of that tooth, since it did not perforate the oral
mucosa, but rather only stretched it. Meanwhile, the 33
erupted spontaneously. Thereafter, maxillary and mandibular
fixed appliance was bonded, and corrective orthodontics
was accomplished for further 1 year and 3 months. The
deciduous mandibular left second molar was maintained up
to spontaneous exfoliation, for later replacement by a dental
implant.
The appliance was removed after 3 years and 2 months
of therapy, (Figure 2). At this stage, there was still incomplete
root formation of the mandibular right second premolar, and
the permanent maxillary right second molar (17) was
unerupted (Figure 2f). A retainer was designed to avoid
extrusion of the 17 at completion of eruption, and this retainer
will be kept until completion of growth, when a dental implant
will be placed at mandibular right second molar area.
DISCUSSION
Besides dentigerous cyst causing retention of 32 and
delayed development of the neighboring tooth, 33, this
interesting case displays the concomitant occurrence of five
remarkable dental anomalies: agenesis of the third molars,
agenesis of the mandibular right permanent second molar,
agenesis of the mandibular left second premolars, and
distoangular position and delayed development of the
mandibular right second premolar. A considerable amount
of evidence exists suggesting that genes play a fundamental
role in the etiology of many dental anomalies of clinical
significance. It has also been inferred that a common genetic
defect may give rise to different phenotypic manifestations,
including tooth agenesis, delayed development and
ectopia10, 13, 14, 22, 23, 25, 30-32, which were observed in the present
suggested that, when a third molar or second premolar is
absent, agenesis of the remaining teeth is more likely to
occur24, 28.
Tooth agenesis clearly has a genetic basis. Grahnen16
conducted a study in children with tooth agenesis and
found that up to half of their siblings and parents also had
tooth agenesis, a high prevalence when compared to the
expected population rate. A twin study interestingly found
a high concordance rate for tooth agenesis in monozygotic
twins, while all dizygotic twin pairs were discordant18. These
studies suggested that the mode of transmission could be
explained by a single autosomal dominant gene with
incomplete penetrance. Recently, Vastardis, et al.26, analyzing
a large family with agenesis of all second premolars and
third molars, identified a mutation in the MSX1 gene on
chromosome 4. It is further suggested that delayed eruption,
as well as microdontia, constitute a partial expressivity of
the same gene leading to tooth agenesis15, 33.
In a sample with unilateral MnP2 agenesis, Shalish, et
al. 13 observed that the contralateral MnP2 tooth bud
presented a mean increase of 10º in the distoangular position
compared to a control group, and thus this alteration in
tooth positioning would constitute a different phenotype
of the same genetic defect that led to tooth agenesis
occurrence. When measured on the panoramic radiograph,
the mean angle formed between the inferior mandibular
border and the long axis of the unerupted MnP2
corresponded to 85.5º in the control group and 75.6º in the
experimental group. A similar situation was observed in the
present case report, yet more severe. The initial mandibular
right second premolar angulation was 25º. On the basis of
literature reports stating that MnP2 malposition usually self-
corrects and the tooth erupts spontaneously in the dental
arch10, 12, 13, 29, a more passive approach was initially adopted,
with extraction of the preceding deciduous tooth. However,
after a 6-month follow-up, there was an improvement of only
5º in the tooth bud angulation, and after one year and a half,
the period expected for spontaneous correction of the
ectopic eruption pathway29, the tooth bud displayed a mild
distal movement, yet still exhibited an angulation of 31º.
The remarkable distoangular malposition of the right MnP2
may have contributed to conservative approach failure,
even though Collett29 has reported a good response to the
same intervention in a case of a MnP2 with its long axis
lying transversely.
Another controversial aspect of the present case is the
approach adopted in the management of the mandibular left
second premolar agenesis. Unilateral orthodontic space
closure would certainly lead to dental midline deviation to
the left34, 35, unless the mesial movement of the permanent
left first molar could be anchored by implants. As recently
described, in earlier stages of mixed dentition, controlled
slicing, hemisection and removal of the distal half of the
433
 ASSOCIATED DENTAL ANOMALIES: CASE REPORT

deciduous second molar followed by further removal of the
mesial portion would led to continuing space closure with
no or minor collateral effects36, 37. However, the mesial drift
of the mandibular first and second molar, considering the
third molar absence, could leave de maxillary second molar
with no antagonist. On the other hand, a longitudinal follow-
up has demonstrated that, in cases with agenesis of
premolars, the deciduous molars may be kept in the oral
cavity for a long period of time38-40. Bjerklin and Bennet38
investigated subjects with agenesis of mandibular second
premolars and retained mandibular second molars from 11
years of age until the third decade of life. During the
observation period, only 2 of the 59 primary teeth were
exfoliated, and beyond the age of 20 years no teeth were
lost. Besides, 45% of the deciduous molars showed no infra-
occlusion and in the teeth affected, the infra-occlusion
increased by less than 1 to 1.4 mm until the age of 18 years.
Complementing this study, Sletten, et al.40 evaluated
longitudinally the retained mandibular deciduous molars in
adults (from 36.1 + 12.9 until 48.5 + 13. 9 years of age). Of the
28 retained deciduous molars, 24 (86%) continued to
function. Only 4 (14%) were lost at a mean age of 51 years
because of caries or periodontal breakdown. Considering
the results and the fact that the average shortening of all

a b

c d

f
e
FIGURE 2- (a-f) Final intraoral photographs and panoramic radiograph.

434
GARIB D G, ZANELLA N L M, PECK S
deciduous root lengths was negligible (0.16mm), the authors
concluded that retention of healthy deciduous mandibular
second molars is a viable treatment alternative.
The only negative aspect of mandibular deciduous
second molar maintenance is the impossibility to finalize
the treatment with a Class I molar relationship at the same
side (Figure 2c). However, extraction of the deciduous tooth
to allow the molar relationship adjustment from Class II to
Class I might lead to significant alveolar bone loss until
growth completion for implant placement41. After being
informed on all these issues, the patient and her family
decided to keep the deciduous second molar, and were aware
of the future prosthetic replacement need in case the
deciduous tooth was exfoliated. The one-year follow-up after
the treatment demonstrated that the deciduous molar
remained unchanged.
The clinical implications of genetically controlled
patterns of dental anomalies are very important. Peck, et
al.23 found certain dental anomalies occurring frequently in
anatomically specific groupings, patterned according to
anterior and posterior orofacial genetic fields. Further, the
early diagnosis of one dental abnormality may alert the
professional to the possible development of others the same
patient or other family members13, 33, sometimes facilitating
appropriate orthodontic intervention.
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5- Rolling S. Hypodontia of permanent teeth in Danish schoolchildren.
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6- Garn S, Lewis A, Vicinus J. Third molar polymorphism and its
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8- Ravn JJ, Nielsen HG. A longitudinal radiographic study of the
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in patients with oligodontia. Angle Orthod. 1993;63(1):31-7.
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its significance to dental genetics. J Dent Res. 1963;42:1344-63.
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second premolar: treatment outcome with orthodontic space closure.
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436
CLINICIAN’S CORNER

Congenitally missing mandibular second

premolars: Clinical options
Vincent G. Kokicha and Vincent O. Kokichb
Seattle, Wash

Introduction: Congenital absence of mandibular second premolars affects many orthodontic patients. The
orthodontist must make the proper decision at the appropriate time regarding management of the edentulous
space. These spaces can be closed or left open. Implications: If the space will be left open for an eventual
restoration, the keys during orthodontic treatment are to create the correct amount of space and to leave the
alveolar ridge in an ideal condition for a future restoration. If the space will be closed, the clinician must avoid
any detrimental alterations to the occlusion and the facial profile. Significance: Some early decisions that the
orthodontist makes for a patient whose mandibular second premolars are congenitally missing will affect his
or her dental health for a lifetime. Therefore, the correct decision must be made at the appropriate time.
Purpose: In this article, we present and discuss various treatment alternatives for managing orthodontic
patients with at least 1 congenitally missing mandibular second premolar. (Am J Orthod Dentofacial Orthop
2006;130:437-44)

C
ongenital absence of mandibular second pre-
molars affects many orthodontic patients. The
orthodontist must make the proper decision at
the appropriate time regarding management of the
edentulous space. These spaces can be closed or left
open. If the space will be left open for an eventual
restoration, the keys during orthodontic treatment are to
create the correct amount of space and to leave the
alveolar ridge in an ideal condition for a future resto-
ration. If the space will be closed, the clinician must
avoid any detrimental alterations to the occlusion and
the facial profile. Some early decisions that the orth-
odontist makes for a patient whose mandibular second
premolars are congenitally missing will affect his or her
dental health for a lifetime. Therefore, the correct
decision must be made at the appropriate time. We
present and discuss various treatment alternatives for
managing orthodontic patients with at least 1 congeni-
tally missing mandibular second premolar.
merged below the occlusal levels of the adjacent teeth
(Fig 1, A). The radiograph of the deciduous tooth
showed that the bone levels between the deciduous
molar and the adjacent permanent teeth were flat (Fig 1,
B). This indicated that the deciduous tooth was not
ankylosed and had erupted evenly with the adjacent
teeth. The mesiodistal width of the deciduous molar
was 13 mm (Fig 1, C); the normal width of an average
mandibular second premolar is 7.5 mm. Although a
single-tooth implant was the planned replacement for
the missing premolar, the patient was too young and
still growing. To preserve the buccolingual bone for an
eventual implant, the deciduous molar was reduced in
width (Fig 1, D and E) and restored with composite
(Fig 1, F and G), and the remaining space was closed to
produce Angle Class I molar and canine relationships
after orthodontic therapy (Fig 1, H and I).
PATIENT 2

PATIENT 1 A girl, age 8 years 3 months, had bilateral

A girl, age 12 years 4 months, was congenitally
missing the mandibular right second premolar. The
deciduous right second molar was present but sub-
From the Department of Orthodontics, School of Dentistry, University of
Washington, Seattle.
a
Professor.
b
Affiliate assisant professor.
Reprint requests to: Vincent G. Kokich, 1950 South Cedar, Tacoma, WA
98405; e-mail, vgkokich@u.washington.edu.
Submitted, March 2006; revised and accepted, May 2006.
0889-5406/$32.00
Copyright © 2006 by the American Association of Orthodontists.
doi:10.1016/j.ajodo.2006.05.025
submerged mandibular second molars (Fig 2, A). The
radiograph (Fig 2, B) showed that the bone levels
between the right deciduous second molar and the
adjacent permanent first molar were angled or
oblique, indicating that the permanent tooth had
continued to erupt. All remaining deciduous teeth
were extracted, no space-maintaining appliances
were placed, and the remaining permanent teeth were
allowed to erupt (Fig 2, C). Even though a significant
vertical bony defect remained immediately after
extraction of the submerged deciduous molar, subse-
quent tooth eruption brought the bone and tissue up
437
438 Kokich and Kokich American Journal of Orthodontics and Dentofacial Orthopedics
October 2006

Fig 1. A, Girl was congenitally missing permanent right mandibular second premolar; deciduous
second molar was present and submerged below occlusal plane. B, radiograph showed that root
had not resorbed. Because bone levels were flat between deciduous and adjacent permanent teeth,
tooth was maintained. C-E, Tooth was too wide, so mesial and distal surfaces were reduced
substantially. F and G, Tooth was built up with composite to reduce caries risk. H-I, Pulp was not
damaged after space was closed and posterior teeth were brought into occlusion.

to their normal levels (Fig 2, D) and eliminated the
alveolar defect. Because the mandibular incisors
were located so far to the lingual aspect (Fig 2, E),
they were proclined labially, and space was opened
between the premolar and the molar (Fig 2, F) for a
single-tooth implant (Fig 2, G). This implant was
restored with a second premolar crown (Fig 2, H),
which helped to reestablish proper occlusion (Fig 2,
I). The bone for the implant was created through
orthodontic implant-site development.
PATIENT 3
This woman was missing her right mandibular
second premolar and first molar. The mandibular sec-
ond molar was in an Angle Class II relationship with
the maxillary first molar (Fig 3, A), and the edentulous
space between the second molar and the first premolar
(Fig 3, B) was too large for 1 tooth and too small for 2
teeth. After initial orthodontic alignment (Fig 3, C), a
diagnostic wax-up was constructed to determine the
precise position for a second premolar implant (Fig 3,
D). After integration of the implant, a provisional
crown was attached (Fig 3, E), and a bracket was placed
on the implant-supported crown (Fig 3, F). The implant
was used as an anchor to move the right mandibular
second molar mesially into an Angle Class I relation-
ship, without jeopardizing orthodontic anchorage, the
position of the remaining anterior teeth (Fig 3, G), or
the patient’s facial profile. The final porcelain crown on
the implant (Fig 3, H) was the appropriate size, and the
eventual posttreatment occlusion was finished in an
ideal Angle Class I relationship (Fig 3, I). The maxil-
lary second molar was left without an occlusal antag-
onist. If the maxillary second molar eventually su-
pererupts, it can be extracted, or an implant can be
placed distally to the mandibular second molar. Using
American Journal of Orthodontics and Dentofacial Orthopedics Kokich and Kokich 439
Volume 130, Number 4

Fig 2. A and B, Girl was missing permanent right and left mandibular second premolars; deciduous first
and second molars were ankylosed and submerged. C and D, All deciduous molars were extracted;
permanent first premolar and first molar drifted together and closed the space. E-H, Because
mandibular incisors were positioned lingually relative to chin, treatment plan involved opening second
premolar space, followed by placement of implant and porcelain crown. I, Treatment plan resulted in
Angle Class I molar and canine relationships.

the implant as an anchor for partial closure of a 2-tooth
space minimized the complexity of the orthodontic
treatment and the restorative management for this
patient.
PATIENT 4
This girl, age 13 years 8 months, had an Angle
Class II malocclusion, with a 5-mm anterior overjet
(Fig 4, A). She had a minor arch-length deficiency in
both arches but was congenitally missing the right
maxillary, and right and left permanent mandibular
second premolars (Fig 4, B). Her maxilla and mandible
were well related (Fig 4, C), and the maxillary and
mandibular incisors were in a relatively normal antero-
posterior position. Extraction of the left maxillary
second premolar and remaining deciduous second mo-
lars and closure of all edentulous spaces would have
been detrimental to her facial profile by overly retract-
ing the lips relative to the chin. The only options for
avoiding the incisor retraction were placement of mini-
implants for anchorage to protract the maxillary and
mandibular first molars, and extraoral anchorage to
achieve the same objective. Because this patient was
treated before the era of mini-implants, a chincup and
elastics were used to slide the maxillary and mandibular
first molars mesially along a continuous archwire. The
posttreatment dental casts (Fig 4, D) show that an
Angle Class I molar relationship was achieved. The
panoramic radiograph (Fig 4, E) shows the amount of
tooth movement, and the cephalometric superimposi-
tion before and after orthodontic treatment (Fig 4, F)
verifies that the mandibular incisors did not move
lingually, but that the mandibular molars moved en-
tirely mesially with the protraction force. Although this
tooth movement required 4 years of orthodontic treat-
ment, the patient has no restorations, and her facial
440 Kokich and Kokich American Journal of Orthodontics and Dentofacial Orthopedics
October 2006

Fig 3. A, Woman was missing right mandibular second premolar and permanent first molar. B and C,
There was too much space for 1-tooth replacement and too little space for 2-tooth replacement. D
and E, Implant was placed in first premolar position and restored. F, Bracket was placed on implant
provisional crown. G, Implant was used to close remaining edentulous spaced. H and I, Width
of final premolar crown was normal, and Angle Class I molar and canine relationships were
achieved.

profile was maintained despite the 3 congenitally miss-
ing premolars.
PATIENT 5
This girl, age 14 years 6 months, was congenitally
missing her left mandibular second premolar (Fig 5, A),
and the deciduous second molar was ankylosed and
submerged. The left maxillary second premolar was
present but delayed in its eruption. After the deciduous
second molar was extracted, substantial bone resorption
with significant vertical and buccolingual narrowing of
the alveolar ridge occurred (Fig 5, B). This ridge defect
would probably have narrowed even further and re-
quired a bone graft before implant replacement. How-
ever, another approach involved moving the first pre-
molar into the second premolar position (Fig 3, C-E);
this created an adequate ridge for the first premolar
implant. When the flap was elevated to place the
implant, sufficient alveolar bone was located distally to
the premolar where the ridge had been deficient (Fig 5,
F). By using the adjacent tooth as the stimulus for
alveolar-site development, no bone graft was necessary
when the implant was placed at 17 years of age, after
cephalometric superimpositions showed that her facial
growth was completed (Fig 5, G). The final crown on
the mandibular implant (Fig 5, H) provided the proper
space and support for the occlusion, and the first
premolar functions nicely in the second premolar posi-
tion (Fig 5, I).
DISCUSSION
Congenital absence of mandibular second premolars
affects many orthodontic patients. The clinician must
make the proper decision at the appropriate time regarding
management of the edentulous space.1 If the space will
be left open for an eventual restoration, the correct
American Journal of Orthodontics and Dentofacial Orthopedics Kokich and Kokich 441
Volume 130, Number 4

Fig 4. A and B, Girl had end-to-end malocclusion with 3 congenitally missing second premolars.
C, Facial profile was ideal. D, To avoid future restorations and prevent negative facial changes,
chincup and elastics were used to protract maxillary and mandibular molars into Angle Class I
relationship. E and F, Significant tooth movement eliminated need for extensive restorative dentistry
without jeopardizing facial profile.

amount of space must be created and the alveolar ridge
must be left in an ideal condition for a future restora-
tion. In the past, either conventional bridges or resin-
bonded bridges were used to fill edentulous spaces.
However, full-coverage conventional bridges in young
patients can result in devitalization of the pulp and
require root canal therapy.2 Resin-bonded posterior
bridges have questionable survival rates.3-5 Today, the
first choice of restoration for a congenitally missing
mandibular premolar should be a single-tooth implant.6
But if the implant cannot be placed until the patient’s
facial growth is complete, how should the edentulous
ridge be preserved?
Ostler and Kokich7 evaluated the long-term
changes in the width of the alveolar ridge after extract-
ing deciduous mandibular second molars. Their data
showed that the ridge narrows by 25% during the first
4 years after deciduous tooth extraction. After 7 years,
the ridge narrows another 5%, for a total reduction of
30% over 7 years. However, the authors showed that
these ridges were still broad enough to receive a dental
implant. Unfortunately, the ridge resorbs more on the
facial side than on the lingual side, and, therefore,
although the implant can be placed without a bone
graft, the implant position is more to the lingual side.
This factor requires the restorative dentist to alter the
loading of the buccal and lingual cusps of the crown on
the implant to prevent fracture of the abutment or the
implant crown.8
Another option is to maintain the deciduous tooth
until the patient is old enough for the implant. The
appropriate age for implant placement is determined by
the cessation of vertical facial growth. That parameter
is determined by comparing serial cephalometric radio-
graphs to determine when ramus growth and therefore
vertical changes in facial growth have stopped. Fudalej
et al9 showed that, on average, girls’ facial growth
continues until about 17 years of age, whereas the
average boy’s facial vertical growth is complete at
about 21 years of age. Therefore, maintaining the
deciduous tooth until the end of growth is desirable.
But deciduous molars are too wide mesiodistally, and
this could affect the fit of the posterior teeth. Thus, it is
advantageous to reduce the width of the deciduous
second molar to the size of a second premolar.1
The reduction of a deciduous molar should be
accomplished with a sharp carbide fissure bur or a
diamond bur. The key is to remove sufficient tooth
structure to create space but not enough to cause pulpal
necrosis. A guide to estimating the correct amount of
reduction is to measure the mesiodistal width of the
deciduous molar at the level of the cementoenamel
junction on a bitewing radiograph (Fig 1). This distance
can be transferred to and marked on the occlusal
surface of the deciduous molar with a pencil or marking
pen. Then the bur is positioned to follow this line and
cut toward the gingiva to remove a wafer of enamel and
the underlying dentin on both the mesial and distal
442 Kokich and Kokich American Journal of Orthodontics and Dentofacial Orthopedics
October 2006

Fig 5. A, Late-adolescent girl was congenitally missing left mandibular second premolar, and
deciduous molar was ankylosed and submerged. B, Deciduous molar was extracted, resulting in
significant narrowing of edentulous ridge. C-E, First premolar was pushed distally into second
premolar position. F and G, Orthodontic movement allowed implant in newly regenerated bone.
H and I, After restoration of first premolar implant in second premolar position, it is difficult to see
difference.

surfaces (Fig 1). About 2 mm can be removed from
both surfaces; this should leave the crown about 7 to 8
mm wide.
A potential problem of reducing the deciduous
molar in this way is that it leaves exposed dentin on the
mesial and distal surfaces of the tooth. As the spaces
are closed, it is difficult for the patient to adequately
clean these interproximal surfaces, and the tooth could
decay easily. Therefore, to prevent decay, a layer of
light-cured restorative composite should be applied to
the mesial and distal surfaces to protect the deciduous
tooth. In addition to protecting these exposed dentinal
surfaces, the addition of restorative composite will
build up the occlusal surface of the typically short
deciduous molar, so that it can function with the teeth
in the opposing dental arch and prevent supereruption.
After composite restoration, the interproximal spaces
can be closed, and the deciduous molar functions as a
premolar (Fig 1).
A common concern about closing these interproxi-
mal spaces after reduction of the deciduous tooth is that
its roots will prevent complete space closure, because
they tend to diverge beyond the width of the crown.
However, in most cases, as the socket wall of the
permanent teeth move near and into contact with the
deciduous tooth roots, the latter will resorb. After
resorption, these deciduous roots are replaced by bone;
this is an ideal way to prepare this site for a future
implant.1
Occasionally, a deciduous second molar becomes
ankylosed. If the ankylosis occurs while the patient is
young and still undergoing significant facial growth,
the tooth will become submerged relative to the adja-
cent erupting permanent teeth.1 If this region will be
restored with a future implant, the alveolar ridge could
be compromised vertically and require a bone graft.10
However, vertical bone grafting is often unpredictable
and an added expense for the patient.11 Therefore,
American Journal of Orthodontics and Dentofacial Orthopedics
Volume 130, Number 4
extraction of ankylosed deciduous molars is recom-
mended, if the patient is missing the deciduous second
molar and the face is still growing. But how does the
clinician diagnose ankylosis in a child or an adolescent?
The most reliable indicator of deciduous molar anky-
losis is to evaluate the alveolar bone levels between the
deciduous molar and the adjacent permanent first molar
and first premolar.1 If the bone is flat, this indicates that
the deciduous tooth and the adjacent teeth are erupting
evenly. However, if the alveolar bone level becomes
oblique, with the bone level located more apically
around the deciduous tooth, this confirms ankylosis
(Fig 2). If the patient has little facial growth remaining,
and the deciduous molar is submerged only slightly, the
tooth can be maintained to preserve the width of the
alveolus for the future implant. However, if the patient
has significant growth remaining, the deciduous molar
must be extracted to prevent a significant ridge defect.
A common question after deciduous molar extrac-
tion is whether to place a space maintainer to preserve
arch length. We do not place space maintainers in most
of these situations, especially if implants will be used
for restoring the edentulous space. If the edentulous
space is not maintained, the adjacent permanent first
molar and first premolar should erupt together (Fig 2).
Although this could require longer orthodontic treat-
ment to push the teeth apart to create the implant space,
this type of tooth movement will also result in a more
robust alveolar ridge (Fig 2). As the roots of adjacent
teeth move apart, they deposit bone behind that equals
the width of the premolar and molar, and will produce
an excellent ridge in which to place the implant. This
process is called orthodontic implant-site development.
Occasionally, the decision to extract an ankylosed
and submerged deciduous second molar will be made
too late, resulting in a narrow alveolar ridge with a
vertical defect. If an implant will be placed in this site,
a bone graft might be necessary to provide adequate
ridge width and height. However, another possibility
exists, especially if the patient will undergo orthodontic
therapy. It might be advantageous to push the first
premolar into the second premolar position, thereby
creating space for the single-tooth implant in the first
premolar location. When faced with this decision,
clinicians are often fearful that there is insufficient
alveolar ridge width in which to move the permanent
first premolar. However, previous studies showed that a
wider tooth root can be pushed through a narrow
alveolar ridge without compromising the eventual bone
support around the repositioned tooth root.12,13 We
performed this type of tooth movement on several
occasions, and it resulted in a much better ridge in
which to place the implant (Fig 5).
Kokich and Kokich 443
Another possible situation is a patient who is
missing not only the second premolar, but also the first
permanent molar (Fig 3). If some drifting of the
adjacent teeth has occurred, the resulting edentulous
space can be too large for a 1-tooth replacement and too
small for a 2-tooth replacement. Then it could be
advantageous to place a single-tooth implant in the
appropriate position before orthodontic treatment. This
implant can be restored and used as an anchor to close
any excess and remaining space, by using the implant
as an anchor to prevent unwanted occlusal changes in
the remaining dentition.14 The advantage to the patient
is that fewer restorations are required to fill the eden-
tulous space. The advantage to the orthodontist is that
an immobile anchor in the bone is available to protract
or retract the adjacent teeth to close the space. This
interdisciplinary treatment requires proper planning,
the construction of a diagnostic wax-up, and precise
positioning of the implant to satisfy the orthodontic,
surgical, and restorative objectives (Fig 3).
If an implant is used to move adjacent teeth and
close an edentulous space, the timing of implant load-
ing is an important factor. In the past, implant loading
traditionally was delayed until the implant had fully
integrated with the surrounding bone.15 However, re-
cent studies showed that early or immediate loading is
possible,16,17 especially in orthodontic patients.18 The
difference is that an orthodontic load is continuous and
in 1 direction, whereas an occlusal load is intermittent
and in different directions. Researchers18 have shown
that a continuous load in the same direction actually
stimulates bone formation, which further enhances the
osseointegration of the implant. So, in most orthodontic
situations, implants can be loaded early, soon after the
restorative dentist has placed the temporary restoration.
Another alternative for treating a patient with con-
genitally missing mandibular second premolars is to
simply close the space.19 If the patient has crowding in
the opposite dental arch or a protrusive facial profile,
closure of the edentulous space would be advantageous.
However, in a patient with no dental crowding and a
normal facial profile, closure of the edentulous space
from a congenitally missing second premolar could
produce an undesirable facial profile. In these situa-
tions, the orthodontist requires additional anchorage,
either extraoral or intraoral, to prevent these unwanted
facial changes. A protraction facemask and a chincup
(Fig 4) are examples of extraoral appliances that will
accomplish this type of tooth movement. Miniscrews20
and mini-implants are intraoral methods of providing
additional anchorage to close these edentulous spaces
without altering the patient’s facial profile. Another
method of closing the edentulous space is to hemisect
444 Kokich and Kokich
the deciduous second molar at an early age21,22 and
allow the permanent molar to erupt in a mesial direction
without affecting the position of the mandibular inci-
sors. If the orthodontist sees the patient at an early age
and monitors him or her regularly, this alternative is
especially attractive.
SUMMARY
We described and illustrated several methods of
managing patients with congenitally missing mandibu-
lar second premolars. In the past, orthodontists primar-
ily made the treatment decisions for these patients.
However, with newer solutions for restoring edentulous
spaces, surgeons and restorative dentists can play sig-
nificant roles in helping to manage these orthodontic
patients. Although the orthodontist sees the patient at a
young age, some decisions made at that time will affect
him or her for a lifetime. We emphasized the interdis-
ciplinary aspects of treating a patient with congenitally
missing mandibular second premolars to provide the
best possible result that teamwork dentistry can offer.
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an update. J Am Dent Assoc 2004;135:92-7.
7. Ostler M, Kokich V. Alveolar ridge changes in patients congen-
itally missing mandibular second molars. J Prosthet Dent 1994;
71:144-9.
American Journal of Orthodontics and Dentofacial Orthopedics
October 2006
8. Kokich V, Spear F. Guidelines for managing the orthodontic-
restorative patient. Semin Orthod 1997;3:3-20.
9. Fudalej P, Kokich V, Leroux B. Determining the cessation of
facial growth to facilitate placement of single-tooth implants.
Am J Orthod Dentofacial Orthop 2006 (in press).
10. Chen S, Darby I, Adams G, Reynolds E. A prospective clinical
study of bone augmentation techniques at immediate implants.
Clin Oral Implants Res 2005;16:176-84.
11. Jemt T, Lekholm U. Single implants and buccal bone grafts in
the anterior maxilla: measurements of buccal crestal contours in
a 6-year prospective clinical study. Clin Implant Dent Relat Res
2005;7:127-35.
12. Stepovich M. A clinical study on closing edentulous spaces in the
mandible. Angle Orthod 1979;49:227-33.
13. Hom B, Turley P. The effects of space closure of the mandibular
first molar area in adults. Am J Orthod 1984;85:457-69.
14. Kokich V. Comprehensive management of implant anchorage in
the multidisciplinary patient. In: Higuchi K, editor. Orthodontic
applications of osseointegrated implants. Coal Stream, Ill: Quin-
tessence; 2000. p. 21-32.
15. Adell R, Lekholm U, Rockler B. A 15-year study of osseointe-
grated implants in the treatment of the edentulous jaw. Int J Oral
Surg 1981;10:387-416.
16. Tarnow D, Emtiaz S, Classi A. Immediate loading of threaded
implants at stage 1 surgery in edentulous arches: ten consecutive
case reports with 1- to 5-year data. Int J Oral Maxillofac Implants
1997;12:319-24.
17. Piattelli A, Corigliano M, Scarano A. Immediate loading of
titanium plasma-sprayed implants: an histologic analysis in
monkeys. J Periodontol 1998;69:321-7.
18. Duyck J, Ronold H, Van Oosterwyck H. The influence of static
and dynamic loading on marginal bone reactions around os-
seointegrated implants: an animal experimental study. Clin Oral
Implants Res 2001;12:207-18.
19. Fines C, Rebellato J, Saiar M. Congenitally missing mandibular
second premolar: treatment outcome with orthodontic space
closure. Am J Orthod Dentofacial Orthop 2003;123:676-82.
20. Giancotti A, Greco M, Mampieri G. The use of titanium
miniscrews for molar protraction in extraction treatment. Prog
Orthod 2004;5:236-47.
21. Northway W. Hemisection: one large step toward management
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Am J Orthod Dentofacial Orthop 2005;127:606-10.
 Original Article

Increased Occurrence of Dental Anomalies Associated with

Second-Premolar Agenesis
Daniela G. Gariba; Sheldon Peckb; Simone Carinhena Gomesc

ABSTRACT
Objective: To evaluate the prevalence of dental anomalies in patients with agenesis of second
premolars and compare the findings with the prevalence of these anomalies in the general pop-
ulation.
Materials and Methods: A Brazilian sample of 203 patients aged 8 to 22 years was selected. All
patients presented agenesis of at least one second premolar. Panoramic and periapical radio-
graphs and dental casts were used to analyze the presence of other associated dental anomalies,
including agenesis of other permanent teeth, ectopia of unerupted permanent teeth, infraocclusion
of deciduous molars, microdontia of maxillary lateral incisors, and supernumerary teeth. The oc-
currence of these anomalies was compared with occurrence data previously reported for the
general population. Statistical testing was performed using the chi-square test (P ! .05) and the
odds ratio.
Results: The sample with agenesis of at least one second premolar presented a significantly
increased prevalence rate of permanent tooth agenesis (21%), excluding third molars. Among the
sample segment aged 14 years or greater (N " 77), occurrence of third-molar agenesis (48%)
exceeded twice its normal frequency. Significant increases in occurrence of microdontia of max-
illary lateral incisors (20.6%), infraocclusion of deciduous molars (24.6%), and distoangulation of
mandibular second premolars (7.8%) were observed. Palatally displaced canine anomaly was
also significantly elevated (8.1%).
Conclusion: The results provide evidence that agenesis of other permanent teeth, microdontia,
deciduous molar infraocclusion, and certain dental ectopias are the products of the same genetic
mechanisms that cause second-premolar agenesis. (Angle Orthod. 2009;79:436–441.)
KEY WORDS: Agenesis; Dental anomalies; Second premolar

INTRODUCTION alence in the general population. A study of twins dem-

onstrated a high percentage of concordance for agen-
There is considerable evidence suggesting that
esis between homozygotic twins, whereas pairs of het-
genes play a fundamental role in the etiology of tooth
erozygotic twins presented discordance for this dental
agenesis. Grahnén1 conducted a study on children
anomaly.2 Vastardis3 analyzed a large family with
with tooth agenesis and reported that more than 50%
agenesis of all second premolars and third molars and
of siblings and relatives also presented with hypodon-
identified a mutation in gene MSX1 on chromosome
tia, a high prevalence compared to the expected prev-
4p.
Moreover, there seems to be a genetic relationship
a
Associate Professor, Department of Orthodontics, University in the determination of different dental anomalies, con-
of São Paulo City, Brazil.
b
Clinical Professor, Department of Developmental Biology, sidering the high frequency of patterns of association.
Harvard School of Dental Medicine, Boston, Mass. A single genetic defect may result in different pheno-
c
Graduate Student, Department of Orthodontics, University typic expressions, including such various traits as
of São Paulo City, Brazil. tooth agenesis, microdontia, ectopic tooth position,
Corresponding author: Dr Daniela G. Garib, Rua Rio Branco
19-18, Bauru-São Paulo 17040-480, Brazil
and delayed development of different teeth.4 Garn and
(e-mail: dgarib@uol.com.br) Lewis5,6 observed that patients with agenesis of third
Accepted: May 2008. Submitted: February 2008.
molars presented an increased prevalence of agene-
! 2009 by The EH Angle Education and Research Foundation, sis of other permanent teeth, as well as a general re-
Inc. duction in tooth size. In 1992, Bjerklin et al7 observed

Angle Orthodontist, Vol 79, No 3, 2009 436 DOI: 10.2319/021308-87.1

DENTAL ANOMALIES ASSOCIATED WITH PREMOLAR AGENESIS
a high frequency of association in the occurrence of
agenesis of premolars, ectopic eruption of permanent
maxillary first molars, ectopic eruption of maxillary ca-
nines, and infraocclusion of deciduous molars, sug-
gesting that these anomalies presented a common ge-
netic etiology. Peck et al8 observed high prevalence of
tooth agenesis and peg-shaped lateral incisors in pa-
tients with a transposition of the maxillary canine and
first premolar. They reported similar findings in sam-
ples of patients with palatally displaced canines (PDC)
and transposition between mandibular canines and
lateral incisors.9,10 Baccetti11 observed that agenesis of
second premolars, microdontia of maxillary lateral in-
cisors, PDC, infraocclusion of deciduous molars, ec-
topic eruption of maxillary first molars, and enamel hy-
poplasia are frequently related dental anomalies. Shal-
ish et al12 demonstrated that patients with unilateral
agenesis of second premolars often exhibit distal an-
gulation and delayed development of the unerupted
contralateral second premolar.
Even though previous studies reported associations
between tooth agenesis and other dental anomalies,
no study investigated the frequency of dental anoma-
lies occurring in a significantly large sample with sec-
ond premolar agenesis. Therefore, this study aimed to
determine the prevalence of permanent tooth agene-
sis, discrete ectopias, microdontia, deciduous molar
infraocclusion, and supernumerary teeth in patients
with agenesis of second premolars and compare the
prevalence of these with the frequency expected in the
general population. The null hypothesis was that sub-
jects with agenesis of at least one second premolar do
not demonstrate a significantly increased prevalence
of other dental anomalies.
MATERIALS AND METHODS
A sample of 203 Brazilians with agenesis of one or
more second premolars was selected from the ortho-
dontic patient files of a university dental school and
eight private dental offices. The subjects ranged in age
from 8 to 22 years at the time of construction of the
diagnostic records used in this study. The total sample
consisted of 134 females and 69 males, a sex ratio of
2F:1M. Given the widely heterogeneous backgrounds
within the Brazilian population, a rough estimate of the
ethnic makeup of the sample was derived subjectively
from facial photographic records: white (84%), black
(13%), and Japanese (3%).
Panoramic radiographs, periapical radiographs, and
dental casts were used to investigate the presence of
the following dental anomalies:
1. Agenesis of permanent teeth
2. Supernumerary teeth
3. Microdontia of maxillary lateral incisors
437
4. Infraocclusion of deciduous molars
5. Three types of tooth ectopia
a. PDC
b. Distal angulation of mandibular second premo-
lars
c. Mesial angulation of mandibular second molars
The critical age of 14 years was considered to be
confirmation of the absence of third molars.5 This cri-
terion was used to restrict the sample for evaluation
of third-molar agenesis to only those with diagnostic
records at greater or equal to 14 years of age. Infra-
occlusion of deciduous teeth was determined by visual
inspection.11 Diagnosis of palatally displaced maxillary
canines followed the radiographic parameters sug-
gested by Lindauer et al,13 confirmed by interpretation
of periapical radiographs using the tube shift tech-
nique, a method of object localization using two pro-
jections with significantly different x-ray tube angula-
tions. Based on the findings of Ericson and Kurol14 that
an attempt to determine the eruption path of maxillary
canines radiographically is generally of little value in
children younger than 10 years, subjects whose only
diagnostic records were from an age under 10 years
were omitted from the sample in evaluating for PDC.
Diagnosis of distal angulation of mandibular second
premolars followed the criteria described by Shalish et
al,12 using the inferior border of the mandible as a base
line. The maxillary lateral incisor was considered as
presenting microdontia when the maximum mesiodis-
tal crown diameter was smaller compared to the same
dimension of opposing mandibular lateral incisor in the
same patient. This category also included conical or
peg-shaped maxillary lateral incisors.
The results were analyzed with the chi-square test
for goodness of fit in order to compare the frequency
of dental anomalies in the sample with previously pub-
lished reference values. These comparison reference
data came from studies that had samples more racially
and ethnically homogeneous than the experimental
sample for the present study. Previous investigations
have shown concordance among ethnicities or racial
groups in the general frequencies of dental anomalies
observed in this study. For hypothesis testing in this
study, the 5% level of significance was employed. The
odds ratio (OR) was calculated at the 95% confidence
interval to measure the strength of associations be-
tween agenesis of second premolars and the pres-
ence of other dental anomalies investigated.
RESULTS
In the sample of 203 patients with agenesis of sec-
ond premolars, there was a significantly higher prev-
alence of agenesis of other permanent teeth (OR "
5.6), excluding third molars, compared to reference
Angle Orthodontist, Vol 79, No 3, 2009
438
Table 1. Prevalence Rate of Tooth Agenesis and Supernumerary Teeth in Subjects with Second Premolar (P2) Agenesis, Compared with
Reference Values
Prevalence Rate
Reference Values
in P2 Agenesis
Dental Anomaly Sample Prevalence Rate
Tooth agenesis (excluding third
molars) 21.2% (43/203) 5.0% (53/1064)
Maxillary lateral incisor agenesis 16.3% (33/203) 1.9% (109/5738)
Third molar agenesis 48.1% (37/77) 20.7% (427/2061)
Supernumerary teeth 3.0% (6/203) 3.9% (39/1000)
values in the general population1,11,15,16 (Table 1). The
most commonly absent tooth was the maxillary lateral
incisor (Figure 1), with an eightfold-increased preva-
lence of agenesis compared to the general population
(Table 1). The prevalence of third molar agenesis was
also significantly increased (OR " 3.5) in the sample
(Table 1). In contrast, the prevalence of supernumer-
ary teeth was not different from reference values ob-
served for the general population (Table 1).
The prevalence of dental anomalies for the sizes
and positions evaluated in the sample are presented
in Table 2. Compared to the general population,11,17–20
patients with agenesis of second premolars presented
significantly higher prevalence of microdontia of max-
illary lateral incisors (OR " 5.2), palatally displaced
maxillary canines (OR " 5.0), distal angulation of
mandibular second premolars (OR " 43.1), mesial an-
gulation of mandibular second molars (OR " 16.5),
and infraocclusion of deciduous molars (OR " 3.3).
DISCUSSION
In the group of patients characterized by agenesis
of second premolars, the prevalence of agenesis of
other permanent teeth was significantly increased (Ta-
ble 1). Previous analysis of tooth agenesis across ra-
cial and ethnic lines would suggest that the results of
Figure 1. Prevalence of agenesis of permanent teeth in the sample with second premolar agenesis.
Angle Orthodontist, Vol 79, No 3, 2009
GARIB, PECK, GOMES
Difference 95%
Chi-Square Odds Confidence
Study (Year) (P-value) Ratio Interval
Grahnén1 (1956) 73.20 (!.001) 5.63 (3.65–8.70)
Le Bot & Salmon15 (1977) 173.21 (!.001) 10.02 (6.60–15.23)
Bredy et al16 (1991) 32.64 (!.001) 3.54 (2.24–5.6)
Baccetti11 (1998) 0.42 (!.518) 0.75 (0.31–1.80)
this study would be materially unchanged regardless
of the race or ethnicity of the subjects or comparative
samples.21
Only one previous study in the literature addressed
the association of tooth agenesis occurrence. In the
1960s, Garn and Lewis5 observed that patients with
third-molar agenesis presented an increased preva-
lence of other missing permanent teeth. The preva-
lence of agenesis of permanent teeth in the group with
third-molar agenesis was 13 times higher compared to
the prevalence of agenesis in the control group. Even
developmentally stable teeth such as central incisors,
canines, and first premolars were missing in the sam-
ple with agenesis of third molars. Specifically, con-
cerning the second premolars, the prevalence of agen-
esis observed within the study group corresponded to
11%, compared to 1.5% in the control group.
The present study confirmed the results of Garn and
Lewis5 showing other physical dental traits associated
with the occurrence of tooth agenesis. It contributes to
mounting evidence that agenesis and its associated
abnormalities are under genetic control. The possible
explanation is that a single genetic defect may give
rise to different anomalies, so that two or more dental
anomalies in the same patient may present a common
genetic origin. Studies of families,2,3,22–24 as well as in-
DENTAL ANOMALIES ASSOCIATED WITH PREMOLAR AGENESIS
Table 2. Prevalence Rate of Dental Anomalies of Size and Position in Subjects with Second Premolar (P2) Agenesis, Compared with Ref-
erence Values
Reference Values
Prevalence Rate
Dental Anomaly in Study Sample Prevalence Rate
Small maxillary lateral incisor 20.6% (42/203) 4.7% (47/1000) Baccetti11 (1998)
Palatally displaced canines 8.1% (15/185) 1.7% (25/1450) Dachi and Howell17 (1961)
Mandibular second premolar 7.8% (16/203) 0.20% (52/26,264) Matteson et al18 (1982)
distoangulation
Mandibular second molar 1.0% (2/203) 0.06% (3/5000)
mesioangulation
Deciduous molar infraocclusion 24.6% (50/203) 8.9% (94/1059)
vestigations of the association of agenesis and other
types of dental anomalies,6,8,10,11 previously highlighted
the role played by genetic mechanisms in the etiology
of various dental anomalies.
The prevalence of supernumerary teeth in the ana-
lyzed sample was not statistically different from the
prevalence observed for the general population (Table
1). This suggests that these anomalies present differ-
ent or independent etiologic factors. This fact is co-
herent, considering that tooth agenesis is a hypoplas-
tic dental anomaly, whereas supernumerary teeth rep-
resent hyperplastic anomalies. No previous study re-
ported an association between tooth agenesis and
supernumerary teeth. Baccetti11 investigated this as-
sociation and also did not find any statistically signifi-
cant difference in the prevalence of supernumerary
teeth between a sample with agenesis of second pre-
molars and a control group.
Compared to the general population, patients with
agenesis of second premolars presented significantly
higher prevalence of microdontia of maxillary lateral
incisors (Table 2). The results showed that 20% of pa-
tients with second premolar agenesis also presented
reduced size of lateral incisors. These results corrob-
orate previous studies and suggest that agenesis and
microdontia are different expressions of the same ge-
netic defect, since these phenotypes are frequently as-
sociated. Garn and Lewis6 observed that patients with
agenesis of third molars presented a general and sig-
nificant reduction in tooth size, more significantly in pa-
tients with multiple agenesis. Brook23 analyzed families
of patients with dental anomalies and observed that
agenesis and microdontia often occur concomitantly.
Baccetti11 observed results similar to the present
study, demonstrating that 18% of patients with agen-
esis of second premolars presented microdontia of
maxillary lateral incisors, and nearly half of patients
with small maxillary lateral incisors (42%) presented
agenesis of second premolars. The practical implica-
tions of these findings are related to the fact that or-
thodontists will rarely observe crowding in patients
with agenesis, while spacing is the common picture.
439
Difference 95%
Chi-Square Odds Confidence
Study (Year) (P-value) Ratio Interval
62.97 (!.001) 5.29 (3.38–8.28)
28.02 (!.001) 5.03 (2.60–9.73)
464.1 (!.001) 43.13 (24.18–76.92)
Grover and Lorton19 17.39 (!.001) 16.50 (2.75–99.74)
(1985)
Kurol20 (1981) 41.83 (!.001) 3.35 (2.29–4.92)
Therefore, difficulty in mechanical space closure in
these patients can be expected.
Distoangulation of mandibular second premolars
was also evaluated in this study. The results revealed
that 7.9% of patients in the sample presented this ec-
topia, representing a 40-fold increase in occurrence
compared to the general population (Table 2). The oc-
currence of distoangulation in the general population
is rare, with a prevalence of 0.20%.18 Shalish et al12
investigated a sample with unilateral agenesis of man-
dibular second premolars and observed that the con-
tralateral tooth bud presented a mean 10# increase in
distal angulation compared to a control group without
agenesis. They concluded that distal angulation of
mandibular second premolars represents a different
phenotype of the same genetic defect causing the
agenesis. This type of association is similar to the
classical clinical situation of microdontia of maxillary
lateral incisors in patients with unilateral agenesis of
this tooth. Symons and Taverne24 observed distal an-
gulation of the tooth buds of mandibular second pre-
molars as well as delayed tooth development in indi-
viduals of the same family presenting multiple agen-
esis, including mandibular second premolars.
An additional finding provided by the present study
was that distoangulation of mandibular second pre-
molars is observed not only in individuals with unilat-
eral agenesis of mandibular second premolars but
also in patients with agenesis of maxillary second pre-
molars. Nearly 25% of individuals with distal angula-
tion had agenesis of maxillary premolars only, where-
as the remaining 75% of patients with this ectopia pre-
sented unilateral agenesis of second premolars in the
mandible. Therefore, clinicians should not be surprised
when observing this anomaly of tooth position in pa-
tients with tooth agenesis. This ectopia usually self-
corrects and does not require intervention12,25 unless it
is very severe.26
The present sample included two cases of mesial
angulation and impaction of mandibular second mo-
lars, a rare irregularity of eruption affecting 0.06% of
the population.19 The occurrence of two cases in 203
Angle Orthodontist, Vol 79, No 3, 2009
440
patients represents a prevalence rate of 1%, which is
significantly higher compared to the prevalence for the
general population (Table 2). Impaction of mesially an-
gulated permanent mandibular second molars is an
eruption disturbance which the etiology is frequently
assigned to local factors, such as deficient dental arch
perimeter.27 There is a lack of previous studies inves-
tigating the occurrence of ectopic eruption of mandib-
ular second molars associated with other dental anom-
alies, even though this association was mentioned in
some case reports.27,28 Not all cases of retention of
mandibular second molars may be assigned to local
causes, such as deficient dental arch space and me-
chanics involving distalization of mandibular first mo-
lars. In some cases, a normally developing tooth bud
of a mandibular second molar may, in a short time and
without apparent causes, change its angulation to a
significant mesial inclination, thus remaining impacted
on the distal aspect of the mandibular first molar.27 Ac-
cording to the present study’s results, this event may
represent another genetically programmed dental
anomaly.
This study also investigated PDC. The prevalence
rate (8.1%) of this anomaly in the study sample was
nearly five times higher compared to that in the gen-
eral population (Table 2). These data corroborate pre-
vious results that the PDC presents an occurrence
pattern that suggests an essentially genetic origin.9,29,30
Peck et al9,30 observed that patients with PDC pre-
sented a significantly increased prevalence of agene-
sis of second premolars and third molars. They further
observed that PDC is significantly associated with mi-
crodontia of one or both maxillary lateral incisors but
not to agenesis of these teeth, the prevalence of which
was not different compared to the general population.
These data present important clinical relevance for the
possibility of early diagnosis of PDC, since patients
with second premolar agenesis have a considerable
chance of developing ectopic eruption of maxillary ca-
nines during the late mixed dentition period. Thus,
based on a ‘‘red flag’’ presented by second-premolar
agenesis, early detection of associated anomalies
could permit early intervention and, in most of the cas-
es, avoid canine impaction as well as the possible se-
quelae of resorption of the roots of neighboring teeth.31
Among patients with agenesis of second premolars,
24.6% presented infraocclusion of deciduous molars
(Table 2). This prevalence rate was significantly larger
than the value representing occurrence in the general
population (8.9%). The present results suggest that
genetic factors are involved in the etiology of infraoc-
clusion, in agreement with other studies.7,11,20 Kurol20
earlier observed that the prevalence of infraocclusion
is increased in siblings of affected subjects and noted
significantly associated increases in occurrence of ec-
Angle Orthodontist, Vol 79, No 3, 2009
GARIB, PECK, GOMES
topic eruption of permanent maxillary first molars, ec-
topic eruption of maxillary canines, and agenesis of
second premolars.7
In summary, the clinical implications of patterns of
associated dental anomalies are important, since early
detection of a single dental anomaly (such as the
emergence of a conical maxillary lateral incisor or ra-
diographic evidence of second premolar agenesis)
may call the attention of professionals to the possible
development of other associated anomalies in the
same patient or in the family, allowing timely ortho-
dontic intervention.
CONCLUSIONS
• There was strong association between agenesis of
second premolars and agenesis of other permanent
teeth, as well as significantly increased occurrence
of microdontia of maxillary lateral incisors and of clin-
ically important anomalies of tooth position, such as
palatal displacement of canines. Thus, these results
justified rejection of the null hypothesis that subjects
with agenesis of at least one second premolar do
not demonstrate a significantly increased prevalence
of other dental anomalies.
• The findings of this study provide additional evi-
dence that tooth agenesis, microdontia, and certain
discrete tooth ectopia are related in occurrence
through shared genetic mechanisms.
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Orthod J. 1996;14:168–171.
25. Collett AR. Conservative management of lower second pre-
molar impaction. Aust Dent J. 2000;45:279–281.
26. Garib DG, Zanella NLM, Peck S. Associated dental anom-
alies: case report. J Appl Oral Sci. 2005;13:431–436.
27. Shapira Y, Borell G, Nahlieli O, Kuftinec MM. Uprighting
mesially impacted mandibular permanent second molars.
Angle Orthod. 1998;68:173–178.
28. Leonardi R, Peck S, Caltabiano M, Barbato E. Palatally dis-
placed canine anomaly in monozygotic twins. Angle Orthod.
2003;73:466–470.
29. Peck S, Peck L, Kataja M. The palatally displaced canine
as a dental anomaly of genetic origin. Angle Orthod. 1994;
64:249–256.
30. Peck S, Peck L, Kataja M. Concomitant occurrence of ca-
nine malposition and tooth agenesis: evidence of orofacial
genetic fields. Am J Orthod Dentofacial Orthop. 2002;122:
657–660.
31. Ericson S, Kurol J. Early treatment of palatally erupting
maxillary canines by extraction of the primary canines. Eur
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Angle Orthodontist, Vol 79, No 3, 2009
TÓPICO ESPECIAL

Anomalias dentárias associadas: o ortodontista

decodificando a genética que rege os distúrbios
de desenvolvimento dentário
Daniela Gamba Garib*, Bárbara Maria Alencar**, Flávio Vellini Ferreira***, Terumi Okada Ozawa****

Resumo

O presente trabalho versa sobre o diagnóstico e a abordagem ortodôntica das anomalias dentárias,
enfatizando os aspectos etiológicos que definem tais irregularidades de desenvolvimento. Parece
existir uma inter-relação genética na determinação de algumas dessas anomalias, considerando-se a
alta frequência de associações. Um mesmo defeito genético pode originar diferentes manifestações
fenotípicas, incluindo agenesias, microdontias, ectopias e atraso no desenvolvimento dentário. As
implicações clínicas das anomalias dentárias associadas são muito relevantes, uma vez que o diag-
nóstico precoce de uma determinada anomalia dentária pode alertar o clínico sobre a possibilidade
de desenvolvimento de outras anomalias associadas no mesmo paciente ou em outros membros da
família, permitindo a intervenção ortodôntica em época oportuna.

Palavras-chave: Genética. Anomalias dentárias. Agenesia. Etiologia. Ortodontia.

INTRODUÇÃO anomalias dentárias. As anomalias expressam-se

Caracterizada por complexos e precisos pro-
cessos biológicos de substituição de dentes decí-
duos por dentes permanentes, a dentadura mista
representa uma das manifestações de perfeição
da natureza. Mas, como todo curso natural, o
desenvolvimento da dentição pode mostrar algu-
mas imperfeições e, no transcorrer da dentadu-
ra mista – com certa frequência –, o profissional
depara-se com irregularidades odontogênicas: as
com distintos graus de severidade. Da manifesta-
ção mais branda para a mais severa – representa-
das, respectivamente, desde o atraso cronológico
na odontogênese até a ausência completa do ger-
me dentário ou agenesia –, existe uma miríade
de expressões, compreendendo as microdontias,
os desvios na morfologia dentária e as ectopias.
Este artigo volta-se aos erros da natureza aplica-
dos ao desenvolvimento da dentição, discutindo a

* Professora doutora em Ortodontia. Hospital de Reabilitação de Anomalias Craniofaciais e Faculdade de Odontologia de Bauru – Universidade de São
Paulo, Bauru/SP.
** Mestre em Ortodontia pela Universidade Cidade de São Paulo (Unicid), São Paulo/SP.
*** Coordenador do curso de mestrado em Ortodontia da Unicid.
**** Professora do programa de pós-graduação em Ciência da Reabilitação. Hospital de Reabilitação de Anomalias Craniofaciais – Universidade de São Paulo,
Bauru-SP.

Dental Press J. Orthod. 138 v. 15, no. 2, p. 138-157, Mar./Apr. 2010


etiologia das anomalias dentárias, os detalhes para
um acurado diagnóstico, assim como algumas
condutas terapêuticas no intento de interceptá-
las em época conveniente.
A influência de fatores genéticos e ambientais
na etiologia das más oclusões representa tema
de grande importância na Ortodontia. Quanto
maior a contribuição genética na origem de uma
irregularidade dentofacial, menor a possibilidade
de preveni-la e, como regra, pior o prognóstico de
tratamento ortodôntico/ortopédico22. E os novos
rumos da pesquisa em Odontologia caminham
para o conhecimento do genótipo humano30. Di-
versos estudos sugeriram uma tendência genética
e hereditária na etiologia das anomalias dentá-
rias de número, tamanho, posição, assim como
nos distúrbios de erupção2,4,13,14,15,17,18,20,23,24,25,30.
Tais evidências provêm de investigações em fa-
mílias17,18,30, em gêmeos monozigóticos20, e da
observação de associações na ocorrência de de-
terminadas anomalias2,4,13,14,15,23,24,25.
Quando uma determinada irregularidade mos-
tra uma prevalência aumentada em famílias de
pacientes afetados, comparado às prevalências
esperadas para a população em geral, credita-se à
genética uma influência predominante na etiologia
do problema. O prognatismo mandibular da famí-
lia imperial austro-húngara Hapsburg representa
o mais clássico exemplo de característica genética
de interesse ortodôntico, em humanos, transmiti-
da por sucessivas gerações22. Muitas das anomalias
dentárias discutidas durante esse estudo mostra-
ram prevalências aumentadas em famílias de pa-
cientes afetados17,18,30, como ilustrado nas figuras 1
a 7. Atualmente, a leitura do código genético pode
isolar genes mutantes em famílias, desde que diver-
sos membros expressem a mesma irregularidade30.
Gêmeos monozigóticos compartilham códi-
gos genéticos idênticos. Portanto, as características
geneticamente definidas expressam-se em ambos
os gêmeos monozigóticos de maneira semelhante.
Quando se constata uma alta concordância para
uma determinada irregularidade, em pares de
Dental Press J. Orthod.
Garib DG, Alencar BM, Ferreira FV, Ozawa TO
gêmeos homozigóticos, conclui-se que a genética
consiste na etiologia primordial de tal anormalida-
de. Diferentemente, gêmeos heterozigóticos, por
apresentarem genótipos distintos, manifestam bai-
xo índice de concordância para a mesma irregula-
ridade. Estudos prévios com gêmeos constituem
importantes evidências sobre o caráter genético
de determinadas anomalias dentárias20,22.
Certas anomalias dentárias aparecem frequen-
temente associadas em um mesmo paciente, mais
do que se esperaria ao acaso. Isso se explica porque
um mesmo defeito genético pode originar dife-
rentes manifestações ou fenótipos, incluindo age-
nesias, microdontias, ectopias e atraso no desen-
volvimento2,4,13,14,15,23,24,25. De uma maneira sim-
plista, poderíamos dizer que um gene “defeituoso”
ou mutante pode se expressar diversamente em
diferentes dentes permanentes. A associação entre
a agenesia unilateral do incisivo lateral superior e
a microdontia do incisivo contralateral, frequente-
mente observada na rotina clínica, ilustra bem essa
condição. Nesse caso, o mesmo defeito genético
que determinou a agenesia se expressou de for-
ma incompleta do lado oposto da arcada, ocasio-
nando a microdontia. No entanto, as associações
entre as anomalias dentárias não se restringem a
esse clássico exemplo. Existem muitas outras in-
terações entre distintas anomalias dentárias, que
serão expostas ao longo do desenvolvimento des-
te artigo. As implicações clínicas são importantes,
pois o diagnóstico precoce de uma determinada
anomalia dentária pode alertar o profissional para
o possível desenvolvimento de outras anomalias
associadas, no mesmo paciente ou em familiares,
possibilitando o diagnóstico e interceptação orto-
dôntica oportunos.
Esse artigo objetiva auxiliar o clínico a re-
conhecer as principais anomalias dentárias de
origem essencialmente genética, discutindo nu-
ances importantes do diagnóstico e tratamento
ortodôntico precoce. Adicionalmente, visa pro-
mover o entendimento do padrão de anomalias
dentárias associadas.
139 v. 15, no. 2, p. 138-157, Mar./Apr. 2010
Anomalias dentárias associadas: o ortodontista decodificando a genética que rege os distúrbios de desenvolvimento dentário

Agenesias dentárias inferiores representam os dentes mais comumen-

A agenesia dentária constitui a anomalia de te ausentes, seguidos pelo incisivo lateral superior
desenvolvimento mais comum da dentição hu- e pelos segundos pré-molares superiores26. Em
mana, ocorrendo em aproximadamente 25% da pacientes leucodermas, a ocorrência da agenesia
população13. O terceiro molar representa o den- dentária poderia ser classificada como: comum,
te mais afetado por essa anomalia, exibindo uma quando afeta os segundos pré-molares inferiores,
prevalência de 20,7%13. Excluindo-se os terceiros os incisivos laterais superiores e os segundos pré-
molares, a prevalência de agenesia é de aproxi- molares superiores; menos comum, que inclui,
madamente 4,3 a 7,8%. Os segundos pré-molares em ordem decrescente de ocorrência, os incisivos

24 25
18 12 22 28

48 38

45 34 35

FIGURA 1 - Paciente de 30 anos de idade, do gênero feminino, com agenesia de onze dentes permanentes, representando um típico caso de oligodontia.

18 12 28

FIGURA 2 - Primo em primeiro grau da paciente ilustrada na figura 1. Observe a agenesia de três dentes permanentes na arcada superior. Os primeiros
molares inferiores foram perdidos por extrações.

15 25

47

45 44 35

FIGURA 3 - Filha do casal ilustrado nas figuras 1 e 2. Essa jovem de 9 anos de idade apresenta agenesia de todos os segundos pré-molares, do primeiro
pré-molar inferior direito e do segundo molar inferior direito. A ausência dos terceiros molares ainda não pode ser confirmada devido à idade prematura.

Dental Press J. Orthod. 140 v. 15, no. 2, p. 138-157, Mar./Apr. 2010

 Garib DG, Alencar BM, Ferreira FV, Ozawa TO

18 28
12 22

48 38

45 44

FIGURA 4 - Tia materna da paciente ilustrada na figura 1. Observe a agenesia de oito dentes permanentes, incluindo pré-molares, incisivos laterais
superiores e terceiros molares.

18 12 22 28

48 38

FIGURA 5 - Irmã mais velha da paciente apresentada na figura 4, com um padrão semelhante de agenesia.

18 15 14 13 23 24 25 28

48 38
45 44 34 35
41 31

FIGURA 6 - Jovem de 15 anos de idade, sobrinho da paciente ilustrada na figura 1. Apresenta-se com agenesia de 16 dentes permanentes, incluindo os
incisivos centrais inferiores, os caninos superiores, todos os pré-molares, assim como os terceiros molares.

15 14 24 25

45 34 35

FIGURA 7 - Irmão mais jovem do paciente mostrado na figura 6. Aos 10 anos de idade apresenta agenesia de sete dentes permanentes, excetuando-se
os terceiros molares.

Dental Press J. Orthod. 141 v. 15, no. 2, p. 138-157, Mar./Apr. 2010

Anomalias dentárias associadas: o ortodontista decodificando a genética que rege os distúrbios de desenvolvimento dentário

centrais inferiores, os incisivos laterais inferiores Na década de 60, Garn e Lewis14 observaram
e primeiros pré-molares superiores, caninos su- que pacientes com agenesia de terceiros molares
periores e segundos molares inferiores; e raras, apresentaram prevalência aumentada de agene-
compreendendo, em ordem decrescente de fre- sias de outros dentes permanentes. A prevalência
quência, a agenesia de primeiros e segundos mo- de agenesia de dentes permanentes em pacientes
lares superiores, caninos inferiores, primeiros mo- com agenesia de terceiros molares mostrou-se
lares inferiores e incisivos centrais superiores26. 13 vezes maior do que a prevalência de agenesia
É importante lembrar que existe uma diferença em pacientes que apresentavam todos os tercei-
étnica na prevalência de agenesias. Estudos epide- ros molares presentes. Mesmo dentes mais está-
miológicos mostram uma menor prevalência de veis – como incisivos centrais, caninos e primeiros
agenesias em pacientes negros – se comparados pré-molares – estavam ausentes no grupo com
aos leucodermas –, enquanto os asiáticos tendem agenesia de terceiros molares. A explicação é que
a mostrar uma frequência aumentada de agene- um mesmo defeito genético pode dar origem a di-
sia26. Mesmo dentre indivíduos leucodermas de versas anomalias, em outras palavras, duas ou mais
diferentes continentes, as prevalências de agene- agenesias no mesmo paciente podem apresentar
sias oscilam suavemente26. Por exemplo, cauca- origem genética comum.
sianos europeus e australianos apresentam uma Resultados semelhantes foram observados
prevalência maior de agenesia se comparados aos em pacientes com agenesia de segundos pré-
caucasianos norte-americanos26. Existem também molares13 (Gráf. 1). Nesses pacientes, a proba-
diferenças sexuais na prevalência de agenesias. bilidade de ocorrência de agenesia de outros
De um modo geral, as mulheres são mais afetadas dentes permanentes, excluindo os terceiros
que os homens26. A grande maioria dos pacientes molares, mostrou-se aproximadamente cinco
com agenesia (76 a 83%) exibe a ausência de um vezes maior (21%). A chance de ocorrência de
ou dois dentes permanentes26. A ocorrência uni- agenesia de terceiros molares apresentou-se
lateral predomina, com exceção da agenesia dos mais de três vezes maior (48%). De modo inte-
incisivos laterais superiores, em que a ocorrência ressante, quanto maior o número de segundos
bilateral supera a unilateral26. pré-molares ausentes, maior a prevalência de
A genética provavelmente representa o fa-
tor etiológico primordial das agenesias dentárias.
A prevalência da agenesia mostra-se elevada na
família de pacientes afetados22. As figuras 1 a 7 25%
apresentam membros de uma família brasileira, 21,0%

20%
com casamentos consanguíneos, demonstrando 16,3%

agenesia de múltiplos dentes permanentes. Re- 15%

11,3%

centemente, identificou-se uma mutação no gene 10%

6,9% 7,4%
5,9%
MSX1 do cromossomo 4 numa ampla família 5% 3,4%
2,0% 2,0%
com agenesia de todos os segundos pré-molares e
1,5% 1,5%
0,0% 0,0%

0%
terceiros molares30.
(11-21)

(12-22)

(13-23)

(14-24)

(16-26)

(17-27)

(31-41)

(32-42)

(33-43)

(34-44)

(36-46)

(37-47)
total
(43 pacientes)

Um interessante estudo com gêmeos mostrou

um alto percentual de concordância para as age- superior inferior
nesias entre gêmeos homozigóticos, enquanto to-
dos os pares de gêmeos heterozigóticos mostraram GRÁFICO 1 - Prevalência de agenesias dos dentes permanentes, ex-
cluindo os terceiros molares, em pacientes com agenesia de segundos
discordância para a referida anomalia dentária20. pré-molares (Fonte: Garib, Peck, Gomes13).

Dental Press J. Orthod. 142 v. 15, no. 2, p. 138-157, Mar./Apr. 2010


agenesia de outros dentes permanentes. Pacien-
tes com um ou dois segundos pré-molares au-
sentes apresentaram uma prevalência de age-
nesia de outros dentes permanentes de apro-
ximadamente 15%. Por outro lado, quase 50%
dos pacientes com ausência de três ou quatro
segundos pré-molares mostraram agenesia de
outros dentes permanentes.
As agenesias frequentemente associam-se
com outros tipos de anomalias dentárias, incluin-
do microdontias15, ectopias (erupção ectópica
dos caninos superiores para palatino, transpo-
sições dentárias, distoangulação dos segundos
pré-molares inferiores e erupção ectópica dos
primeiros molares superiores)2,4,13,14,15,23,24,25, in-
fraoclusão dos molares decíduos2,13, atrasos no
desenvolvimento dentário1 e hipoplasia genera-
lizada do esmalte2. Essas constatações ressaltam
o papel dos genes na etiologia dessas anomalias
dentárias, assim como embasam o clínico para
uma maior compreensão de seus pacientes. Em
termos práticos, quando se diagnostica uma ano-
malia dentária, fique atento e procure por outras.
Microdontia
As agenesias, frequentemente, associam-se a
microdontias2,13,15. A redução no tamanho dentá-
rio representa uma expressão parcial do mesmo
defeito genético que define a agenesia. Isso explica
a clássica associação entre a agenesia unilateral do
incisivo lateral superior e a microdontia do dente
contralateral (Fig. 8). Aproximadamente 20% dos
pacientes com agenesia de segundos pré-molares
também apresentam microdontia dos incisivos la-
terais superiores2,13 (Fig. 9).
Como regra, pacientes com agenesia mostram
uma redução generalizada e significativa no tama-
nho dentário, e essa redução não se mostra unifor-
me, pois os dentes anteriores (incisivos e caninos)
aparecem mais reduzidos do que os dentes poste-
riores (pré-molares e molares)15. E diante de age-
nesias múltiplas, a redução do tamanho dentário é
ainda mais marcante15 (Fig. 10).
Dental Press J. Orthod.
Garib DG, Alencar BM, Ferreira FV, Ozawa TO
Estas informações apresentam implicações
clínicas importantes. Raramente o ortodontista
observará apinhamento em casos com agenesias,
enquanto a discrepância dente-osso positiva ou
o espaçamento representam um achado comum
nesses pacientes. Dessa maneira, o tratamento or-
todôntico corretivo dificilmente envolverá extra-
ções dentárias. O desafio maior nesses pacientes
será o fechamento dos espaços generalizados, prin-
cipalmente quando o contorno do perfil facial dita
que a mesialização dos dentes posteriores deve
prevalecer sobre a retração dos dentes anteriores.
Erupção ectópica dos primeiros
molares superiores
Durante o início da dentadura mista, os pri-
meiros molares permanentes irrompem na arcada
dentária, guiando-se pela face distal dos segundos
molares decíduos. A erupção dos primeiros mola-
res superiores desenha uma trajetória direciona-
da para oclusal e mesial. Dessa forma, a natureza
corrige a distoangulação dos germes no interior
do tuber da maxila, e os primeiros molares supe-
riores irrompem com seu longo eixo mais vertica-
lizado em relação ao plano oclusal. Porém, em 4%
das crianças, o primeiro molar superior “erra” a
sua trajetória eruptiva, desvia-se demasiadamen-
te para mesial e acaba por estimular a reabsorção
parcial da raiz dos segundos molares decíduos5
(Fig. 11). Esse distúrbio foi batizado de erupção
ectópica dos primeiros molares permanentes5.
Aproximadamente metade dos casos apresenta
um caráter reversível, e o primeiro molar superior
acaba por irromper espontaneamente na arcada
dentária. Nos casos irreversíveis, os primeiros
molares, inaptos a reabsorver o esmalte dentário,
permanecem retidos por cervical da coroa dos se-
gundos molares decíduos5.
E qual a etiologia desse distúrbio eruptivo?
Na década de 80, relacionava-se a erupção ectó-
pica dos primeiros molares à deficiência de es-
paço na região posterior da maxila. No entanto,
Kurol e Bjerklin17 mostraram que a prevalência
143 v. 15, no. 2, p. 138-157, Mar./Apr. 2010
Anomalias dentárias associadas: o ortodontista decodificando a genética que rege os distúrbios de desenvolvimento dentário

A B C
FIGURA 8 - Associação entre a agenesia unilateral do incisivo lateral superior e a microdontia de seu contralateral.

FIGURA 9 - Radiografia panorâmica de um paciente apresentando asso-

ciação entre múltiplas agenesias dentárias e a microdontia dos incisi-
vos laterais superiores.

FIGURA 10 - Paciente apresentando múltiplas agenesias dentárias, incluindo os terceiros molares, os incisivos laterais superiores e o canino superior
direito. Note a redução generalizada no tamanho dos dentes permanentes presentes.

Dental Press J. Orthod. 144 v. 15, no. 2, p. 138-157, Mar./Apr. 2010


dessa anomalia nas famílias de pacientes afetados
correspondia a aproximadamente 20%, muito au-
mentada em relação à população em geral (4%),
denunciando uma tendência genética na etiolo-
gia da erupção ectópica. Quase 10 anos depois,
Bjerklin, Kurol e Valentin4 reforçaram essa evi-
dência ao constatar que a erupção ectópica dos
primeiros molares superiores frequentemente as-
socia-se com outras anomalias dentárias de caráter
genético, como a infraoclusão dos molares decídu-
os, a erupção ectópica dos caninos superiores e a
agenesia de segundos pré-molares. A prevalência
dessas anomalias em pacientes com erupção ectó-
pica dos primeiros molares correspondeu a 20,7%;
5,4% e 6,5%, respectivamente – frequências maio-
res do que as esperadas para a população em geral.
Invertendo o foco de observação, Baccetti2 mos-
trou que pacientes com infraoclusão de molares
decíduos, agenesia de segundos pré-molares ou
microdontia do incisivo lateral superior tinham
duas a três vezes mais chances de apresentar ecto-
pia dos primeiros molares superiores. Com todas
essas evidências, a erupção ectópica dos primeiros
molares superiores entrou para a lista das anoma-
lias dentárias geneticamente determinadas.
A frequência de ocorrência da erupção ectópica
dos primeiros molares permanentes justifica que o
ortodontista atente ao padrão eruptivo destes den-
tes sempre que examinar um paciente durante o
primeiro período transitório da dentadura mista.
Nessa fase, o sinal clínico representado pela erup-
ção parcial do primeiro molar superior (Fig. 11A),
somado ao aspecto radiográfico apontando a rizóli-
se prematura do segundo molar decíduo e a mesio-
angulação dos primeiros molares permanentes (Fig.
11B), inferem o trajeto ectópico de erupção do pri-
meiro molar. Essa anomalia deve ser interceptada
precocemente, no intento de evitar a perda prema-
tura do segundo molar decíduo e a consequente re-
dução do perímetro da arcada dentária. A intercep-
tação é simples e resume-se na aplicação de uma
força suave, direcionada para distal, na coroa semi-
irrompida do primeiro molar ectópico (Fig. 11C).
Dental Press J. Orthod.
Garib DG, Alencar BM, Ferreira FV, Ozawa TO
A finalidade é obter um suave movimento de in-
clinação distal do primeiro molar ectópico e retido.
Com esse intento, uma diversidade de aparelhos
pode ser utilizada. Após o tratamento, o prognós-
tico de permanência do segundo molar decíduo na
arcada dentária até a sua fase normal de esfoliação
mostra-se muito bom, mesmo diante de uma rizóli-
se atípica de magnitude variável e precoce.
Transposição entre incisivo lateral e canino
permanentes inferiores
Conceitua-se como transposição dentária, a
ectopia de dentes permanentes que redunda na
inversão de suas posições naturais na arcada den-
tária, no mesmo quadrante6. Dois tipos de trans-
posições dentárias são apontados na literatura
como apresentando etiologia essencialmente ge-
nética e, portanto, comumente associadas a outras
anomalias dentárias: a transposição entre canino e
primeiro pré-molar na arcada superior, e a trans-
posição entre canino e incisivo lateral permanen-
tes na arcada inferior25.
Uma transposição quase sempre incompleta
entre o incisivo lateral e o canino inferiores resulta
da erupção ectópica do incisivo lateral para distal,
durante o primeiro período transitório da denta-
dura mista. Nessa circunstância, o dente ectópico
é o incisivo lateral. O canino permanente man-
tém-se em seu trajeto eruptivo normal. O incisivo
lateral inferior permanente, quando “erra” o seu
trajeto eruptivo, desloca-se para distal, com uma
marcante angulação de seu longo eixo de modo
que a coroa desloca-se para distal (geralmente
com rotação mesiolingual), chocando-se contra e
reabsorvendo a raiz do primeiro molar decíduo,
enquanto o ápice radicular localiza-se próximo à
sua posição normal (Fig. 12). No final do segundo
período transitório da dentadura mista – quando o
problema não é interceptado –, o canino inferior,
geralmente em sua posição normal na arcada den-
tária, ao irromper define a transposição dentária.
Essa anomalia apresenta uma prevalência
rara, aparecendo em aproximadamente 0,03% da
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Anomalias dentárias associadas: o ortodontista decodificando a genética que rege os distúrbios de desenvolvimento dentário

A B C

D E
FIGURA 11 - Erupção ectópica do primeiro molar superior. A) Aspecto clínico mostrando a erupção parcial do primeiro molar superior. B) Radiografia
panorâmica revelando uma rizólise prematura dos segundos molares decíduos e a mesioangulação dos primeiros molares permanentes. C) Interceptação
da erupção ectópica do primeiro molar com aparelho fixo banda-gancho. D) Aspecto clínico pós-tratamento. E) Radiografia panorâmica pós-tratamento.
Observe a sequela da erupção ectópica dos primeiros molares, representada pela rizólise parcial, precoce e irreversível dos segundos molares decíduos.

população, e afeta predominantemente o gênero fe- posição permutada desses dentes na arcada den-
minino (75% dos casos). Expressa-se bilateralmen- tária23. Duas razões justificam essa abordagem
te em, aproximadamente, 17% dos casos e, quando terapêutica. A primeira delas é o paralelismo
ocorre unilateralmente, o lado direito aparece mais radicular dos dentes envolvidos na transposição,
afetado (68%) do que o esquerdo (32%)23. observado após o estágio de dentadura mista23.
Existem algumas evidências de que a etiologia Outra característica morfológica local que in-
da transposição entre o incisivo lateral e o canino valida a tentativa de reverter a ordem dentária
inferior apresenta um caráter genético23,25. Peck, diz respeito à quantidade de osso disponível na
Peck e Kataja23, numa notável amostra de 60 pa- mandíbula, no sentido vestibulolingual. Diferen-
cientes com esse tipo de transposição, acharam temente, quando a transposição é diagnosticada
uma prevalência aumentada de agenesias e de in- mais precocemente, ainda na dentadura mista, o
cisivos laterais conoides associada a essa anomalia tratamento interceptor bem conduzido pode pre-
de posição (Tab. 1). Mais especificamente, essa venir a determinação efetiva da transposição. No
modalidade de transposição associa-se com alta estágio que precede a erupção do canino inferior,
prevalência de agenesias de segundos pré-molares somente a coroa do incisivo lateral mostra-se em
e terceiros molares, enquanto a prevalência de posição ectópica, enquanto o ápice mantém sua
agenesia de incisivos laterais superiores não difere posição normal23,29. Nessa fase, a verticalização
da população em geral23. do incisivo lateral inferior, mediante mecânica
Na dentadura permanente, o tratamento da com aparelho fixo parcial, ou nivelamento 4x2,
transposição entre o incisivo lateral e o canino evita a ocorrência da transposição com a erupção
inferior resume-se no alinhamento, mantendo a dos caninos inferiores29 (Fig. 13).

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 Garib DG, Alencar BM, Ferreira FV, Ozawa TO

TABELA 1 - Prevalência de agenesias dentárias e incisivo lateral su-

perior conoide em pacientes com transposição entre incisivo lateral e
canino permanentes inferiores (n = 60), comparada com a prevalência
da população em geral (Fonte: Peck, Peck e Kataja23).

PREVALÊNCIA EM
PACIENTES COM
ANOMALIAS PREVALÊN-
TRANSPOSIÇÃO ENTRE
DENTÁRIAS CIA NORMAL
INCISIVO LATERAL E
CANINO INFERIORES
Agenesia dentária
(incluindo terceiros 40% 25%
molares)
Agenesia de ter-
37% 21%
ceiros molares
FIGURA 12 - Imagem radiográfica ilustrativa de erupção ectópica do in-
cisivo lateral inferior, ocorrendo unilateralmente do lado direito. Obser- Agenesia dentária
ve a marcante angulação distal do longo eixo do incisivo lateral inferior (excluindo tercei- 12% 5%
direito, evidente na radiografia panorâmica. ros molares)
Agenesia de
segundos 8% 2%
pré-molares
Agenesia de
incisivos laterais 2% 2%
Erupção ectópica dos caninos superiores
permanentes superiores Incisivo lateral
10% 2%
conoide
Os caninos superiores representam os dentes
que se formam mais distantes da arcada dentária,
ladeando a cavidade piriforme e, portanto, dese-
nham o trajeto mais longo de erupção dentre todos
os dentes permanentes. Por isso também apresen- dos caninos superiores redunda em algum grau de
tam a raiz mais longa, comparativamente a toda a reabsorção radicular dos dentes vizinhos11.
dentição permanente. Enquanto se movimentam Mas qual a etiologia da erupção ectópica dos
em direção à cavidade bucal, sua coroa volumosa caninos permanentes superiores? O que leva esses
atravessando o estreito rebordo alveolar superior dentes a assumirem um trajeto eruptivo comple-
pode ser palpada sob a mucosa vestibular, acima tamente não usual?
dos caninos decíduos10. Quando essa palpação é A retenção dos caninos superiores por vesti-
positiva, significa que esses dentes apresentam um bular relaciona-se à falta de espaço na arcada den-
excelente prognóstico de erupção espontânea10. tária e, geralmente, representa uma manifestação
No entanto, em aproximadamente 1,5% da popu- clínica do apinhamento dentário16. Por outro lado,
lação, os caninos assumem uma trajetória ectópica na maioria dos casos de caninos retidos por pala-
de erupção, desviando-se para palatino em relação tino, existe espaço suficiente para acomodar todos
aos incisivos laterais13. Ao encontrar uma cortical os dentes no perímetro da arcada dentária16. Na
óssea densa, recoberta por uma mucosa palatina década de 90, Peck, Peck e Kataja24 compilaram
espessa e fibrosa, acabam ficando retidos. algumas evidências – provenientes da literatura
A erupção ectópica dos caninos superiores para pregressa – de que a erupção ectópica dos caninos
palatino (EECP) representa uma anomalia dentá- superiores por palatino apresenta uma etiologia
ria que preocupa o ortodontista sob dois aspec- predominantemente genética. Listaram fortes in-
tos biologicamente relevantes. Além de impedir a dícios para sustentar tal hipótese, como a ocorrên-
erupção espontânea dos caninos, em uma expres- cia concomitante com outras anomalias dentárias,
siva porcentagem dos casos, a erupção ectópica os relatos de história familiar dessa anomalia, a

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Anomalias dentárias associadas: o ortodontista decodificando a genética que rege os distúrbios de desenvolvimento dentário

FIGURA 13 - Interceptação da erupção ectópica do incisivo lateral inferior (Fonte: Silva Filho, Zinsly, Okada e Ferrari Junior29).

frequente ocorrência bilateral e as diferenças nas incisivos laterais, a ausência dos incisivos laterais
prevalências entre os gêneros e entre diferentes ou a “resistência” dos caninos decíduos à rizólise3.
populações. Tais assertivas renderam indignação Poucos anos mais tarde, os mesmos autores
por parte de alguns ortodontistas, que relutavam constataram que pacientes com erupção ectópi-
em acreditar que os caninos erram seu trajeto de ca dos caninos permanentes por palatino apre-
erupção por algum motivo além de fatores mera- sentam uma prevalência significativamente au-
mente locais, tais como a morfologia da raiz dos mentada de agenesias de dentes permanentes

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(17%, desconsiderando-se os terceiros molares),
sobretudo dos segundos pré-molares inferiores,
ausentes em 14% dos casos25. Ainda observaram
que essa ectopia envolvendo os caninos superio-
res associa-se constantemente com a microdontia
dos incisivos laterais permanentes, observada em
17% dos casos, não necessariamente no mesmo
quadrante do distúrbio eruptivo dos caninos. Esses
pesquisadores concluíram que a erupção ectópica
dos caninos por palatino, as agenesias e a micro-
dontia seriam covariáveis biológicas que compar-
tilham uma origem genética comum.
Somando-se a essas contundentes evidências
sobre a influência dos genes na etiologia da EECP,
observou-se que pacientes com essa ectopia ten-
dem a apresentar atraso na odontogênese e uma
redução generalizada no tamanho dentário. Essa
última informação explica porque a grande maio-
ria dos casos de EECP não apresentam apinha-
mento dentário e podem ser solucionados orto-
donticamente sem extrações.
Sob o ângulo de observação inversa, verificou-
se que pacientes com agenesias dentárias, micro-
dontia de incisivos laterais, infraoclusão de mola-
res decíduos ou hipoplasia generalizada de esmal-
te apresentam chances mais elevadas de desen-
volver erupção ectópica do canino para palatino
no transcorrer da dentadura mista2,13. Esses dados
apresentam importância clínica extrema quando
consideramos a possibilidade de diagnóstico pre-
coce da EECP. O clínico deve estar consciente de
que, de um modo genérico, uma criança apresenta
aproximadamente 1,5% de chances de apresen-
tar erupção ectópica dos caninos superiores para
palatino, enquanto uma criança com agenesia de
pelo menos um segundo pré-molar, por exemplo,
apresenta uma chance cinco vezes maior de de-
senvolver o mesmo distúrbio de erupção13 (Fig.
14). A associação fica ainda mais estreita com a
microdontia, uma vez que um estudo na popu-
lação italiana mostrou que 34% dos pacientes
com incisivo lateral superior conoide desenvol-
vem erupção ectópica dos caninos superiores para
Dental Press J. Orthod.
Garib DG, Alencar BM, Ferreira FV, Ozawa TO
palatino2. A infraoclusão de molares decíduos (Fig.
15), assim como a hipoplasia generalizada do es-
malte (Fig. 16), também representam irregulari-
dades que anunciam precocemente um risco mais
elevado para o desenvolvimento da EECP2. Essas
informações, sem dúvida nenhuma, refinam a ca-
pacidade de diagnóstico precoce da EECP. Levan-
do em conta que a erupção ectópica dos caninos
pode ser interceptada precocemente9 – prevenin-
do a reabsorção radicular dos incisivos adjacentes,
assim como a retenção dos caninos –, torna-se
imperativo que o clínico centre sua atenção no
desenvolvimento eruptivo dos caninos superiores
em todos as crianças, e especialmente naquelas
que apresentam alguma das anomalias dentárias
inter-relacionadas com a EECP. Essas anomalias
dentárias funcionam como indicadores de risco
para o desenvolvimento da EECP.
Transposição entre canino e primeiro
pré-molar superiores
Excluindo os terceiros molares, os caninos su-
periores constituem os dentes permanentes que
mais frequentemente demonstram distúrbios
eruptivos. Além da erupção ectópica por palatino,
outra importante, porém bem menos frequente,
ectopia que envolve os caninos superiores consiste
na transposição entre esse dente e o primeiro pré-
molar superior. O quadro clínico típico mostra o
canino superior permanente irrompido por ves-
tibular entre os dois pré-molares superiores. Fre-
quentemente, o canino apresenta-se girado para
distal e o primeiro pré-molar apresenta-se girado
para mesial e com uma angulação da coroa para
distal. Esse é o tipo de transposição mais comum
na espécie humana e acomete aproximadamente
de 0,03 a 0,25% da população. Aproximadamente
em ¼ dos casos expressa-se bilateralmente, com
uma ocorrência predominante no gênero femini-
no (proporção entre os gêneros = 1,5:1)25.
A etiologia da transposição entre o canino e o
primeiro pré-molar superior correlaciona-se com
fatores genéticos25. Na literatura, muitos relatos de
149 v. 15, no. 2, p. 138-157, Mar./Apr. 2010
Anomalias dentárias associadas: o ortodontista decodificando a genética que rege os distúrbios de desenvolvimento dentário

A B

FIGURA 14 - Paciente com agenesia dos segundos pré-molares e segundos molares inferiores: A) aos 10 anos de idade e B) aos 14 anos. Note o desen-
volvimento de erupção ectópica dos caninos superiores (para palatino) da primeira para a segunda radiografia. Importante observar o notável atraso no
desenvolvimento dentário aos 10 anos de idade.

A B

FIGURA 15 - A) Paciente com infraoclusão de molares decíduos diagnosticada no período intertransitório da dentadura mista. B) O acompanhamento lon-
gitudinal do desenvolvimento da dentição favoreceu o diagnóstico precoce da erupção ectópica do canino superior esquerdo, ainda durante a dentadura
mista. Na segunda radiografia, o segundo molar inferior esquerdo mostra uma mesioangulação.

casos clínicos reportaram um ou mais membros observa em aproximadamente 16% dos casos25.
da família mostrando a mesma característica, sem, Na dentadura permanente completa, o tra-
contudo, identificar histórico de trauma na região tamento desse tipo de transposição é desafiador
dentofacial. Além disso, pacientes com transposi- quando se almeja corrigir a posição invertida dos
ção entre canino e primeiro pré-molar superiores dentes envolvidos6. Esse planejamento demanda
apresentam uma expressiva prevalência de agene- mecânicas mais complexas e um período mais
sia de dentes permanentes, excluindo os terceiros prolongado de tratamento. Por essa razão, esses ca-
molares, equivalente a aproximadamente 37% a sos geralmente são tratados mantendo-se a posição
40%25 (Fig. 17). Especificamente essa modalidade invertida dos dentes envolvidos, movimentando
de transposição associa-se com uma alta prevalên- os primeiros pré-molares para mesial e nivelando
cia de agenesias de segundos pré-molares (12%) os caninos entre os dois pré-molares6. A presença
e incisivos laterais superiores (26%), enquanto a frequente de agenesias e microdontias associadas
prevalência de agenesia de terceiros molares não geralmente dificulta ainda mais o planejamento.
difere da população em geral25. A microdontia do A transposição entre caninos e primeiros pré-
incisivo lateral representa outra anomalia dentária molares superiores é passível de interceptação
frequentemente associada à transposição entre o ortodôntica. A época mais oportuna para tanto
canino e o primeiro pré-molar superior, como se mostra-se muito específica: logo após a erupção do

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 Garib DG, Alencar BM, Ferreira FV, Ozawa TO

A B C

D E F

G G G

H I
FIGURA 16 - Associação entre hipoplasia generalizada de esmalte (A a E) e erupção ectópica do dente 13 para palatino (F, G). A hipoplasia de esmalte
representa alerta clínico para o desenvolvimento dessa ectopia envolvendo os caninos superiores. Após o diagnóstico precoce e a interceptação por
meio da exodontia do canino antecessor decíduo, observou-se normalização da trajetória eruptiva do dente 13 (H), que irrompeu espontaneamente na
cavidade bucal (I).

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Anomalias dentárias associadas: o ortodontista decodificando a genética que rege os distúrbios de desenvolvimento dentário

primeiro pré-molar, porém antes da erupção dos Distoangulação do segundo pré-molar inferior
caninos superiores. Nesses casos, o primeiro passo A ectopia mais comumente observada nos se-
consiste na correção do longo eixo dos primeiro gundos pré-molares inferiores refere-se à distoan-
pré-molar com aparelho fixo, procedimento possí- gulação do germe19. Tal ectopia relaciona-se com
vel devido à posição vestibular ocupada pelo cani- a agenesia do segundo pré-molar inferior homó-
no permanente ainda não-irrompido. Esse procedi- logo28 (Fig. 18). Shalish et al.28, numa amostra de
mento é seguido pela extração do canino decíduo pacientes com agenesia unilateral dos segundos
no mesmo quadrante e, finalmente, pela exposição pré-molares inferiores, observaram que o germe
cirúrgica, colagem e tracionamento do canino per- do dente contralateral apresentava-se em média
manente para sua posição usual na arcada dentária. 10º mais angulado para distal, em comparação a
um grupo controle sem agenesias. Concluíram,
assim, que a distoangulação dos segundos pré-mo-
lares inferiores representa um diferente fenótipo
ou uma expressão mais branda do mesmo defeito
genético que ocasionou a agenesia. Esse tipo de
associação assemelha-se muito ao clássico quadro
clínico composto pela observação da microdontia
do incisivo lateral superior em pacientes com age-
nesia unilateral do referido dente.
A ocorrência da distoangulação na popula-
ção em geral é bastante rara, considerando-se sua
prevalência de 0,19%19. Diferentemente, em pa-
FIGURA 17 - Radiografia panorâmica de um paciente apresentando cientes com agenesia de pelo menos um segundo
transposição entre canino e primeiro pré-molar superior do lado direito,
associada à agenesia do incisivo lateral superior no mesmo quadrante. pré-molar, essa prevalência cresce para 7,8%13.

48

FIGURA 18 - Associação entre a agenesia de segundo pré-molar inferior e a erupção ectópica do canino superior para palatino. A mesma paciente ainda
apresentava distoangulação do segundo pré-molar inferior contralateral e hipoplasia generalizada de esmalte.

Dental Press J. Orthod. 152 v. 15, no. 2, p. 138-157, Mar./Apr. 2010


Portanto, o risco relativo de um paciente com age-
nesia de segundo pré-molar apresentar também
essa anomalia mostra-se 45 vezes maior. Uma in-
formação interessante, proveniente de um estudo
em brasileiros, é que a distoangulação dos segun-
dos pré-molares inferiores não é observada so-
mente em indivíduos com agenesia unilateral dos
segundos pré-molares inferiores, mas também em
pacientes com agenesia dos segundos pré-molares
superiores13. Aproximadamente 25% dos casos de
distoangulação foram observados em pacientes
com agenesia de pré-molares superiores, enquan-
to os outros 75% dos pacientes com essa ectopia
apresentavam agenesia unilateral dos segundos
pré-molares na arcada inferior13. Portanto, o clínico
não deve surpreender-se ao observar essa anomalia
de posição em pacientes com agenesias.
A distoangulação do segundo pré-molar infe-
rior geralmente se autocorrige e não exige inter-
venção12. Essa ectopia define-se em estágios preco-
ces da odontogênese. À medida que a rizogênese
se processa, o germe vai assumindo uma posição
cada vez mais vertical, até irromper espontanea-
mente na arcada dentária (Fig. 19). Acompanhar
o desenvolvimento dentário longitudinalmente
constitui o único procedimento necessário. No
entanto, quando a distoangulação apresentar um
caráter severo, morfologicamente traduzido por
uma posição mais horizontal do germe, a erupção
espontânea torna-se imprevisível (Fig. 20). Nesses
FIGURA 19 - Acompanhamento longitudinal da distoangulação do segundo pré-molar inferior. Observe a associação dessa anomalia com a agenesia
de seu contralateral. O germe do dente 35 ectópico verticalizou gradativamente durante a rizogênese e irrompeu espontaneamente na arcada dentária.
Dental Press J. Orthod.
Garib DG, Alencar BM, Ferreira FV, Ozawa TO
casos, a ectopia associa-se frequentemente com o
atraso no desenvolvimento dentário e pode exigir
tracionamento ortodôntico12.
Infraoclusão dos molares decíduos
A infraoclusão dos molares decíduos acomete
aproximadamente 8,9% das crianças e caracteriza-
se pela localização da face oclusal dos molares em
questão aquém do plano oclusal18. Sugere-se que
a infraoclusão dos molares represente uma conse-
quência da anquilose dentária. Em algum ponto
da raiz, uma ponte de tecido mineralizado subs-
titui o espaço do ligamento periodontal, unindo
osso alveolar e cemento. A partir desse momento,
o dente inapto a desenvolver-se no sentido verti-
cal vai ficando progressivamente em infraoclusão,
à medida que a face cresce.
Uma sequência de evidências apontou que a
genética apresenta influência na determinação da
infraoclusão dos molares decíduos. Kurol18 verifi-
cou que a prevalência da infraoclusão mostra-se
bastante aumentada em irmãos de pacientes afeta-
dos, de modo que a prevalência dessa irregularida-
de alcança aproximadamente 20%, ou seja, o dobro
do esperado para a população em geral. Bjerklin,
Kurol e Valentin4 constataram associação entre a
ocorrência da infraoclusão dos molares decíduos
e a erupção ectópica dos primeiros molares per-
manentes superiores, erupção ectópica dos caninos
superiores e a agenesia de segundos pré-molares.
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A B

C D
FIGURA 20 - Paciente apresentando associação entre a agenesia do segundo pré-molar inferior esquerdo e a distoangulação de seu contralateral (A).
Após acompanhamento do desenvolvimento do germe do dente 45 durante por 1,5 anos (B), optou-se pelo seu tracionamento em campo fechado. Ao final
do tratamento (C), observa-se o segundo pré-molar inferior verticalizado. Cinco anos após o tratamento (D), a sua odontogênese mostra-se completa.

Baccetti2 constatou que pacientes com infraoclu- A infraoclusão de um molar decíduo não in-
são de molares decíduos apresentam uma preva- fluencia o ritmo da odontogênese do sucessor per-
lência significativamente aumentada de agenesia de manente que, geralmente, irrompe na época espe-
segundos pré-molares (14%), incisivo lateral conoi- rada, com no máximo 6 meses de atraso. Portanto,
de (13%), erupção ectópica dos primeiros molares a infraoclusão suave ou moderada requer apenas
(18%) e dos caninos superiores para palatino (14%). acompanhamento longitudinal. Contrariamente,
Além disso, o autor verificou que pacientes selecio- a infraoclusão severa, assim classificada quando o
nados por uma dessas anomalias dentárias também plano oclusal do molar decíduo afetado já se en-
apresentam prevalência aumentada de infraoclusão contra abaixo do ponto de contato com os den-
de molares decíduos. Garib, Peck, Gomes13 verifi- tes vizinhos, necessita de intervenção (Fig. 15A).
caram que 25% dos pacientes com agenesia de se- Nessas condições, o molar decíduo não pode mais
gundos pré-molares apresentaram infraoclusão dos funcionar como mantenedor de espaço, existe o
molares decíduos, o equivalente a ¼ dos pacientes. risco de redução no perímetro da arcada além da
Essa prevalência mostrou-se significativamente au- probabilidade do dente decíduo ficar totalmente
mentada em relação ao esperado para a população subgengival com a progressão da infraoclusão. Ba-
em geral (8,9%). Isso quer dizer que pacientes com seado nessas justificativas, a conduta terapêutica
agenesia de segundos pré-molares apresentam três mais coerente consiste na extração do dente decí-
vezes mais riscos de desenvolver a infraoclusão do duo afetado e na instalação de um aparelho man-
que o restante da população em geral. tenedor de espaço (Fig. 15B).

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Atraso no desenvolvimento dentário
Pacientes com agenesia tendem a apresentar
um desenvolvimento odontogênico mais lento
e a idade dentária atrasada em relação à idade
cronológica1. Explicada pela inter-relação ge-
nética na causalidade dessas anomalias, essa in-
formação merece atenção do clínico. Os jovens
com agenesias dentárias geralmente alcançam a
maturidade oclusal mais tardiamente. A denta-
dura permanente pode se completar alguns anos
mais tarde do que a idade usual (Fig. 14). Por
isso, o ortodontista não deve se apressar em ini-
ciar a fase 2 do tratamento ortodôntico em tais
pacientes. O diagnóstico precoce aliado ao trata-
mento ortodôntico corretivo tardio representaria
a combinação perfeita nos casos com padrão de
anomalias dentárias associadas.
Somado ao generalizado atraso no desenvol-
vimento dentário comumente observado em pa-
cientes com anomalias, um tipo dentário específi-
co pode exibir uma odontogênese marcantemen-
te atrasada em relação ao restante da dentição: os
segundos pré-molares. Os segundos pré-molares
apresentam uma grande instabilidade de desen-
volvimento. Além da alta prevalência de agenesia,
esses dentes comumente exibem atrasos de desen-
volvimento, especialmente quando existe a age-
nesia de outros dentes permanentes (Fig. 21, 22).
FIGURA 21 - Atraso na odontogênese do segundo pré-molar superior
direito. Note a associação dessa anomalia com a agenesia dos demais
segundos pré-molares.
Dental Press J. Orthod.
Garib DG, Alencar BM, Ferreira FV, Ozawa TO
Tudo indica que o atraso odontogênico do segun-
do pré-molar representa uma expressão incom-
pleta do mesmo genótipo que define a agenesia.
A mineralização inicial dos segundos pré-molares
inferiores ocorre em média aos 3 anos de idade
(variando de 2 anos e 3 meses a 3 anos e 7 me-
ses)21, porém esse dente pode aparecer mais tar-
diamente27. Geralmente, seu aparecimento tar-
dio ocorre até por volta dos 6 anos de idade27,
e alguns raros relatos da literatura mostraram
o aparecimento radiográfico dos segundos pré-
molares em idades ainda mais avançadas: após os
9 anos e mesmo aos 13 anos de idade8. Quando
mineralizam tardiamente, irrompem tardiamen-
te, geralmente sucedendo os segundos molares
permanentes, teoricamente os últimos dentes
permanentes a alcançar o plano oclusal, descon-
siderando-se os terceiros molares.
Sob a luz desses conhecimentos, a constata-
ção de segundos pré-molares não-irrompidos em
pacientes na pós-adolescência não deve ocasio-
nar preocupação (Fig. 21, 22). Se os germes esti-
verem bem posicionados e não existir nenhuma
patologia local, significa que os segundos pré-
molares apresentam um atraso desenvolvimen-
tal. O acompanhamento permitirá ao clínico
assistir o seu surgimento espontâneo, ainda que
tardio, na cavidade bucal.
45 35
FIGURA 22 - Atraso no desenvolvimento dos segundos pré-molares
superiores em um paciente com agenesia dos segundos pré-molares
inferiores.
155 v. 15, no. 2, p. 138-157, Mar./Apr. 2010
Anomalias dentárias associadas: o ortodontista decodificando a genética que rege os distúrbios de desenvolvimento dentário

Hipoplasia de esmalte acentuada de flúor ou antibioticoterapia –, podem

Apesar de ainda constituir um tema não muito funcionar de alerta clínico para o desenvolvimen-
explorado pela literatura, existem algumas evidên- to de outras anomalias dentárias no decorrer do
cias de que a hipoplasia generalizada do esmalte desenvolvimento da dentição.
integra a lista de anomalias dentárias associadas,
reguladas geneticamente (Fig. 16, 18). Isso porque CONCLUSÃO
a hipoplasia de esmalte é diagnosticada, nos ca- A implicação clínica do padrão de anomalias
sos com anomalias dentárias, mais comumente do dentárias associadas é muito relevante, uma vez
que se esperaria ao acaso2. Além disso, em uma que o diagnóstico precoce de uma determinada
amostra de jovens selecionados pela presença de anomalia dentária (como a agenesia de um segun-
hipoplasia, constatou-se uma prevalência elevada do pré-molar ou a presença de um incisivo lateral
de agenesias, microdontia e ectopias, incluindo a superior cônico) pode alertar o clínico da possi-
erupção ectópica dos caninos para palatino2. Des- bilidade de desenvolvimento de outras anomalias
sa maneira, manchas brancas presentes generali- associadas no mesmo paciente ou em outros mem-
zadamente no esmalte dos dentes permanentes, bros da família, permitindo o diagnóstico precoce
dissociadas de causas ambientais – como ingestão e a intervenção ortodôntica em tempo oportuno.

Associated dental anomalies: The orthodontist decoding the genetics which

regulates the dental development disturbances

Abstract

This article aims to approach the diagnosis and orthodontic intervention of the dental anomalies, emphasizing the
etiological aspects which define these developmental irregularities. It seems to exist a genetic inter-relationship de-
termining some dental anomalies, considering the high frequency of associations. The same genetic defect may give
rise to different phenotypes, including tooth agenesis, microdontia, ectopias and delayed dental development. The
clinical implications of the associated dental anomalies are relevant, since early detection of a single dental anomaly
may call the attention of professionals to the possible development of other associated anomalies in the same patient
or in the family, allowing timely orthodontic intervention.

Keywords: Genetics. Dental anomalies. Tooth agenesis. Etiology. Orthodontics.

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Enviado em: novembro de 2009

Revisado e aceito: dezembro de 2009

Endereço para correspondência

Daniela Gamba Garib
Faculdade de Odontologia de Bauru
Al. Octávio Pinheiro de Brisola 9-75
CEP: 17.012-901 – Bauru/SP
E-mail: dgarib@uol.com.br

Dental Press J. Orthod. 157 v. 15, no. 2, p. 138-157, Mar./Apr. 2010

 DOMÍNIO CONEXO

Etiologia das más oclusões: perspectiva clínica

(Parte I) — fatores genéticos
Etiology of malocclusions: Clinical perspective (Part I) — Genetic factors

Daniela G. Garib*
Omar Gabriel da Silva Filho**
Guilherme JanSon***

Resumo Abstract

A etiologia das más oclusões repre-
senta um tema de importância rele-
vante na especialidade Ortodontia.
Primeiro, por cumprir um compro-
misso acadêmico, a erudição fun-
damental do especialista. Segundo,
por possibilitar ao ortodontista uma
visão mais aprofundada, e por isso
mais refinada, da origem do pro-
blema. O arsenal de informações
permite ao profissional ponderar
sobre a possibilidade de prevenção
de uma determinada irregularidade,
delinear seu prognóstico de trata-
mento e a estabilidade da correção,
bem como valorizar a sua manifes-
tação provável na árvore genealó-
gica. O presente trabalho investe
numa classificação simples e em
consonância com a prática clínica,
dividindo os fatores etiológicos em
dois grandes grupos: fatores genéti-
cos e fatores ambientais. É oportu-
no comentar de antemão que, pela
diversidade morfológica, esses dois
fatores podem estar presentes na
mesma má oclusão, somando seus
efeitos. Por motivos unicamente di-
dáticos, o texto abrangendo os dois
fatores etiológicos será dividido em
3 partes. A parte I discute as carac-
terísticas dentofaciais com marcan-
te determinação genética. A parte
II destaca os fatores ambientais que
provocam más oclusões. A parte
III retrata as fissuras labiopalatinas,
cuja etiologia congrega fatores ge-
néticos e ambientais.
The etiology of malocclusions is a
subject of relevant importance in Or-
thodontics. At first, it is important for
meeting an academic commitment, the
fundamental erudition of the specialist.
Second, it is relevant for opening to the
orthodontist the possibility of a broad
and detailed view of the origin of the
problem. The arsenal of information
allows the professional to rationalize the
possibility of prevention, the treatment
prognosis and the stability of the correc-
tion, as well as to consider the manifes-
tation in other members of the patient’s
family. This study demonstrates a sim-
ple classification with consonance to the
clinical practice, dividing the etiological
factors into two large groups: Genetic
factors and environmental factors.
It is appropriate to highlight that due
to morphological diversity, these two
factors may be present in the same
malocclusion, mixing its effects. For
didactical reasons, the article is divided
into 3 parts. Part I discusses the dento-
facial characteristics with preponderant
genetic determination. Part II highlights
the environmental factors which causes
malocclusions. Part III discusses the
etiology of cleft lip and palate, which
associates both genetic and environ-
mental factors.

Palavras-chave: Keywords:
Etiologia. Má oclusão. Genética. Etiology. Malocclusion. Genetics.

* Professora doutora de Ortodontia, Hospital de Reabilitação de Anomalias Craniofaciais e Faculdade de Odon-

tologia de Bauru, Universidade de São Paulo.
** Ortodontista do Hospital de Reabilitação de Anomalias Craniofaciais, Universidade de São Paulo. Coorde-
nador do Curso de Ortodontia Preventiva e Interceptiva da Sociedade de Promoção Social do Fissurado
Labiopalatal (PROFIS).
*** Professor titular e chefe do departamento de Odontopediatria, Ortodontia e Saúde Coletiva da Faculdade de
Odontologia de Bauru, Universidade de São Paulo.

Rev Clín Ortod Dental Press. 2010 abr-maio;9(2):77-97 77

DOMÍNIO CONEXO
INTRODUÇÃO
A etiologia das más oclusões constitui um capítulo essen-
cial da Ortodontia. Ao longo da história da ciência ortodônti-
ca, foram apresentadas diversas versões para a etiologia des-
se problema. No final do século XIX, prevalecia o conceito de
que a herança genética representava o principal fator etio-
lógico das más oclusões16. Esse conceito mudou a partir do
século XX, com a visão de Edward Hartley Angle fortalecendo
os fatores ambientais3. Angle3 admitia que as más oclusões
apresentavam causas exclusivamente locais. A prova de que
não acreditava na genética como determinante do problema
é que tratava os apinhamentos com mecânica expansionis-
ta, defendendo, em grande parte de sua vida, a abordagem
não-extracionista. Angle devotou o capítulo IV da sétima edi-
ção de seu livro à etiologia das más oclusões. Nesse capítulo,
o pai da Ortodontia apenas enumerou as causas prováveis,
todas elas ambientais, sem a pretensão de classificá-las, in-
cluindo em sua lista a perda prematura de dentes decíduos,
a perda de dentes permanentes, a realização de restaurações
incorretas, a retenção prolongada de dentes decíduos, a
erupção tardia de dentes permanentes, dentes supranumerá-
rios, transposições dentárias, o desuso, o freio labial anormal,
hábitos bucais deletérios e a obstrução nasal.
Contemporâneo de Angle, nem por isso compartilhando
das mesmas ideias, Case5 dedicou cinco capítulos da parte II
de seu livro para a descrição dos fatores etiológicos das más
oclusões, ressaltando a importância da hereditariedade.
O europeu Korkhaus31, em 1939, dividiu os fatores etio-
lógicos em endógenos, de origem sistêmica e exógenos,
representados por fatores ambientais locais. Guardo13, na
década de 1950, subdividiu os fatores etiológicos em cin-
co grupos, incluindo os fatores hereditários, congênitos,
adquiridos gerais, locais e proximais. Esse último grupo
incluía os hábitos bucais. Salzmann27 classificou os fatores
etiológicos das más oclusões em pré-natais e pós-natais. Na
mesma época, Graber11 organizou as causas das más oclu-
sões em fatores intrínsecos, ou locais; e fatores extrínsecos,
ou gerais. Considerou como fatores intrínsecos aqueles de
responsabilidade do cirurgião-dentista, como as anomalias
dentárias, freios, perda prematura e retenção prolongada
de dentes decíduos, erupção tardia de dentes permanen-
tes, ectopias, anquilose, cárie e restaurações inadequadas.
Como fatores extrínsecos ou gerais, categorizou a heredita-
riedade, as doenças congênitas, o meio ambiente, as doen-
ças metabólicas, os problemas dietéticos, os hábitos, a pos-
tura e acidentes e traumatismos, dificilmente resolvidos pelo
profissional. Moyers24 sugeriu uma equação ortodôntica en-
volvendo os fatores etiológicos (hereditariedade, causas
78 Rev Clín Ortod Dental Press. 2010 abr-maio;9(2):77-97
Etiologia das más oclusões: perspectiva clínica (Parte I) — fatores genéticos
desenvolvimentais de origem desconhecida, traumatismos,
agentes físicos, hábitos, enfermidades sistêmicas e locais, e
má nutrição), sua época (idade) e modo de atuação (contí-
nuo ou intermitente), o tecido (neuromuscular, dente, osso e
cartilagem, tecidos moles) e os resultados produzidos (fun-
ção inadequada, má oclusão ou displasias ósseas). Proffit,
Fields Jr e Sarver26, recentemente, dividiram os fatores etio-
lógicos em causas específicas (como a causa da acromega-
lia, por exemplo), influência genética e influência ambiental.
Essa breve revisão da literatura demonstra a ausência de
uma abordagem consensual sobre o tema, além da dificul-
dade em se estabelecer critérios para uma categorização
prática dos fatores etiológicos. Muitas abordagens clássi-
cas da etiologia das más oclusões confundiram a origem do
problema com a sua época de manifestação. Anormalidades
de origens completamente distintas — genéticas e ambien-
tais — porém manifestadas na mesma época, como na vida
intrauterina, foram algumas vezes classificadas num mesmo
grupo, denominado alterações congênitas ou pré-natais13,27.
Nessa perspectiva agrupavam-se a microssomia hemifacial
ocasionada pela talidomida com a disostose cleidocraniana
ocasionada por mutação gênica. Adicionalmente, muitas
classificações confundiram os adjetivos hereditário, genéti-
co e congênito13,27. É importante ressaltar que toda irregula-
ridade hereditária apresenta caráter genético. No entanto,
o contrário não é verdadeiro. Muitas alterações genéticas
não são herdadas e sim determinadas por mutações22. Não
raro, os termos genético e congênito são usados erronea-
mente. Congênito diz respeito a alterações visualizadas ao
nascimento. Nem toda alteração congênita apresenta ca-
ráter genético. As malformações ocasionadas por drogas
teratogênicas, apesar de congênitas, representam irregula-
ridades ambientais e, portanto, não são transmitidas para
os descendentes. Da mesma maneira, nem todo problema
genético pode ser diagnosticado ao nascimento, desmere-
cendo a qualificação de congênito. Nessa categoria, pode-
ríamos enumerar o Diabetes Mellitus do tipo I, a agenesia
dentária e o Padrão esquelético III.
Os equívocos abarcam, também, os fatores ambien-
tais. Influências ambientais podem agir na vida intrauteri-
na e ocasionar alterações congênitas, como deformidades
causadas por medicamentos, ou podem atuar na vida pós-
natal, a exemplo do trauma ou da cárie dentária, ou ainda
em ambas as fases, como a má nutrição. Portanto, irregu-
laridades pós-natais não deveriam ser empregadas como
sinônimo de fatores ambientais ou adquiridos, uma vez que
muitos deles apresentam base genética. Observe o exem-
plo da agenesia dentária, incluída dentre os fatores adquiri-
dos locais na classificação de Guardo13, enquanto apresenta
Garib DG, Silva Filho OG, Janson G

uma etiologia essencialmente genética. Tampouco o termo
adquirido adequa-se a representar exclusivamente os fa-
tores ambientais, posto que mutações gênicas podem ser
adquiridas em vez de herdadas.
Essa discussão inicial acerca da etiologia das más oclu-
sões, filosófica e bastante acadêmica, tornou-se necessá-
ria para justificar a proposta do presente artigo: a busca
de uma simplificação no agrupamento dos fatores que
causam más oclusões. O sistema de classificação do pre-
sente artigo, em fatores genéticos e fatores ambientais, é,
sem dúvida, mais simples, mais prático, contemporâneo,
compatível com as novas descobertas da genética a par-
tir do projeto Genoma Humano e está em consonância
com a prática clínica. Numa perspectiva histórica, o co-
nhecimento do século XXI reconhece que as característi-
cas dentofaciais — como morfologia, número, posição e
cor dos dentes, bem como tamanho e posição das bases
ósseas estruturando o Padrão esquelético da face — são
definidas fortemente pela codificação genética22,23. O or-
todontista britânico Mossey22,23 afirmou que a chave para
a determinação da etiologia da má oclusão e para definir
o seu prognóstico de tratamento depende da habilidade
de diferenciar o efeito relativo dos genes e do ambiente
sobre as estruturas dentofaciais, em cada paciente.
Resumindo, o presente artigo agrupa as causas das más
oclusões em fatores genéticos e fatores ambientais. Não
raro, más oclusões podem resultar da associação desses dois
fatores etiológicos. Em geral, quanto maior a influência am-
biental em detrimento da influência genética, maior a possi-
bilidade de prevenção, melhor o prognóstico de correção e
maiores as chances de estabilidade pós-tratamento, desde
que a causa seja eliminada. A comparação entre a mordi-
da aberta predominantemente dentoalveolar e a mordida
aberta predominantemente esquelética representa ótima
exemplificação (Fig. 1, 2). Apesar da influência multifatorial
de fatores genéticos e ambientais concorrer para a etiolo-
gia de ambas, na primeira predomina a influência ambiental
— representada pelos hábitos bucais deletérios —, enquan-
to na última predomina a influência genética, vinculada ao
padrão de crescimento facial predominantemente vertical.
Dessa maneira, a mordida aberta dentoalveolar apresenta
maior possibilidade de prevenção, melhor prognóstico de
tratamento e maior estabilidade pós-tratamento, desde que
os hábitos sejam abandonados.

A B C

Figura 1 Má oclusão de Classe I, com mordida aberta anterior. O aspecto circular e a restrição à região
dos incisivos evoca a sucção como etiologia e confere à mordida aberta a conotação de dentoalveo-
lar. A correção envolveu mecânica ortodôntica com extrusão dos incisivos e a eliminação do hábito. D

E F G

Rev Clín Ortod Dental Press. 2010 abr-maio;9(2):77-97 79

DOMÍNIO CONEXO
A B
D E
Figura 2 Má oclusão de Classe III, com mordida aberta anterior. O aspecto mais difuso e retangular da mordida aberta anterior evoca etiologia rela-
cionada com o crescimento facial. A participação da face na determinação da mordida aberta anterior confere a conotação de esquelética. Mesmo
na dentadura decídua, o tratamento não evoluiu bem e a mordida aberta anterior progrediu para a dentadura mista. A correção deve ser planejada
com cirurgia ortognática.
A importância do reconhecimento da genética ultra-
passa o limite das intervenções ortodônticas. Elucida, por
exemplo, a possibilidade de transmissão de determina-
da característica aos descendentes. Quanto maior o pa-
pel da genética na determinação de uma irregularidade
dentofacial, maior a chance de observarmos a incidência
dessa característica aumentada nos descendentes de pa-
cientes afetados.
Todas as más oclusões representam interações da
genética e do ambiente. Seria errôneo acreditar que
as dimensões e a morfologia craniofacial são determi-
nadas exclusivamente pela genética ou por fatores am-
bientais 22,23. A face e a dentição são influenciadas pela
complexa interação de ambos, e cada má oclusão ocupa
uma determinada posição no espectro gene/ambiente.
Portanto, seria correto pronunciar que determinada má
oclusão apresenta etiologia eminentemente genética
ou etiologia essencialmente ambiental, caracterizando a
preponderância do genótipo ou do meio ambiente na
determinação de cada má oclusão. Esse entendimento
apresenta um reflexo direto em uma das mais importan-
tes preocupações da Ortodontia: a determinação da ex-
tensão em que uma determinada má oclusão pode ser
influenciada pela intervenção terapêutica ambiental, ou
seja, o prognóstico da correção ortodôntica. Dessa ma-
neira, o presente artigo propõe-se a discutir os fatores
etiológicos das más oclusões sob a perspectiva das in-
fluências genéticas e ambientais.
80 Rev Clín Ortod Dental Press. 2010 abr-maio;9(2):77-97
Etiologia das más oclusões: perspectiva clínica (Parte I) — fatores genéticos
C
F
PARTE I - FATORES GENÉTICOS
Resumo
Os fatores genéticos não são prevenidos, simplesmente
instalam-se como fatalidade biológica. Podem ser atenuados
com intervenção ortodôntica, ortopédica e/ou cirúrgica, na
dependência da localização, extensão e gravidade da má
oclusão. Tais fatores são aqui apresentados nos seguintes
tópicos: Tipo facial, Padrão esquelético sagital da face, Dis-
crepâncias dente-osso, Anomalias dentárias, Infraoclusão de
molares decíduos e Anomalias craniofaciais.
O CÓDIGO GENÉTICO E A MÁ OCLUSÃO
O código genético humano, ou genoma humano, cor-
responde ao conjunto de cerca de 27.000 genes distribuí-
dos nos 23 pares de cromossomos contidos em cada uma
das células humanas diploides. Esses genes se organizam
numa estrutura de dupla hélice formada por 4 bases quí-
micas nitrogenadas que se unem sempre aos pares: A-T e
C-G (adenina e timina, citosina e guanina). Na linguagem
da Genética, o gene é um segmento de um cromossomo
ao qual corresponde um código distinto: uma informação
para produzir uma determinada proteína ou controlar uma
característica como, por exemplo, a cor dos olhos. Portan-
to, o código genético humano contém a informação básica
Garib DG, Silva Filho OG, Janson G
necessária para o desenvolvimento físico e psíquico de um
ser humano, sendo responsável pela aparência e persona-
lidade, bem como pelo risco de doenças. Nesse contexto,
o código genético explica muito da morfologia dentofacial.
No íntimo da célula, define-se o tamanho, a forma e po-
sição dentária, bem como o tamanho relativo e a disposi-
ção espacial dos ossos faciais, maxila e mandíbula, na face.
A constituição gênica de um indivíduo é conhecida como
genótipo, enquanto as características manifestas são co-
nhecidas como fenótipo22. O sequenciamento do genoma
humano, comemorado em 2001, foi realizado pelo Projeto
Genoma Humano, desenvolvido por mais de cinco mil cien-
tistas do mundo inteiro, possibilitando avanços expressivos
na Genética e na Medicina.
O código genético de cada ser humano depende da he-
rança e das mutações gênicas22. As mutações são caracteri-
zadas por alterações que ocorrem no genótipo após a fertili-
zação e, portanto, não são herdadas, porém transmitidas aos
descendentes a partir daquela geração.
Quando as características qualitativas, como cor dos
olhos ou grupo sanguíneo, são determinadas por um único
par de genes, apresentam uma herança que segue o padrão
mendeliano22. Nesse caso, se a manifestação dessa caracte-
rística é imposta pela presença de apenas um gene, indepen-
dentemente do gene alelo (ou par), o modo de transmissão é
considerado autossômico dominante. Se houver necessida-
de de dois genes para a expressão de uma determinada ca-
racterística, a transmissão é considerada autossômica reces-
siva22. A herança recessiva e ligada ao gênero (cromossomo
X) também segue um padrão de transmissão mendeliano e
explica, por exemplo, a manifestação da hemofilia e da calví-
cie, afetando somente o gênero masculino.
As características quantitativas, tais como a altura corpo-
ral e as dimensões dos dentes e ossos faciais, são definidas
pela interação de diversos pares de genes. Portanto, são
características transmitidas pela herança poligênica22. A he-
rança poligênica, contrariamente à herança mendeliana au-
tossômica ou ligada ao gênero, sofre influência ambiental.
A exposição a certos fatores ambientais pode potencializar
a expressão de características reguladas por poligenes22. A
morfologia craniofacial, as más oclusões, certas anomalias
dentárias e a fissura labiopalatina representam caracterís-
ticas moduladas pelo padrão de herança poligênica. Inte-
ressante atentar para o comentário de Mossey22 de que a
maioria das más oclusões apresenta herança multifatorial
contínua: “As más oclusões não deveriam ser consideradas
como anormais ou doenças, mas sim variações na forma nor-
mal de oclusão... considerando que há uma enorme escala
de variação morfológica para essa característica”.
A evidência de que determinada irregularidade dentofacial
apresenta supremacia genética em sua etiologia provém de es-
tudos em famílias e em gêmeos23. Quando uma determinada
irregularidade mostra uma prevalência aumentada em famílias
de pacientes afetados, comparada às prevalências esperadas
para a população em geral, credita-se à genética uma influ-
ência importante na etiologia do problema. O prognatismo
mandibular da família imperial austro-húngara Habsburg re-
presenta o mais clássico exemplo de característica genética de
interesse ortodôntico, em humanos, transmitida por sucessivas
gerações. Atualmente, a leitura do código genético pode isolar
genes mutantes em famílias, desde que diversos membros ex-
pressem a mesma irregularidade. Recentes avanços no campo
da Biologia Molecular e da Genética humana têm influenciado
significativamente os estudos da morfologia dentofacial22.
Gêmeos monozigóticos compartilham códigos genéticos
muito semelhantes. Portanto, as características genetica-
mente definidas expressam-se em ambos os gêmeos mono-
zigóticos de maneira semelhante. Quando se constata uma
alta concordância para uma determinada irregularidade, em
pares de gêmeos homozigóticos, conclui-se que a genética
consiste um fator importante na etiologia de tal anormalida-
de. Diferentemente, gêmeos heterozigóticos, por apresenta-
rem genótipos distintos, manifestam baixo índice de concor-
dância para a mesma irregularidade22.
As características dentofaciais com etiologia genética
preponderante e de interesse para o ortodontista serão ex-
postas obedecendo a seguinte ordem: tipo facial, padrão es-
quelético sagital da face, discrepâncias dente-osso, diversos
tipos de anomalias dentárias, infraoclusão de molares decí-
duos, e grande parte das anomalias craniofaciais.
O Tipo Facial
Ao analisar o paciente sob uma perspectiva frontal, re-
conhecemos três tipos faciais distintos, de acordo com a
proporção entre a altura e a largura da face: braquifacial,
mesofacial e dolicofacial (Fig. 3). Os pacientes mesofaciais
apresentam a distância bizigomática proporcional à altura
facial, quantificada desde o násio até o mento. Os pacien-
tes dolicofaciais apresentam predominância da altura facial
em relação à largura. De modo oposto, os braquifaciais exi-
bem uma face mais larga do que longa. Observam-se dife-
renças também na vista lateral, com os braquifaciais mos-
trando uma maior profundidade da face comparativamente
aos dolicofacais. As denominações braquifacial, mesofacial
e dolicofacial originam-se da antropologia e implicam não
somente na morfologia da face, mas também do crânio4,7.
Diferentes etnias demonstram predominância de distintos
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A B

C D

Figura 3 Tipos faciais: A, B) mesofacial, C, D) do-

licofacial e E, F) braquifacial. E F

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Garib DG, Silva Filho OG, Janson G
tipos faciais: indivíduos de origem anglo-saxônica apresen-
tam morfologia predominantemente dolicofacial, enquan-
to, dentre os asiáticos, prevalece o tipo braquifacial4.
O tipo facial consiste em uma característica predominan-
temente genética, sobre a qual o ambiente e as mecânicas
ortopédicas exercem influência mínima23. A Ortopedia Facial
e a Ortodontia não são capazes de alterar o tipo facial herda-
do1,22,30. Por exemplo, a utilização de mentoneira vertical não
transforma o tipo dolicofacial em mesofacial. As medidas ce-
falométricas que expressam o padrão de crescimento facial
mostram-se inertes aos efeitos de aparelhos ortopédicos ou
ortodônticos, como registram a infinidade de estudos cefalo-
métricos publicados nas últimas décadas. Os hábitos bucais,
como a respiração bucal crônica, representativos de influên-
cias ambientais podem até acentuar um padrão vertical de
crescimento facial em termos numéricos, porém inexistem
evidências de que essas alterações alcancem magnitude su-
ficiente para alterar o tipo facial determinado geneticamente
(a discussão sobre esse tema será enfatizada na parte II desse
artigo). Portanto, o código genético mostra-se soberano na
definição da morfologia facial frontal, e a intenção de alterá-
la com aparelhos ortodônticos ou ortopédicos traduz metas
inatingíveis. Do ponto de vista genético, é mais fácil admitir
que faces com predominância vertical favorecem a respiração
bucal do que vice-versa. Nas faces com predominância verti-
cal, a largura e a profundidade da faringe são menores, favo-
recendo a redução da permeabilidade aérea. A eliminação de
obstruções nasais e/ou faringeanas torna a via aérea permeá-
vel, mudando a função respiratória de bucal para mista, mas
não consegue mudança facial com impacto clínico.
O Padrão Esquelético Sagital da Face
A morfologia do perfil facial apresenta uma forte deter-
minação genética. Uma sólida evidência da influência mor-
fogenética sobre a arquitetura facial consiste na observação
de que as diferentes etnias apresentam características es-
pecíficas que as diferenciam. Os negros apresentam maior
protrusão bimaxilar comparados aos brancos, enquanto os
asiáticos apresentam um grau de protrusão intermediário en-
tre o dos brancos e negros.
Os padrões esquelético-faciais I, II e III também mostram
uma determinação predominantemente genética. A mor-
fologia facial estabelece-se precocemente, sendo possível
o seu diagnóstico desde a dentadura decídua e, em regra,
o crescimento facial preserva o padrão esquelético. Assim,
o comportamento médio permite afirmar que, uma vez Pa-
drão esquelético I, sempre Padrão I. Essa máxima estende-
se aos Padrões esqueléticos II e III, desde que não tratados.
Seguindo uma herança poligênica, os distintos padrões es-
queléticos sagitais (I, II e III) mostram prevalências aumenta-
das em famílias de pacientes afetados23.
A hipótese de que o aleitamento materno contribui posi-
tivamente para o crescimento mandibular pós-natal é sugeri-
da na literatura, mas carece de comprovação científica20. Essa
premissa salienta a influência ambiental no crescimento e ig-
nora o papel da genética na determinação do padrão facial.
A fim de que essa hipótese ganhasse comprovação, estudos
deveriam atestar que crianças que não foram amamentadas
apresentam prevalência aumentada de deficiência mandibu-
lar se comparadas a crianças que foram amamentadas por
um longo período de tempo. Será que crianças que foram
abandonadas ao nascimento e privadas do aleitamento ma-
terno apresentam uma prevalência de deficiência mandibular
mais elevada do que a população em geral? Essas evidên-
cias inexistem na literatura. Um estudo epidemiológico, com
crianças na fase da dentadura mista, não identificou dife-
renças significativas na prevalência de Padrão esquelético II
por deficiência mandibular entre crianças com histórico de
amamentação igual ou superior a seis meses, quando com-
parada à de crianças não-amamentadas como recomenda a
Organização Mundial de Saúde20. Tais resultados reforçam a
preponderância do código genético sobre o fator ambiental
na determinação da morfologia facial.
Observou-se um índice de correlação entre pais e filhos
para a má oclusão de Classe II, divisão 1, maior do que de
pares da população selecionados aleatoriamente23 (Fig. 4).
Estudos prévios documentaram a ocorrência familial da má
oclusão de Classe II, divisão 2, incluindo estudos em gêmeos
e trigêmeos e em linhagens familiares23. Em um estudo clíni-
co e cefalométrico com 114 casos de má oclusão de Classe
II, divisão 2 — sendo 48 pares de gêmeos e seis conjuntos
de trigêmeos —, dos pares monozigóticos, 100% demons-
traram concordância para a má oclusão de Classe II, divisão
2; enquanto aproximadamente 90% dos gêmeos dizigóticos
mostravam-se discordantes23.
Um rico conjunto de estudos também assinala o papel
da genética na etiologia do Padrão esquelético III. A partir
de uma detalhada análise genealógica da dinastia Habsburg,
concluiu-se que o prognatismo mandibular foi transmitido
como uma herança autossômica dominante23. Numa fase
prévia à invenção da fotografia, as pinturas de grandes mes-
tres denunciaram que o prognatismo mandibular constituía
característica que se repetia na família real austro-húngara
(Fig. 5). Na década de 60, Susuki29 estudou 243 famílias de
pacientes Classe III e encontrou uma prevalência de 34% des-
sa má oclusão dentre os familiares, em comparação a uma
prevalência de 7% de Classe III na população local em geral.
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A B C

D E F

G H I

J K L

Figura 4 Padrão esquelético e má oclusão de Classe II: mãe (A – F) e filho (G – L).

84 Rev Clín Ortod Dental Press. 2010 abr-maio;9(2):77-97

Garib DG, Silva Filho OG, Janson G
Figura 5 Família real austro-húngara de Habsburg. As pinturas ilustram quatro gerações de monarcas demonstrando Padrão esquelético Classe III. Da
esquerda para a direita: Felipe II da Espanha, Felipe III da Espanha, Felipe IV da Espanha e Carlos II (Fonte: http://en.wikipedia.org/wiki/Philip_III_of_Spain).
Relatou que filhos de mães ou pais prognatas apresentam
20% de chance de mostrar o prognatismo mandibular, en-
quanto filhos de mães e pais prognatas apresentam o dobro
de chance de exibir um prognatismo mandibular (40%). Um
estudo europeu em pares de gêmeos apontou que a concor-
dância para a má oclusão de Classe III em gêmeos monozi-
góticos mostrava-se seis vezes maior se comparada aos pa-
res de gêmeos dizigóticos23. Litton et al.18 descreveram uma
transmissão multifatorial e poligênica da Classe III e sugeri-
ram que diferentes modos de transmissão podem operar em
diferentes famílias ou populações. Recentemente, no Brasil,
Cruz et al.6 estudaram famílias de prognatas e sugeriram que
o prognatismo apresenta uma herança multifatorial, porém
com um gene principal autossômico dominante.
Outra fonte de evidência que reforça o papel da herança
na determinação da morfologia craniofacial é a constatação
de que aparelhos ortodônticos e ortopédicos não exercem
influência significativa em longo prazo sobre as bases api-
cais1,26. Aparelhos ortopédicos representam uma forma de in-
terferência ambiental sobre o crescimento facial. Estudos lon-
gitudinais sobre o tratamento da má oclusão de Classe II com
Ortopedia Funcional dos Maxilares mostraram que os apare-
lhos podem induzir apenas um efeito temporário na relação
maxilomandibular1,26 (Fig. 6). Após a remoção do aparelho, a
face tende a retomar o seu padrão original de crescimento e
o efeito esquelético do tratamento mostra instabilidade, pau-
latinamente, no período que sucede o tratamento. Uma vas-
ta revisão da literatura concluiu que ainda existe pouca evi-
dência científica de que o ortodontista seja capaz de alterar
permanentemente, na criança em crescimento, o padrão do
esqueleto facial herdado1. Investigações longitudinais do tra-
tamento do prognatismo mandibular com mentoneira apon-
tam para a mesma direção. Apesar do período de tratamen-
to mostrar alguma restrição da velocidade de alongamento
mandibular, após a remoção da mentoneira o crescimento da
mandíbula volta a se comportar como em grupos controles
sem tratamento, denotando que a genética retoma a batuta
que rege a melodia do crescimento. A exceção é constatada
se a mentoneira for utilizada até o final do crescimento, quan-
do haverá diferença em relação ao grupo controle.
Atualmente, acredita-se que o genoma expressa-se pri-
mariamente nas atividades neuromusculares e em menor
grau nas cartilagens26. O crescimento sutural seria apenas
responsivo ao comando proveniente dos músculos e car-
tilagens. Por esse motivo, a manipulação ortopédica da
mandíbula ainda é mais restrita do que a influência dos
aparelhos sobre a maxila. Muitos poderiam atribuir essa
diferença apenas ao crescimento sutural intramembrano-
so da maxila versus o crescimento condilar endocondral
da mandíbula. Porém, considerando-se a importância da
musculatura no crescimento facial, é mais provável que
forças ortopédicas devem sobrepujar a musculatura masti-
gatória, um fator restritivo significativamente mais envolvi-
do na mandíbula do que na maxila26.
Diferentemente das bases apicais, a região dentoalveo-
lar mostra-se muito vulnerável a influências ambientais26. A
incompetência labial, os hábitos de sucção e a respiração
bucal podem agravar o trespasse horizontal na má oclusão
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DOMÍNIO CONEXO Etiologia das más oclusões: perspectiva clínica (Parte I) — fatores genéticos

A B

C D E

Figura 6A - 6J Tratamento da má oclusão de

Classe II com aparelho ortopédico funcional
(associado ao aparelho extrabucal cervical).
O tratamento foi eficaz em corrigir a má oclu-
são de Classe II. No entanto, na análise facial,
não ocorreu mudança significativa na expres-
são da mandíbula no sentido anteroposterior
(A – E: fotografias iniciais; F – J: fotografias finais).

F G

H I J

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Garib DG, Silva Filho OG, Janson G
K L
M N
Figura 6K - 6O Cinco anos após a finalização do tratamento.
de Classe II, divisão 1, ao ocasionar uma inclinação adicio-
nal dos incisivos superiores para vestibular e, no caso do
hábito de sucção de dedo, uma retroinclinação dos incisi-
vos inferiores. Crianças com hábitos de sucção prolongada
mostram prevalência suavemente aumentada de má oclu-
são de Classe II, comparada à de crianças sem hábitos20.
No entanto, a influência dos hábitos parece restringir-se
à região dentoalveolar, uma vez que a prevalência de Pa-
drão esquelético II não difere entre pacientes com e sem
hábito prolongado de sucção de dedo e chupeta20. A pró-
pria possibilidade de realizar compensações dentárias nas
más oclusões esqueléticas representa prova irrefutável da
grande vulnerabilidade da região dentoalveolar a fatores
ambientais (Fig. 7). O ortodontista pode alterar de manei-
ra previsível a morfologia dentoalveolar por meio da movi-
mentação dentária induzida ou mesmo por meio de apare-
lhos ortopédicos. A distinção entre o comportamento das
bases ósseas e da região dentoalveolar, descrita nesse tópi-
co, elucida de forma realista as possibilidades e limitações
da especialidade inaugurada por Edward H. Angle.
O
As Discrepâncias Dente-Osso
A dimensão e, ocasionalmente, a morfologia das bases
maxilares seguem predominantemente um comando gené-
tico. Estudos em gêmeos demonstraram que o tamanho das
coroas dentárias também se mostra fortemente determinado
pela genética23. Se os tamanhos dos dentes e dos maxila-
res mostram-se subservientes ao genoma, as discrepâncias
dente-osso, incluindo o apinhamento e o espaçamento den-
tário (Fig. 8), sofrem grande influência genética. Num estudo
clássico, Lundstrom19 observou um elevado grau de concor-
dância entre gêmeos homozigóticos para o apinhamento e
para o espaçamento dentário.
As características quantitativas como as dimensões den-
tárias e o comprimento das bases ósseas seguem uma he-
rança poligênica22,23. Portanto, é errônea a noção de que
pacientes com apinhamento dos incisivos permanentes her-
daram “dentes grandes” dos pais e “maxilares pequenos da
mãe”. Na realidade, o tamanho dos dentes é determinado
por uma miríade de genes provenientes do pai e da mãe,
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A B C

D E F

G H

I J K

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Garib DG, Silva Filho OG, Janson G
Figura 7 Tratamento ortodôntico compensa-
tório da má oclusão de Classe III com elásticos
intermaxilares. Nota-se que a má oclusão foi
corrigida, com manutenção das características
faciais originais do padrão esquelético III (A – F:
fotografias iniciais; G – M: fotografias finais).
L M
A B
assim como o tamanho dos maxilares. Dado o caráter ge-
nético do apinhamento e do espaçamento, essas caracte-
rísticas oclusais não são passíveis de prevenção, podendo
apenas ser corrigidas.
No apinhamento genético, o tratamento é voltado para
a redução da massa dentária28. A proposta é compatibilizar a
massa dentária com o perímetro do arco alveolar. A morfolo-
gia dos arcos alveolares, portanto, é considerada normal. No
entanto, o apinhamento pode apresentar caráter ambiental28.
Nesse caso, a irregularidade dos dentes reflete uma discre-
pância entre a massa dentária e a morfologia dos arcos al-
veolares. A atresia das arcadas dentárias está acarretando a
irregularidade na disposição dos dentes ao longo do rebordo
alveolar (Fig. 9). O tratamento indicado, ao contrário do api-
nhamento genético, é a mecânica transversal para expansão
dos arcos alveolares28. O apinhamento ambiental pode se rela-
cionar com a perda precoce de dentes decíduos ou de dentes
permanentes28,30 (Fig. 9). Nesses casos, o apinhamento pode
ser prevenido com a utilização dos mantenedores de espaço.
Em síntese, o apinhamento pode ter caráter genético ou am-
biental e isso interfere no planejamento ortodôntico.
Aqui cabe a discussão sobre um diastema muito especí-
fico, aquele localizado entre os incisivos centrais superiores
na dentadura permanente, e sua relação com o freio labial. O
freio labial superior consiste em um cordão de tecido fibroso,
com formato triangular. No recém-nascido, o freio estende-
se desde o lábio superior até a papila incisiva, cruzando e
sulcando o rebordo alveolar. Durante o desenvolvimento da
Figura 8 Discrepância dente-osso, apinhamen-
to (A) e espaçamento (B) apresentam etiologia
eminentemente genética.
oclusão, a inserção fibrosa do freio assume uma nova posi-
ção, próxima ao limite mucogengival por vestibular. Essa alte-
ração mostra-se gradativa e relaciona-se ao desenvolvimen-
to vertical do rebordo alveolar e à compressão ocasionada
pela erupção dos dentes anterossuperiores2. Nas dentadu-
ras decídua e mista, o diastema interincisivos centrais pode
representar característica normal e fisiológica. Ao adentrar
na dentadura permanente, esse diastema é eliminado, em
condições de normalidade, pela influência da erupção dos
incisivos laterais e caninos superiores. No entanto, em uma
pequena porcentagem da população, o diastema interincisi-
vos centrais permanece na dentadura permanente completa
e pode ser explicado tanto por fatores genéticos como am-
bientais, tais como: agenesia (Fig. 10A) ou microdontia (Fig.
10B) dos incisivos laterais superiores; discrepância dente-osso
positiva (Fig. 10C); presença de supranumerários mesiodens
e protrusão dentária provocada por hábitos de sucção2 (Fig.
10D). Com a manutenção do diastema devido a qualquer um
dos fatores etiológicos listados, o freio labial superior pode
manter-se inserido inferiormente, dificultando a identificação
da real participação da inserção fibrosa na persistência desse
espaço interdentário. Surge, então, a discussão semelhante à
do ovo e da galinha: quem veio primeiro? Atentando à fisio-
logia normal do freio labial, tudo indica que o freio represen-
te a consequência, e não a causa, do diastema interincisivos
centrais superiores. Poderíamos culpar o freio pela persis-
tência do diastema interincisivos centrais superiores apenas
diante da ausência das demais causas reconhecidas.
Rev Clín Ortod Dental Press. 2010 abr-maio;9(2):77-97 89
DOMÍNIO CONEXO Etiologia das más oclusões: perspectiva clínica (Parte I) — fatores genéticos

A B C

D E

F G H

I J K

Figura 9 Apinhamamento dentário de caráter ambiental: A – E) na região dos incisivos superiores, em um paciente com atresia maxilar ocasionada por
hábitos bucais deletérios; F – J) na região posterior, ocasionado pela perda precoce de dentes decíduos.

As Anomalias Dentárias diferentes manifestações ou fenótipos, incluindo agenesias,

Diversas investigações sugeriram uma base genética e
hereditária na etiologia de anomalias dentárias de número,
tamanho, posição e época de desenvolvimento9,10,14,15,17,21.
Tais evidências provêm de estudos em famílias, em gême-
os monozigóticos e da observação de frequentes associa-
ções entre as anomalias dentárias. Certas anomalias dentá-
rias aparecem frequentemente associadas em um mesmo
paciente, mais do que se esperaria ao acaso. Isso se ex-
plica porque um mesmo defeito genético pode originar
microdontias, ectopias e atraso no desenvolvimento. De
uma maneira simplista, poderíamos dizer que um gene “de-
feituoso” ou mutante pode se expressar diversamente em
diferentes dentes permanentes. Vale aqui a teoria do gene
pleiotrópico, aquele responsável por mais de uma caracte-
rística morfológica e/ou funcional. Dessa maneira, um pa-
ciente que demonstra uma determinada anomalia dentária,
como a agenesia ou a microdontia, apresenta mais chances
de desenvolver outras anomalias dentárias no transcorrer
do desenvolvimento da oclusão8.

90 Rev Clín Ortod Dental Press. 2010 abr-maio;9(2):77-97

Garib DG, Silva Filho OG, Janson G
A B
C D
Grahnen12 conduziu um estudo em crianças com agene-
sias dentárias e verificou que 50% dos irmãos e parentes tam-
bém possuíam agenesias, uma alta prevalência comparada à
frequência esperada para a população em geral. Um estudo
com gêmeos achou uma alta concordância para a agenesia
dentária entre pares de gêmeos homozigóticos, enquanto os
pares de gêmeos heterozigóticos eram discordantes21.
A genética molecular revelou mutações nos genes MSX1,
PAX9, AXIN2 e EDA em famílias cujos membros apresentavam
múltiplas agenesias dentárias22. Os genes homeobox apre-
sentam particular influência sobre o desenvolvimento den-
tário e, portanto, sobre a Ortodontia. Os genes homeobox
músculo-específico MSX-1 e MSX-2 parecem estar envolvidos
na interação epitélio-mesênquima, influenciam o desenvolvi-
mento craniofacial e, principalmente, a iniciação, a posição e
o desenvolvimento dos germes dentários. O gene homeobox
músculo-específico (MSX1) apresenta forte expressão no me-
sênquima dentário nas fases da odontogênese de iniciação,
casquete e campânula22. O bloqueio do gene MSX1 ocasiona,
entre outros defeitos, uma falha completa no desenvolvimen-
to dentário no estágio de iniciação do germe22.
Segundo as Leis Evolucionistas de Darwin, fatores am-
bientais particulares garantem a permanência dos genes
mais favoráveis, determinando uma seleção natural. No caso
da agenesia dentária, a diminuição do número de dentes não
compromete a sobrevivência da espécie humana diante do
atual tipo de dieta. Isso favorece que esses genes mutantes
sejam transmitidos aos descendentes, perpetuando o fenóti-
po da agenesia dentária de geração a geração.
A microdontia, o atraso eruptivo e alguns tipos de ecto-
pia parecem representar uma expressão parcial dos mesmos
Figura 10 O diastema interincisivos centrais su-
periores na dentadura permanente represen-
ta irregularidade e pode ser ocasionado por:
A) agenesia dos incisivos laterais superiores;
B) microdontia dos incisivos laterais superiores;
C) discrepância dente-osso positiva com diaste-
mas generalizados em ambas as arcadas; D) há-
bito persistente de sucção não-nutritiva.
genes que determinam a agenesia dentária, uma vez que a
prevalência dessas anomalias mostra-se aumentada em pa-
cientes com agenesias8,9.
Demonstrou-se que a agenesia e a redução do tama-
nho dos dentes são, de fato, controladas pelos mesmos
loci genéticos ou por loci genéticos relacionados23. A
associação entre a agenesia unilateral do incisivo lateral
superior e a microdontia do incisivo contralateral, fre-
quentemente observada na rotina clínica, constitui uma
clássica exemplificação. Aproximadamente 20% dos pa-
cientes com agenesia de segundos pré-molares também
apresentam microdontia dos incisivos laterais superiores 9
(Fig. 11). Em regra, pacientes com agenesia costumam
mostrar uma redução generalizada no tamanho dentário
e, diante de agenesias múltiplas, a redução do tamanho
dentário é ainda mais marcante 10.
O atraso no desenvolvimento dentário, traduzido por uma
marcante assincronia entre a idade cronológica e a idade den-
tária, parece representar outra expressão fenotípica do mesmo
genótipo que define as agenesias dentárias. Pacientes com age-
nesias geralmente alcançam a maturidade oclusal mais tardia-
mente. Os segundos pré-molares, especificamente, podem mos-
trar atrasos eruptivos acentuados em pacientes com agenesia8.
Ademais, reconhece-se o papel da genética na etiologia
de determinadas ectopias dentárias, como as transposições
dentárias entre canino e primeiro pré-molar superior, canino
e incisivo lateral inferior, retenção dos caninos superiores por
palatino e erupção ectópica dos primeiros molares superio-
res (Fig. 12). Tais ectopias mostram uma prevalência aumen-
tada na família de pacientes afetados e frequentemente se
associam com as agenesias dentárias8.
Rev Clín Ortod Dental Press. 2010 abr-maio;9(2):77-97 91
DOMÍNIO CONEXO Etiologia das más oclusões: perspectiva clínica (Parte I) — fatores genéticos

Os dentes supranumerários também parecem ser geneti-
camente determinados. Essa anomalia encontra-se frequen-
temente presente em pais e irmãos de pacientes portado-
res, apesar da herança não seguir um padrão mendeliano
simples23. Evidências verificadas em gêmeos com supranu-
merários também sustentam essa hipótese15. No entanto,
é importante ressaltar que as agenesias dentárias e os su-
pranumerários apresentam uma origem genética distinta ou
independente, uma vez que não se verifica associações fre-
quentes entre essas anomalias9. Esse fato apresenta coerên-
cia, considerando-se que a agenesia dentária constitui uma
anomalia hipoplasiante — contrariamente aos supranumerá-
rios, que representam anomalias hiperplasiantes.
Os dentes supranumerários tornam-se particularmente
preocupantes para o ortodontista quando funcionam como
obstáculo para a erupção dos dentes numerários. O movi-
mento dentário em pacientes com indicação de tratamento
ortodôntico pode também ser impedido pela presença de
dentes supranumerários não-irrompidos (Fig. 13A). Quando
conseguem irromper na arcada dentária, os supranumerários
tendem a criar uma discrepância dente-osso negativa e um
comprometimento estético (Fig. 13B).

Figura 11 Radiografia panorâmica ilustrando a

associação entre a agenesia de segundos pré-
molares e a microdontia dos incisivos laterais
superiores.

A B

Figura 12 Ectopias dentárias de caráter genético:

A) canino superior deslocado para palatino (23)
e distoangulação do segundo pré-molar inferior
(35); B) transposição entre canino e primeiro pré-
molar superior (lado direito); C) erupção ectópica
do incisivo lateral inferior (lado direito); D) erupção
ectópica do primeiro molar superior esquerdo.

C D

Figura 13 Dentes supranumerários: retido (A)

A B e irrompido na arcada dentária (B).

92 Rev Clín Ortod Dental Press. 2010 abr-maio;9(2):77-97

Garib DG, Silva Filho OG, Janson G
Infraoclusão de molares decíduos
A infraoclusão retrata a condição clínica em que um dente,
a qualquer momento durante ou depois da sua completa erup-
ção, não consegue manter sua altura no plano oclusal, distan-
ciando-se paulatinamente dos dentes antagonistas e posicio-
nando-se apicalmente em relação aos dentes contíguos. Essa
alteração no nível oclusal constitui traço revelador da anquilose,
processo no qual ocorre o sumiço do ligamento periodontal
devido à fusão do cemento e/ou dentina com o osso alveolar,
deixando o dente em questão paralisado enquanto os demais
dentes emergem junto com o osso alveolar em direção oclusal,
como parte do processo contínuo de erupção. Em síntese, o
dente conserva o nível oclusal de antes da anquilose, enquanto
os outros dentes acompanham o crescimento alveolar vertical
normal. A inércia provocada pela anquilose explica o caráter
progressivo da infraoclusão17. A infraoclusão dos molares decí-
duos acomete aproximadamente 8,9% das crianças17.
Uma sequência de evidências reforça a influência da genéti-
ca na determinação da infraoclusão de molares decíduos. Kurol17
verificou que a prevalência da infraoclusão mostra-se bastante
aumentada em irmãos de pacientes afetados, de modo que a
prevalência dessa irregularidade alcança quase 20%, ou seja, o
A B
C D
dobro do esperado para a população em geral. Constatou-se,
ainda, a associação na ocorrência da infraoclusão de molares
decíduos com outras anomalias dentárias, como a erupção ec-
tópica dos primeiros molares permanentes superiores, erupção
ectópica dos caninos permanentes superiores e com a agenesia
de segundos pré-molares8. Pacientes com infraoclusão de mola-
res decíduos apresentam uma prevalência significativamente au-
mentada de agenesia de segundos pré-molares (14%), incisivo
lateral conoide (13%), erupção ectópica dos primeiros molares
permanentes (18%) e ectopia dos caninos superiores para pa-
latino (14%)8. Além disso, verificou-se que pacientes seleciona-
dos por uma dessas anomalias dentárias também apresentam
prevalência aumentada de infraoclusão de molares decíduos8.
Garib, Peck e Gomes9 verificaram que 25% dos pacientes com
agenesia de segundos pré-molares apresentaram infraoclusão
dos molares decíduos. Essa prevalência mostrou-se significati-
vamente aumentada em relação ao esperado para a população
em geral (8,9%). Isso quer dizer que pacientes com agenesia
de segundos pré-molares apresentam três vezes mais risco de
desenvolver a infraoclusão do que o restante da população em
geral. Finalmente, Helpin e Duncan14 verificaram um alto índice
de concordância para a infraoclusão em pares de gêmeos ho-
mozigóticos (Fig. 14).
E
Rev Clín Ortod Dental Press. 2010 abr-maio;9(2):77-97 93
DOMÍNIO CONEXO Etiologia das más oclusões: perspectiva clínica (Parte I) — fatores genéticos

F G H

I J

K L M

N O P

Figura 14 Gêmeas homozigóticas apresentando infraoclusão dos molares decíduos, bilateralmente, em ambas as arcadas dentárias.

94 Rev Clín Ortod Dental Press. 2010 abr-maio;9(2):77-97

Garib DG, Silva Filho OG, Janson G
Anomalias Craniofaciais
As anomalias craniofaciais com base genética são ocasio-
nadas por alterações cromossômicas, monogênicas ou po-
ligênicas. As anomalias de origem cromossômica são bem
representadas pela Síndrome de Down, ocasionada pela tris-
somia do cromossomo 21. Isso significa que o paciente com
Síndrome de Down apresenta 47 cromossomos, em vez de
46. Como exemplos de anomalias craniofaciais monogênicas
de interesse para o ortodontista, destacam-se a disostose
cleidocraniana e a displasia ectodérmica, ocasionadas pela
mutação de um único par de genes. Algumas síndromes são
determinadas pela mutação de um gene pleiotrópico, gene
responsável por mais de uma característica morfológica e/ou
funcional. Como esse gene influencia diversas características,
a sua mutação, apesar de produzir um efeito ou modifica-
ção simples em nível molecular, quase sempre resulta numa
sequência de anormalidades genéticas. Outras anomalias,
como por exemplo as fissuras labiopalatinas, representam
malformações craniofaciais de origem poligênica, um grupo
de genes atuando para determinar o fenótipo, interagindo
com fatores ambientais. Por isso sua etiologia é considerada
multifatorial, isso é: uma congregação de genes com intera-
ções ambientais determina o fenótipo final22.
A B
C D
A disostose cleidocraniana consiste numa anomalia rara asso-
ciada com agenesia ou hipoplasia clavicular, fechamento tardio
das fontanelas cranianas, presença de múltiplos dentes supranu-
merários, atraso indeterminado na esfoliação dos dentes decí-
duos e retenção de dentes permanentes (Fig. 15). A prevalência
da disostose cleidocraniana equivale a uma em um milhão, sem
predileção por gênero ou grupo étnico. Essa desordem é oca-
sionada pela mutação no gene CBFA1, localizado no braço curto
do cromossomo 6p2125. Diante desse defeito gênico, define-se
uma deficiência na troca de informações entre o periósteo e os
condrócitos, essencial para a formação óssea endocondral25.
A displasia ectodérmica representa uma desordem hetero-
gênea com muitos tipos clinicamente distintos, e caracteriza-se
pela tríade hipotricose (pouco cabelo), hipohidratação (falta de
glândulas sudoríparas) e hipodontia (reduzido número de den-
tes). A hipodontia na displasia ectodérmica varia desde poucos
dentes ausentes até a completa anodontia; e a forma e o tama-
nho dentário também podem ser afetados22. A displasia ectodér-
mica apresenta etiologia genética e pode advir de mutações nos
genes EDA, EDAR ou EDARADD.
No que se refere à etiologia das fissuras labiopalatinas, tanto
o background genético quanto as influências ambientais mos-
tram-se expressivos. Portanto, essa anomalia craniofacial merece-
rá uma discussão especial na parte III dessa sequência de artigos.
E
Rev Clín Ortod Dental Press. 2010 abr-maio;9(2):77-97 95
DOMÍNIO CONEXO Etiologia das más oclusões: perspectiva clínica (Parte I) — fatores genéticos

F G

H I J

K L

M N

Figura 15 Paciente do gênero masculino, sete anos de idade, com disostose cleidocraniana.

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Garib DG, Silva Filho OG, Janson G
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DG, Silva Filho OG. editores. Pro-Odonto Ortodontia. Porto Alegre: Artmed/
Panamericana; 2007. p. 59-102.
9. Garib DG, Peck S, Gomes SC. Increased occurrence of dental anomalies associated
with second-premolar agenesis. Angle Orthod. 2009 May;79(3):436-41.
10. Garn SM, Lewis AB. The gradient and the pattern of crown-size reduction in simple
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11. Graber T. Ortodoncia. Teoria y Práctica. México: Nueva Editorial
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12. Grahnen H. Hypodontia in the permanent dentition. A clinical and genetical
investigation. Odontol Revy. 1956;7:1-100.
13. Guardo A. Temas de ortodoncia. Buenos Aires: Ateneo; 1953.
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17. Kurol J. Infraocclusion of primary molars: an epidemiologic and familial study.
Community Dent Oral Epidemiol. 1981 Apr;9(2):94-102.
18. Litton SF, Ackermann LV, Isaacson RJ, Shapiro BL. A genetic study of Class 3
malocclusion. Am J Orthod. 1970 Dec;58(6):565-77.
19. Lundstrom A. An investigation of 202 pairs of twins regarding fundamental factors
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mandibular retrusion: a cross-sectional study of children in the mixed dentition. Am
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Mutations involving the transcription factor CBFA1 cause cleidocranial dysplasia.
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ENDEREÇO PARA CORRESPONDÊNCIA
Daniela G. Garib
Faculdade de Odontologia de Bauru-USP
Al. Octávio Pinheiro Brisola 9-75 – 17.012-901 – Bauru/SP
E-mail: dgarib@uol.com.br
97
ONLINE ONLY

Agenesis of maxillary lateral incisors and

associated dental anomalies
Daniela Gamba Garib,a Bárbara Maria Alencar,b José Roberto Pereira Lauris,c and Tiziano Baccettid
Bauru, São Paulo, Brazil, and Florence, Italy

Introduction: The objectives of this study were to evaluate the prevalence of dental anomalies in patients with
agenesis of maxillary lateral incisors and to compare the findings with the prevalence of these anomalies in the
general population. Methods: A sample of 126 patients, aged 7 to 35 years, with agenesis of at least 1 max-
illary lateral incisor was selected. Panoramic and periapical radiographs and dental casts were used to analyze
other associated dental anomalies, including agenesis of other permanent teeth, ectopia of unerupted perma-
nent teeth, microdontia of maxillary lateral incisors, and supernumerary teeth. The occurrence of these anom-
alies was compared with prevalence data previously reported for the general population. Statistical testing
was performed with the chi-square test (P \0.05) and the odds ratio. Results: Patients with maxillary lateral
incisor agenesis had a significantly increased prevalence rate of permanent tooth agenesis (18.2%), excluding
the third molars. The occurrence of third-molar agenesis in a subgroup aged 14 years or older (n 5 76) was
35.5%. The frequencies of maxillary second premolar agenesis (10.3%), mandibular second premolar
agenesis (7.9%), microdontia of maxillary lateral incisors (38.8%), and distoangulation of mandibular
second premolars (3.9%) were significantly increased in our sample compared with the general population.
In a subgroup of patients aged 10 years or older (n 5 115), the prevalence of palatally displaced canines
was elevated (5.2%). The prevalences of mesioangulation of mandibular second molars and supernumerary
teeth were not higher in the sample. Conclusions: Permanent tooth agenesis, maxillary lateral incisor micro-
dontia, palatally displaced canines, and distoangulation of mandibular second premolars are frequently asso-
ciated with maxillary lateral incisor agenesis, providing additional evidence of a genetic interrelationship in the
causes of these dental anomalies. (Am J Orthod Dentofacial Orthop 2010;137:732.e1-732.e6)

T
ooth agenesis is the most common dental abnor-
mality, and genetics play a fundamental role in its
etiology.1 The various clinical manifestations of
tooth agenesis reflect the genetically and phenotypically
heterogeneity of this condition.2 Molecular genetics
have shown mutations in MSX1, PAX9, and AXIN2 in
families with multiple dental agenesis.1-3 Additionally,
mutations in many other genes have been identified in
a
Assistant professor, Department of Orthodontics, Hospital of Rehabilitation of
Craniofacial Anomalies, Bauru Dental School, University of São Paulo, Bauru,
São Paulo, Brazil.
b
Postgraduate student, Department of Orthodontics, Bauru Dental School,
University of São Paulo, Bauru, São Paulo, Brazil.
c
Associate professor, Department of Public Health, Bauru Dental School,
University of São Paulo, Bauru, São Paulo, Brazil.
d
Assistant professor, Department of Orthodontics, University of Florence,
Florence, Italy; Thomas M. Graber Visiting Scholar, Department of Orthodon-
tics and Pediatric Dentistry, School of Dentistry, University of Michigan,
Ann Arbor, Mich.
The authors report no commercial, proprietary, or financial interest in the prod-
ucts or companies described in this article.
Reprint requests to: Daniela G. Garib, Department of Orthodontics, Bauru Den-
tal School, University of São Paulo, Alameda Octávio Pinheiro Brisolla 9-75,
Bauru, Bauru, São Paulo, Brazil 17012-901; e-mail, dgarib@uol.com.br.
Submitted, October 2009; revised and accepted, December 2009.
0889-5406/$36.00
Copyright ! 2010 by the American Association of Orthodontists.
doi:10.1016/j.ajodo.2009.12.024
syndromes and congenital abnormalities in which
tooth agenesis is a regular feature.2
Tooth agenesis is frequently associated with other
dental anomalies such as microdontia, delayed dental
development, and some discrete tooth ectopias.4-16
These dental anomalies commonly appear together in
the same patient; the possible explanation is that
a certain genetic mutation might cause a series of
different phenotypic expressions. In other words,
different dental anomalies in the same subject could
be distinctive expressions of the same genetic code.
Garn et al4 and Garn and Lewis5,6 were the first
investigators to identify a pattern of associated dental
anomalies. They found that patients with third molar
agenesis had an increased prevalence of agenesis of
other permanent teeth, as well as a general reduction
in tooth size and delayed dental development. The
agenesis of second premolars was also associated with
higher prevalences of agenesis of other permanent
teeth,14 microdontia of maxillary lateral incisors,11,14
infraocclusion of mandibular deciduous molars,11,14
and some types of ectopic eruptions.9,11,13,14 Palatally
displaced maxillary canines, distoangulation of
mandibular second premolars, ectopic eruption of
maxillary first molars, mesioangulation of mandibular
732.e1
732.e2 Garib et al
second molars, and some types of tooth transpositions
are dental ectopias frequently associated with second
premolar agenesis.9,11,13,14
In addition to third molars and second premolars,
maxillary lateral incisors have a high prevalence rate
of agenesis.17 Although previous studies reported an
association between maxillary lateral incisor agenesis
and tooth transpositions,13 palatally displaced canines
(PDC),16 and premolar rotations,18 no study has evalu-
ated the frequency of associated dental anomalies in
a large sample of subjects with maxillary lateral incisor
agenesis compared with reference values.
Therefore, in this study, we aimed to determine the
prevalence of permanent tooth agenesis, discrete ecto-
pias, microdontia, and supernumerary teeth in patients
with agenesis of the maxillary lateral incisors, compar-
ing these prevalences with those in the general popula-
tion. The hypothesis was that subjects with agenesis of
maxillary lateral incisors have significantly increased
prevalences of other dental anomalies.
MATERIAL AND METHODS
A sample of 126 subjects with agenesis of the max-
illary lateral incisors was selected from the orthodontic
patient files of the dental school of the University of São
Paulo City in Brazil and some private dental offices in
Brazil. The subjects ranged in age from 7 to 35 years,
and there were 84 female and 42 male subjects, with
a sex ratio of 2:1. Because of the widely heterogeneous
backgrounds of Brazilians, a rough estimate of the eth-
nic makeup of the sample was derived subjectively from
facial photographic records: white (80%) and black
mixture (20%). No Asian subjects were included in
the sample. Panoramic radiographs, periapical radio-
graphs, and dental casts were used to investigate these
dental anomalies: agenesis of permanent teeth; supernu-
merary teeth; microdontia of maxillary lateral incisors;
and 3 types of tooth ectopia including PDC, distal angu-
lation of mandibular second premolars, and mesial
angulation of mandibular second molars.
The critical age of 14 years was considered to con-
firm the absence of third molars.5 This criterion was
used to restrict the sample for evaluation of third-
molar agenesis to only those with diagnostic records
at 14 years of age or older (n 5 76). Diagnosis of pala-
tally displaced maxillary canines followed the radio-
graphic parameters suggested by Lindauer et al,19 and
it was confirmed by interpretation of periapical radio-
graphs by the tube-shift technique, a method of object
localization with 2 projections with significantly differ-
ent x-ray tube angulations. Taking into account the find-
ings of Ericson and Kurol20 that the attempt to
American Journal of Orthodontics and Dentofacial Orthopedics
June 2010
determine the eruption path of maxillary canines radio-
graphically is generally of little value in children youn-
ger than 10 years, only subjects 10 years of age or older
were considered in evaluating PDC (n 5 115). Diagno-
sis of distal angulation of mandibular second premolars
followed the criteria of Shalish et al,12 using the inferior
border of the mandible as a baseline. The maxillary lat-
eral incisor was considered as having microdontia when
the maximum mesiodistal crown diameter was smaller
than the same dimension of the opposing incisor in
the same patient.14 This category also included conical
and peg-shaped maxillary lateral incisors.
Statistical analysis
The diagnosis of all dental anomalies was consid-
ered as a single statistical unit even for bilateral occur-
rence of the anomaly in the same subject. Therefore,
subjects and not single dental anomalies were consid-
ered for the analysis. This is correct due to the possible
genetic background underlying the bilateral occurrence
of the dental anomalies.
Two calibrated investigators (D.G.G., B.M.A.) ex-
amined the records and diagnosed the dental anomalies
simultaneously. Consensus was obtained in case of di-
vergent diagnoses. The results were analyzed with the
chi-square test for goodness of fit to compare the
frequency of dental anomalies in the sample with
previously published reference values.11,17,21-25 The
hypothesis was tested at the 5% level of significance.
The odds ratio (OR) was calculated at the 95% CI to
measure the strength of associations between agenesis
of maxillary lateral incisors and the other dental
anomalies investigated.
RESULTS
In the sample of 126 patients with agenesis of max-
illary lateral incisors, 51.6% (n 5 65) had bilateral ex-
pression, and 27.7% (n 5 35) had right unilateral and
20.7% (n 5 26) had left unilateral expression.
The prevalence of other permanent tooth agenesis in
the sample, excluding third molars, was 18.2%, a 3-fold
increased prevalence (OR, 3.5) compared with refer-
ence values in the general population (Table I). The fre-
quencies of maxillary second premolar (OR, 7.5),
mandibular second premolar (OR, 2.7), and mandibular
third molar (OR, 2.0) agenesis were significantly higher
in the sample compared with the general population
(Table I). No differences between the sample and the
reference values were observed for the prevalence of
supernumerary teeth (Table I).
Patients with agenesis of maxillary lateral incisors
showed a significantly higher prevalence of microdontia
American Journal of Orthodontics and Dentofacial Orthopedics Garib et al 732.e3
Volume 137, Number 6

Prevalence rates of tooth agenesis and supernumerary teeth in subjects with maxillary lateral incisor agenesis
Table I.
compared with reference values
Prevalence rate in Difference 95% CI
Dental anomaly study sample Reference values chi-square OR OR

Tooth agenesis 18.2% 5.0% Grahnen,23 1956 25.31 3.57 (2.11-6.02)

(excluding third molars) 23/126 53/1064 P \0.001
Maxillary second 10.3% 1.5% Polder et al,17 2004 65.40 7.58 (4.25-13.52)
premolar agenesis 13/126 722/48274 P \0.001
Mandibular second 7.9% 3.0% Polder et al,17 2004 10,01 2.73 (1.43-5.21)
premolar agenesis 10/126 1479/48274 P \0.002
Third molar agenesis 35.5% 20.7% Bredy et al,21 1991 9.61 2.11 (1.30-3.41)
27/76 427/2061 P \0.002
Supernumerary teeth 0.8% 3.9% Baccetti,11 1998 3.15 0.20 (0.03-1.45)
1/126 39/1000 P 5 0.076 (NS)

NS, Not significant.

Table II. Prevalence rates of dental anomalies of size and position in subjects with maxillary lateral incisor agenesis
compared with reference values
Prevalence rate in Difference 95% CI
Dental anomaly study sample Reference values chi-square OR OR

Small maxillary lateral incisor 38.8% 4.7% Baccetti,111998 167.71 12.90 (8.12-20.49)
49/126 47/1000 P \0.001
PDC 5.2% 1.7% Dachi and Howell,22 1961 6.7 3.14 (1.26-7.81)
6/115 25/1450 P \0.010
Mandibular second premolar 3.9% 0.20% Matteson et al,25 1982 82.71 20.83 (8.18-53.05)
distoangulation 5/126 52/26264 P \0.001
Mandibular second molar 0.0% 0.06% Grover and Lorton,24 1985 0.08 0.00 (——)
mesioangulation 0/126 3/5000 P 5 0.783
(NS)

NS, Not significant.

of maxillary lateral incisors (OR, 12.9), as shown in
Table II. Considering only the patients with unilateral
agenesis of maxillary lateral incisors (n 5 61), 80.3%
(n 5 49) had a size reduction of the contralateral tooth.
The prevalences of PDC and distal angulation of
mandibular second premolars were significantly in-
creased in the sample compared with the general popula-
tion: 5.2% (OR, 3.1) and 3.9% (OR, 20.8), respectively
(Table II). In contrast, no difference was observed for
the frequency of mesial angulation of mandibular second
molars in the sample compared with the reference values
(Table II).
DISCUSSION
We analyzed the associations between missing max-
illary lateral incisors and other tooth disturbances in
a large sample of subjects using reference data from
control population groups. These comparison data
came from studies with samples more homogeneous ra-
cially and ethnically than our sample. Previous investi-
gations, however, showed small differences among
ethnicities or racial groups in the general frequencies
of some dental anomalies observed in this study.17,26
Also, much of the reference data derives from
orthodontic patients before treatment, when the
prevalence rates for dental anomalies could be
different from those of subjects not screened for
orthodontic needs.11 In spite of this, the main purpose
of this study was to verify the association between den-
tal anomalies; our methodology was used previously in
many other investigations.7,9,10,13-15
In the sample of subjects with agenesis of maxillary
lateral incisors, the frequency of agenesis of other per-
manent teeth was significantly higher (Table I). The
prevalence of other missing permanent teeth, excluding
third molars, was 18.2% (OR, 3.5). Interestingly, among
the patients with agenesis of other permanent teeth (n 5
23), 73.9% (n 5 17) had bilateral expression of maxil-
lary lateral incisor agenesis. Therefore, considering
only the subsample of patients with bilateral agenesis
of maxillary lateral incisors (n 5 65), the frequency of
732.e4 Garib et al
associated permanent tooth agenesis was 26.1%. In
other words, a quarter of the patients with bilateral lat-
eral incisor absence were missing other permanent
teeth, excluding the third molars. The more severe ex-
pression of the phenotype represented by missing lateral
incisors was therefore concurrent with the higher prev-
alence of other missing teeth in the same subjects, thus
indicating a strong level of expressivity of the related
genotype.
When we analyzed the complete sample, all cate-
gories of permanent teeth could be absent, with the ex-
ceptions of the maxillary and mandibular first molars.
The maxillary second premolar followed by the mandib-
ular second premolar were the most frequently absent
teeth with a 7-fold and 2.5-fold increased prevalence
compared with general population, respectively. In a sub-
group of patients older than 14 years, the prevalence of
third molar agenesis was significantly higher (35.5%)
compared with the reference values (Table I).
Garn and Lewis5 reported a 13-fold increased prev-
alence of tooth agenesis in patients without third molars
compared with a control group. Even developmentally
stable teeth such as canines and first premolars were
missing in the sample with agenesis of third molars,
with the exception of first molars and maxillary central
incisors.5 Specifically concerning the maxillary lateral
incisor, the prevalence of agenesis in the study group
was 12%, compared with 1.2% in the control group.5
Garib et al14 observed that 21% of the patients with sec-
ond premolar agenesis had other permanent teeth miss-
ing, excluding the third molars, a 4-fold increased
prevalence compared with the general population. All
dental groups were affected, but the maxillary lateral in-
cisor was the most commonly absent teeth, with an
8-fold increased frequency of agenesis (16.3%) com-
pared with the reference values (1.9%).14 Our study
showed an association between different permanent
tooth agenesis; this agrees with the results of Garn
and Lewis5 and Garib et al.14 The possible explanation
is that 1 gene mutation might interfere in the morpho-
genesis of more than 1 group of teeth. Studies of fami-
lies and investigations of the association of agenesis and
other dental anomalies previously highlighted the
role of genetic mechanisms in the etiology of tooth
agenesis.7,9-11,13,15,16,23,27
Unlike tooth agenesis, the prevalence of supernu-
merary teeth in our sample was not statistically different
from that of the general population (Table I). This sug-
gests that these anomalies have different or independent
etiologic factors. This is understandable, considering
that tooth agenesis is a hypoplastic dental anomaly,
whereas supernumerary teeth are hyperplastic anoma-
lies. These results corroborate the findings of Baccetti11
American Journal of Orthodontics and Dentofacial Orthopedics
June 2010
and Garib et al,14 who did not find higher frequencies of
supernumerary teeth in samples with second premolar
agenesis.
The unilateral agenesis of the maxillary lateral inci-
sor and microdontia of its antimere represent a classic
association of dental anomalies in the literature.28 In
this study sample, the prevalence of maxillary lateral in-
cisor size reduction was 38.8% (OR, 12.9), an 8-fold in-
creased prevalence compared with the reference values
(Table II). In reality, considering only the subsample
with unilateral maxillary lateral incisor agenesis, con-
tralateral size reduction was observed in 80.3% of the
patients. These results are in agreement with previous
studies pointing out that tooth agenesis and microdontia
are different expressions of the same genetic defect once
these phenotypes appear associated.6,28,29 Garn and
Lewis6 observed a general reduction in tooth size in pa-
tients with third molar agenesis. This reduction was
even more remarkable in patients with oligodontia.
Brook29 analyzed families of patients with dental anom-
alies and observed that agenesis and microdontia often
occur concomitantly. Baccetti11 also obtained similar
results, demonstrating that 18% of patients with agene-
sis of second premolars had microdontia of maxillary
lateral incisors, and nearly half of patients with small
maxillary lateral incisors (42%) had agenesis of second
premolars. Garib et al14 found that approximately 20%
of the patients with second premolar agenesis also had
maxillary lateral incisor microdontia. These findings
have clinical relevance in orthodontics. A treatment
plan that includes replacement of the missing lateral in-
cisor in patients with unilateral agenesis of the maxil-
lary lateral incisor should consider augmentation of its
antimere to obtain a balanced and symmetrical smile.
The prevalence of PDC in the sample was 5.2%,
a 3-fold increased prevalence (OR, 3.1) compared
with the general population (Table II). Among the 6 pa-
tients identified, 5 had unilateral PDC, and 1 had
bilateral occurrence, for a total of 7 ectopic maxillary
canines. The ectopic eruption toward the palate coin-
cided with the same quadrant of maxillary lateral incisor
agenesis for all maxillary canines, except one that was
observed at the side of a small maxillary lateral incisor.
Conversely, in a sample of 19 patients with a phenotype
associating unilateral expression of maxillary lateral in-
cisor agenesis and PDC, Becker et al30 found that canine
ectopia occurred more frequently on the side of the
small lateral incisor than on the side of the lateral incisor
agenesis.
Previous studies have shown frequent associations
of PDC with second premolar agenesis, third molar
agenesis, microdontia of maxillary lateral incisors,
and infraocclusion of deciduous molars.9,11,13,14 In
American Journal of Orthodontics and Dentofacial Orthopedics
Volume 137, Number 6
accordance with our study, Sacerdoti and Baccetti16 re-
ported an increased prevalence of PDC (20%) in a sam-
ple of subjects with maxillary lateral incisor agenesis
(n 5 40), compared with a control group. However,
the reciprocal association was not found in investiga-
tions of the prevalence of maxillary lateral agenesis in
subjects primarily selected with PDC.9,13,16 A
significant increased prevalence of maxillary lateral
incisor agenesis (18.9%) was found only for subjects
with unilateral expression of PDC.16
Currently, 2 theories explain the occurrence of the
PDC anomaly. Becker et al31,32 proposed that local
factors such as agenesis and microdontia of maxillary
lateral incisors are the major etiologic factors of
maxillary canine ectopic eruption. Based on the
‘‘guidance theory of canine palatal displacement,’’ the
roots of maxillary lateral incisors work as guides for
maxillary canine eruption.33 Without a maxillary lateral
incisor or with an anomalous root morphology, a maxil-
lary canine could develop an ectopic eruption path.33
This theory, however, can explain only approximately
20% of PDC cases.33 Another explanation for PDC oc-
currence is the genetic theory.8 Peck et al8 compiled
some evidence of the genetic etiology of PDC including
concomitant occurrence with other genetic anomalies
such as tooth agenesis, frequent familial history, and dif-
ferences in the prevalences observed for the sexes and
different populations. Under this light, maxillary lateral
incisor agenesis and PDC might share a common ge-
netic background. These data have clinical relevance
since absence of maxillary lateral incisors might be an
early risk indicator for PDC development. However,
considering the prevalence rate of PDC associated
with other dental anomalies, maxillary lateral incisor
agenesis is weaker as a risk indicator for PDC than sec-
ond premolar agenesis, maxillary lateral incisor micro-
dontia, and infraocclusion of deciduous molars.
Therefore, these results, in addition to the data of Sacer-
doti and Baccetti,16 do not support the guidance theory,
because the most severe expression of a presumed ‘‘lack
of guidance’’ for the erupting canine offered by the lat-
eral incisor (absence of the incisor) has a smaller asso-
ciation value with PDC than anomalies in regions of the
dental arch distant from the canine.
The ectopic eruption of mandibular second premo-
lars toward the distal aspect seems to be a mild expres-
sion of the same genetic base that determines second
premolar agenesis. Symons and Taverne34 observed
the distoangulation of mandibular second premolar
buds in a family with multiple agenesis including the
second premolars. Shalish et al12 demonstrated that pa-
tients with unilateral agenesis of mandibular second
premolars often exhibit distal angulation and delayed
Garib et al 732.e5
development of the unerupted contralateral second pre-
molar. Garib et al14 found a higher prevalence of man-
dibular second premolar distoangulation (7.9%) in
a sample of patients with second premolar agenesis
compared with the prevalence expected in the general
population (0.2%). Our results showed that 4% of the
patients with maxillary lateral incisor agenesis have dis-
toangulation of mandibular second premolars, a 20-fold
increased prevalence (OR, 20.8) compared with the ref-
erence values (Table II). Among the 5 patients in the
sample with ectopic eruption of mandibular second pre-
molars, just 2 had agenesis of second premolars.
Distoangulation of mandibular second premolars is
usually mild and self-corrects during tooth eruption.12
Therefore, our methodology might have underestimated
this prevalence because the ages of the subjects with
mandibular second premolar distoangulation varied
from 9 to 15 years, whereas the complete sample had
a wider age range. Patients examined in the third decade
of life usually had fully erupted mandibular second
premolars.
Impaction of mesially angulated mandibular second
permanent molars is a rare eruption disturbance affect-
ing 0.06% of the population24; the etiology is frequently
assigned to local factors, such as a deficient dental arch
perimeter.35 Not all cases of retention of mandibular
second molars can be assigned to local causes, such as
deficient dental arch space and mechanics involving dis-
talization of mandibular first molars. In some patients,
a normally developing tooth bud of a mandibular second
molar might in a short time change its angulation to
a significant mesial inclination, without apparent cause,
thus remaining impacted on the distal aspect of the man-
dibular first molar.35 Garib et al14 observed an increased
prevalence of mesioangulation of mandibular second
molars (1%) in a sample of patients with second premo-
lar agenesis compared with the prevalence reported for
the general population. Differently, no cases of mesial
angulation of mandibular second molars were found
in our study sample. Therefore, no association between
agenesis of maxillary lateral incisors and mesial angula-
tion of mandibular second molars could be established.
This study highlights the importance of genetics
with associated dental anomalies. With the advances
in molecular biology, future diagnostic tools for preven-
tion of some dental anomalies might include genetic
mapping.
CONCLUSIONS
The hypothesis that subjects with maxillary lateral
incisor agenesis demonstrate increased prevalence of
other dental anomalies was corroborated. There was
732.e6 Garib et al
a significant association between agenesis of maxillary
lateral incisors and agenesis of other permanent teeth, as
well as increased occurrence of microdontia of maxil-
lary lateral incisors, palatal displacement of canines,
and distal angulation of mandibular second premolars.
These associations can be explained by a previously
postulated genetic interrelationship in the causes of
these dental anomalies.
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ONLINE ONLY

Effect of rapid maxillary expansion and

transpalatal arch treatment associated with
deciduous canine extraction on the eruption of
palatally displaced canines: A 2-center
prospective study
Lauren M. Sigler,a Tiziano Baccetti,b and James A. McNamara, Jrc
Ann Arbor, Mich, and Florence, Italy

Introduction: Our aim was to investigate the effect of rapid maxillary expansion and transpalatal arch therapy
combined with deciduous canine extraction on the eruption rate of palatally displaced canines (PDCs) in patients
in the late mixed dentition in a 2-center prospective study. Methods: Seventy subjects were enrolled based on
PDCs diagnosed on panoramic radiographs. The treatment group (TG, 40 subjects) underwent RME followed by
TPA therapy and extraction of the deciduous canines. The control group (CG, 30 subjects) received no ortho-
dontic treatment. At the start of the trial, panoramic radiographs and dental casts were compared between
the TG and the CG with the Mann-Whitney U test (P \0.05). At the second observation (cervical vertebral
maturation stage 5 or 6), all subjects were reevaluated, and the eruption of the maxillary permanent canines
was assessed. The rates of success in the TG were compared with those in the CG by means of chi-square
tests (P \0.05). The association of PDCs with other dental anomalies was reported. Results: No statistically
significant difference was found for any measurement at the start of the trial between the 2 groups. The preva-
lence rates of eruption of the maxillary canines were 80% for the TG and 28% in the CG, a statistically significant
difference (chi-square 516.26, P \0.001). The prevalence rate at the start for the pubertal stages of cervical
vertebral maturation (63%) was significantly greater in the unsuccessfully treated subjects than in the success-
fully treated ones (16%). In the CG, all successful subjects had PDCs that overlapped the corresponding
deciduous canine or the distal aspect of the lateral incisor. Eruption of PDCs in both groups was associated
significantly with an open root apex. Conclusions: Rapid maxillary expansion therapy followed by a transpalatal
arch combined with extraction of the deciduous canine is effective in treating patients in the late mixed dentition
with PDCs. Pretreatment variables indicating success of treatment on the eruption of PDCs were less severe
sectors of displacement, prepubertal stages of skeletal maturity, and open root apices of PDCs. Several dental
anomalies were associated significantly with PDCs, thus confirming the genetic etiology of this eruption
disturbance. (Am J Orthod Dentofacial Orthop 2011;139:e235-e244)

P
alatal canine displacement (PCD) is a genetic
disorder that is a precursor to palatal canine im-
paction, a dental anomaly that afflicts 0.2% to
2.3% of orthodontic populations.1 Treatment for palatal
canine impaction involves surgical exposure and guiding
a
Research assistant, Department of Orthodontics and Pediatric Dentistry, University
of Michigan, Ann Arbor.
b
Assistant professor, Department of Orthodontics, University of Florence, Florence,
Italy; Thomas M. Graber Visiting Scholar, Department of Orthodontics and Pediatric
Dentistry, School of Dentistry, University of Michigan, Ann Arbor.
c
Thomas M. and Doris Graber Endowed Professor, Department of Orthodontics and
Pediatric Dentistry, School of Dentistry; professor, Cell and Developmental Biology,
School of Medicine; research scientist, Center for Human Growth and Development,
University of Michigan, Ann Arbor; private practice, Ann Arbor, Mich.
The authors report no commercial, proprietary, or financial interest in the prod-
ucts or companies described in this article.
mechanics to bring the canine into normal occlusion.2
Patients with PCD must be identified and treated promptly
upon diagnosis to reduce the likelihood of impaction.3
Prevention of palatal impaction is of significant impor-
tance because canine impaction lengthens orthodontic
Supported by funds made available through the Thomas M. and Doris Graber
Endowed Professorship at the University of Michigan.
Reprint requests to: Tiziano Baccetti, Dipartimento di Odontostomatologia,
Universita degli Studi di Firenze, Via del Ponte di Mezzo, 46-48 50127, Firenze,
Italy; e-mail, tbaccetti@unifi.it.
Submitted, May 2009; revised and accepted, July 2009.
0889-5406/$36.00
Copyright ! 2011 by the American Association of Orthodontists.
doi:10.1016/j.ajodo.2009.07.015

e235
e236
treatment time, complicates orthodontic mechanics, and
increases treatment costs.3,4 Furthermore, canine
impaction can have deleterious consequences for
adjacent teeth, causing root resorption or cyst formation.5
The most common treatment for the prevention of
palatal canine impaction is the extraction of the under-
lying deciduous canine. In a clinical trial, Ericson and
Kurol6 reported an improvement in the eruption path
of 78% of palatally displaced canines (PDCs) after ex-
traction of the deciduous canine, and Power and Short7
reported a 62% successful eruption rate with the same
interceptive technique. Another prospective longitudinal
study conducted by Baccetti et al8 with an untreated
control group indicated that 65% of patients with
PDCs who had extraction of the deciduous canine re-
sulted in successful eruption of the permanent canine
with no other treatment. The prevalence rate of canine
eruption can be improved significantly (up to 88%) by
adding forces that prevent mesial migration of the max-
illary posterior teeth after extraction of the deciduous
canine, such as those exerted by cervical-pull headgear.8
Recent data suggest that rapid maxillary expansion
(RME) is a valid interceptive treatment option in patients
with PDCs. A recent randomized clinical trial reported
that RME therapy in the early mixed dentition prevented
impaction in 66% of the PDC patients when compared
with an untreated control group (14%).9 This study used
posteroanterior radiographs to measure the distance of
the palatally displaced canine cusp to the face midline
to diagnose a PDC. Recent data have indicated that
PDCs are not correlated to narrow maxillary arches.10 In
this study, RME was performed on PCD patients with
the primary aim of relieving mild-to-moderate crowding.
Our study was intended to evaluate further the im-
pact of RME on the eruption rates of PDCs when intercep-
tive treatment is carried out in the late mixed dentition;
this has been indicated as an appropriate time to improve
arch perimeter by maxillary expansion.11 The aim of this
prospective controlled study was to assess the prevalence
rates of successfully erupted PDCs diagnosed in the late
mixed dentition by means of panoramic radiographs
and subsequent treatment with RME, TPA, and deciduous
canine extraction. Additional aims of this study were (1) to
evaluate further the genetic origin of PCD by investigating
its association with other dental anomalies of genetic or-
igin and (2) to identify pretreatment variables associated
with successful outcomes of interceptive treatment of
PDCs with RME and TPA therapy.
MATERIAL AND METHODS
The control and treated groups consisted of patients
included in a 2-center prospective longitudinal clinical
March 2011 " Vol 139 " Issue 3 American Journal of Orthodontics and Dentofacial Orthopedics
Sigler, Baccetti, and McNamara Jr.
trial at the Department of Orthodontics and Pediatric
Dentistry of the University Michigan and the Department
of Orthodontics at the University of Florence in Italy.
Criteria for enrollment of subjects in the clinical trial at
the 2 research units were the following.
1. White race.
2. Age from 9.5 to 13.0 years at the start of treatment
(T1).
3. Late mixed dentition.
4. Diagnosis of intraosseous malposition of at least 1
maxillary permanent canine, derived from the anal-
ysis of panoramic radiographs according to the
method of Ericson and Kurol12 by means of alpha
angle, d distance, and sector measurements. PDCs
with an alpha angle $15! were included in the trial
(milder forms of PCD were not included). PCD was
confirmed by evaluating the position of the canine
on the lateral cephalogram and, when necessary,
with Clark’s tube shift rule by using multiple intrao-
ral radiographs of the canine region.13 Such PDCs
were either unilateral or bilateral.
5. Stage of skeletal growth from cervical stage (CS) 1 to
CS 4 as assessed on lateral cephalograms of the sub-
jects according to the cervical vertebral maturation
(CVM) method.14
6. Dentoskeletal Class II or Class III tendency or mild
tooth size-arch length discrepancy.
7. No previous orthodontic treatment.
8. No supernumerary teeth, odontomas, cysts, craniofa-
cial malformations, or sequelae of traumatic injuries.
A total of 70 subjects were enrolled at T1. They were
allocated to 2 groups: treatment group (TG; 40 subjects,
25 girls and 15 boys) or control group (CG; 30 subjects,
18 girls and 12 boys). The TG subjects received treatment
from 1 faculty group practitioner (J.A.M.) using a stan-
dardized treatment protocol, as described below. The CG
subjects had no orthodontic treatment and were ob-
served at the Department of Orthodontics of the Univer-
sity of Florence. Ethical approval was obtained for the
enrollment of the subjects in the CG. Informed consent
was signed by the parents of all subjects enrolled in
the trial at both research sites.
Treatment protocol
The 40 subjects in the TG underwent RME. Thirty-
five patients were treated with a bonded acrylic splint
RME that covered the maxillary first and second decidu-
ous molars and the maxillary first permanent molars, and
the remaining 5 subjects, who had exfoliated deciduous
molars, were treated with a banded RME with bands on
the maxillary first permanent molars and first premolars.
Sigler, Baccetti, and McNamara Jr.
The midline expansion screw was expanded a quarter
turn per day until expansion of about 7 mm was
achieved (based on the number of turns recorded in
the chart. The duration of active expansion was about
1.1 months, or approximately 5 weeks). After expansion,
the RME appliance remained in place for an additional 4
to 5 months to allow for the reorganization of the
disrupted sutural tissues. After removal of the RME,
a TPA was placed on the maxillary first molars and acti-
vated according to the protocol described by McNamara
and Brudon.15 Subjects who were not yet in the
advanced late mixed dentition phase after expander
removal wore a maxillary acrylic maintenance plate until
TPA delivery when the maxillary second molars became
loose. TPA treatment is postulated to prevent the mesial
movement of the maxillary first molars during the
transition to the permanent dentition.11 During TPA
treatment, the retained maxillary deciduous canines
corresponding to the PDCs were extracted. A primary
goal for maxillary expansion in the TG was to improve
the intraosseous position of PDCs.9 The CG received no
orthodontic treatment.
Diagnostic measurements at T1
The panoramic radiographs of all subjects at T1 were
analyzed. The following measurements proposed by
Ericson and Kurol12 were made on the panoramic
radiographs (Fig):
1. Alpha angle: mesial inclination of the crown of the
permanent canine to the midline (Fig, A).
2. d distance: distance of the cusp tip of the permanent
canine from the occlusal line (Fig, B).
3. Sector: the mesial position of the crown of the dis-
placed canine with respect to the central and lateral
incisors (5 sectors, with sector 1 indicating the posi-
tion of the crown of the displaced canine posterior
to the distal aspect of the lateral incisor and sector
5 in correspondence with the mesial half of the
maxillary central incisor) (Fig, C).
As indicated by Ericson and Kurol,12 these measure-
ments are valid diagnostic variables for PDCs in the age
range studied in this trial.
The CVM stage was evaluated on the lateral cephalo-
grams of all subjects at T1.14 The development of the
roots of all PDCs was appraised according to the method
developed by Nolla.16
The following measurements proposed by Tollaro
et al17 were made on the dental casts at T1.
1. Maxillary intermolar width: the distance between
the central fossae of the maxillary right and left first
molars.
American Journal of Orthodontics and Dentofacial Orthopedics
e237
2. Mandibular intermolar width: the distance between
the tips of the distal cusps of the mandibular right
and left first molars.
3. Posterior transverse discrepancy: the difference
between the maxillary and mandibular intermolar
widths.
In subjects with normal occlusion, the distobuccal
cusp of the mandibular first molar occludes with the
central fossa of the maxillary first molar.17 Conse-
quently, in subjects with normal occlusion, maxillary
and mandibular intermolar widths are equal. A negative
posterior transverse discrepancy between the dental
arches indicates a narrower maxillary measurement
compared with the mandibular one.17
Appraisal of dental anomalies associated with PCD
PDCs have been hypothesized to be part of a genetic
cluster that includes other dental anomalies clinically
associated with canine displacement.18 The TG and CG
subjects analyzed in this study provided a sample of
adequate size to investigate significant associations
between PCD and the following dental anomalies18-21:
small maxillary lateral incisors, agenesis of second
premolars, distally displaced erupting mandibular
second premolars, and infraocclusion of deciduous
molars. Small maxillary lateral incisors were defined as
a severe crown-size reduction, in some cases associated
with narrowing in diameter from the cervix to the incisal
edge (peg-shaped lateral incisors). Distally displaced
erupting mandibular second premolars were defined as
an intraosseous anomalous position of the second
premolar with its main axis cutting through the outline
of the crown of the adjacent first permanent molar.
Infraocclusion of deciduous molars occurs with ankylo-
sis of the deciduous tooth, and the occlusal plane of the
deciduous molar is apically positioned relative to the
occlusal plane of the adjacent teeth.
The prevalence rates for these associations were
contrasted with previously published control data from
similar orthodontic populations of similar age ranges.18,19
Reevaluation
According to the prospective design of the trial, all
subjects were reevaluated at a second observation time
(T2) when they were in the early permanent dentition
with a postpubertal stage of CVM (CS 5 or 6). At T2, un-
erupted canines were considered impacted because the
maxillary permanent canines will not erupt spontane-
ously after CS 5.22
The number of dropouts was recorded. The main out-
come investigated at T2 was successful or unsuccessful
eruption of the maxillary permanent canines. A “successful
March 2011 " Vol 139 " Issue 3
e238
Fig. A, B, and C, Graphic representations of measurements on panoramic radiographs of PCD
subjects at T1.
outcome” for PCD was defined as the full eruption of the
canine, thus permitting bracket positioning for final arch
alignment when needed.23 An “unsuccessful outcome”
was evident when there was no eruption of the permanent
canine (impaction) at T2.
The magnification factor for the panoramic films in
both groups was 18%. All measurements were per-
formed with the primary investigator (L.M.S.) blinded
to the groups.
Power of the study and method error
The estimate of the power of the study was per-
formed before the clinical part of the trial. By consider-
ating the standard deviations of the diagnostic measures
on the panoramic radiographs from a previous study and
by using nonparametric or categorical statistics, the
calculated power of the study exceeded 0.90 at an alpha
of 0.05 with the sample sizes of 40 and 30 subjects in the
2 groups.8
The accuracy of the measurements on panoramic
radiographs and dental casts was calculated with
Dahlberg’s formula24 on measurements repeated on 15
subjects selected randomly from the 2 groups. The
method errors were 1.3! for alpha angle, 0.7 mm for
d distance, and \0.2 mm for the 2 dental cast measures.
The appraisal of the sector of canine displacement
showed reproducibility of 100%. Reproducibility for
March 2011 " Vol 139 " Issue 3 American Journal of Orthodontics and Dentofacial Orthopedics
Sigler, Baccetti, and McNamara Jr.
the assessment of dental anomalies associated with
PCD was 100%.
Statistical analysis
The starting forms at T1 for measurements on pano-
ramic films and dental casts were compared between the
TG and the CG with the Mann-Whitney U test (P\0.05).
Maxillary and mandibular intermolar widths were
contrasted with the same test to evaluate a possible
interarch transverse discrepancy at T1. The rates of
development of the roots of the displaced canines were
compared in the 2 groups at T1 as well. The prevalence
rates for sectors of canine displacement and for the
stages in the CVM in the 2 groups at T1 were compared
by means of the chi-square test (P \0.05).
The prevalence rates for successful and unsuccessful
subjects at T2 in the TG were compared with those in the
CG with chi-square tests (P \0.05).
The successful and unsuccessful groups as defined at
the T2 reevaluation were compared with the following
variables at T1: alpha angle, d distance, sector, age,
CVM stage, and rate of bilateral PDCs. The rates of
development of the root of displaced canines at T1
were compared in successful and unsuccessful subjects.
These comparisons were carried out with Mann-Whitney
U tests (P \0.05) for metric measures and chi-square
tests (P \0.05) for categorical measures.
Sigler, Baccetti, and McNamara Jr. e239

Table I. Demographics for the TG and CG at T1

Treated group n 5 39 Control group n 5 29 TG vs CG

Age and age intervals Mean SD Mean SD Mann-Whitney test

Age T1 10 y 5 mo 10 mo 10 y 5 mo 10 mo NS
Age T2 14 y 1 mo 1 y 3 mo 13 y 6 mo 10 mo NS
Average T2-T1 interval 3 y 7 mo 1 y 5 mo 3 y 1 mo 1 y 2 mo NS
Sex Patients (n) Percentage Subjects (n) Percentage Chi-square test
Male 15 38.5% 12 41.4%
Female 24 61.5% 17 58.6% NS
NS, Not significant.

Table II. Dental cast measures for the TG vs the CG at T1

Treated group n 5 39 Control group n 5 29 TG vs CG

Dental cast measurements Mean SD Mean SD Mann-Whitney test

Maxillary intermolar width (mm) 43.3 2.1 44.1 2.1 NS
Mandibular intermolar width (mm) 43.7 1.9 44.3 2.0 NS
Posterior transverse discrepancy (mm) #0.7 0.2 #0.6 0.3 NS

NS, Not significant.

The TG and the CG were combined to calculate the
prevalence rates for dental anomalies associated with
PDCs. These rates were compared with those reported by
Baccetti et al in 199818 and 20099 with chi-square tests
(P \0.05). The CG subjects in this study were derived
from the same orthodontic population from which these
prevalence rates were calculated. Statistical analysis
was performed with software (version 16.0.1, Statistical
Package for the Social Sciences, SPSS, Chicago, Ill).
RESULTS
The number of dropouts from T1 to T2 was 1 subject
in both the TG and the CG. These dropouts were due to
the subjects’ relocating with their families during the ob-
servation period. The final samples (Table I) comprised
39 subjects (24 girls and 15 boys with 65 PDCs) in the
TG and 29 subjects (17 girls and 12 boys with 48
PDCs) in the CG. The few dropouts did not affect the
power of the study. The mean age at T1 for both groups
was 10 years 5 months 6 10 months. The average age
for the TG at T2 was 14 years 1 month 6 1 year 3
months, and the mean duration of observation was 3
years 7 months. The average age for the CG at T2 was
13 years 6 months 6 10 months, and the mean duration
of observation was 3 years 1 month. There was no statis-
tically significant difference in sex distribution between
the TG and the CG.
The descriptive statistics for the measurements on the
dental casts and panoramic films at T1 in the 2 groups
are reported in Tables II and III. The average maxillary
intermolar widths were 43.3 6 2.1 mm in the TG and
44.1 6 2.1 mm in the CG; the average mandibular
intermolar widths were 43.7 6 1.9 mm in the TG and
44.3 6 2.0 mm in the CG. Posterior transverse
discrepancies were –0.7 6 0.3 mm in the TG and –0.6
6 0.3 mm in the CG. No statistically significant
differences between the TG and CG were evident for
any variable. The posterior transverse discrepancy in
neither group was significant.
The comparison between the TG and the CG as to
alpha angle, d distance, sector of canine displacement,
CVM stage, and unilateral vs bilateral occurrence of
PCD did not show any significant differences at T1.
Root development of PDCs was similar in the 2 groups
at T1 as well.
The prevalence rates for successful eruption of PDCs
were 79.5% (31 subjects) in the TG and 27.6% (8 subjects)
in the CG. The comparison was statistically significant
(chi-square 5 16.26; likelihood ratio 5 19.05; P\0.001).
The comparison between successful vs unsuccessful
subjects in the TG (Table IV) showed that, although there
was no statistically significant difference for the alpha
angle or the d distance, the prevalence rate for less severe
sectors of canine displacement (sectors 1 and 2) was sig-
nificantly greater in successfully treated subjects than in
the unsuccessful ones. The prevalence rate at T1 for the
pubertal stages of CVM (CS 3 or 4, 62.5%) was signifi-
cantly greater in unsuccessfully treated subjectss than
in successful ones, when 84% were in a prepubertal
stage. In the CG (Table V), in all successful subjects,

American Journal of Orthodontics and Dentofacial Orthopedics March 2011 " Vol 139 " Issue 3
e240 Sigler, Baccetti, and McNamara Jr.

Table III. Radiographic data comparisons for the TG and the CG at T1

Treated group Control group
n 5 39 n 5 29 TG vs CG
Radiographic
measurements Mean SD Mean SD Mann-Whitney test
Alpha angle (! ) 29.5 7.9 28.5 11.0
d distance (mm) 16.9 2.8 17.5 3.9 NS
Patients (n) Percentage Subjects (n) Percentage Chi-square test
Sector 1 6 15.4% 8 27.6% NS
Sector 2 20 51.3% 14 48.3%
Sector 3 10 25.6% 3 10.3%
Sector 4 3 7.7% 4 13.8%
CS 1 14 35.9% 7 24.1% NS
CS 2 15 38.5% 12 41.4%
CS 3 8 20.5% 10 34.5%
CS 4 2 5.1% 0 0.0%
Unilateral 12 30.8% 10 34.5% NS
Bilateral 27 69.2% 19 65.5%
Median Range Median Range Mann-Whitney test
Root development of PCD 8.75 7.25-9.50 9.00 7.50-9.75 NS

NS, Not significant.

Table IV. Comparison between successful vs unsuccessful subjects in the TG

Unsuccessful Successful
n58 n 5 31
Radiographic
measurements Mean SD Mean SD Mean difference Mann-Whitney test
Alpha angle at T1 (! ) 33.2 9.6 28.5 5.1 #4.7 NS
d distance at T1 (mm) 15.8 3.8 17.5 2 1.7 NS
Patients (n) Percentage Patients (n) Percentage Chi-square test
y
Sector 1 0 0.0% Mild/moderate 5 25% 5 16.1% Mild/moderate 5 77.4%
Sector 2 2 25.0% 19 61.3%
Sector 3 4 50.0% Severe 5 75% 6 19.4% Severe 5 22.6%
Sector 4 2 25.0% 1 3.2%
y
CS 1 0 0.0% Prepubertal 5 37.5% 14 45.2% Prepubertal 5 83.9%
CS 2 3 37.5% 12 38.7%
CS 3 3 37.5% Pubertal 5 62.5% 5 16.1% Pubertal 5 16.1%
CS 4 2 25.0% 0 0.0%
Unilateral 2 25.0% 10 32.3% NS
Bilateral 6 75.0% 21 67.7%
Median Range Stage 9 Median Range Stage 9 Mann-Whitney test
Root development of PCD 9.00 8.25-9.75 9.6% 8.00 7.25-9.25 50% *

*P \0.01; yP\0.001; NS, not significant.

the PDCs were exclusively in sectors 1 and 2. The unsuc-
cessful subjects in both groups had significantly more
advanced development of the root of the displaced ca-
nine than did the successful cases. The percentage of
subjects with root development stage 9 according to
Nolla16 (closed root apex) was 4 times greater in unsuc-
cessfully treated subjects than in successfully treated
subjects (Table IV), and 2 times greater in unsuccessful
control subjects than in successful control subjects
(Table V). No differences were found regarding bilateral
vs unilateral PCD with regard to canine eruption (Tables
IV and V).
Subjects with PDCs exhibited significantly greater
prevalences of small lateral incisors (P \0.001, 6 times
greater than in the CG; Table VI), distally displaced erupt-
ing mandibular second premolars (P \0.001, 3 times
greater than in the control population), and infraocclusion
of deciduous molars (P \0.05, 2.5 times greater than in

March 2011 " Vol 139 " Issue 3 American Journal of Orthodontics and Dentofacial Orthopedics
Sigler, Baccetti, and McNamara Jr. e241

Table V. Comparison between successful vs unsuccessful subjects in the CG

Unsuccessful Successful
n 5 21 n58
Radiographic
measurements Mean SD Mean SD Mean difference Mann-Whitney test
Alpha angle at T1 (! ) 31.0 11.5 21.7 5.8 #9.3 NS
d distance at T1 (mm) 17.3 4.5 18.3 1.8 1.0 NS
Subjects (n) Percentage Subjects (n) Percentage Chi-square test
Sector 1 2 9.5% Mild/moderate 5 66.7% 6 75.0% Mild/moderate 5 100% Test not allowed
Sector 2 12 57.1% 2 25.0%
Sector 3 3 14.3% Severe 5 33.3% 0 0.0% Severe 5 0%
Sector 4 4 19.0% 0 0.0%
Unilateral 8 38.1% 2 25.0% NS
Bilateral 13 61.9% 6 75.0%
Median Range Stage 9 Median Range Stage 9 Mann–Whitney test
Root development of PCD 9.00 8.00-9.75 57.2% 8.25 7.25-9.25 25% *

*P \0.05; NS, not significant.

Table VI. Prevalence of dental anomalies in the TG and CG (combined sample at T1) vs control data
Total

CG TG (CG 1 TG)
Dental anomaly n 5 29 n 5 39 n 5 68 Prevalence Control data Chi-square test
y
Small lateral incisors 10 11 21 30.9% 4.7%
Agenesis of mandibular second premolars 2 2 4 5.9% 5.8% NS
y
Distally displaced erupting mandibular second premolars 11 8 19 27.9% 8.2%
Infraocclusion of deciduous molars 4 5 9 13.2% 5.6% *

*P \0.05; yP \0.001; NS, not significant.

the control population). No significantly increased preva-
lence rate for agenesis of the second premolars was found
in either group.
DISCUSSION
In this 2-center prospective longitudinal study, we
investigated the effectiveness of RME combined with
TPA and extraction of the deciduous canine as an inter-
ceptive treatment modality for PCD in subjects in the late
mixed dentition. PCD was diagnosed via measurements
developed by Ericson and Kurol12 using panoramic films.
A canine with an alpha angle of $15! in sectors 2
through 5 and an intraosseous position in the palate
as observed on the patient’s corresponding lateral
cephalogram was deemed to be a PCD. A canine was
considered to have erupted successfully at T2 (in the
permanent dentition) when bracket placement on its
crown became possible without surgical intervention.23
In the patients, the RME protocol was carried out
with the main objective of improving the eruption
process of PDCs with other orthodontic indications
(eg, mild-to-moderate crowding of the dental arches
or tendency toward Class II or Class III malocclusion).
When transverse interarch relationships at T1 were
evaluated, the treated and untreated subjects did
not have significant amounts of maxillary transverse
deficiency. This confirms previous observations in the
literature that show that PDCs are not associated with
a narrow maxilla.9,10
The outcomes of this study provide further evidence
for the genetic origin of PCD, in that it was found to be
associated with other dental anomalies of known genetic
origin such as small lateral incisors.1,18 PDCs also were
associated significantly with increased occurrence of
both infraocclusion of deciduous molars and distally
displaced erupting mandibular second premolars. The
significant associations between PCD and these 3 dental
anomalies confirm previous data.18,19,25 In particular,
PCD subjects exhibited a greater prevalence of small
lateral incisors (6 times greater compared with control
data from previous studies), distally displaced premolars
(3 times greater than in the same control data),
and infraocclusion of deciduous molars (2.5 times
greater).18,19 Because these tooth disturbances manifest

American Journal of Orthodontics and Dentofacial Orthopedics March 2011 " Vol 139 " Issue 3
e242
before PCD becomes apparent, these dental anomalies can
be considered early risk indicators for PCD (especially
when they are combined in the same subject), and they
indicate that the patient is a candidate for future
interceptive treatment of eruption anomalies of the
maxillary permanent canines.1,18,19,25
RME followed by TPA in conjunction with extraction
of the deciduous canines in late mixed dentition patients
was significantly more effective at inducing successful
eruption of PDCs (80%) than was no treatment (28%).
These results can be contrasted with those from a recent
randomized clinical trial in which RME was found to
increase the rate of successful canine eruption in early
mixed dentition PCD patients (65%) when compared
with an untreated control group (14%).9 However, in
that study, diagnosis of PCD had been carried out on
posteroanterior radiographs before the age of 9 years,
and no TPA was used during treatment.
When comparing the prevalence rates for successful
eruption of PDCs between RME interceptive treatment
in this study with previous studies that used other inter-
ceptive treatment modalities, the RME and TPA protocol
had a slightly higher rate of effectiveness (80%) than
what was reported for extraction of the deciduous
canine alone (78% according to Ericson and Kurol,6
and 62% according to Power and Short7). However,
the prevalence rate for favorable outcomes in the study
by Ericson and Kurol6 included both canine eruption and
improvement of the canine eruption path; in our clinical
trial, only full eruption of the canines was considered.
Also, the prevalence rates reported in both the studies
by Ericson and Kurol and Power and Short referred to
individual PDCs, whereas the prevalence rates for success
and failure in our study refer to subjects who had unilat-
eral or bilateral PDCs. Because palatal displacement of
maxillary canines has been shown to have a fundamental
component of genetic origin, the use of single canines as
statistical units is not recommended, since general
etiologic factors can affect the eruption process of
both maxillary canines in the same subject.1,18
The success rate of RME and TPA treatment com-
pared with extraction of the deciduous canine combined
with fixed appliance therapy (75% according to Olive26)
was similar, whereas the success rate was slightly lower
than the prevalence rate for the eruption of the canines
after the use of cervical-pull headgear and extraction of
the deciduous canine (88%) as determined by Baccetti
et al.8 However, when the prevalence rates for successful
eruption of PDCs were compared between the TG and
the CG in this study and the study by Baccetti et al8 in
2008, the proportion of favorable outcomes in the
RME, TPA, and deciduous canine extraction sample
over the respective controls (2.9 times more) was greater
March 2011 " Vol 139 " Issue 3 American Journal of Orthodontics and Dentofacial Orthopedics
Sigler, Baccetti, and McNamara Jr.
than the proportion in subjects treated with cervical-pull
headgear and deciduous canine extraction over the
respective controls (2.4 times more).
Pretreatment variables associated with a successful
outcome of interceptive treatment of PDCs with RME,
TPA, and extraction of the deciduous canine protocol
were identified. RME treatment in the late mixed denti-
tion was less successful in facilitating canine eruption in
patients who began treatment at CS 3 or 4 in CVM
(pubertal patients) than in patients who began treatment
at CS 1 or 2 (prepubertal patients). Sixty-three percent of
patients in the unsuccessful TG were at pubertal stages
in skeletal maturation, and 84% of patients in the suc-
cessful TG were at prepubertal stages. Moreover, canines
with more severe displacement as shown by the sector
measurement were less likely to erupt successfully. Sim-
ilarly, recent retrospective studies by Olive27 and Zuccati
et al4 found that the more mesial the cusps of the PDCs
(a measurement analogous to the sector measurement)
before treatment, the longer the treatment for impacted
canines. These results are also similar to findings by
Baccetti et al,28 who found the sector measurement to
be a valuable prognostic indicator for the success of
combined surgical and orthodontic treatment of im-
pacted canines. In contrast to these previous studies,
the pretreatment alpha angle was not associated with
success or unsuccess of PCD interceptive treatment.4,28
The sector of canine displacement at T1 was
significantly related to the possibility of spontaneous
eruption of the canine in the CG as well.
PDCs with a fully developed root demonstrated sig-
nificantly less probability of successful eruption. Both
groups showed lower prevalences of successful eruption
of PDCs when the root apex was closed (Nolla’s stage
9).16 A higher prevalence rate of eruption was seen for
PDCs in which the root apex was still developing (even
when more than two thirds of the root had already
formed, as in Nolla’s stage 8).16 These data confirm
previous observations by Kokich and Mathews,29 who
reported a high probability of impaction when the root
apex of the tooth is complete. When the information de-
rived from the canine root development was combined
with the data concerning the CVM staging of our sub-
jects, it could be concluded that interceptive treatment
for PDCs at a prepubertal stage in skeletal maturation
and before the closure of the canine’s root apex leads
to significantly more successful outcomes than postpon-
ing treatment until puberty or when its apex is formed
completely.
A general overview of the possibilities of various
protocols of interceptive treatment for PCD suggests
that extraction of the deciduous canine alone can double
the chance of eruption of the palatally displaced
Sigler, Baccetti, and McNamara Jr.
maxillary permanent canine between 10 and 13 years of
age (about 60%-65% eruption).6-8 The addition of other
therapeutic adjuncts in the late mixed dentition, such as
the RME and TPA approach described here or the
cervical-pull headgear investigated by Baccetti et al,8
increases the prevalence rate of successful eruption of
the canine after interceptive treatment up to 80% to
90%. However, a greater burden of treatment is placed
on the patient when these more complex approaches
are used compared with the simple extraction of the as-
sociated deciduous tooth. In patients with an indication
for either of the 2 combination treatment protocols,
such as maxillary transverse deficiencies for the RME
approach, need for molar distalization for the headgear
approach, or Class II or Class III tendencies or mild-
to-moderate tooth size-arch length discrepancy, the
highly significant facilitation of eruption of PDCs should
be considered an extremely favorable side effect of
these orthodontic treatment options in the late mixed
dentition.11,30,31
CONCLUSIONS
We found that RME followed by TPA coupled with
extraction of the deciduous canine is an effective inter-
ceptive treatment option for patients from 9 years 5
months to 13 years of age with PDCs. The use of this
protocol in subjects in the late mixed dentition increases
the rate of eruption of PDCs significantly (80%) when
compared with an untreated PCD control group (28%).
The following radiographic factors are significantly
associated with palatal canine impaction after intercep-
tive treatment including RME and TPA therapy: pubertal
CVM stages vs prepubertal, more mesial sectors of intra-
osseous displacement of the canine, and closure of the
canine root apex. This study confirmed that several
dental anomalies are significantly associated with PDCs
and are valuable as early risk indicators for PCD: small
lateral incisors, infraocclusion of deciduous molars,
and distally displaced erupting mandibular second
premolars.
We thank Heidi Novak for her assistance in evaluating
the stages of root development of PDCs.
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doi:10.1093/ejo/cjq139 All rights reserved. For permissions, please email: journals.permissions@oup.com
Advance Access Publication 8 November 2010

An RCT on treatment of palatally displaced canines with RME

and/or a transpalatal arch
Tiziano Baccetti*, Lauren M. Sigler** and James A. McNamara Jr**
*Department of Orthodontics, The University of Florence, Italy and **Department of Orthodontics and Dentofacial
Orthopedics, The University of Michigan, Ann Arbor, USA

Correspondence to: Dr Tiziano Baccetti, Via E. Pistelli, 11, 50135 Firenze, Italy. E-mail: tbaccetti@unifi.it

SUMMARY
Aim: To investigate the effect of rapid maxillary expansion (RME) and/or transpalatal arch (TPA) therapy
in combination with deciduous canine extraction on the eruption of palatally displaced canines (PDCs).
Subjects and Methods: Hundred and twenty subjects were enrolled in an RCT based on PDCs diagnosed
on panoramic radiographs and they were randomly assigned to one of four study groups. Three treatment
groups (TGs) (RME followed by TPA therapy plus extraction of deciduous canines, RME/TPA/EC group,
40 subjects; TPA therapy plus extraction of deciduous canines, TPA/EC group, 25 subjects; extraction of
deciduous canines, EC group, 25 subjects) were analyzed. A control group (CG, 30 subjects) received no
orthodontic treatment. Prevalence rates of eruption of PDCs in the three TGs were compared with the CG
at T2. Predictive features at T1 for successful canine eruption were tested in the three TGs.
Results and Discussion: The prevalence of canine eruption was 80 per cent for the RME/TPA/EC group,
79 per cent for the TPA/EC group, 62.5 per cent for the EC group, versus 28 per cent in the CG, with
statistically significant differences between all the groups, with the exception of the comparison between
RME/TPA/EC and TPA/EC. Predictive pretreatment variables for the success of treatment were less severe
sectors of canine displacement, prepubertal stages of skeletal maturity, and an open root apex of PDCs.
Conclusions: The use of a TPA in absence of RME can be equally effective than the RME/TPA combination
in PDC cases not requiring maxillary expansion, thus reducing the burden of treatment for the patient.

Introduction
Palatal canine displacement is a genetic disorder that is a
precursor to palatal canine impaction, a dental anomaly that
afflicts 0.2–2.3 per cent of orthodontic populations (Peck
et al., 1994). Treatment for palatal canine impaction
involves surgical exposure and guiding mechanics that
bring the canine into normal occlusion (Kohavi et al.,
1984). Patients with palatally displaced canines (PDCs)
must be identified and treated promptly upon diagnosis to
reduce the likelihood of impaction (Baccetti et al., 2008a).
Prevention of palatal impaction is of significant importance
because canine impaction lengthens orthodontic treatment
time, complicates orthodontic mechanics, and increases
treatment costs (Zuccati et al., 2006; Barlow et al., 2009).
Furthermore, canine impaction can have deleterious
consequences for adjacent teeth, causing root resorption
and/or cyst formation (Becker and Chaushu, 2005).
The most commonly used treatment for the prevention of
palatal canine impaction is the extraction of the deciduous
canine. Clinical trials performed by Ericson and Kurol
(1988) reported an improvement in the eruption path of 78
per cent of PDCs following extraction of the deciduous
canine, while Power and Short (1993) have reported a 62
per cent successful eruption rate with the same interceptive
technique. Both these clinical studies lacked the evaluation
of an untreated control group (CG). Another prospective
longitudinal study conducted by Baccetti et al. (2008a) with
the inclusion of an untreated CG indicated that 65 per cent
of PDC cases that underwent the extraction of the deciduous
canine resulted in successful eruption of permanent canines
without any other treatment. The prevalence rate of canine
eruption can be improved significantly (up to 88 per cent)
by adding forces that prevent mesial migration of the upper
posterior teeth after extraction of the deciduous canine,
such as those exerted by cervical-pull headgear (Baccetti
et al. (2008a).
Recent data suggest rapid maxillary expansion (RME) to
be a valid interceptive treatment option in PDC patients. A
randomized clinical trial (Baccetti et al., 2009) reported that
RME therapy in the early mixed dentition successfully
encouraged spontaneous eruption in 66 per cent of PDC
patients, which only occurred in 14 per cent in an untreated
CG of similarly affected individuals. This study used
postero-anterior (PA) radiographs to measure the distance of
the palatally displaced canine cusp to the face midline to
diagnose the presence of PDC. Although maxillary
expansion has been proposed as an alternative interceptive
treatment for impacted canines (McConnell et al., 1996;
Schindel and Duffy, 2007), palatally displaced canines are
not correlated to narrow maxillary arches (Langberg and
Peck, 2000), and RME therapy is performed in PDC patients
with the primary aim of relieving mild to moderate crowding.
602
The current randomized clinical study was intended to
evaluate further the impact of interceptive treatment in
subjects presenting with PDCs in the late mixed dentition,
which has been indicated as an appropriate time to improve
arch perimeter by maxillary expansion (McNamara et al.,
2003). The aim of the present prospective controlled study
was therefore to assess the prevalence rate of successful
eruption of PDCs as diagnosed in the late mixed dentition
by means of panoramic radiographs and subsequent
treatment with RME, transpalatal arch (TPA), and deciduous
canine extraction versus PDCs treated with the use of a TPA
and deciduous canine extraction only. An additional aim of
this study was to identify pre-treatment predictors of
successful outcomes of interceptive treatment of PDCs.
Subjects and methods
The treated and CGs consisted of patients included in a
randomized prospective longitudinal clinical trial designed
at the Department of Orthodontics of the University of
Florence, Italy. It is standard practice that orthodontic
patients in the University clinic are given a serial number as
they enroll for orthodontic treatment or monitoring. The
design of the present study started with patient #4500
through patient #8500 (1991–2009). Criteria for enrollment
of subjects in the clinical trial units were as follows:
• Caucasian race;
• age range from 9.5 to 13.0 years at the start of treatment;
• late mixed dentition stage;
• diagnosis of intraosseous malposition of the upper per-
manent canine(s) derived from the analysis of pano-
ramic radiographs according to the method by Ericson
and Kurol (1987) by means of alpha angle, d distance,
and sector measurements. PDCs showing an alpha
angle greater than or equal to 15 degrees were included
in the trial (milder forms of PDC were not enrolled).
Palatal displacement of the canine(s) was confirmed by
evaluating the position of the canine on the lateral
cephalogram, and, when necessary, by means of Clark’s
tube shift rule using multiple intraoral radiographs of
the canine region (Bishara et al., 1976). Such PDCs
either were unilateral or bilateral.
• stage of skeletal growth ranging from CS 1 to CS 4 as
assessed on lateral cephalograms of the examined sub-
jects according to the cervical vertebral maturation
method (Baccetti et al., 2005);
• presence of Class II or Class III tendency or mild tooth-
size/arch-size discrepancy;
• absence of previous orthodontic treatment; and
• absence of supernumerary teeth, odontomas, cysts,
craniofacial malformations, or sequelae of traumatic
injuries.
A total of 120 subjects in the late mixed dentition stage
with either unilateral or bilateral palatally displaced canines
T. BACCETTI ET AL.
(3 per cent of the total orthodontic population during the
study period) were enrolled in the beginning of the trial
(T1). The subjects were allocated to four groups: three
treatment groups (TGs; RME followed by TPA therapy plus
extraction of deciduous canines, RME/TPA/EC group,
40 subjects, 25 females and 15 males; TPA therapy plus
extraction of deciduous canines, TPA/EC group, 25 subjects,
15 females and 10 males; extraction of deciduous canines,
EC group, 25 subjects, 14 females and 11 males); CG
(30 cases, 18 females and 12 males). Ethical approval was
obtained for the enrollment of the subjects in the clinical
trial. Informed consent was also signed by the parents of all
subjects enrolled in the trial.
Treatment protocols
In the RME/TPA/EC group, the 40 late mixed dentition
subjects enrolled for treatment underwent RME. They were
treated with a bonded acrylic splint RME that covered the
maxillary deciduous first and second molars and maxillary
permanent first molars. The midline expansion screw was
attached to the appliance with a heavy (0.045 inch) wire
framework and routinely was expanded a activated a quarter
turn per day until an expansion of about 7 mm was achieved
(duration of active expansion was about 1.5 months). After
expansion, the RME appliance remained in place for an
additional 4–5 months to allow for the reorganization of the
disrupted sutural tissue. Following removal of the RME, a
TPA was placed on the maxillary first molars and activated
according to the protocol described by McNamara and
Brudon (2001). TPA treatment is postulated to prevent the
mesial movement of maxillary first molars during the
transition to the permanent dentition (McNamara et al., 2003).
During the TPA treatment, retained maxillary deciduous
canines corresponding to the PDCs were extracted. A primary
goal for maxillary expansion was to improve the intraosseous
position of PDCs (Baccetti et al., 2009). The TPA/EC group
received just the TPA in combination with extraction of the
deciduous canine/s corresponding to the PDCs, while subjects
in the EC group received only the deciduous canine extraction.
The CG did not receive any orthodontic treatment.
Diagnostic measurements at T1
Panoramic radiographs of all subjects at T1 were analyzed.
The following measurements proposed by Ericson and
Kurol (1987) were performed on panoramic radiographs
(Figure 1):
• a angle: mesial inclination of the crown of the per-
manent canine to the midline;
• d distance: distance of the cusp tip of the permanent
canine from the occlusal line;
• sector: indicating the mesial position of the crown
of the displaced canine with respect to the central and
lateral incisors (5 sectors, with sector 1 indicating the
RCT ON PDC TREATMENT WITH RME OR TPA
Figure 1 Measurements on panoramic radiographs: (A) alpha angle; (B) d distance; (C) sector of displacement (5 areas).
position of the crown of the displaced canine posterior
to the distal aspect of the lateral incisor and sector 5 in
correspondence with the mesial half of the upper cen-
tral incisor).
These measurements are valid diagnostic variables for
PDC within the age range studied in this trial (Ericson and
Kurol, 1987).
The cervical vertebral maturation stage (Baccetti et al.,
2005) was evaluated on the lateral cephalograms of all
subjects at T1. The development of the root of each PDC
was appraised according to the method developed by Nolla
(1960).
Re-evaluation at T2
According to the prospective design of the trial, all cases
were re-evaluated at a second observation time point (T2)
when all subjects would present with an early permanent
dentition and a post-pubertal stage of cervical vertebral
maturation (CS 5 or CS 6). At T2, unerupted canines were
considered impacted because upper permanent canines
will not erupt spontaneously after CS 5 (Baccetti et al.,
2008b).
The number of enrollment dropouts was recorded. The
main outcome investigated at T2 was ‘successful’ or
‘unsuccessful eruption’ of the maxillary permanent
canines. A ‘successful outcome’ for PDC was defined as
the full eruption of the canine, thus permitting bracket
positioning for final arch alignment when needed (Leonardi
et al., 2004). An ‘unsuccessful outcome’ was evident when
there was a lack of eruption of the permanent canine
(impaction) at the completion of the clinical observation
period (T2).
603
The magnification factor for the panoramic films in both
groups was 18 per cent. All measurements were performed,
with the investigator blinded as to the group investigated.
Power of the study and method error
The estimate of the power of the study was performed
before the beginning of the clinical part of the trial. Taking
into consideration the standard deviations of the diagnostic
measures on the panoramic radiographs and the use of non-
parametric or categorical statistics, the calculated power of
the study exceeded 0.90 at an alpha = 0.05 with sample
sizes of the examined groups ranging from 25 subjects to 40
subjects.
Accuracy of measurements on panoramic radiographs
and dental casts was calculated using the Dahlberg’s formula
(Dahlberg, 1940) on measures repeated on 15 subjects
selected randomly from the two groups. The method error
was 1.3 degrees for a angle, 0.7 mm for the d distance, and
less than 0.2 mm for the 2 dental cast measures. The appraisal
of the sector of canine displacement showed a reproducibility
of 100 per cent.
Statistical analysis
The starting forms at T1 for measurements on panoramic
films and for dental cast measurements were compared in
the TG versus the CG with Kruskall–Wallis test and
Dunn’s post hoc tests (P < 0.05). The rate of development
of the root of displaced canines was compared in the four
groups at T1 as well. The prevalence rates for sectors of
canine displacement and for the stages in CVM in the four
groups at T1 were compared by means of chi-squared
tests (P < 0.05).
604 T. BACCETTI ET AL.

The prevalence rates for successful and unsuccessful
cases at T2 in the four groups were compared by means of
chi-squared tests (P < 0.05). The successful and unsuccessful
subjects as defined at the T2 re-evaluation time point in a
comprehensive ‘TG’ that included all treated subjects
(n = 88 subjects) were compared as to the following
variables at T1: alpha angle, d distance, sector, age, cervical
vertebral maturation stage, and rate of bilateral PDCs. The
rate of development of the root of displaced canines at T1
was compared in successful versus unsuccessful cases.
These comparisons were carried out with Mann–Whitney
U tests (P < 0.05) for metric measures and with chi-squared
tests (P < 0.05) for categorical measures.
Results
The number of enrollment dropouts from T1 to T2 was one
subject in each of the TPA/EC, EC, and CGs (total of
3 dropouts). Dropouts were due to subjects relocating with
their families during the T1–T2 observation period. The
final sample (Table 1) was comprised 40 subjects (with
66 PDCs) in the RME/TPA/EC group, 24 subjects (with
36 PDCs) in the TPA/EC group, 24 subjects (with 34 PDCs)
in the EC group, and 29 subjects (with 42 PDCs) in the CG.
The few dropouts did not affect the power of the study.
Mean age at T1 for the four groups is reported in Table 1.
There were no statistically significant differences among
the four groups as to age or gender distribution.
The descriptive statistics for the measurements on dental
casts and panoramic films at T1 in the four groups is
reported in Table 2. The comparison between the TGs and
the CG as to alpha angle, d distance, sector of canine
displacement, CVM stage, and unilateral versus bilateral
occurrence of PDC did not show any significant difference
at T1. Root development of PDCs was similar in the four
groups at T1 as well.
The prevalence rate of successful eruption of the
maxillary canines was 80 per cent for the RME/TPA/EC
group (32/40 subjects), 79.2 per cent for the TPA/EC group
(19/24 subjects), 62.5 per cent for the EC group (15/24
subjects), and 27.6 per cent in the CG (8/29 subjects), with
statistically significant differences between all the groups,
with the exception of the comparison between RME/TPA/
EC and TPA/EC.

Table 1 Demographic data for the treated and untreated groups at T1 (y, years and m, months).

RME/TPA/EC, n =40 TPA/EC, n =24 EC, n =24 CG, n =29 Statistical comparison

Age at T1 10y5m ± 10m 10y9m ± 11m 11y1m ± 11m 10y5m ± 10m NS

Age at T2 14y0m ± 15m 13y7m ± 10m 13y1m ± 9m 13y6m ± 10m NS
T2–T1 interval 3y6m ± 16m 2y9m ± 13m 2y2m ± 10m 3y1m ± 14m NS
Male/female ratio 15/25 10/14 10/14 11/18 NS

NS, not significant.

Table 2 Radiographic data comparisons for the treatment and CGs at T1.

RME/TPA/EC TPA/EC EC group, Control group, Statistical

group, n = 40 group, n = 24 n = 24 n = 29 comparisons

Radiographic measures K-W with Dunn’s tests

Alpha angle (degrees) 29.5 ± 7.9 7.9 28.5 11.0 NS
d distance (mm) 16.9 ± 2.9 2.8 17.5 3.9 NS
Chi-squared tests
Sector 1 (%) 15.4 16.6 16.6 27.6
Sector 2 (%) 51.3 41.6 33.3 48.3 NS
Sector 3 (%) 25.6 33.4 41.6 10.3
Sector 4 (%) 7.7 8.3 8.7 13.8
CS 1 (%) 35.9 16.6 33.3 24.1 NS
CS 2 (%) 38.5 50.0 41.6 41.4
CS 3 (%) 20.5 33.4 16.6 34.5
CS 4 (%) 5.1 0.0 8.3 0.0
Unilateral (%) 30.8 41.6 33.3 34.5 NS
Bilateral (%) 69.2 58.4 66.7 65.5
Median Median Median Range K-W with Dunn’s tests
Root development of PDC (range) 8.75 (7.25–9.50) 8.25 (7.00–9.50) 8.50 (7.50–9.50) 8.75 (7.50–9.50) NS

NS, not significant.

RCT ON PDC TREATMENT WITH RME OR TPA 605

The comparison between successful versus unsuccessful

Mann–Whitney test

Mann–Whitney test
subjects in the three TGs combined together (TG group,

Chi-squared test
Table 3) revealed that, while there was no statistically
significant difference for d distance, the alpha angle was
*** significantly smaller in successful cases. Also, the prevalence

***

***
NS

NS

**
rate for less severe sectors of canine displacement (sectors 1
and 2) was significantly greater in successfully treated cases
than in unsuccessful ones. The prevalence rate at T1 for
‘Mild/moderate’ = 68.7%

pubertal stages of CVM (CS 3 or CS 4, 62 per cent) was

‘Pre-pubertal’ = 82.0%
Successful, n = 67 (RME/TPA/EC = 32;TPA/EC = 19; EC = 16)

% PDC stage 9 or >9

significantly greater in unsuccessful treated cases than in

‘Pubertal’ = 18.0%
‘Severe’ = 31.3%
Mean Difference

successful treated cases, in which 82 per cent presented

Comparison between successful versus unsuccessful subjects in the treated groups (including RME/TPA/EC, TPA/EC, and EC, total = 88).

in a pre-pubertal stage at the beginning of interceptive

orthodontic treatment. The unsuccessful cases in treated
groups presented with a significantly more advanced
−9.3
−0.5

10.0
development of the root of displaced canine/s than successful
cases. The percentage of cases with a root development
stage 9 or >9 according to Nolla (closed root apex;
Percentage

7.00–9.25

Nolla, 1960) was five times greater in unsuccessful treated

Range
6.9
3.1

17.9
50.8
26.8
2.3
34.3
47.7
18.0
0.0
32.9
67.1

subjects than in successful treated subjects (Table 3). No

SD

differences were found regarding bilateral versus unilateral

occurrence of PDC with regard to canine eruption (Table 3).
Number of cases

Discussion
Median

This randomized prospective longitudinal study investigated

Mean

8.00
24.6
16.5

13
34
18
2
23
32
11
0
22
45

the effectiveness of TPA and extraction of the deciduous

canine, either preceded or not preceded by RME, as an
interceptive treatment modality for PDC in late mixed
‘Mild/moderate’ = 28.5%

dentition subjects. PDC was diagnosed via measurements

‘Pre-pubertal’ = 38.0%

% PDC stage 9 or >9

Unsuccessful, n = 21 (RME/TPA/EC = 8;TPA/EC = 5;EC = 8)

developed by Ericson and Kurol (1988) using panoramic

‘Pubertal’ = 62.0%
‘Severe’ = 71.5%

films. A canine with an alpha angle greater than or equal

to 15 degrees, within sectors 2–5, and an intraosseous
position within the palate as observed on the patient’s
corresponding lateral cephalogram, was diagnosed as a
54.0

PDC. A canine was considered to have erupted successfully

at the end of the observation period (in the permanent
dentition) when bracket placement on its crown became
Percentage

8.00–9.75

possible without surgical intervention (Leonardi et al.,

Range
7.0
3.8

4.7
23.8
47.9
23.8
14.2
23.8
44.4
17.6
35.2
64.8

2004).
SD

In the RME/TPA/EC patients, the RME protocol was

carried out with the main objective of improving the
Number of cases

eruption process of PDCs within other orthodontic

indications (e.g., mild to moderate crowding of the dental
**P < 0.01; ***P < 0.001; NS, not significant.

arches, tendency toward Class II or Class III malocclusion).

Median
Mean

9.00

RME followed by a TPA in conjunction with extraction of

33.9
17.0

1
5
10
5
3
5
9
4
8
13

the deciduous canines in late mixed dentition patients was

significantly more effective at inducing successful eruption
of PDCs (80 per cent) than no treatment (28 per cent), or
Alpha angle T1 (degrees)

Root development of PDC

extraction of the deciduous canine/s only (62.5 per cent).

Radiographic measures

d distance T1 (mm)

These results can be contrasted with those from a recent

randomized clinical trial that found RME to increase the
rate of successful canine eruption in early mixed dentition
Unilateral
Bilateral
Sector 1
Sector 2
Sector 3
Sector 4

PDC patients (65 per cent) when compared to an untreated

Table 3

CS 1
CS 2
CS 3
CS 4

CG (14 per cent; Baccetti et al., 2009). However, in this

previous study diagnosis of PDC had been carried out on PA
606
radiographs before the age of 9 years, and the TPA was not
used to prevent mesial migration of maxillary posterior
teeth. Also the use of a TPA in conjunction with extraction
of the deciduous canines in late mixed dentition patients, in
absence of previous use of an RME, was significantly more
effective at inducing successful eruption of PDCs (79.2 per
cent) than no treatment or extraction of the deciduous
canine/s only (62.5 per cent).
When comparing the prevalence rate for successful PDC
eruption between RME interceptive treatment in this study
with previous studies that used other interceptive treatment
modalities, both the RME/TPA and the TPA groups
presented with a slightly higher rate of effectiveness (about
80 per cent) than what has been reported for extraction of
the deciduous canine alone (78 per cent according to Ericson
and Kurol (1988) and 62 per cent according to Power and
Short (1993). It should be noted, however, that the
prevalence rate for favorable outcomes in the study by
Ericson and Kurol (1988) included both canine eruption
and improvement of canine eruption path, while in the
present clinical trial, only full eruption of the canines was
considered. Also, the prevalence rates reported in both the
studies (Ericson and Kurol, 1987; Power and Short, 1993)
refer to individual PDCs, while the prevalence rates for
success/failure in the current study refer to ‘subjects’ who
may present with unilateral or bilateral PDCs. As palatal
displacement of upper canines has been shown to have a
fundamental component of genetic origin (Peck et al., 1994;
Leonardi et al., 2004), the use of single canines as statistical
units is not recommended since general etiologic factors
may affect the eruption process of both upper canines within
the same subject.
The success rate of RME/TPA or TPA treatment as
compared to extraction of the deciduous canine in
combination with fixed appliance therapy (75per cent
according to Olive (2002) is similar, whereas the success
rate is slightly smaller than the prevalence rate for the
eruption of the canines following the use of cervical-pull
headgear and extraction of the deciduous canine (88 per
cent) as determined by Baccetti et al. (2008a). However,
when the prevalence rate for successful eruption of PDCs is
compared between treated and CGs within the present study
and the study by Baccetti et al. (2008a), the proportion of
favorable outcomes in the RME/TPA/EC or the TPA/EC
samples over the respective controls (2.8 times more)
actually is greater than the proportion found in subjects
treated with cervical pull headgear/deciduous canine
extraction over the respective controls (2.4 times more).
Possible pre-treatment predictors of a successful outcome
of interceptive treatment of PDCs by means of interceptive
orthodontic therapy were identified. Interceptive treatment
of PDCs in the late mixed dentition was less successful in
facilitating canine eruption in patients who began treatment
at CS 3 or CS 4 in cervical vertebral maturation (pubertal
patients) than in patients who began treatment at CS 1 or
T. BACCETTI ET AL.
CS 2 (pre-pubertal patients). Sixty-two per cent of patients
in the unsuccessful TG were at the pubertal stages in
skeletal maturation, and 82 per cent of patients in the
successful TG were at a pre-pubertal cervical stage.
Moreover, canines that exhibited more severe displacement
as revealed by the alpha angle or ‘sector’ measures
were less likely to erupt successfully. Similarly, a recent
retrospective study conducted by Olive (2005) found that
the more mesial the cusp of the PDC (a measurement
analogous to the sector measurement) before treatment, the
longer the duration of treatment for impacted canines.
These results are also similar to findings by Baccetti et al.
(2007), who found the two measurements on panoramic
radiographs to be a valuable prognostic indicator for
success of combined surgical and orthodontic treatment of
impacted canines
PDCs with a fully developed root demonstrated
significantly less probability of successful eruption
following interceptive treatment. TGs showed a smaller
prevalence of successful eruption of PDCs when the root
apex was closed (Nolla’s stage 9 or greater; Nolla, 1960). A
higher prevalence rate of eruption was seen for PDCs in
which the root apex was still developing (even when more
than two-thirds of the root had already formed as in Nolla’s
stage 8; Nolla, 1960). These data confirm previous
observations by Kokich and Mathews (1993), who reported
a high probability of impaction when the root apex of the
tooth is complete. When the information derived from the
canine root development is combined with the data
concerning the CVM staging of observed subjects in the
present study, it can be concluded that interceptive treatment
for PDCs at a pre-pubertal stage in skeletal maturation and
before the closure of the PDC root apex leads to significantly
more successful outcomes than postponing treatment until
puberty or at a time when the apex of the canine is formed
completely.
A general overview of the possibilities offered by various
protocols of interceptive treatment for PDCs suggests that
the extraction of the deciduous canine alone is able to
double the chance of eruption of the palatally displaced
upper permanent canine between 10 and 13 years of age
(about 60 to 65 per cent eruption) (Ericson and Kurol, 1988;
Power and Short, 1993; Baccetti et al., 2008a). The addition
of other therapeutic adjuncts in the late mixed dentition,
such as the RME/TPA approach described here or the
cervical-pull headgear investigated by Baccetti et al.
(2008a) increase the prevalence rate of successful eruption
of the canine following interceptive treatment up to
80–90%. However, a greater burden of treatment is placed
on the patient when these more complex approaches are
used in comparison to the simple extraction of the associated
deciduous tooth. In cases showing an indication for either
one of the two combination treatment protocols, such as
maxillary transverse deficiencies for the RME approach or
the need for molar distalization for the headgear approach,
RCT ON PDC TREATMENT WITH RME OR TPA
the highly significant facilitation of eruption of PDCs
should be considered as an extremely favorable side effect
of these orthodontic options in the late mixed dentition. An
alternative effective approach that can be recommended in
a large variety of clinical conditions associated with PDCs
is the use of a TPA in combination with the extraction of the
deciduous canines, as this space maintenance protocol is
compliance-free, is minimally invasive on the patient, and it
leads to a prevalence rate of successful outcomes similar to
the more complex treatment protocols that include either
RME or headgears.
Conclusions
This RCT found that RME followed by a TPA coupled with
extraction of the deciduous canine, as well as TPA and
deciduous canine extraction alone, to be n effective
interceptive treatment options for patients from 9 years 5
months to 13 years of age who present with palatally
displaced canines. The use of these protocols in late mixed
dentition subjects increases the rate of eruption of PDCs
significantly (about 80 per cent for the RME/TPA/EC and
TPA/EC groups and 65.2 per cent for the EC group) when
compared with an untreated PDC CG (28 per cent).
The following radiographic factors are indicative of
prognosis of impaction following interceptive treatment
including RME/TPA therapy: pubertal CVM stages versus
pre-pubertal, more mesial sectors of intraosseous
displacement of the canine, greater alpha angles, and closure
of the canine root apex.
When the burden of treatment and an effort/benefit
analysis of the outcomes of interceptive treatment of PDCs
are considered, treatment represented by the use of a TPA in
combination with the extraction of the deciduous canine/s
in the late mixed dentition appears to be a reasonable and
efficient procedure to avoid palatal impaction of maxillary
canines.
References
Baccetti T, Franchi L, McNamara J A Jr 2005 The cervical vertebral
maturation (CVM) method for the assessment of optimal treatment
timing in dentofacial orthopedics. Seminar in Orthodontics 11: 119–129
Baccetti T, Leonardi M, Armi P 2008a A randomized clinical study of two
interceptive approaches to palatally displaced canines. European Journal
of Orthodontics 30: 381–385
Baccetti T, Franchi L, De Lisa S, Giuntini V 2008b Eruption of the
maxillary canines in relation to skeletal maturity. American Journal of
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of palatal impaction of maxillary canines with rapid maxillary
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maxillary incisors after resolution of an etiologically associated
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1996 Maxillary canine impaction in patients with transverse maxillary
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 Original Article

Effect of RME and headgear treatment on the eruption of palatally

displaced canines
A randomized clinical study
Pamela Armia; Paola Cozzab; Tiziano Baccettic

ABSTRACT
Objective: To determine the effectiveness of orthodontic treatment finalized on the maintenance/
improvement the upper arch perimeter to assist in the successful eruption of palatally displaced
maxillary canines (PDCs).
Materials and Methods: The randomized prospective design comprised 64 subjects with PDCs
who were randomly assigned to one of three groups: cervical pull headgear (HG); rapid maxillary
expansion and cervical pull headgear (RME/HG); or untreated control group (CG). Panoramic
radiographs and lateral cephalograms were evaluated at the time of initial observation (T1) and
after an average period of 18 months (T2). At T2 the success of canine eruption was evaluated. A
superimposition study on lateral cephalograms was undertaken to evaluate the T1–T2 changes in
the sagittal position of the upper molars in the three groups.
Results: The prevalence of successful eruption was 85.7% in the RME/HG group and 82.3% in the
HG group. Both these prevalence rates were significantly greater than the success rate in
untreated control subjects (36%). The cephalometric superimposition study showed a significant
mesial movement of the upper first molars in the CG compared with the HG and RME/HG groups.
Conclusions: The use of rapid maxillary expansion and headgear (or headgear alone) in PDC
cases increases the success rate of eruption of the canine significantly (almost three times more
than in untreated controls). (Angle Orthod. 2011;81:370–374.)
KEY WORDS: Palatally displaced canines; Rapid maxillary expansion; Headgear; Interceptive
treatment

INTRODUCTION ments.’’1 The prevalence of palatally displaced canines

Palatal displacement of the maxillary canine is
defined as the ‘‘developmental dislocation of the upper
canine […] to a palatal site often resulting in tooth
impaction requiring surgical and orthodontic treat-
a
Research Assistant, Department of Orthodontics, The Uni-
versity of Florence, Florence, Italy.
b
Professor and Department Chair, Department of Orthodon-
tics, Università degli Studi di Roma ‘‘Tor Vergata,’’ Rome, Italy.
c
Associate Professor, Department of Orthodontics, The
University of Florence, Florence, Italy; Thomas M. Graber
Visiting Scholar, Department of Orthodontics and Pediatric
Dentistry, School of Dentistry, The University of Michigan, Ann
Arbor, Mich.
Corresponding author: Dr Tiziano Baccetti, Department of
Orthodontics, Università degli Studi di Firenze, Via Ponte di
Mezzo 48 Firenze, Italy 50127 Italy
(e-mail: tbaccetti@unifi.it)
Accepted: November 2010. Submitted: June 2010.
Published Online: February 7, 2011
G 2011 by The EH Angle Education and Research Foundation,
Inc.
(PDCs) fluctuates between 0.8% and 5.2%.2–6 The
most frequent consequence of PDCs is impaction of
the canine.7–9 If orthodontic treatment (early or inter-
ceptive treatment) is not started in a timely manner in
subjects with a PDC, other possible sequelae may
occur, such as resorption of the roots of the neighbor-
ing permanent teeth10–12 and cysts.4,13,14 Several
treatment procedures (or associations of them) have
been proposed for impacted canines, and they are
complex, require interdisciplinary work, and are ex-
pensive for the patient: surgical exposure of the crown
of the canine, either performed alone or followed by
orthodontic traction of the impacted tooth14–16 extrac-
tion of the canine and replacement with implants17; and
reimplantation of the displaced tooth.18,19
Despite extensive interest in both etiology and
therapy of PDC, only a few studies in the past 20 years
have focused on preventive measures for canine
palatal impaction.7,20–24 The clinical protocols proposed
include extraction of the corresponding primary canine,

Angle Orthodontist, Vol 81, No 3, 2011 370 DOI: 10.2319/062210-339.1

RME/HG TREATMENT WITH PDCS
with or without orthodontic procedures to gain space in
the upper arch (ie, distalization of the upper buccal
segments, maxillary expansion).23,24 The procedure of
reducing the prevalence of impacted PDC by extracting
the primary canine has been reported in the dental
literature since Buchner.25 The outcomes in several
individual subjects during the subsequent 50 years
corroborated the clinical recommendation for this
interceptive measure.21 Finally, the prospective study
by Ericson and Kurol20 analyzed the effects of extraction
of the primary canine on PDC in terms of rate and time
of ‘‘spontaneous’’ eruption. In 36 of 46 canines (78%),
palatal eruption changed to normal, with the eruption
time ranging from 6 to 12 months. In a longitudinal 2-
year investigation, Power and Short22 described the
achievement of a normal eruptive position of PDC in
62% of the subjects after extraction of the primary
canines. Those authors suggested combining the tooth
extraction with procedures to increase arch length, such
as distalization of the upper buccal segments.
A randomized controlled trial by Baccetti and col-
leagues,8 which incorporated untreated controls and a
statistically appropriate number of subjects, showed that
extracting the primary canine is an effective procedure to
increase the rate of normal eruption of maxillary PDC
(two times more than in untreated controls). Use of a
cervical pull headgear in addition to extracting the
primary canine significantly increased the rate of
successful eruption of the permanent canine (almost
three times more than in untreated controls). In a recent
study,9 the use of rapid maxillary expansion (RME) in the
very early developmental phases (at the age of 8 or
9 years) in subjects where PDC had been diagnosed on
posteroanterior (PA) films according to Sambataro and
colleagues26 showed a success rate of about 65%.
The aims of the present randomized clinical trial, which
included an untreated control group, were as follows:
N To evaluate the prevalence of successful eruption of
PDC during orthodontic treatment finalized to main-
tenance/improvement of the upper arch perimeter
(headgear or RME in combination with headgear) in
absence of the extraction of the deciduous canine
corresponding to the PDC;
N To assess the changes in the sagittal position of the
upper teeth posterior to the deciduous canine (upper
first molars) after the interceptive treatment approaches.
MATERIALS AND METHODS
The examined sample consisted of subjects enrolled
in a prospective study at the Department of Orthodon-
tics of the University of Florence and at the Depart-
ment of Orthodontics of the University of Roma (Tor
Vergata). The study project was approved by the
371
Ethical Committee at the University of Florence and
Rome. The following inclusion criteria had to be fulfilled
by the subjects enrolled in the study:
N White ancestry;
N Either unilateral or bilateral PDC on a panoramic
radiograph. PDC was diagnosed as intraosseous
palatal position of the maxillary permanent canines
from panoramic radiographs and periapical radio-
graphs. The displacement of the upper canine to the
palatal side was checked by means of double-
determination periapical radiographs;
N Dental age older than 8 years and younger than
13 years according to the method of Becker and
Chaushu27;
N Skeletal age showing active phases of skeletal
growth according to the cervical vertebral maturation
method (before CS 4)28;
N Presence of mild crowding at the maxillary arch and/
or molar relation showing Class II tendency.
The following exclusion criteria were established:
N Previous orthodontic treatment;
N Craniofacial syndromes, odontomas, cysts, cleft lip
and/or palate, sequelae of traumatic injuries to the
face, or multiple and/or advanced caries;
N Aplasia or severe hypoplasia of the crown of upper
lateral incisors.
A sample of 64 subjects with 81 palatally displaced
canines was enrolled for the study, and informed
consent was obtained. The following material was
collected in the PDC sample: panoramic radiographs
and lateral cephalograms at time of initial observation
(T1) and after an average period of 18 months
subsequent to T1 (T2); and dental casts at T1. For
each patient the radiographs at T1 and at T2 were
taken with the same radiograph machine. All subjects
with PDCs were assigned randomly to one of the
following three groups:
N Headgear (HG) group, where the cervical pull head-
gear was used alone for 1 year for 12–14 hours a day.
N Rapid maxillary expansion/headgear (RME/HG)
group; these subjects were treated with a banded
rapid maxillary expander (7 mm of active expansion;
at the end of expansion all patients retained the
expander for 6 month) followed by use of a cervical-
pull headgear like in the HG group.
N Control group (CG); these subjects did not receive
any treatment between T1 and T2.
Four subjects did not complete the clinical trial
because they moved from the area of clinical care or
asked to be transferred to other clinicians. The
remaining 60 subjects showed the following distribution:
Angle Orthodontist, Vol 81, No 3, 2011
372
N HG group: 17 subjects, mean age of 11.9 years at
T1, 9 males and 8 females, and 25 PDCs
N RME/HG group: 21 subjects, mean age of 11.1 years
at T1, 9 males and 12 females, and 30 PDCs
N CG, 22 subjects, mean age of 11.6 years at T1, 9
males and 13 females, and 26 PDCs
Severity of canine displacement was similar in the
three groups at T1, and it was not a discriminant factor
for case assignment. The power of the present study
was greater than 0.85.
Assessment of Successful Outcome
A successful outcome for PDC was defined as the
full eruption of the tooth, thus permitting bracket
positioning for final arch alignment when needed.
Unsuccessful outcome was defined as the lack of
eruption of the permanent canine at the completion of
the clinical observation period (T2, 18 months after the
initial observation).
Superimposition Study on Lateral Cephalograms
Change in the sagittal position of the upper first
molar with regard to maxillary stable structures was
performed according to the method of Björk and
Skieller29 by means of superimposition of the T2 film
on the T1 film for each subject. The distance between
the most mesial point on the crown of the molar at T1
and T2 was recorded by means of computerized
cephalometric software (Viewbox, version 3.0, dHAL
Software, Kifissia, Greece). A positive value would
indicate mesial movement of the molar, a negative
value distal movement of the molar.
Statistical Analysis
The prevalence rates of successful and unsuccess-
ful subjects in the HG group were compared with those
in the RME/HG group and the CG by means of x2 tests
with Bonferroni correction for multiple comparisons
(P , .016). Kruskall-Wallis test with Bonferroni correc-
tion for multiple comparisons (P , .016) was used to
evaluate the differences among the three groups with
regard to the amount of molar movement as assessed
in the cephalometric superimposition study.
All statistical computations were carried out with the
aid of a commercial statistical package (Statistical
Package for Social Sciences, release 10.0, SPSS Inc,
Chicago, Ill).
RESULTS
Effectiveness of the Two interceptive Procedures
The prevalence rates of subjects with successful
eruption of the permanent canine were 82.3% in the
Angle Orthodontist, Vol 81, No 3, 2011
ARMI, COZZA, BACCETTI
HG group (x2 5 49.1, P , .001) and 85.7% in the
RME/HG (x 2 5 55.2, P , .001), which were
significantly greater than those of the CG. No
statistically significant difference was found for the
prevalence of successful subjects between the HG and
RME/HG groups (x2 5 0.07, P 5 .786).
Change in the Sagittal Position of the Upper
First Molars
The amount of mesial movement of the upper first
molars was significantly smaller in the HG and RME/
HG groups compared with the CG (P , .01). The
average amount of sagittal displacement of the upper
first molar in the two treatment groups (HG and RME/
HG) was close to zero (0.2 mm in both groups),
whereas it was 2.32 mm in the CG. It should be noted
that none of the examined subjects presented with
exfoliation of upper second primary molars at T2.
DISCUSSION
The present investigation reached an adequate
power (. 0.85) because of the number of subjects
enrolled in the examined groups. The study included a
group of subjects with PDC who were left untreated
during the observation period. These subjects formed
the CG, which was used to test the effectiveness of
interceptive approaches to PDC.
N None of the examined subjects in either treated
groups received any additional orthodontic/surgical
therapy beyond cervical pull headgear alone or in
combination with RME throughout the observation
time; none of the subjects underwent extraction of
the deciduous canines either.
N The duration of the observation period for canine
eruption (18 months) was appropriate as established
by a previous study by Ericson and Kurol.20
N A superimposition study was performed to assess
changes in upper molar position concurrent with
alternative interceptive approaches to PDC.
The results of the current study showed that the
maintenance or improvement of the perimeter of the
upper arch as a measure to intercept palatal displace-
ment of maxillary canines is effective in preventing
canine impaction of PDCs (Figure 1A, B). The rate of
success in the RME/HG and HG groups (85.7% and
82.3%, respectively) is slightly more favorable than
previous results by Olive,24 who found that 75% of the
canines emerged after orthodontic treatment with fixed
appliances to create space in the upper arch after
extraction of the primary canine.
These findings confirmed the outcome of a prelim-
inary report on smaller groups of subjects with PDC by
Leonardi and colleagues7 and the follow-up study by
RME/HG TREATMENT WITH PDCS
Figure 1. (A) Female patient (enrolled in the headgear group), age
11 years 8 months, with palatally displaced 1.3; (B) After 11 months
of headgear treatment (at night only) the canine is fully erupted.
Baccetti and colleagues8 in terms of the greater
successful eruption of the PDCs with the use of
cervical pull headgear. These success rates are higher
than those obtained with the extraction of the primary
tooth corresponding to the PDC as reported in
previous longitudinal studies: 78% according to Eric-
son and Kurol20 (who also included PDCs showing just
an improvement in the eruption pattern), 62% accord-
ing to Power and Short,22 and 65.2% according to
Baccetti and colleagues.8 It should be noted that the
permanence of the deciduous canine on the upper
arch can be extremely useful in cases requiring
surgical/orthodontic approach to impacted PDCs when
the evolution of the PDC is unfavorable. The presence
of the deciduous canine allows for the tunnel tech-
nique, which is one of the procedures indicated for an
optimal periodontal success associated with canine
repositioning in the long term.30
Interestingly, the superimposition study showed that
a significant mesial movement of the upper first molars
(about 2.5 mm) occurred in subjects with untreated
PDCs. On the contrary, headgear wear resulted in a
significant reduction in the amount of mesial displace-
ment of the upper molar that exhibited an actual lack of
mesial movement of the molar (0.2 mm). The addition
of part-time wear of the cervical pull headgear to the
interceptive treatment of PDC apparently restrained
the distal segment of the upper dental arch from
moving mesially, thus maintaining the space available
for canine eruption. It is legitimate to speculate that the
goal of avoiding mesial movement of the upper
373
posterior might be achieved by means of less
compliance-dependent appliances than a headgear,
such as transpalatal arches or space-holding devices
in addition to a palatal Nance button.
With respect to the findings of a very recent study9
about the use of RME in the very early developmental
phases (at the age of 8 or 9 years) in subjects where
PDC had been diagnosed on PA films according to
Sambataro and colleagues26 (success rate of about
65%), the present outcomes identified a significantly
greater potential of success for the RME approach in
combination with a headgear used at a later age
(11 years). At this time, the diagnosis of PDC is more
reliable4 and its interceptive treatment appears to be
more successful.
Finally, it should be considered that the orthodontic
treatment protocols used in the present study are not
specific for the interceptive treatment of PDC. There-
fore, the improvement in the eruption rate of PDCs is a
significant bonus associated with the expected classi-
cal orthodontic outcomes of the two therapies. The use
of a headgear combined with RME in subjects with
PDCs is therefore indicated in cases presenting with
clinical indications for molar distalization or maxillary
expansion and molar distalization. In absence of these
indications, the favorable outcomes of other intercep-
tive procedures that are specific for the PDC and
easier for the patient (such as extraction of the
deciduous canine) deserve to be taken into consider-
ation.
CONCLUSIONS
N Orthodontic treatment finalized to the maintenance/
improvement of the perimeter in the upper arch in the
late mixed dentition (RME and/or cervical pull
headgear) can significantly increase the rate of
successful eruption of the permanent canine (almost
three times more than in untreated controls). These
results are achieved without extracting the deciduous
canines corresponding to the PDCs.
N In PDC subjects treated with the use of a headgear
(alone or combined with RME) the physiological
mesial movement of the upper first molars (2.5 mm)
is prevented.
REFERENCES
1. Peck S, Peck L, Kataja M. Site-specificity of tooth maxillary
agenesis in subjects with canine malpositions. Angle Orthod.
1996;66:473–476.
2. Thilander B, Jakobsson S. Local factors in impaction of
maxillary canines. Acta Odont Scand. 1968;26:145–168.
3. Brin I, Becker A, Shalhav M. Position of the permanent
canine in relation to anomalous or missing lateral incisors: a
population study. Eur J Orthod. 1986;8:12–16.
Angle Orthodontist, Vol 81, No 3, 2011
374
4. Ericson S, Kurol J. Radiographic examination of ectopically
erupting maxillary canines. Am J Orthod Dentofacial Orthop.
1987;91:483–492.
5. Baccetti T. A controlled study of associated dental anom-
alies. Angle Orthod. 1998;68:267–274.
6. Chu FC, Li TK, Lui VK, Newsome PR, Chow RL, Cheung
LK. Prevalence of impacted teeth and associated patholo-
gies—a radiographic study of the Hong Kong Chinese
population. Hong Kong Med J. 2003;9:158–163.
7. Leonardi M, Armi P, Franchi L, Baccetti T. Two interceptive
approaches to palatally displaced canines: a prospective
longitudinal study. Angle Orthod. 2004;75:581–586.
8. Baccetti T, Leonardi M, Armi P. A randomized clinical study
of two interceptive approaches to palatally displaced canines.
Eur J Orthod. 2008;30:381–385.
9. Baccetti T, Mucedero M, Leonardi M, Cozza P. Interceptive
treatment of palatal impaction of maxillary canines with rapid
maxillary expansion: a randomized clinical trial. Am J Orthod
Dentofacial Orthop. 2009;136:657–661.
10. Rimes RJ, Mitchell CNT, Willmot DR. Maxillary incisor root
resorption in relation to the ectopic canine: a review of 26
patients. Eur J Orthod. 1997;19:79–84.
11. Ericson S, Kurol J. Resorption of incisors after ectopic
eruption of maxillary canines. A CT study. Angle Orthod.
2000;70:415–423.
12. Ericson S, Bjerklin K, Falahat B. Does the canine dental
follicle cause resorption of permanent incisor roots? A
computed tomographic study of erupting maxillary canines.
Angle Orthod. 2002;72:95–104.
13. Bishara SE. Impacted maxillary canines: a review. Am J Orthod
Dentofacial Orthop. 1992;101:159–171.
14. McSherry PF. The ectopic maxillary canine: a review. Br J
Orthod. 1998;25:209–216.
15. Burden DJ, Mullally BH, Robinson SN. Palatally ectopic
canines: closed eruption versus open eruption. Am J Orthod
Dentofacial Orthop. 1999;115:640–644.
16. Usiskin LA. Management of the palatal ectopic and
unerupted maxillary canine. Br J Orthod. 1991;18:339–346.
17. Mazor Z, Peleg M, Redlich M. Immediate placement of
implants in extraction sites of maxillary impacted canines.
J Am Dent Assoc. 1999;130:1767–1770.
18. Berglund L, Kurol J, Kvint S. Orthodontic pre-treatment for
autotrasplantation of palatally impacted maxillary canines.
Angle Orthodontist, Vol 81, No 3, 2011
ARMI, COZZA, BACCETTI
Case reports on a new approach. Eur J Orthod. 1996;18:
449–456.
19. Moss JP. Autogenous transplantation of maxillary canines.
J Oral Surg. 1968;26:775–783.
20. Ericson S, Kurol J. Early treatment of palatally erupting
maxillary canines by extraction of the primary canines.
Eur J Orthod. 1988;10:283–295.
21. Jacobs SG. Reducing the incidence of unerupted palatally
displaced canines by extraction of primary canines. The
history and application of this procedure with some case
reports. Aust Dent J. 1998;43:20–27.
22. Power SM, Short MB. An investigation into the response of
palatally displaced canines to the removal of primary
canines and an assessment of factors contributing to
favourable eruption. Br J Orthod. 1993;20:215–223.
23. McConnell TL, Hoffmann DL, Forbes DP, Janzen EK,
Weintraub NH. Maxillary canine impaction in patients with
transverse maxillary deficiency. ASDC J Dent Child. 1996;
63:190–195.
24. Olive RJ. Orthodontic treatment of palatally impacted
maxillary canines. Aust Orthod J. 2002;18:64–70.
25. Buchner HJ. Root resorption caused by ectopic eruption of
maxillary cuspid. Inl J Orthod. 1936;22:1236–1237.
26. Sambataro S, Baccetti T, Franchi L, Antonini F. Early
predictive variables for upper canine impaction as derived
from posteroanterior cephalograms. Angle Orthod. 2005;75:
28–34.
27. Becker A, Chaushu S. Dental age in maxillary canine ectopia.
Am J Orthod Dentofacial Orthop. 2000;117:657–662.
28. Baccetti T, Franchi L, McNamara JA Jr. The cervical
vertebral maturation (CVM) method for the assessment of
optimal treatment timing in dentofacial orthopedics. Semin
Orthod. 2005;11:119–129.
29. Björk A, Skieller V. Normal and abnormal growth of the
mandible. A synthesis of longitudinal cephalometric implant
studies over a period of 25 years. Eur J Orthod. 1983;5:
1–46.
30. Crescini A, Nieri M, Rotundo R, Baccetti T, Cortellini P, Pini
Prato GP. Combined surgical and orthodontic approach to
reproduce the physiologic eruption pattern in impacted
canine: report of 25 patients. Int J Period Rest Dent. 2007;
27:529–537.
CASE REPORT

Complications of misdiagnosis of maxillary

canine ectopic eruption
Daniela Gamba Garib,a Guilherme Janson,b Taiana de Oliveira Baldo,c and Patr!ıcia Bittencourt Dutra dos Santosc
Bauru, S~ao Paulo, Brazil

Ectopic eruption of maxillary canines can be associated with root resorption of adjacent teeth. This case report
describes and discusses an interesting case of a 15-year-old girl with a Class III malocclusion and an impacted
maxillary canine. Because of the unfavorable position of the ectopic canine and the severe root resorption of the
maxillary left central and lateral incisors, the treatment options included extraction of the maxillary permanent
canines. The mandibular first premolars were extracted to compensate for the Class III malocclusion. A pano-
ramic radiograph taken earlier in the mixed dentition already indicated a possible eruption disturbance of the
maxillary left permanent canine. The importance of early diagnosis of maxillary canine ectopic eruption is high-
lighted in this case report. The early identification of radiographic signs of an ectopic pathway of eruption should
be followed by deciduous canine extraction to prevent canine retention and maxillary incisor root resorption. (Am
J Orthod Dentofacial Orthop 2012;142:256-63)

M
axillary permanent canines show the highest
frequency of impaction, excluding the third
molars.1,2 According to previous reports, the
prevalence of maxillary canine impaction ranges from
0.9% to 2.5%.2-5 Although this might seem to be
a relatively small prevalence, it is speculated that, in
clinical orthodontic practice, the frequency might be
higher.6
The diagnosis and assessment of the extent of max-
illary incisor resorption are fundamentally important for
the prevention of impaction and the reduction of subse-
quent complications of canine eruption.7 Panoramic
radiographs can provide worthwhile information regard-
ing the presence and general location of maxillary canine
ectopic eruption in the late mixed dentition.5 In approx-
imately 80% of patients with impacted canines, the cusp
tips overlap the lateral incisor roots during the mixed
dentition, as observed in panoramic radiographs.5,8
Ericson and Kurol9 reported that extraction of the
maxillary deciduous canines has a favorable effect on
From the Department of Orthodontics, Bauru Dental School, University of S~ao
Paulo, Bauru, S~ao Paulo, Brazil.
a
Associate professor.
b
Professor and head.
c
Postgraduate student.
The authors report no commercial, proprietary, or financial interest in the prod-
ucts or companies described in this article.
Reprint requests to: Daniela Gamba Garib, Department of Orthodontics, Bauru
Dental School, University of S~ao Paulo, Alameda Oct!avio Pinheiro Brisolla
9-75, Bauru, S~ao Paulo 17012-901, Brazil; e-mail, dgarib@uol.com.br.
Submitted, September 2010; revised and accepted, December 2010.
0889-5406/$36.00
Copyright ! 2012 by the American Association of Orthodontists.
doi:10.1016/j.ajodo.2010.12.023
256
maxillary canine ectopic eruption in most patients
(78%), if extraction treatment is performed in time, be-
tween 10 and 13 years of age.
Root resorption of the maxillary permanent incisors
related to maxillary canine ectopic eruption is probably
caused by inherent pressure from migration of the dis-
placed erupting canine combined with physical contact
between the root of the incisor and the prominence of
the canine crown.10 Associated root resorption of max-
illary permanent incisors occurs in 48% of children
with maxillary canine ectopic eruption between 9 and
15 years of age, and it is often a serious complication,
prolonging orthodontic treatment in many patients.11,12
Early diagnosis and intervention could avoid these
unfavorable effects. Therefore, the aim of this case
report of a patient with severe root resorption of the
maxillary incisors related to a palatally displaced
canine is to highlight the importance of early diagnosis
of maxillary canine ectopic eruption.
DIAGNOSIS AND ETIOLOGY
A 15-year-old girl in the permanent dentition sought
orthodontic treatment because of dental crowding in the
first author's private office. The patient was unhappy
about the appearance of her smile (Fig 1). At the first
appointment, her parents reported that she had already
had previous orthodontic treatment with maxillary
expansion and facial mask therapy at 8 years of age.
The facial analysis showed a mild Class III skeletal
relationship (Fig 2). The intraoral examination revealed
a mild Class III molar occlusion with an anterior
Garib et al 257

Fig 1. Pretreatment facial and intraoral photographs.

edge-to-edge relationship, bilateral posterior crossbite,

Fig 2. Pretreatment cephalometric tracing.
mild mandibular and severe maxillary dental crowding,
and an unerupted maxillary left canine. The maxillary
right canine was labially displaced (Fig 3). The patient’s
oral hygiene was excellent.
The panoramic radiographic examination confirmed
the impaction of the maxillary left canine, which had
complete root formation (Fig 4). Periapical radiographs
showed severe resorption of the maxillary incisor roots,
especially the central incisor, and 2 periapical radio-
graphs taken with Clark's technique confirmed the
palatal displacement of the impacted tooth (Fig 5).
The patient had been previously treated with maxil-
lary expansion and facial mask therapy in the mixed
dentition to correct the Class III malocclusion. The
panoramic radiograph of the mixed dentition showed
signs of ectopic eruption of the maxillary left permanent
canine according to the study of Lindauer et al5 (Fig 6).

American Journal of Orthodontics and Dentofacial Orthopedics August 2012 ! Vol 142 ! Issue 2
258 Garib et al

Fig 3. Pretreatment orthodontic models.

Fig 4. Pretreatment panoramic radiograph.

Fig 5. Two periapical radiographs taken with the Clark

TREATMENT OBJECTIVES
The treatment goals were to manage the impacted
canine; correct the Class III malocclusion, the anterior
edge-to-edge relationship, the posterior crossbite, and
the dental crowding; and improve her smile. The
patient's facial esthetics were acceptable and could be
maintained.
TREATMENT ALTERNATIVES
One treatment option consisted of maxillary
expansion, extraction of the 4 first premolars, surgical
exposure, and traction of the maxillary left canine.
technique confirmed the palatal displacement of the max-
illary left canine.
The second treatment option included maxillary
expansion, and extractions of the mandibular first
premolars, and the maxillary right first premolar and
left canine.
The third treatment option included maxillary
expansion, extractions of the mandibular first premolars
and the maxillary right and left canines. The first premo-
lars would replace the canines. This was the selected
alternative because of the poor prognosis for canine
traction and to obtain symmetry of the anterior section
of the maxillary arch.

August 2012 ! Vol 142 ! Issue 2 American Journal of Orthodontics and Dentofacial Orthopedics
Garib et al
Fig 6. Panoramic radiograph in the intertransitory period
of the mixed dentition. Observe the superimposition of the
unerupted maxillary left canine and the maxillary left
lateral incisor root already visible in the early mixed
dentition.
TREATMENT PROGRESS
The maxillary arch was expanded with a hyrax ex-
pander. Four months after the expansion, the expander
was removed, and the mandibular first premolars and
the maxillary canines were extracted. Preadjusted
0.022 3 0.025-in fixed appliances were used. Sectional
mechanics was used to retract the mandibular canines to
maintain the incisor sagittal position (Fig 7). A lip
bumper was installed to reinforce anchorage in the man-
dibular arch. After initial mandibular canine retraction,
the incisors were bonded, and leveling and alignment
with nickel-titanium archwires (0.012, 0.014, and
0.016 in), followed by stainless steel archwires (0.018,
0.020, and 0.019 3 0.025 in) in both arches, were
initiated.
Anterior retraction in the mandibular arch was per-
formed with rectangular stainless steel archwires
(0.019 3 0.025 in) and Class III elastics (Fig 8). The Class
III elastics also produced mesial drift of the maxillary
posterior teeth to close the additional extraction spaces
without moving the maxillary incisors, which had short
roots. Conventional orthodontic finishing procedures
were then undertaken. The total treatment time was
32 months. Retention consisted of a circumferential
retainer in the maxillary arch and a bonded canine-to-
canine retainer in the mandibular arch.
RESULTS
The orthodontic treatment produced excellent im-
provement of the dental esthetics as well as correction
of the dental problems. The facial photographs and the
cephalometric tracing show that the posttreatment
profile was satisfactory with slight changes only in lip
position (Figs 9 and 10). The patient was satisfied with
her smile and facial esthetics. The final occlusion
American Journal of Orthodontics and Dentofacial Orthopedics
259
showed Class I canine and molar relationships on both
sides (Fig 11). The changes were confirmed in the super-
imposed pretreatment and posttreatment lateral cepha-
lometric tracing (Fig 12). The final radiographs showed
that the maxillary incisor roots remained unchanged
(Figs 13 and 14). The patient's parents were advised
that the unerupted third molars would probably need
to be extracted in the future.
DISCUSSION
Maxillary canines have the longest period of develop-
ment, as well as the longest and most tortuous eruption
pathway until reaching occlusion.13 Consequently, these
teeth are more prone to have eruption disturbances
during the mixed dentition.
Two major theories have been proposed to explain
the occurrence of palatally displaced maxillary canines:
guidance and genetic.14 According to the guidance the-
ory, local conditions are responsible for the displacement
of maxillary canines.15-17 While erupting, the canine
lacks (from hypoplasia or agenesis of the lateral
incisor) the guidance that, in normal conditions, would
be provided by the root of this tooth. The genetic
theory assigns the eruption anomaly of the maxillary
permanent canine to a multifactorial complex that
controls the expression of other, possibly concurrent,
tooth anomalies.18 Peck et al18 also found multiple
evidential categories for the genetic origin of palatally
displaced maxillary canines: familial occurrence, bilat-
eral occurrence (17%-45%), sex differences (indicating
involvement of the sexual chromosomes), differences
in prevalence rates among different populations, and
increased occurrence of other concomitant dental
anomalies. Other studies have also added evidence to
support the genetic theory as the explanation for pala-
tally displaced canines.14,19
Most clinicians agree that the presence of the maxil-
lary permanent canines in the dental arch is important
for both esthetic and functional occlusion and should
be preserved whenever possible. In the case of impacted
canines, the orthodontist should make a maximum ef-
fort to bring those teeth into alignment. However, in
some situations when impaction of a maxillary perma-
nent canine is severe, extraction might be a feasible
option that satisfies the treatment goals for esthetics,
function, and stability.3
From many reports of ectopic eruption and impac-
tion of maxillary canines, it can be concluded that
complications such as root resorption of the maxillary
permanent incisors are common.11,12,20 Root
resorption of the maxillary incisors due to ectopic
eruption of the canines can be observed as early as 10
August 2012 ! Vol 142 ! Issue 2
260
Fig 7. Expansion of the maxillary arch and initial retraction of the mandibular canines.
Fig 8. Orthodontic retraction of the mandibular incisors.
and 11 years of age.12 In periapical radiographs, root
resorption can be observed in approximately 12% of
the incisors adjacent to ectopically erupting maxillary
canines.7 However, this prevalence is higher when the
analysis is performed by computed tomography, because
it is much more sensitive than periapical radiographs.
Studies have shown that root resorption of the maxillary
incisors in 48% of the patients with maxillary canine
ectopic eruption is observed in computed tomography
analysis.11,20 This investigation confirmed previous
suggestions that root resorption caused by ectopic
canines occurs more often than is generally assumed.7
Although incisor root resorption caused by ectopic
maxillary canines can be silent and devastating, an
effective protocol has been developed for early detection
and management of this condition.12 Palpation and
radiographic evaluation are combined with deciduous
canine removal in certain patients.9 A radiographic study
showed that, in children older than 10 years, the inability
to palpate the canine strongly indicates an eruption
disturbance, which can be confirmed by supplementary
radiographic investigation.4 Early diagnosis showing
the location and full extent of resorption can be a critical
factor in minimizing damage and serious long-term
sequelae.12
In our patient, a previous panoramic radiograph
taken in the mixed dentition had already indicated a pos-
sible eruption disturbance of the maxillary left
August 2012 ! Vol 142 ! Issue 2 American Journal of Orthodontics and Dentofacial Orthopedics
Garib et al
permanent canine (Fig 6). A slight superimposition of
the maxillary canine crown with the lateral incisor root
on the left side indicated that the maxillary canine would
have an ectopic pathway of eruption.5 Once the possible
ectopic pathway of eruption was diagnosed, treatment
should have included deciduous canine extraction to
prevent canine retention and maxillary incisor root re-
sorption.21 If early intervention had been performed to
prevent maxillary canine impaction, perhaps the maxil-
lary incisor roots would not have been severely resorbed.
Interestingly, the maxillary left central incisor root
was more resorbed than the maxillary left lateral incisor
adjacent to the impacted teeth. However, previous
reports have shown that the maxillary central incisors
are less commonly resorbed than are the maxillary lateral
incisors.12,22
Due to the severe malpositon of the ectopic maxillary
left canine, which was horizontally and mesially located,
and the poor prognosis for orthodontic traction with
a significant risk to accentuate the incisor root resorp-
tion, we decided to extract the impacted tooth. Accord-
ing to Kokich,23 certain impactions can be frustrating,
and the esthetic outcome can be unpredictable.
The decision to extract the maxillary right canine was
based on the goal for symmetry of the smile, mechanical
simplification, and achievement of a pleasant smile and
gingival esthetics. The maxillary right canine was labially
displaced, and the clinical crown had an increased
length. The treatment option of maxillary right first
premolar extraction could have led to an unfavorable
increase of the canine's clinical crown length, because
of the initially small amount of gingiva.24 The unesthetic
smile could have been related to the different clinical
crown lengths.24 So, the maxillary right canine was
also extracted to obtain anterior symmetry with bilateral
premolar substitutions. Extraction of both maxillary
canines provided, at the end of treatment, a symmetrical
and harmonious smile and group function in lateral
excursions. It also allowed the application of symmetri-
cal mechanics on both sides.
Garib et al
Fig 9. Posttreatment facial and intraoral photographs.
Fig 10. Posttreatment cephalometric tracing.
American Journal of Orthodontics and Dentofacial Orthopedics
261
The patient had a slight Class III facial pattern with
a retrognathic maxilla and a mild Class III malocclusion.
Her acceptable facial esthetics and the severity of the
malocclusion permitted a camouflage orthodontic
treatment plan. In the mandible, the objectives were to
extract the first premolars, align the teeth, and close
the spaces. The maxillary arch was expanded, and the
transverse relationship was corrected. The occlusal
objectives were to improve the intercuspation of the
posterior teeth and promote satisfactory overbite and
overjet. The advantage of this treatment plan was to
simplify mechanics, avoiding maxillary incisor move-
ment, which could increase the severity of root
resorption.
The final result showed a slight difference in the
gingival margin levels of the maxillary right and left
central incisors (Fig 9); this was present in the initial
malocclusion (Fig 1). An option to level the gingival
margins would be to intrude the maxillary right central
incisor followed by resin augmentation.24,25 However,
August 2012 ! Vol 142 ! Issue 2
262 Garib et al

Fig 11. Final orthodontic models.

Fig 12. Pretreatment and posttreatment lateral cephalometric tracings: A, superimposed overall (on
SN, centered at S); B, maxillary (on palatal plane, centered at ANS); and C, mandibular (on mandibular
plane, centered at Pog).

the severe root resorption contraindicated this
procedure.
The severe incisor root resorption in this patient
did not contraindicate orthodontic treatment, since
we used simplified mechanics, light forces, and
careful follow-ups with periapical radiographs during
treatment.
During orthodontic finishing, we wanted to avoid
occlusal contacts on the maxillary incisor in centric
occlusion to prevent further root resorption. In the

August 2012 ! Vol 142 ! Issue 2 American Journal of Orthodontics and Dentofacial Orthopedics
Garib et al
Fig 13. Posttreatment panoramic radiograph.
Fig 14. Posttreatment periapical radiograph.
long term, even severely resorbed teeth do not show
continuous resorption, increasing mobility, or discolor-
ation, and might not require splinting.26
Although the maxillary incisor roots had severe
resorption, especially the central incisors, there was no
contraindication for orthodontic treatment. The maxil-
lary canines and the mandibular first premolars were ex-
tracted, the spaces were closed, and favorable esthetics
and excellent long-term occlusal results were obtained.
CONCLUSIONS
This patient highlights the importance of early
diagnosis of maxillary canine ectopic eruption. The
identification of early radiographic signs of an ectopic
pathway of eruption should be followed by deciduous
canine extraction to prevent canine retention and
maxillary incisor root resorption.
REFERENCES
1. Dachi SF, Howell FV. A survey of 3,874 routine full-month
radiographs. II. A study of impacted teeth. Oral Surg Oral Med
Oral Pathol 1961;14:1165-9.
2. Thilander B, Jakobsson SO. Local factors in impaction of maxillary
canines. Acta Odontol Scand 1968;26:145-68.
3. Bishara SE. Impacted maxillary canines: a review. Am J Orthod
Dentofacial Orthop 1992;101:159-71.
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4. Ericson S, Kurol J. Radiographic assessment of maxillary canine
eruption in children with clinical signs of eruption disturbance.
Eur J Orthod 1986;8:133-40.
5. Lindauer SJ, Rubenstein LK, Hang WM, Andersen WC, Isaacson RJ.
Canine impaction identified early with panoramic radiographs.
J Am Dent Assoc 1992;123:91-2:95-7.
6. Ferguson JW. Management of the unerupted maxillary canine. Br
Dent J 1990;169:11-7.
7. Ericson S, Kurol J. Radiographic examination of ectopically
erupting maxillary canines. Am J Orthod Dentofacial Orthop
1987;91:483-92.
8. Warford JH Jr, Grandhi RK, Tira DE. Prediction of maxillary canine
impaction using sectors and angular measurement. Am J Orthod
Dentofacial Orthop 2003;124:651-5.
9. Ericson S, Kurol J. Early treatment of palatally erupting maxillary
canines by extraction of the primary canines. Eur J Orthod 1988;
10:283-95.
10. Becker A, Shteyer A, Lustman J. Surgical exposure of impacted teeth.
In: Becker A, editor. The orthodontic treatment of impacted teeth.
London, United Kingdom: Informa Healthcare; 1998. p. 26-35.
11. Ericson S, Kurol PJ. Resorption of incisors after ectopic eruption of
maxillary canines: a CT study. Angle Orthod 2000;70:415-23.
12. Ericson S, Kurol J. Incisor resorption caused by maxillary cuspids. A
radiographic study. Angle Orthod 1987;57:332-46.
13. Dewel BF. The upper cuspid: its development and impaction.
Angle Orthod 1949;19:79-90.
14. Sacerdoti R, Baccetti T. Dentoskeletal features associated with
unilateral or bilateral palatal displacement of maxillary canines.
Angle Orthod 2004;74:725-32.
15. Becker A, Sharabi S, Chaushu S. Maxillary tooth size variation in
dentitions with palatal canine displacement. Eur J Orthod 2002;
24:313-8.
16. Becker A, Smith P, Behar R. The incidence of anomalous maxillary
lateral incisors in relation to palatally-displaced cuspids. Angle
Orthod 1981;51:24-9.
17. Becker A, Zilberman Y, Tsur B. Root length of lateral incisors
adjacent to palatally-displaced maxillary cuspids. Angle Orthod
1984;54:218-25.
18. Peck S, Peck L, Kataja M. The palatally displaced canine as a dental
anomaly of genetic origin. Angle Orthod 1994;64:249-56.
19. Garib DG, Alencar BM, Lauris JRP, Baccetti T. Agenesis of maxillary
lateral incisors and associated dental anomalies. Am J Orthod
Dentofacial Orthop 2010;137:732.e1-6.
20. Ericson S, Kurol J. Incisor root resorptions due to ectopic maxillary
canines imaged by computerized tomography: a comparative
study in extracted teeth. Angle Orthod 2000;70:276-83.
21. Ericson S, Kurol J. Resorption of maxillary lateral incisors caused
by ectopic eruption of the canines. A clinical and radiographic
analysis of predisposing factors. Am J Orthod Dentofacial Orthop
1988;94:503-13.
22. Knight H. Tooth resorption associated with the eruption of
maxillary canines. Br J Orthod 1987;14:21-31.
23. Kokich VG. Surgical and orthodontic management of impacted max-
illary canines. Am J Orthod Dentofacial Orthop 2004;126:278-83.
24. Kokich VG, Nappen DL, Shapiro PA. Gingival contour and clinical
crown length: their effect on the esthetic appearance of maxillary
anterior teeth. Am J Orthod 1984;86:89-94.
25. Kokich VG. Excellence in finishing: modifications for the perio-
restorative patient. Semin Orthod 2003;9:184-203.
26. Becker A, Chaushu S. Long-term follow-up of severely resorbed
maxillary incisors after resolution of an etiologically associated
impacted canine. Am J Orthod Dentofacial Orthop 2005;127:
650-4.
August 2012 ! Vol 142 ! Issue 2
 European Journal of Orthodontics, 2015, 209–218
doi:10.1093/ejo/cju040
Advance Access publication September 22, 2014

Randomized controlled trial

Extraction of the deciduous canine as an

interceptive treatment in children with palatal
displaced canines—part I: shall we extract the
deciduous canine or not?
Julia Naoumova, Jüri Kurol and Heidrun Kjellberg
Department of Orthodontics, Institute of Odontology at the Sahlgrenska Academy, University of Gothenburg, Göteborg, Sweden

Correspondence to: Julia Naoumova, Department of Orthodontics, Institute of Odontology at the Sahlgrenska Academy,
University of Gothenburg, PO Box 450, SE-405 30 Göteborg, Sweden. E-mail: julia.naoumova@vgregion.se

Summary
Objectives: To analyse whether extraction of the deciduous canines facilitates eruption of the palatal
displaced canines (PDCs), and to analyse root resorption in adjacent teeth caused by the PDCs.
Materials and methods: Eligibility criteria for participants were as follows: children at age 10-13 years
with either maxillary unilateral or bilateral PDC, persisting deciduous canine and no previous experience
of orthodontic treatment. Sixty-seven patients (40 girls and 27 boys; age: mean ± standard deviation:
11.4 ± 1.0) with unilateral (45) or bilateral (22) PDCs were consecutively recruited and randomly allocated
using permuted block randomization method to extraction or non-extraction. No patients dropped out
after the randomization or during the study. Patients underwent a clinical examination and cone beam
computed tomography at baseline (T0), after 6 (T1) and 12 months (T2). The total observation time
was 24 months. Outcome measures were eruption, positional changes, length of time until eruption,
and root resorption of adjacent teeth. The baseline images were measured blinded while the 6- and
12-month control images were not, since it was not possible to blind the extracted canine.
Results: Significantly more spontaneous eruptions of the PDCs were seen in the extraction group
(EG) than in the control group (CG), with rates of 69 and 39 per cent, respectively, with a mean
eruption time of 15.6 ± 5.6 months in the EG and 18.8 ± 5.8 months in the CG. Significant differences
in changes between the groups, in favour of the EG, were found for all variables except for the
sagittal angle. In the EG, the changes in the distances of the canine cusp-tip were larger during
the first 6 months, while the change of apex was larger between 6 and 12 months. There were no
significant differences in resorption of adjacent teeth between the groups.
Limitations: Imputation values were used for the PDCs who had erupted atT2, since no x-rays were taken
for ethical reasons, which might have given uncertainty in the positional changes between T1 and T2.
Conclusions: Extraction of the deciduous canine is an effective treatment in patients with PDCs.
Significantly more positional changes and shorter mean eruption time were seen in the EG.
Resorptions of lateral incisors were seen in both groups, but none exceeded grade 2 (resorption
up to half of the dentine thickness to the pulp).
Registration: This trial was registered in ”FoU i Sverige” (http://www.fou.nu/is/sverige), registration
number: 40921.
Protocol: The protocol was not published before trial commencement.
Funding: The Local Research and Development Board for Gothenburg and Södra Bohuslän and
from the Health & Medical Care Committee of the Regional Executive Board, Västra Götaland Region.

© The Author 2014. Published by Oxford University Press on behalf of the European Orthodontic Society. All rights reserved.
209
For permissions, please email: journals.permissions@oup.com
210
Introduction
Prevention of palatally displaced canines (PDCs) from becoming
impacted is of significant importance because an impaction length-
ens the orthodontic treatment, complicates orthodontic mechan-
ics (1, 2), increases the treatment costs (3), and increases the risk of
root resorption of adjacent teeth with a potential result of tooth loss
(4–6). Early interceptive treatment is therefore desirable. The preva-
lence of PDC varies between 0.9 and 2.8 per cent and depends on
the patient’s ethnic origin, gender, and the diagnostic methods used.
Canine impaction occurs twice as frequently in females than in males
and 85 per cent of the impacted canines are located palatally (7–9).
The aetiology of PDC is still unknown, but two theories are widely
mentioned in the literature, i.e. the guidance theory (10, 11) and the
genetic theory 12–15.
One of the most common methods used to diagnose PDC is
comprised of two periapical radiographs taken from different views,
known as Clark’s rule (16–18). Cone beam computed tomography
(CBCT) has recently been presented for imaging the craniofacial
field, and several studies have reported the advantage of CBCT over
conventional radiographs for localizing canines and identifying root
resorptions on adjacent teeth (19–21).
Interceptive extraction of the deciduous canine was recom-
mended in 1936 to facilitate the eruption of the impacted maxillary
canines and prevent the risk of resorption (22). This treatment was
later evaluated in a prospective uncontrolled study by Ericson and
Kurol (23), who concluded that extraction in patients with PDCs is
an effective intervention and the success rate depends on the mesio-
distal location of the crown and the patient’s age at the diagnosis.
The authors presented a treatment protocol that is widely used by
many dentists all over the world.
However, in two newly published systematic reviews assessing
whether interceptive treatment in the mixed dentition prevents impac-
tion of PDC, it was concluded that the scientific evidence still is too
weak to fully evaluate the effect that interceptive treatment might have
on PDC (24, 25). Several randomized controlled trial (RCT) studies have
been published after the two systematic reviews, comparing extraction
of the deciduous canine to other treatment methods such as expansion
(26), space maintainer (27), or double extraction, i.e. extraction of the
deciduous canine concomitant to extraction of the first deciduous molar
(28). All three treatment methods resulted in more successful canine
eruption than extraction of the deciduous canine alone. A new pro-
spective study comparing extraction of the deciduous canines with no
extraction on patients with bilateral PDC was very recently published
and concluded that extraction is an effective measure (29). According
to the studies mentioned previously, the results show that extraction of
the deciduous canine is effective in patients with PDC, but no previous
study has assessed the three-dimensional (3D) ‘depth’ of the impaction
and the outcome using the CBCT technique.
Therefore, the aims of this study were to
1. Evaluate the effect of interceptive extraction of the deciduous
canine in children with PDC compared with a control group
(CG) using an RCT methodology with a CBCT technique.
2. Assess the radiographic changes in eruption between the extrac-
tion group (EG) and the CG in time, i.e. between 0 to 6 and 6 to
12 months after extraction.
3. Analyse root resorption on adjacent teeth caused by the PDCs.
It was hypothesized that there are no significant differences between
the EG and the CG regarding 1) the success rate of spontaneous
eruption of the PDC, 2) change in eruption pattern, or 3) for the
number of root resorptions of adjacent teeth, after interceptive
extraction of the deciduous canine.
European Journal of Orthodontics, 2015, Vol. 37, No. 2
Materials and methods
Trial design
This randomized controlled clinical trial with an equal patient allo-
cation to the two groups:
r
Extraction group (EG)
r
Control group (CG)
which took place at the clinic of orthodontics, University Clinics of
Odontology, Gothenburg, Sweden.
Patients with unilateral PDC were randomized either to have
extraction of the deciduous canine or non-extraction and patients
with bilateral PDC were randomized to have either the right or the
left deciduous canine extracted (Figure 1).
Registration
This trial was registered in ”FoU i Sverige” (http://www.fou.nu/is/sverige),
registration number: 40921.
Ethical issue
The research ethics committee of the Sahlgrenska Academy,
Gothenburg, Sweden, approved the protocol of the study (Dnr 578-
08). Children and parents received verbal and written information,
and informed consent was provided by the child and their parent or
by an adult with parental responsibilities and rights in accordance
with the Declaration of Helsinki.
Screening of PDC
The general practitioner identified participants for the trial, who were
consecutively recruited from 15 public dental clinics in Gothenburg,
Västra Götaland County Council, Sweden, between September 2008 and
January 2011. During their visit to the public dental clinic, the consulting
orthodontist then invited the potential patients to participate in the study.
Subjects, eligibility criteria and setting
Study setting and eligibility criteria
Patients interested in participating received an appointment letter in
which a website (http://www.odontologi.gu.se/horntand.html) was
enclosed that contained information about the study. Another web-
site (http://www.odontologi.gu.se/horntand_tdl) was established for
the general practitioners and for the orthodontists, where they could
access information about the study.
The inclusion criteria were as follows:
r
Caucasians at age 10–13 years with either maxillary unilateral
or bilateral PDC
r
Persisting deciduous canine
r
No previous experience of orthodontic treatment
The canine was considered palatally displaced when clinical palpa-
tion of a labial canine bulge was absent and when the canine crown
was diagnosed on intraoral radiographs as palatally positioned,
using Clark’s rule (30).
Criteria for exclusion were as follows:
r
Crowding in the maxilla exceeding 2 mm
r
Ongoing orthodontic treatment
r
Resorption of the adjacent teeth, grades 3 and 4 according to
Ericson and Kurol (31), either at the start or during the trial
caused by the displaced canine.
r
Craniofacial syndromes
r
Odontomas, cysts
r
Cleft lip and/or palate
J. Naoumova et al. 211

Assessed for eligibility

N = 70

Declined to enter the

study N= 3. Age (mean
± SD: 11.5±0.7)

Randomized patients N = 67
40 girls (mean age ± SD:
11.3± 1.1), 27 boys (mean
age ± SD: 11.4± 0.9)

Unilateral PDC bilateral PDCs

Allocated to non-extraction Allocated to extraction of Allocated to extraction of Allocated to extraction of the

N = 22; 7 boys, 15 girls the deciduous canine the right deciduous canine left deciduous canine
Age (mean ± SD: 11.3±1.1) N = 23; 9 boys, 14 girls N = 22; 11 boys, 11 girls N = 22; 11 boys, 11 girls
Age (mean ± SD: 11.2±1.1) Age (mean ± SD: 11.6 ± 1.0) Age (mean ± SD: 11.6 ± 1.0

Baseline, T0 Non-extraction of the Extraction of the deciduous

Clinical examination, CBCT deciduous canine i.e. control canine i.e. extraction group
N = 67 group (CG) (EG)
(40 girls, 27 boys) N = 44 PDCs N = 45 PDCs

6 month control, T1 Non-extraction of the Extraction of the deciduous

Clinical examination, CBTC deciduous canine i.e. control canine i.e. extraction group
N = 67 group (CG) (EG)
(40 girls, 27 boys) N = 44 PDCs N = 45 PDCs

12 month control, T2
Clinical examination, CBCT Analysed
N = 67 N = 52 N = 89 PDCs
(40 girls, 27 boys)

Individual treatment plan

N =71 PDCs

Impairment or no Improved position

change of the canine of the canine
position
Clinical
Surgical exposure examination. X-
and orthodontic ray if needed, total
treatment observation period
N = 41 PDCs 24 months
N = 30 PDCs

N: number of patients, PDCs: palatally displaced canines; SD: standard deviation; CBCT: cone beam computer tomography

Figure 1. Flowchart describing the protocol and the patients included in the study. No patients dropped out after the randomization or during the study.

The Ericson and Kurol (31) classification of root resorption is to the pulp or more, the pulp lining being unbroken; and 4) severe
1) no resorption, intact root surfaces, and the cementum layer may resorption, the pulp is exposed by the resorption. Resorption
be lost; 2) slight resorption, resorption up to half of the dentine grades 3 and 4 were excluded from the trial, while 1 and 2 were
thickness to the pulp; 3) moderate resorption, resorption midway included.
212
A total of 70 patients were invited to take part in the study. Three
patients, all girls with bilateral PDCs, declined to participate at the
first visit when information was given about the study, i.e. before they
were randomized. Two out of the three patients declined due to fear
of extraction and one patient thought it was too far to travel to the
clinic of orthodontics, University Clinics of Odontology, Gothenburg,
Sweden. No patients dropped out after the randomization or during
the study. Thus, in total 67 patients were randomly allocated to the
extraction or the CG. Of these, 45 patients had unilateral PDC and
22 patients had bilateral PDCs (Figure 1).
Randomization method
For randomization, the permuted block randomization method was
used and the allocations were concealed in sequentially numbered,
sealed opaque envelopes opened by a dental nurse after the written
consent was obtained.
Treatment protocol and process
All patients who decided to participate in the study, regardless of the
group to which they were randomized, underwent a radiographic
examination consisting of CBCT images at the Department of Oral
and Maxillofacial Radiology, Institute of Odontology, Sahlgrenska
Academy, Gothenburg, Sweden. The radiographic examination is
explained in detailed in a previously published study (32). Extraction
of the deciduous canines was carried out by one orthodontist (JN)
on the same day as the baseline radiographic examination (T0) in
order to get a precise timing of the start of the intervention.
After 6 months (T1), patients in the EG and the CG were clini-
cally examined by the same orthodontist who carried out the baseline
examinations. If the permanent canine was not clinically visible, the
Figure 2. Radiographic measurements of the cone beam computed tomography images assessed in coronal, sagittal, and axial plane.
European Journal of Orthodontics, 2015, Vol. 37, No. 2
patient underwent a new radiographic examination (CBCT images)
the same day. This procedure was repeated at the 12 month control
(T2). Figure 1 describes the protocol and the patients included in the
study. All patients were given a diary to document the date of the
eruption in those cases the canine started to erupt before the next
check-up. In patients with clinically visible canines, i.e. that emerged
through the gingiva, no further CBCTs were taken.
An individual treatment plan was drawn up for patients with
unerupted PDCs after 12 months. The unerupted canines, in cases
that the canine had improved its position on the radiographic exami-
nation, were followed until they emerged through the gingiva with
continuing check-ups in the EG. In the CG, the deciduous canine was
extracted if mobility of the tooth was not present. When the canine
showed impairment or no change in its position at the 12 month con-
trol, a combined surgical exposure and orthodontic treatment was
performed, regardless of the group to which the patient belonged.
Blinding
One oral radiologist unaware of the group to which the patients
belonged carried out all the measurements on the CBCT images in
axial, sagittal, and frontal views. The baseline images were, there-
fore, measured blinded, while the 6 and 12 month control images
were not because it was not possible to blind the extracted canine.
The following outcome measures were assessed:
Primary outcome
r
Eruption of the permanent canine, i.e. successful outcome
(defined as canine emerged through the gingiva) during the total
observation time, i.e. 24 months.
J. Naoumova et al. 213

Secondary outcome
r
Positional changes of the permanent canine over time (T1–T0
and T2–T1) measured from the radiographs: mesioangular angle,
sagittal angle, vertical position, canine cusp tip-dental arch plane,
canine root apex-dental arch plane, canine cusp tip-midline
(Figure 2) and changes between T1–T0 and T2–T1 within and
between the EG and the CG.
r
Root resorption of adjacent teeth.
Positive values for the variables: canine cusp tip-dental arch plane
and canine root apex-dental arch plane indicate a palatal position of
the cusp-tip or apex and a negative value buccal position in relation
to the dental arch plane.
The methodology of the radiographic measurements has been
described in detail in a previously published study, in which the intra-
and inter-examiner error of the 3D measurement and the validity of the
measured angles were also evaluated (32). All randomized patients were
included in the groups to which they were randomly assigned regardless
of the treatment they actually received and regardless of a deviation
from the protocol as randomized. Thus, in the analysis, the intention-to-
treat (ITT) approach was applied.
Imputation of measurement values
Missing data can introduce bias and affect the results because most
statistical packages ‘automatically’ discard cases with missing values.
This can be avoided by applying imputation, a statistical process of
replacing missing data with probability values based on other avail-
able information. In this case, angular and linear measurements of
fully erupted maxillary canines were imputed.
As described previously, in patients in whom the permanent
canine had started to erupt and was clinically visible, no further radi-
ographic examinations were done. Instead, imputation values were
used (applicable only at T2, 12 months), which were calculated by
measuring the mean angular and linear measurements of 10 unilat-
eral patients (8 girls, age: mean ± standard deviation [SD]: 11.2 ± 0.9;
2 boys, 11.7 and 10.6 years of age at baseline), whose contralateral
non-PDC was fully or partial erupted.
Sample size calculation
The sample size was based on the alpha significance level of 0.05 and
a beta of 0.10 to achieve a 90 per cent power to detect a difference of
5 degrees (SD 6.38) of the angle measured in the frontal and sagittal
views, between the extraction and the CG. The calculation indicated
that in total 60 patients with unilateral PDC were needed, i.e. 30
patients in each group. Inclusion of bilateral PDC reduced the num-
ber of patients needed. To compensate for possible dropouts during
the study, in total 70 patients were identified, 67 were enrolled.
non-EG, gender, extraction site, and extraction versus non-extrac-
tion. To test whether the bilateral group would be considered inde-
pendent observations or dependent paired observations, the main
outcome, i.e. eruption or non-eruption, was tested with Fisher’s
exact test and McNemar’s test. As no multiple comparisons have
been tested, adjustment or correction with statistical analysis was
not needed.
Harms
No harms were detected during the study.
Results
The extracted deciduous canines showed no root resorption or less
than one-third of the root length resorbed, and none were mobile.
Participant flow
Fifteen out of the 67 patients (3 bilateral PDC and 12 unilateral PDC
[3 from the CG and 9 from the EG]) did not have a radiographic
examination at the 12 month control because the canines had
emerged through the gingiva and were under eruption, i.e. clinically
visible between T1 and T2. Imputation values were used in these cases
(Figure 1).
Baseline findings
There were no significant differences at T0, either for the mean age
between the unilateral and bilateral groups (Table 1) or between the
angular and linear measurements in the EG and the CG (Table 2).
Dividing the subject into age groups of 10–11- and 12–13-year-old
individuals showed that there were a larger number of patients in
the younger group. There were more females than males in total, but
no significant differences were seen in gender distribution between
the unilateral and bilateral groups or the extraction and non-EGs. In
addition, no differences were seen between the left and right extrac-
tion sites (Table 1).
It was decided to analyse the whole material and not only the
unilateral group as two independent observations because there was
no difference in the correlation between extraction and successful
outcome between independent observations and dependent paired
observations in the bilateral group. Further, there were no significant
differences in the patients’ characteristics when the bilateral and uni-
lateral PDC patients were put together in the EG and CG.
Table 1. Patient characteristics in the unilateral and bilateral
groups at baseline. PDC, palatal displaced canines; SD, standard
deviation
Unilateral PDC Bilateral PDC Total

Patients (n) 45 22 67
Statistics Age (mean ± SD) 11.2 ± 0.9 11.6 ± 1.0 11.4 ± 1.0
The data were statistically analysed using SAS, version 9.3 for Age (y), n (%)
10–11 30 (67) 13 (59) 43 (64)
Windows (SAS Institute Inc., Cary, North Carolina, USA). Arithmetic
12–13 15 (33) 9 (41) 24 (36)
means and standard deviations were measured for numerical vari-
Female, n (%) 29 (64) 11 (50) 40 (60)
ables. Dependent and independent t-tests were used to compare Male, n (%) 16 (36) 11 (50) 27 (40)
the baseline variables and changes in time between and within the Extraction, n (%) 23 (51) 22 (49) 45 (51)
groups, respectively. The independent t-test was used to test whether Right side, n (%) 7 (30) 13 (59) 20 (45)
there were any significant differences in the linear and angular vari- Left side, n (%) 16 (70) 9 (41) 25 (55)
ables between successful versus non-successful outcome. Fisher’s Non-extraction, n (%) 22 (50) 22 (50) 44 (49)
exact test was used to calculate differences in categorical data, such
as the success in the eruption rate between the extraction versus the n indicates number of patients and % indicates percentage of patients.
214 European Journal of Orthodontics, 2015, Vol. 37, No. 2

Table 2. Baseline variables (T0) for the unilateral and bilateral groups with mean, standard deviations (SD), and P-values. CG, control
group; EG, extraction group; PDC, palatally displaced canines; SD, standard deviation.

Unilateral PDC (patients, n = 45) Bilateral PDC (patients, n = 22)

EG (n = 23 CG (n = 22 EG (n = 22 CG (n = 22
PDC) PDC) PDC) PDC)

Mean ± SD Mean ± SD Mean ± SD Mean ± SD

P-value*
Variable at T0 11.2 ± 0.9 11.4 ± 1.1 P-value* 11.6 ± 1.0 11.6 ± 1.0 P-value* EG-CG

Mesioangular angle (°) 105.2 ± 5.4 107.7 ± 9.6 0.182 106.1 ± 7.1 108.0 ± 7.1 0.371 NS
Sagittal angle (°) 98.0 ± 8.1 101.1 ± 9.5 0.232 100.1 ± 8.6 99.6 ± 8.7 0.337 NS
Vertical position (mm) 15.9 ± 2.2 14.9 ± 2.4 0.178 14.6 ± 2.7 15.0 ± 2.3 0.597 NS
Canine cusp tip-dental arch plane (mm) 1.9 ± 1.2 2.5 ± 2.0 0.300 3.0 ± 1.0 3.2 ± 2.2 0.626 NS
Canine root apex-dental arch plane (mm) 2.2 ± 1.6 2.7 ± 1.7 0.224 2.8 ± 1.7 2.6 ± 1.8 0.654 NS
Canine cusp tip-midline (mm) 9.7 ± 2.2 9.2 ± 2.7 0.322 9.7 ± 2.6 9.3 ± 1.8 0.597 NS

NS, Not significant.

*P-value < 0.05 is considered statistically significant.

Primary outcome
Significantly more PDCs erupted on the extraction site compared
with the untreated control site, with a prevalence rate of 69 and 39
per cent, respectively, (P = 0.001). The mean eruption time in the EG
was 15.6 months (SD 5.6) and in the CG was 18.3 months (SD 5.8),
with no significant difference for the mean eruption time between
the younger (age 10–11 years) and the older patients (12–13 years)
(P = 0.238). At T2, 14 PDCs in the EG and 27 PDCs in the CG
had impairment or no changes of the canine position. These teeth
were surgically exposed and orthodontically treated. All remaining
PDCs that were followed up after T2 erupted in both groups, with
the latest at the 24 month control (Table 3). Of 10 PDCs in the CG
that were followed up, five deciduous canines without mobility were
extracted, while the mobile ones were left to spontaneously exfoliate.
Online supplementary figures 1 and 2 exemplify successful and
impaired changes in position of the PDCs with two patients.
Secondary outcome
Positional changes of the canine over time observed by
radiographic means
Between T0 and T1, five of six variables in the EG and three of six in
the CG improved significantly. Between T1 and T2, five variables out
of six in the EG and two in the CG improved significantly. Significant
differences in changes between the groups, in favour of the EG, were
found for three of six variables between T0 and T1 and for all vari-
ables except for the sagittal angle between T1 and T2 (Table 4).
Table 3. Number of palatally displaced canines (PDCs) in the ex-
traction (EG) and the control group (CG) that had erupted, were
impaired or had not changed at the 6 month control (T1), 12 month
control (T2), or after T2 (>T2)
EG (N = 45 PDCs) CG (N = 44 PDCs)
T1 T2 >T2 T1 T2
Erupted PDCs 0 11 20 0 7
Impaired PDCs or — 14 — — 27
no changes
*Note that five deciduous canines in the control group that were not mobile
(n = 5) were extracted at T2.
The variables with significant changes between T0–T1 and T1–
T2 in the EG and the CG, respectively, are presented in Figure 3.
In the EG, significant larger changes between T0–T1 than T1–T2
were observed for the distance: canine cusp tip-dental arch plane
(P = 0.0026) and canine cusp tip-midline (P = 0.0276), while
the variable: canine root apex-dental arch plane (P = 0.0085)
changed more between T1–T2 than between T0–T1 (Figure 3).
When changes over time were compared between the groups,
the variables for the distances: canine cusp tip-dental arch plane
(P = 0.0013) and canine root apex-dental arch plane (P = 0.050)
deviated more between the EG and CG between T1–T2 than
between T0–T1.
Root resorption of permanent adjacent teeth
None of the patients were excluded in this trial due to resorption
grades 3 and 4 of the adjacent teeth caused by the PDC either at
the start of or during the study. Thirteen patients (14 PDC) showed
root resorption grade 2 on adjacent teeth at the start of the trial,
16 patients (17 PDC) at the 6 month control and 20 patients (21
PDC) at the 12 month control (Table 5). Although more teeth where
resorbed in the CG than the EG, significant differences were not
found for either T1 (P = 0.4218) or T2 (P = 0.2123). The adjacent
teeth that had root resorption caused by the PDC were all lateral
incisors.
Discussion
The effectiveness of extracting the deciduous canine as an intercep-
tive approach to achieve spontaneous eruption of PDC compared
with non-extraction was investigated in this prospective, rand-
omized, clinical longitudinal trial. The findings in the study show
that extraction of the deciduous canine allows the PDCs to sponta-
neously correct in the majority of the cases. Significantly more radio-
graphical changes over time were noted in the EG. We can thereby
reject the first 2 null hypotheses. Although more adjacent teeth were
>T2
resorbed at T1 and T2 in the CG than the EG, significant differences
10* were not found, i.e. we accept our final null hypothesis.
— As patients with both bilateral and unilateral PDC were
included in the study, the tooth rather than the patient was used
as the unit of analysis. The observations in the bilateral group
could preferably have been assessed as dependent paired observa-
tions but, as the same significant results were achieved when the
Table 4. Positional changes over time of the permanent canine: T1–T0 (6 months–baseline) and T2–T1 (12 months–6 months) with mean, standard deviation (SD), mean differences, and 95%
confidence interval (CI), between the extraction (EG) and non-extraction (CG) site

T1–T0 (patients, n = 67) T2–T1 (patients, n = 67)

EG (n = 45 PDCs) CG (n = 44 PDCs) Differences EG-CG EG (n = 45 PDCs) CG (n = 44 PDCs) Differences EG-CG

J. Naoumova et al.

Variable Mean ± SD P-value* Mean ± SD P-value* Mean (95% CI) P-value* Mean ± SD P-value* Mean ± SD P-value* Mean (95% CI) P-value*

Mesioangular angle (°) −3.4 ± 5.8 0.000 −0.8 ± 5.8 0.369 −2.6 (−5.1, 0.030 −3.3 ± 6.4 0.000 −0.5 ± 5.9 0.563 −2.8 (−5.4, −0.2) 0.034
−0.10)
Sagittal angle (°) 1.9 ± 5.9 0.030 1.2 ± 7.3 0.300 0.7 (−2.1, 3.6) 0.604 2.5 ± 5.3 0.000 1.7 ± 8.6 0.201 1.7(−1.2, 4.7) 0.249
Vertical position (mm) 2.7 ± 1.5 0.000 1.7 ± 1.6 0.000 0.9 (0.3, 1.6) 0.003 3.2 ± 1.8 0.000 1.9 ± 1.9 0.000 1.2 (0.5, 2.0) 0.002
Canine cusp tip-dental arch plane (mm) −1.9 ± 1.5 0.000 −0.9 ± 1.7 0.002 −0.3 (−1.2, 0.6) 0.492 −0.5 ± 2.4 0.195 −0.1 ± 1.9 0.609 −1.1 (−1.8, −0.4) 0.001
Canine cusp apex-dental arch plane (mm) 0.2 ± 1.9 0.419 −0.1 ± 1.3 0.838 0.2 (−0.4, 0.8) 0.463 −0.6 ± 1.1 0.000 −0.0 ± 1.4 0.939 0.8 (0.2, 1.4) 0.012
Canine cusp tip-midline 2.3 ± 1.5 0.000 0.6 ± 1.9 0.037 1.7 (0.9, 2.5) 0.000 1.6 ± 1.6 0.000 0.7 ± 1.3 0.000 −0.62 (−1.1, −0.1) 0.017

Significant differences between and within the groups are given in P-values.
*P-value < 0.05 is considered statistically significant.

one group.

than male patients (23, 29, 33, 34).

indicate differences between T1–T0 and T1–T2.
(CG), respectively, with mean and P-values (**0.001 and *0.05). P-values
between T1–T0 and T1–T2 for the extraction group (EG) and control group
Figure 3. Comparison of positional changes of the permanent canine

the overall stage of dental development of the child and not only the
capture PDCs at an early age. However, it is important to consider
12–13-year-old (36 per cent) patients (Table 1). A possible explana-
observations, the bilateral and unilateral PDCs were merged into
main outcome for the bilateral group was assessed as independent
215

studies on canine displacement, there was a larger number of female

in Sweden, all children at the age of 10 are strictly monitored to
in the age groups, with more 10–11-year-old (64 per cent) than
There was an uneven distribution of the number of patients

and chronological age (33). In accordance with other interceptive

chronological age because there is a poor correlation between dental
tion for the greater number of younger patients in this study is that,
216
Table 5. Root resorption of adjacent permanent teeth during T0–T2 expressed in amount of teeth (N) and % of teeth. CG, control group;
EG, extraction group
EG (N = 45 PDCs)
Grade 1
(no resorption) Grade 2 Grade 3 Grade 4
N % N % N % N %
T0 38 84.5 7 15.5 0 0
T1 38 84.5 7 15.5 0 0
T2 37 82.2 8 17.8 0 0
In a Cochrane systematic review that assessed the effect of
extracting the deciduous canine on the eruption of PDC, several
observations for what should be included in future studies were
discussed (25). The most important factors were concealed random
allocation, blind assessment, sample size, and correct statistical
analysis. We tried to fulfil these criteria in this study, but it was not
possible to blind the patients to the allocated intervention except
at baseline, where the radiographic measurements were blinded. It
was not possible to block out the deciduous canine space on the
radiographs on the 3D radiographs, as can easily be done on pano-
ramic x-ray. An alternative would have been an assessor who had no
knowledge of the study. This was not possible in this study, however,
as a new 3D measurement method to evaluate the canine position
had to be developed together with the oral radiologist (32).
In comparison with previously published studies where pano-
ramic x-ray were used for diagnosis of PDC and assessment of the
outcome, this trial is to our knowledge the first one to assess the
effect of extracting the deciduous canine in patients with PDC using
3D images. A more accurate diagnosis of the canine position and 3D
assessment of the canine movements are possible with 3D images. In
addition, small resorptions of the adjacent teeth caused by the PDC
can be detected.
Several RCT studies discuss the topic of interceptive treatment
of PDCs, both with and without a combination of different appli-
ances such as cervical headgear (HG) (34), rapid maxillary expan-
sion (RME) (35), RME followed by HG (36), extraction of both
the deciduous canine and the first deciduous molar (28), RME fol-
lowed by transpalatal arch (TPA) (27), extraction of the deciduous
canine followed by TPA (26), or extraction of the deciduous canine
on one side in patients with bilateral PDCs (29). These studies all
point toward the benefit of the interceptive treatment. However,
some weaknesses are noted, for example questionable power analy-
sis (26–28), questionable randomization, and the unequal descrip-
tive statistics at baseline between the different groups (26) and
missing allocation concealment concerning unilateral and bilateral
PDCs (26, 27), and uncertain diagnosing of PDC from only pano-
ramic radiography (28). The results of this study showed that sig-
nificantly (P = 0.001) more canines erupted on the extraction site
(69 per cent) compared with the control site (39 per cent). These
findings are comparable and confirm the results of previous studies
that presented successful results between 62 and 67 per cent on the
extraction site and 28 and 42 per cent on the non-extraction site
(26, 29, 33, 34). Some studies present higher success rates of around
80 per cent (23, 28) or a lower success rate of 42 per cent (37). The
high success rate in the prospective uncontrolled study of Ericson
and Kurol (23) can be explained by that the authors having counted
both canine eruption and improvement of the canine eruption path
as a successful outcome. In the study by Bonetti et al. (28), patients
European Journal of Orthodontics, 2015, Vol. 37, No. 2
CG (N = 44 PDCs)
Grade 1
(no resorption) Grade 2 Grade 3 Grade 4
N % N % N % N %
37 84.0 7 16.0 0 0
34 77.3 10 22.7 0 0
31 70.5 13 29.5 0 0
with centrally placed canines together with PDC were included
and the CG was not randomized, which could have influenced the
results. The lower success rate found in the study of Smailienë et al.
(37) might be explained by the older age of the patients that were
included, as a higher age increases the probability of impactions.
Some previous studies (27, 28, 38) defined successful outcome as
fully erupted canines, thus permitting bracket positioning for final
arch alignment when needed or as defined by Bazargani et al. (29)
‘in an esthetical acceptable location in the dental arch’. This varia-
tion in definitions of successful outcome could be another reason for
the different success rates reported. In this clinical trial, canines that
emerged through the gingiva were considered successful. In addition,
in this study, only an ITT approach was used when the outcome was
assessed, which may be another explanation for the differences in
the success rate.
Significantly more changes for both angular and distance vari-
ables were found between both T0–T1 and T1–T2 in the EG, which
was not surprising because the successful outcome was higher in the
EG than in the CG.
In the EG, the movement of the cusp-tip in relation to the den-
tal arch and in relation to the midline was larger during the first
6 months after extraction, while the movement of the apex was
larger between 6 and 12 months (Figure 3). These results support
Ericson and Kurol (23) finding that improvement of the position of
the PDCs can already be seen after 6 months.
The prognosis for successful orthodontic end results when adults
are treated for PDCs is poorer than in younger patients and the
prognosis worsens with age (1). Furthermore, the duration of ortho-
dontic treatment to address impacted canines correlated with age
in that the treatment duration increases with increased age (1, 39).
Permanent canines that have been impacted for many years undergo
pathological changes that prevent their eruption even when all other
factors are favourable (40). The risk for developing ankylosis either
a priori or during treatment is higher the older the patient is (40).
We, therefore, considered it unethical to follow-up patients longer
than 1 year without making any individual treatment plan, especially
as data from this study shows a tendency toward more resorbed
adjacent teeth in the CG at T2 than at T0 and as more canines had
erupted in the EG during the first 12 months. This was also the rea-
son for extracting the remaining deciduous canines in the CG that
were not mobile at T2.
The frequency of root resorption caused by PDCs has been
reported in the literature to be around 50 per cent of which the
majority are lateral incisors (41–44). In this study, however, 23.5
per cent showed resorptions, and only on lateral incisors. The low
figures may be explained by that this study comprise of prospec-
tive randomized design with the exclusion criteria: root resorption
of grades 3 and 4, while the above-mentioned studies either had a
J. Naoumova et al.
retrospective material or included only patients that were selected for
a CT imaging. Furthermore, the patients in this study were younger.
Ericson and Kurol (41) found that the peak frequency of root resorp-
tion is between 11 and 12 years of age. However, as the authors also
mention in their article, the selection and complexity of the material
including more severe cases might have affected the results.
The mean eruption time in the EG was shorter than in the CG
(15.6 versus 18.3 months). In total, 30 PDCs erupted after 12 months:
therefore, canines with an improved position after 1 year follow-up
should, therefore, be clinically and, if necessary, radiographically fol-
lowed up as spontaneous eruption after 12 months is still possible.
Ten of 30 PDCs that erupted after 12 months were in the CG, while
five deciduous canines were extracted at T2, as these canines were
not mobile. If these five extracted deciduous canines are excluded,
the mean eruption time in the CG increased to 19.3 ± 4.7 months.
According to this study, early diagnosis of PDCs and extrac-
tion of the deciduous canine as an interceptive approach is recom-
mended. The protocol with systematic use of CBCT in this trial was
designed so as to make it possible to draw out the results. However,
for everyday diagnostics and follow-up of uneventful cases of lost
canines, we suggest the use of 2D imaging. Furthermore, as some
permanent canines erupt without extracting the deciduous canine
first and some permanent canines do not erupt in spite of extraction
(See online supplementary figure 2), the question arises as to whether
it is possible to distinguish these cases. Thus, unnecessary intercep-
tive extractions may be avoided or perhaps a decision in favour of
surgical exposure of the impacted canine immediately without pre-
ceding interceptive extraction of the deciduous canine can be made.
Because extraction of the deciduous canine or surgical exposure
might be the child’s first experience of invasive dental treatment, it
is important that the child does not develop dental fear as a conse-
quence of the intervention. Although Naoumova et al. (45) showed
that the experience of pain and discomfort during and after extraction
of the deciduous canine in patients with PDC was low, 42 per cent
of the children in their study nevertheless used analgesics, indicating
post-extraction pain. Therefore, some surgical interventions may be
avoided by predicting and calculating cut-off points for a successful
outcome. A more detailed determination of predictors and cut-off
points for successful outcome will be analysed in part II of this study.
Limitations
As no CBCT’s were taken, for ethical reasons, of the PDCs that
were erupted at T2, imputation values were used as an alternative
of excluding these cases. Using the imputation values instead of con-
sidering these patients as dropouts is, in our opinion, an advantage,
as those teeth that had erupted spontaneously probably are those in
“best” position and excluding them would have biased the results.
However, as imputation values of normally erupting canines at T2,
from the unilateral patient group were used in 15 patients, this
might have affected the results of the angular and positional changes
between T1 and T2. To find out how the results might change using
imputation values of normally positioned canines, a comparison
was made between the imputed values and values from the bilateral
patient group that had one PDC under eruption while the other was
still palatally displaced i.e. x-rays were taken at T2. Seven spontane-
ously erupting PDCs were identified and compared. No significant
differences were found either for the angular or for the positional
changes between the erupted PDCs and those with normal position.
However, an imputation can always give uncertainty in the results,
therefore the changes between T1 and T2 should be interpreted with
some caution.
217
Generalization
The results of the main sample obtained from the present sample can be
generalized only in a Caucasian population aged 10-13 years and in the
case that the exclusion criteria are met. The use of imputation values as
mentioned above, may curtail the generalization of the results regarding
the positional changes of the canine between T1 and T2. In addition, due
to the selective exclusion of PDCs resorbing adjacent teeth with grades
3 and 4 at the start and during the trial, may limit its representative-
ness, and thus limit the generalization of the frequence of root resorption
caused by PDCs in a general population.
Conclusions
r
Extraction of the deciduous canine in patients with PDC is an
effective interceptive approach: 69 per cent of the permanent
canines erupted when the deciduous canine was extracted, while
39 per cent erupted in the non-EG. The mean eruption time was
15.6 months in the EG and 18.3 months in the CG.
r
Significantly more angular and distance changes occurred in the
EG compared with the CG.
r
In the EG, the movement of the cusp-tip in relation to the dental
arch and in relation to the midline was larger during the first
6 months after extraction, while the movement of apex was
larger between 6 and 12 months.
r
Canines with an improved position at the 12 month control
should be followed up with a clinical and if necessary a radio-
graphic examination, as spontaneous eruption after 12 months
still is possible.
r
No significant differences in root resorption of adjacent teeth
was found at T2 between the CG and the EG.
Supplementary material
Supplementary material is available at European Journal of
Orthodontics online.
Funding
Local Research and Development Board for Gothenburg and Södra
Bohuslän; Health and Medical Care Committee of the Regional
Executive Board for Västra Götaland Region.
Acknowledgements
This work is dedicated to Prof. Jüri Kurol who suddenly and sadly passed away
during the work of this study. The authors wish to thank the general practi-
tioners and the consulting orthodontists at the Department of Orthodontics,
University Clinics of Odontology, Gothenburg, Sweden, for identifying and
inviting potential patients to participate in the study.
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 www.scielo.br/jaos
http://dx.doi.org/10.1590/1678-775720150535

Risk of developing palatally displaced canines in

patients with early detectable dental anomalies:
a retrospective cohort study
Daniela Gamba GARIB1, Melissa LANCIA2, Renata Mayumi KATO2, Thais Marchini OLIVEIRA1, Lucimara Teixeira
das NEVES3

1- Universidade de São Paulo, Faculdade de Odontologia de Bauru, Departamento de Odontopediatria, Ortodontia e Saúde Coletiva; Hospital de Reabilitação
de Anomalias Craniofaciais, Bauru, SP, Brasil.
2- Universidade de São Paulo, Hospital de Reabilitação de Anomalias Craniofaciais, Bauru, SP, Brasil.
3- Universidade de São Paulo, Faculdade de Odontologia de Bauru, Departamento de Ciências Biológicas; Hospital de Reabilitação de Anomalias Craniofaciais,
Bauru, SP, Brasil.

Corresponding address: Daniela Gamba Garib - Departamento de Odontopediatria, Ortodontia e Saúde Coletiva - Faculdade de Odontologia de Bauru -
Universidade de São Paulo - Alameda Octávio Pinheiro Brisolla, 9-75 - Bauru - SP - Brazil - 17012-901 - Phone/Fax: 55 14 2344480 - e-mail: dgarib@usp.br

Submitted: November 19, 2015 - Modification: April 8, 2016 - Accepted: April 25, 2016

ABSTRACT

T he early recognition of risk factors for the occurrence of palatally displaced canines
(PDC) can increase the possibility of impaction prevention. Objective: To estimate the
risk of palatally displaced canines (PDC) occurrence in children with dental anomalies
identified early during mixed dentition. Material and Methods: The sample comprised 730
longitudinal orthodontic records from children (448 females and 282 males) with an initial
mean age of 8.3 years (SD=1.36). The dental anomaly group (DA) included 263 records of
patients with at least one dental anomaly identified in the initial or middle mixed dentition.
The non-dental anomaly group (NDA) was composed of 467 records of patients with no
dental anomalies. The occurrence of PDC in both groups was diagnosed using panoramic
and periapical radiographs taken in the late mixed dentition or early permanent dentition.
The prevalence of PDC in patients with and without early diagnosed dental anomalies was
compared using the chi-square test (p<0.01), relative risk assessments (RR), and positive
and negative predictive values (PPV and NPV). Results: PDC frequency was 16.35% and
6.2% in DA and NDA groups, respectively. A statistically significant difference was observed
between groups (p<0.01), with greater risk of PDC development in the DA group (RR=2.63).
The PPV and NPV was 16% and 93%, respectively. Small maxillary lateral incisors, deciduous
molar infraocclusion, and mandibular second premolar distoangulation were associated with
PDC. Conclusion: Children with dental anomalies diagnosed during early mixed dentition
have an approximately two and a half fold increased risk of developing PDC during late
mixed dentition compared with children without dental anomalies.

Keywords: Tooth abnormalities. Canine tooth. Etiology. Orthodontics.

INTRODUCTION impaction of permanent maxillary canines reported

Apart from the third molars, the canines
represent the permanent teeth that most commonly
show eruptive disorders14. The prevalence of cases
in which maxillary ectopic canines palatally deviate
is 1.7%14, commonly affecting three females for
each male24,25,27. Less frequently, the maxillary
canines are buccally impacted and this irregularity
seems to be a clinical manifestation of anterior
crowding20. The ratio between buccal and palatal
in literature is 1:620.
Two theories have been presented to explain the
occurrence of palatally displaced maxillary canines
(PDC): “guidance” and “genetic” theories. According
to the guidance theory, local conditions, such as
maxillary lateral incisor agenesis or microdontia, are
related to canine displacement7,8. PDC has a genetic
background according to the genetic theory24, which
was based on observed increased prevalence in
families of affected patients, different prevalences

J Appl Oral Sci. 550

 Risk of developing palatally displaced canines in patients with early detectable dental anomalies: a retrospective cohort study
between genders and ethnical backgrounds, and
increased frequencies of other concomitant dental
anomalies24,26. The search for associated dental
anomalies was considered the most relevant
method to investigate the genetic determinants of
PDC2,24. Peck, Peck and Kataja25 (1996) found that
patients with PDC have increased prevalence of
permanent teeth agenesis, excluding third molars
(17%), and show the mandibular second premolar
as the most frequently absent tooth. Additionally,
these authors found that approximately 20% of
patients with PDC have small lateral incisors not
necessarily at the same arch side of the ectopic
canine.
The study by Sacerdoti and Baccetti27 (2004)
does not offer support to the hypothesis that
local conditions may be a cause for PDC7,8, since
they did not detect association between the
occurrence of bilateral PDC and the occurrence of
bilateral agenesis or microdontia of lateral incisors.
Additionally, unilateral PDC in cases with unilateral
agenesis of maxillary incisors rarely occurs at the
same arch side27. Sigler, Baccetti and McNamara Jr30
(2011) showed that individuals with PDC exhibited
significantly higher prevalence of small maxillary
lateral incisors (six-fold higher), distoangulation of
mandibular second premolars (three-fold higher),
and infraocclusion of deciduous molars (two-fold
higher) compared with a control group. Other
studies verified an increased prevalence of PDC
in patients screened for other dental anomalies
such as second premolar agenesis, small lateral
incisors, infraocclusion of deciduous molars, and
enamel hypoplasia2,19,29. Family history has already
been identified as a risk factor for PDC and other
heritable dental anomalies, as well as the gender
bias mentioned24,26,27.
Ectopic eruption of maxillary canines has two
major clinical concerns: the consequent impaction
of the canine and the possibility of incisor external
root resorption9,15-18. The treatment protocol for PDC
during permanent dentition is often canine traction,
which may present some collateral effects such as
root resorption of neighboring teeth, crest bone
loss at the mesial aspect of the canine, and tooth
discoloration9,13. Extraction may also be indicated
for canines with initial unfavorable position, or in
case of tooth ankyloses16.
Conversely, when there is an early orthodontic
diagnosis of PDC, simpler clinical approaches such
as deciduous canine extraction and rapid maxillary
expansion can lead to spontaneous canine eruption
in a high percentage of children3,5,23,30. These early
approaches can prevent canine impaction, incisor
root resorption, and collateral effects related to
tooth traction. Therefore, the recognition of risk
factors for the occurrence of PDC can increase the
possibility of early diagnosis and intervention. The
J Appl Oral Sci.
objective of this study was to evaluate longitudinal
records of patients with some early-diagnosed
dental anomalies to estimate risks of developing
PDC during the late mixed dentition.
MATERIAL AND METHODS
This retrospective longitudinal study was
approved by the Research Ethical Committee of the
Hospital for Rehabilitation of Craniofacial Anomalies,
University of São Paulo (HRAC-USP) (379/2010).
The patient records was anonymized and de-
identified prior to analysis. The initial sample was
composed of the orthodontic files of 810 children
treated from 1980 to 2005 at the Society for the
Social Promotion of Cleft Lip and Palate Patients
(PROFIS). Inclusion criteria were: presence of an
initial panoramic radiograph taken during the first
transitional period or inter-transitional period of
mixed dentition, according to the Van der Linden31
(1983) classification, and presence of at least one
more panoramic radiograph taken either during
the second transitional period of mixed dentition
or during the early permanent dentition. Exclusion
criteria were: poor quality records (dark or distorted
panoramic radiographs; absence of periapical
radiographs in cases showing ectopic canines) and
presence of syndromes or craniofacial anomalies.
Eighty individuals were excluded based on these
exclusion criteria.
The final sample was composed of 730 orthodontic
records from children with an initial mean age of
8.3 years (SD=1.36), from both genders (448
females and 282 males). A rough estimate of the
ethnic background of the sample based on facial
photograph was: White (84%), Black (12%), and
Asian (4%). The experimental and control groups
included 263 and 467 records, respectively, and
were composed based on the analyses of the
initial panoramic radiographs and dental casts to
investigate the presence of the following dental
anomalies: 1. Agenesis of any permanent teeth,
except for third molars; 2. Microdontia of maxillary
lateral incisors; 3. Infraocclusion of deciduous
molars; 4. Distoangulation of mandibular second
premolars; 5. Tooth transpositions.
All the records were analyzed by a single
calibrated examiner (ML). The examiner was
precalibrated showing an agreement index ranging
from 90 to 100% (Kappa test). The maxillary lateral
incisor was considered as presenting microdontia
when the maximum mesiodistal crown diameter
was smaller than the same dimension of the
opposing mandibular lateral incisor in the same
patient, using the dental casts19. This category also
included conical or peg-shaped maxillary lateral
incisors. The presence of infraocclusion of deciduous
molars was determined by visual inspection of the
551
 GARIB DG, LANCIA M, KATO RM, OLIVEIRA TM, NEVES LT

initial dental casts and panoramic radiograph series.
A deciduous molar was considered in infraocclusion
when more than 1 mm of vertical discrepancy
was measured from the mesial marginal ridge of
the closest permanent first molar29. Maxillary and
mandibular first and second deciduous molars were
considered in the analysis of infraocclusion. The
diagnosis of distoangulation of mandibular second
premolars followed the criteria described by Shalish,
et al.28 (2002).
The sample was divided into two groups. The
dental anomaly group (DA) was composed of 263
patients with at least one dental anomaly identified
in the initial or middle mixed dentition. Records
from children without these dental anomalies in the
early/middle mixed dentition (n=467) composed
the non-dental anomaly group (NDA). Age and
gender distribution in both groups is presented in
Table 1.
Panoramic radiographs from late mixed dentition
and/or early permanent dentition were evaluated
to assess risks for the development of PDC in
both groups. Considering the findings of Ericson
and Kurol15 (1986) showing that the attempt to
radiographically determine the eruption path
of maxillary canines is generally of little value
in children younger than 10 years old, we only
examined panoramic radiographs in records from
children aged 10 years or older. The PDC diagnosis
followed the radiographic parameters suggested
by Lindauer, et al.22 (1992) and was confirmed
through the interpretation of periapical radiographs
according to the Clark’s technique12. Rapid maxillary
expansion (RME) performed during the mixed
dentition was registered in both groups because
RME may have a positive influence on PDC cases6.
The frequency of PDC development was
calculated in DA and NDA groups. Intergroup
comparisons were performed using the Chi-square
test with a significance level of 5%. In order to
measure the strength of associations between
occurrences of early-diagnosed dental anomalies
and PDC, the relative risk (RR) at the 95%
confidence interval and the positive and negative
predictive values (PPV and NPV) were calculated.
Additionally, the frequency of PDC development
was separately calculated for each dental anomaly
and compared with the control group using the Chi-
square test (p<0.01) and relative risk assessment.
RESULTS
Seventy-two individuals were affected by PDC
(9.86%) with a male:female ratio of 1:3 in the
combined DA and NDA groups (n=730). In this
subgroup of individuals with PDC, 29.1% (n=21)
showed bilateral expression, 31.9% (n=23)
unilateral right expression, and 38.9% (n=28)
unilateral left expression.
The DA group presented PDC frequency of
16.3% compared with 6.2% of the NDA group
(Table 2). This difference was statistically significant
and indicated a two and a half fold increase in risk
of PDC in patients with early-diagnosed dental
anomaly (Table 2). Positive predictive value (PPV)
corresponded to 16% and negative predictive value

Table 1- Age and gender distribution in dental anomaly (DA) and non-dental anomaly (NDA) groups

Mean age at fisrt evaluation Mean age at second evaluation Male Female
(SD) (SD)
DA group (n=263) 8 y 2 m (1.46) 10y 10m (0.88) 95 168
NDA group (n=467) 8 y 6 m (1.26) 10y 4m (0.42) 187 280
Total (n=730) 8 y 4 m (1.36) 10y 8m (0.79) 282 448

Table 2- Comparison between dental anomaly (DA) and non-dental anomaly (NDA) groups based on the development of
palatally displaced canines (PDC)

DA group NDA group Pooled groups Difference chi- Relative Risk 95%
(n=263) (n=467) (n=730) square (χ 2 ) (RR) Confidence
Interval
PDC 43 29 72 18.33 2.63 (1.69-4.11)
Development (16.34%) (6.21%) (9.86%) p<0.01*
Absence of 220 438 658
PDC (83.65%) (93.79%) (90.13%)
Total 263 467 730
(100%) (100%) (100%)

* Statistically significant difference at p<0.01

J Appl Oral Sci. 552

 Risk of developing palatally displaced canines in patients with early detectable dental anomalies: a retrospective cohort study

Table 3- Prevalences of palatally displaced canines (PDC) development associated with each separate dental anomaly
compared with the non-dental anomaly group

Dental Number of Prevalence Prevalence Difference p Relative Confidence

Anomaly patients of PDC of PDC in the chi-square Risk interval
Development NDA group (χ 2) (RR) (95%)
Mandibular 49 26.53% 21.85 <0.001* 4.27 (2.38-7.66)
second premolar (13/49)
distoangulation
Agenesis of mandibular 22 9.09% 0.01 0.925 1.46 (0.37-5.75)
second premolars (2/22)
Agenesis of maxillary 8 25.00% 1.99 0.158 4.03 (1.15-14.06)
second premolars (2/8)
Agenesis of maxillary 7 14.29% 6.21% 0.01 0.929 2.30 (0.36-14.61)
lateral incisors (1/7) (29/467)
Small maxillary lateral 82 23.17% 23.07 <0.001* 3.73 (2.20-6.33)
incisor (19/82)
Maxillary lateral 32 15.63% 2.83 0.093 2.52 (1.04-6.06)
incisor and/or second (5/32)
premolar agenesis
Deciduous molar 159 15.09% 10.96 0.001* 2.43 (1.46-4.05)
infraocclusion (24/159)

* Statistically significant difference at p<0.01

Table 4- Frequency of rapid maxillary expansion (RME) performed in both groups during mixed dentition and intergroup
comparison (Chi square test)

RME Non RME Total Difference chi- p

square (χ 2)
DA group 144 (58.5%) 102 (41.5%) 246 (100%) 3.02 0.082
NDA group 219 (52.3%) 208 (48.7%) 427 (100%)

(NPV) was 93%. mixed dentition.

Statistically significant associations were
observed between increased frequencies of PDC
development and some of the dental anomalies
were separately evaluated (Table 3). The relative
risk of PDC in children with these specific dental
anomalies varied from 2.4 to 4.3 (Table 3). Tooth
transposition was absent in the sample.
The frequency of RME performed during the
mixed dentition was similar in both DA and control
groups (Table 4). No other type of transversal
expansion was registered except RME. Extraoral
traction was performed in 38.8% of DA group
and 40.8% of NDA group. Serial extraction was
performed in only one case of DA group and five
cases of NDA group.
DISCUSSION
This study evaluated longitudinal records from
patients with early-diagnosed dental anomalies to
estimate risks for developing PDC during the late
Previous cross-sectional studies showed
an association between PDC and other dental
anomalies including small maxillary lateral incisors,
tooth agenesis, deciduous molar infraocclusion,
and other slight tooth ectopia2,19,25. These studies
evaluated the concomitant occurrence of canine
ectopic eruption and other dental anomalies, and
pointed to some risk indicators for PDC.
The present study is the first to evaluate a
large sample with longitudinal records for dental
anomalies that could be used as markers to
estimate PDC risks11. Our results showed that
children with early recognizable dental anomalies
have an increased risk of 2.5 fold to develop PDC
later in life compared with children without these
anomalies (Table 2). According to positive predictive
value (PPV), the frequency of positive results
(presence of an early-diagnosed dental anomaly)
that were true positive (patients who developed
PDC) was 16%. Considering the negative predictive
value (NPV), 93% of patients with negative results

J Appl Oral Sci. 553

 GARIB DG, LANCIA M, KATO RM, OLIVEIRA TM, NEVES LT
(absence of dental anomaly) were true negative
and did not develop PDC. The results of this study
corroborates that PDC belongs to a spectrum of
interrelated dental anomalies 26. The literature
shows the occurrence of other dental anomalies
concomitant with PDC2,19,24. Additionally, a higher
prevalence of dental anomalies is observed not
only in patients with PDC but also in their first and
second-degree relatives26.
Small maxillary lateral incisors and mandibular
second premolar distoangulation were the main risk
factors for PDC among the early-diagnosed dental
anomalies (Table 3). These results corroborate
previous cross-sectional studies that demonstrated
significant association between small maxillary
lateral incisor and PDC2,25,27. Distoangulation of the
mandibular second premolar was early described
as a mild expression of the same genetic origin
identified for antimere agenesis 28. Recently, a
cross-sectional study demonstrated a statistically
significant difference between the prevalence of
PDC (28%) in patients with distoangulation of
the mandibular second premolars and in a control
group (4.2%)4.
Deciduous molar infraocclusion was also
confirmed to be a risk factor for PDC (Table 3);
this association was previously reported in a cross-
sectional study29. The prevalence of deciduous
molar infraocclusion, reported from cross-sectional
studies in a white population, varies from 1.3%
to 8.9%1,10,21. The prevalence of deciduous molar
infraocclusion in our combined sample (21.8%)
was much higher than the frequency reported in
previous studies (Table 3) and could be explained
by our longitudinal period of observation.
No significant differences were observed
between PDC development in individuals with
agenesis of maxillary lateral incisors or second
premolars, and the NDA group (Table 3). Peck,
Peck and Kataja25 (1996) also showed that agenesis
of maxillary lateral incisors was not significantly
associated with PDC. On the other hand, previous
cross-section studies have shown significant
associations between PDC and second premolar
agenesis2,19,25. Although second premolar agenesis
has been previously identified as a risk indicator
for PDC in cross-sectional studies, the association
was not significant in our cohort evaluation; this
difference could be explained by reference values,
which considered general population frequencies in
the former.
A limitation of this study is the possibility of
false-positive diagnosis for PDC using panoramic
radiographs22. However, the false-positive rate is low
(4.22%) and seems not to compromise the study
results22. The 80 individuals that were excluded
from the sample were not analyzed either because
the absence or bad quality of radiographs. Other
J Appl Oral Sci.
limitation of this study could be the bias of sample
selection because the study was retrospective.
However, the sample selection followed the criteria
of a time interval when the patients started the
orthodontic treatment (from 1980 to 2005).
Another concern regarding the methodology is that
the early orthodontic treatment with RME might
have had an influence on the spontaneous eruption
of ectopic canines. However, both DA and control
groups showed similar RME frequencies (Table 4)
and the prevalence of PDC was still significantly
higher in DA group.
Our results show that small maxillary lateral
incisors, distoangulation of mandibular second
premolar, and deciduous molar infraocclusion are
early risk markers for PDC. Pediatric and orthodontic
population with such dental anomalies diagnosed
during the early mixed dentition should be carefully
monitored during the critical age period for early
diagnosis and intervention of maxillary canine
ectopic eruption. The recognition of risk markers for
the occurrence of PDC can increase the possibility of
early diagnosis and intervention. Future longitudinal
studies could contribute to identify other potential
risk indicators for PDC including family history,
female gender, hypodivergent pattern, and enamel
hypoplasia2,27.
CONCLUSION
Children with some dental anomalies diagnosed
during the early mixed dentition have an
approximately two and a half fold increase in risk
of developing PDC during the late mixed dentition
compared with children without these dental
anomalies. Microdontia of maxillary lateral incisors,
mandibular second premolars distoangulation, and
deciduous molar infraocclusion constitute early risk
markers for PDC development. When the maxillary
canines are not palpable, a panoramic radiograph
is highly recommended in 10-year-old children with
clinically or radiographically diagnosed DA in order
to investigate PDC.
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555
ORIGINAL ARTICLE

Short-term impact of rapid maxillary

expansion on ectopically and normally
erupting canines
!rgio Estelita Barros,a Luciana Hoffelder,b Fernando Arau
Se ! jo,b Guilherme Janson,c Kelly Chiqueto,a
a
and Eduardo Ferreira
Porto Alegre, Rio Grande do Sul, and Bauru, S~ao Paulo, Brazil

Introduction: The purpose of this study was to evaluate the short-term impact of rapid maxillary expansion
(RME) on the eruption paths of ectopically and normally erupting maxillary canines in the mixed dentition.
Methods: Thirty-two patients with 49 ectopically erupting canines (EEC group; age, 9.53 6 1.10 years) and
18 patients with 27 normally erupting canines (NEC group; age, 9.25 6 1.06 years) underwent RME. Thirty-
six subjects with 54 normally erupting canines composed the untreated control group (UC group; age,
9.03 6 0.72 years). Horizontal, vertical, and angular positions of canines and adjacent teeth were evaluated
in the expanded (EEC and NEC groups) and unexpanded (UC group) patients using panoramic radiographs
taken at 2 times with a 1-year interval. The radiographic evaluation methods included score ranking and
proportional measurements to minimize panoramic radiograph limitations. Statistical comparisons were
performed among the groups (P\0.05). Results: Before expansion, the EEC group's canines were significantly
closer to the midline, more distant from the occlusal plane, and more mesially angulated than those in the UC
group. After expansion, the canine positions in the EEC and UC groups were similar, whereas the NEC group
had a more favorable canine position for eruption. The EEC and NEC groups showed similar canine positional
changes, whereas the UC group had the smallest changes. The positions of teeth adjacent to the canine were
also significantly affected by RME, and these changes may be associated with improvement of the ectopic
canine position. Conclusions: The changes produced by RME reduced the percentage of ectopic eruption
paths and maintained the nonectopic eruption percentage. (Am J Orthod Dentofacial Orthop 2018;154:524-34)

D
evelopmental problems such as maxillary nar-
rowing, tooth size-arch length discrepancy, teeth
agenesis, and peg-shaped maxillary lateral
incisor can be diagnosed early, prompting parents to
seek orthodontic treatment for their children during
the mixed dentition. These clinical deviations have
been associated with ectopic eruption and impaction
of the maxillary canine, impelling orthodontists to act
a
Division of Orthodontics, Faculty of Dentistry, Federal University of Rio Grande
do Sul, Porto Alegre, Rio Grande do Sul, Brazil.
b
Division of Pediatric Dentistry, Faculty of Dentistry, Federal University of Rio
Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil.
c
Department of Orthodontics, Bauru Dental School, University of S~ao Paulo,
Bauru, S~ao Paulo, Brazil.
All authors have completed and submitted the ICMJE Form for Disclosure of Po-
tential Conflicts of Interest, and none were reported.
Address correspondence to: S!ergio Estelita Barros, Division of Orthodontics, Fac-
ulty of Dentistry, Federal University of Rio Grande do Sul, Rua Ramiro Barcelos,
2492, Bairro Santana, Porto Alegre, RS 90035-003, Brazil; e-mail,
sergioestelita@yahoo.com.br.
Submitted, June 2017; revised and accepted, January 2018.
0889-5406/$36.00
! 2018 by the American Association of Orthodontists. All rights reserved.
https://doi.org/10.1016/j.ajodo.2018.01.011
524
on malpositioned maxillary canines at an early develop-
ment stage.1-6 It has been speculated that the incidence
of maxillary canine impaction in an orthodontic practice
tends to be much higher (23.5%7,8) than the incidence in
the population (1%-3%).9
When clinical signals are associated with a radiographic
diagnosis of canine ectopic eruption, horizontal, vertical,
and angular displacements have been radiographically
evaluated to predict the canine impaction risk.10-13 The
horizontal displacement of the maxillary canine
overlapping the lateral incisor root toward the midline
seems to be more relevant to predict the impaction risk
than the canine's angular displacement.8,14 However, the
association of other radiographic parameters that
evaluate vertical and angular canine displacement may
increase the impaction prediction accuracy, avoiding
overtreatments.10
Several extraction and nonextraction treatment pro-
tocols have been proposed to prevent maxillary canine
impaction. Extraction can involve only the deciduous
canine,12,15,16 or the deciduous canine and deciduous
first molar,17 but the comparison between them showed
Barros et al
that the latter may be more effective.17 In general, decid-
uous canine extraction associated with rapid maxillary
expansion (RME), transpalatal arch, or cervical headgear
is more effective than only deciduous canine extrac-
tion.16,18-20 Nonextraction treatment protocols include
cervical headgear associated or not with RME.21 Only 1
study evaluated RME alone, but no radiographic
follow-up was performed after RME.22 Thus, lack of
the final radiographic records prevented evaluation of
the short-term impact of RME on the ectopic canines
and adjacent teeth, which could contribute to describe
the dental changes associated with impaction preven-
tion of the maxillary canine. In addition, RME has
been applied to patients with palatally displaced ca-
nines,19-22 which in general do not have a transverse
maxillary deficiency,22,23 limiting the RME procedure
and perhaps its impact on the canine eruption path.
Another point to be considered is that preventive
protocols involving RME, transpalatal arch, or extraoral
headgear can have a symmetric effect between the
sides of the dental arch, but a unilateral ectopic canine
is a frequent finding,2 and the impact of these protocols
on nonectopic canines has not been evaluated. Finally,
clinical observation has suggested significant improve-
ment of the canine's eruption path after 1 year, but no
systematic study has evaluated the impact of RME in
this short term.24
To shed some light on these issues, the objective of
this study was to evaluate the short-term impact of
RME on the eruption path of ectopically and normally
erupting maxillary canines in patients with maxillary
transverse deficiency.
MATERIAL AND METHODS
The sample consisted of patients enrolled in a 2-
center prospective longitudinal clinical trial at the Fac-
ulty of Dentistry, Federal University of Rio Grande do
Sul, and the Orthodontic Service of the Military Poly-
clinic at Porto Alegre, Brazil. The files of the Bauru
Dental School Growth Study, University of S~ao Paulo,
Brazil, provided the orthodontic records for the un-
treated group of this historically controlled study. This
research was approved by the institutional review board
of the Faculty of Dentistry, Federal University of Rio
Grande do Sul. The parents of all subjects at each
research center signed informed consents.
The values of a 5 0.05 (type I error) and b 5 0.2 (type
II error) were used to calculate the sample size together
with the data from a previous study that reported the
success rate of RME for redirecting canine eruption.22
Although the results suggested a minimum of 13 pa-
tients in each group, additional patients were admitted
American Journal of Orthodontics and Dentofacial Orthopedics
525
Fig 1. Ranking of canine horizontal sector according to
the modification of Lindauer et al.11 Sector I is located
distal to a tangent to the distal crown and root of the lateral
incisor; sector II includes the area from the tangent on the
distal surface to a midline bisector of the lateral incisor;
sector III includes the area from the midline bisector to a
tangent to the mesial surface of the lateral incisor crown
and root; sector IV includes all areas mesial to sector III.
because panoramic radiographic measurements may
cause greater variability if the structures are to be re-
measured on subsequent radiographs. In addition, sam-
ple attrition should be considered due to the
longitudinal evaluation.
The selection criteria used in this clinical trial were as
follows: (1) patients in the mixed dentition; (2) RME
indication due to transverse maxillary deficiency; (3) bio-
logic maturity corresponding to half to two-thirds of
canine root completed,25 which can be classified as Nolla
stage26 7.2 to 8; (4) ectopic eruption of at least 1 maxil-
lary canine overlapping sector II, III, or IV of the lateral
incisor root, diagnosed on panoramic radiographs, ac-
cording to the method of Lindauer et al11 (Fig 1); (5)
no previous orthodontic treatment; (6) no supernumer-
ary teeth or lateral incisor agenesis; (7) no early loss of
deciduous teeth that could benefit canine eruption17;
(8) no oral pathology associated with eruption distur-
bance or history of dental trauma; and (9) no craniofa-
cial anomaly or syndrome.
Based on these criteria, 32 patients (13 boys, 19 girls)
with 49 ectopically erupting canines (EEC group) and a
mean age of 9.53 6 1.10 years were selected for treat-
ment with RME.
October 2018 ! Vol 154 ! Issue 4
526 Barros et al

Fig 2. Angular measurements: The a, u, and q angles between the canine midline bisector and the
reference lines were evaluated. Angular positions of the maxillary lateral incisors and first premolars
were similarly evaluated. Skeletal and dental landmarks: orbitale (Or), the lowest point on the border
of the bony orbit; anterior nasal spine (ANS), tip of the ANS at the lowest margin of the anterior nasal
opening; median palatine suture (MPS), lowest point on the median palatine suture; central incisor (1),
midpoint of the incisal edge of the central incisor; first molar (6), midpoint between the lowest and high-
est projections of the mesial cusp tips. Horizontal and vertical lines: infraorbital line (IOL), line that
passes through right and left Or; occlusal line (OL), line that passes through points 1 and 6; sagittal
midline (SM), line that passes through ANS and MPS.

A second treatment group consisted of 9 expanded
patients from the EEC group with unilateral normally
erupting canines and 9 expanded patients with bilateral
normally erupting canines who were recruited according
to the previous selection criteria, except for ectopic
canine positioning. Thus, this group included 27 nor-
mally erupting canines (NEC group) in 18 patients (8
boys, 10 girls) with a mean age of 9.25 6 1.06 years.
The untreated control group (UC group) was retro-
spectively selected from a pool of 256 untreated subjects
longitudinally followed during growth. Selection criteria
included normally erupting canines and matched dental
development stage at each treatment time of the EEC
and NEC groups (before and after expansion). Previous
criteria such as no pathologies, early deciduous loss,
trauma, and dental or craniofacial anomalies associated
with eruption disorders were also observed in this group.
A total of 54 maxillary canines in 36 subjects (17 boys 19
girls) with a mean age of 9.03 6 0.72 years satisfied
these criteria.
The treatment protocol was similar for all 41 treated
patients. The orthodontic appliance included a banded
rapid maxillary expander with bands on the maxillary
permanent first molars and a wire extension to the de-
ciduous molars and canines. The expander was activated
with 2 quarter turns per day until overcorrection was
reached. The RME appliance was maintained in place
during the observation period because an extended
time with fixed retention could reduce patient compli-
ance influence, maintain the overcorrection, and act
similarly as a transpalatal arch.20
The panoramic radiographs were taken at preexpan-
sion (T1) and 1 year postexpansion (T2). The radiographs
were digitized by 1 investigator (L.H.) and checked for
landmark identification by a second examiner (S.E.B.).
The data were analyzed with Radiocef Studio 2 software
(version 2.0, release 12.82; Belo Horizonte, Minas Gerais,
Brazil) using a customized radiographic analysis (Figs 2
and 3).
The radiographic evaluation included the a angle
measurement proposed by Ericson and Kurol12 (Fig 2)
and the horizontal sector ranking proposed by these
same authors and modified by Lindauer et al11 (Fig 1).
A complementary vertical scoring was based on canine
eruption level regarding the lateral incisor, and 2 sta-
tuses were defined: apical level (canine tip level with

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Barros et al 527

Fig 3. Proportional measurements. The distance from canine cusp tip (point 3) to IOL (d1) was divided
by the distance from IOL to OL (d2) to determine the canine vertical position rate. The distance from
canine cusp tip (point 3) to LOL (d1) was divided by the distance from LOL to SM (d2) to determine
the canine horizontal position rate. Similarly, points 2 and 4 were used to evaluate the vertical and hor-
izontal position rate of the maxillary lateral incisor and first premolar. Skeletal and dental landmarks not
defined in Figure 2: orbitale lateral (OrLat), the most lateral point on the border of the bony orbit; lateral
incisor (2), midpoint of the incisal edge of the lateral incisor; canine (3), cusp tip of the canine; first pre-
molar (4), midpoint between the lowest and highest projections of the cusp tips. Vertical line not defined
in Figure 2: lateral orbital line (LOL), line perpendicular to IOL that passes through OrLat.

the apical or middle third of the lateral incisor root) and
occlusal level (canine tip level with the cervical third of
the root or at the crown level of the lateral incisor).
Due to the controversial reliability of linear measure-
ments performed on panoramic radiographs,27-29
vertical and horizontal positions of the canines and
adjacent teeth were evaluated from a relative location
(Fig 3), minimizing the influence of panoramic distor-
tion and magnification on the results.30 Angular and
linear measurements are defined in Figures 2 and 3.
Twenty-two radiographs were randomly selected and
remeasured by the same examiner to evaluate the method
error. Intraobserver agreement for ranking canine hori-
zontal and vertical statuses was evaluated by weighted
Cohen kappa coefficient. The intraclass correlation coef-
ficient was used to check intraobserver reliability and
reproducibility for all linear and angular measurements.
Comparability of the groups regarding initial age,
observation period, sex distribution, and dental arch
side distribution for the evaluated canines was investi-
gated with analysis of variance (ANOVA) and chi-
square tests, respectively.
Distribution of the horizontal sectors and vertical sta-
tuses of the canines in each group was compared at T1
and T2 with chi-square tests.
Intergroup comparisons regarding angular and linear
positions of the canines and adjacent teeth were per-
formed at T1, T2, and T2-T1 using parametric (ANOVA)
or nonparametric (Kruskal-Wallis) tests, followed by Tu-
key post-hoc tests.
Statistical analyses were performed with Statistica for
Windows software (version 7.0; StatSoft, Tulsa, Okla).
The results were considered statistically significant at
P \0.05.

Statistical analysis RESULTS

Parametric or nonparametric tests were used accord- The ranges of Cohen's kappa (0.81-0.85) and intra-
ing to the results of the Shapiro-Wilk tests. Categorical class correlation coefficient (0.921-0.996) demonstrated
variables were compared with chi-square tests. reliable ranking and measurement procedures.

American Journal of Orthodontics and Dentofacial Orthopedics October 2018 ! Vol 154 ! Issue 4
528 Barros et al

Table I. Group comparisons regarding initial age, observation time, sex, evaluated canine side, and categorization of
horizontal and vertical canine position at T1 and T2
EEC group (n 5 49) NEC group (n 5 27) UC group (n 5 54)

Variable Mean SD Mean SD Mean SD P

Age (y) at T1 9.53 1.10 9.25 1.06 9.03 0.72 0.0726*
Observation time (y) 1.11 0.30 1.12 0.32 1.03 0.19 0.2262*
Sex
Male 20 (40.82%) 12 (44.44%) 24 (44.44%) 0.9213y
Female 29 (59.18%) 15 (55.56%) 30 (55.56%)
Canine
Right 27 (55.10%) 11 (40.74%) 31 (57.41%) 0.3435y
Left 22 (44.90%) 16 (59.26%) 23 (42.59%)
Horizontal canine ranking (T1)
Sector I 0 (0%) 27 (100%) 54 (100%) \0.0001yz
Sector II 32 (65.31%) 0 (0%) 0 (0%)
Sector III 14 (28.57%) 0 (0%) 0 (0%)
Sector IV 3 (6.12%) 0 (0%) 0 (0%)
Horizontal canine ranking (T2)
Sector I 22 (44.90%) 25 (92.59%) 37 (68.52%) 0.0012yz
Sector II 25 (51.02%) 2 (7.41%) 16 (29.63%)
Sector III 2 (4.08%) 0 (0%) 1 (1.85%)
Sector IV 0 (0%) 0 (0%) 0 (0%)
Vertical canine ranking (T1)
Apical level 49 (100%) 27 (100%) 54 (100%)
Occlusal level 0 (0%) 0 (0%) 0 (0%)
Vertical canine ranking (T2)
Apical level 22 (44.90%) 9 (33.33%) 33 (61.11%) 0.0251yz
Occlusal level 27 (55.10%) 18 (66.67%) 21 (38.89%)

*ANOVA; yChi-square test; zStatistically significant at P \0.05.

The groups were similar regarding initial age, obser-
vation period, distribution of sexes, and dental arch sides
for the evaluated canines (Table I).
At T1, the EEC group's canines were significantly
more ectopic than those in the UC and NEC groups ac-
cording to the horizontal sector rankings (Tables I and
II). After RME, almost half of the EEC canines achieved
sector I (22 canines), and only 2 were in sector III (Table
I). In general, the EEC canines migrated to less severe sec-
tors. The canine maintenance rates in sector I were 92%
in the NEC group and 65% in the UC group (Table I). The
EEC and UC groups had similar sector distributions at T2
(P 5 0.052). Regarding the vertical changes, the
expanded groups (EEC and NEC) had more canines at
the occlusal level than did the UC group (Table I).
Mesial angulation of the canines was significantly
greater in the EEC and NEC groups at T1 (Table II).
The EEC group had a smaller distal angulation of the
lateral incisors (Table II). Proportional distance measure-
ments showed that the canine and lateral incisor were
significantly closer to the midline and farther from the
occlusal plane in the EEC group (Table II).
At T2, the sector mean scores in the EEC group were
similar to those in the UC group and greater than those
in the NEC group (Table II). The horizontal sector
changes were significantly greater in the EEC group
(Table III). Canine mesial angulation was significantly
reduced in the expanded groups, equaling all groups
at T2 (Tables II and III). In the expanded groups, lateral
incisor angulation changed in opposite directions,
becoming similar at T2 (Tables II and III). In general,
the expanded groups had greater mesial angulation re-
ductions and more uprighted first premolars at T2
(Tables II and III).
Vertical canine positioning was similar at T2, but the
vertical changes toward the occlusal plane were signifi-
cantly greater in the expanded groups (Tables II and III).
The lateral incisors achieved the occlusal plane at T2,
and the expanded groups had greater vertical changes
(Tables II and III). At T2, the first premolar was signifi-
cantly closer to the occlusal plane in the expanded
groups due to a significantly greater vertical change
(Tables II and III).
At T2, the horizontal canine positioning became
similar between the EEC and UC groups, but it was
significantly farther from the midline in the NEC group
(Tables II and III). The horizontal change of the lateral
incisor was greater and distally directed in the EEC

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Barros et al 529

Table II. Group comparisons regarding horizontal, vertical, and angular positions of canines and adjacent teeth at T1
and T2
EEC group (n 5 49) NEC group (n 5 27) UC group (n 5 54)

Variable Mean 6 SD Mean 6 SD Mean 6 SD P

Horizontal sector
T1 2.41a 6 0.60 1.00b 6 0.00 1.00b 6 0.00 \0.0001*y
T2 1.59a 6 0.57 1.07b 6 0.26 1.33ab 6 0.51 0.0001*y
Canine position (" )
a
T1 19.63a 6 9.22 16.66a 6 8.57 12.11b 6 5.13 \0.0001*z
T2 12.18 6 8.93 8.50 6 5.28 10.06 6 6.03 0.2630y
u
T1 59.67a 6 7.92 61.11ab 6 8.22 63.74b 6 6.38 0.0208*z
T2 66.08 6 8.29 70.37 6 8.15 66.52 6 6.94 0.0542z
q
T1 70.56a 6 8.98 73.23a 6 8.59 78.16b 6 5.72 \0.0001*z
T2 78.61 6 9.32 83.25 6 7.32 81.18 6 7.83 0.0591z
Lateral incisor position (" )
a
T1 7.79a 6 5.31 12.43b 6 5.61 12.01b 6 5.55 0.0003*y
T2 9.95a 6 5.13 11.10ab 6 5.42 13.65b 6 6.07 0.0029*y
u
T1 86.31 6 8.36 89.14 6 7.52 87.47 6 7.30 0.3150z
T2 87.46 6 7.89 88.01 6 6.49 89.05 6 7.37 0.5430z
q
T1 97.20a 6 7.14 101.25b 6 7.57 101.89b 6 5.96 0.0016*z
T2 99.98a 6 6.23 100.89ab 6 6.07 103.71b 6 6.13 0.0079*z
First premolar position (" )
a
T1 11.94 6 7.01 9.69 6 6.46 10.34 6 6.69 0.2810y
T2 7.29 6 5.41 6.36 6 4.47 8.01 6 6.77 0.7957y
u
T1 67.94 6 9.05 68.52 6 6.79 67.21 6 9.12 0.6289y
T2 73.96a 6 8.33 77.01a 6 7.40 70.12b 6 8.16 0.0005*y
q
T1 78.86 6 8.05 80.63 6 7.10 81.63 6 9.07 0.2393z
T2 86.49ab 6 7.99 89.90a 6 7.35 84.78b 6 8.54 0.0206*y
Vertical position rate of canine and adjacent teeth
3VPR
T1 0.62a 6 0.06 0.66ab 6 0.07 0.67b 6 0.05 0.0014*y
T2 0.76 6 0.12 0.81 6 0.11 0.75 6 0.07 0.0597y
2VPR
T1 0.95a 6 0.07 0.96ab 6 0.05 0.99b 6 0.02 0.0026*y
T2 0.99 6 0.04 1.00 6 0.02 1.00 6 0.01 0.2081y
4VPR
T1 0.81 6 0.08 0.81 6 0.08 0.82 6 0.08 0.8286y
T2 0.93a 6 0.09 0.94a 6 0.07 0.88b 6 0.09 0.0045*y
Horizontal position rate of canine and adjacent teeth
3HPR
T1 0.72a 6 0.04 0.70b 6 0.04 0.70b 6 0.03 0.0194*z
T2 0.69a 6 0.04 0.66b 6 0.04 0.70a 6 0.03 0.0001*z
2HPR
T1 0.76a 6 0.03 0.74b 6 0.03 0.73b 6 0.03 0.0199*z
T2 0.74 6 0.02 0.74 6 0.03 0.74 6 0.04 0.9179z
4HPR
T1 0.58 6 0.05 0.56 6 0.03 0.58 6 0.04 0.0901z
T2 0.54a 6 0.05 0.51b 6 0.05 0.57c 6 0.04 \0.0001*z

Different letters represent statistically significant differences.

2VPR, 3VPR, and 4VPR, Vertical position rates of the lateral incisor, canine, and first premolar, respectively; 2HPR, 3HPR, and 4HPR, horizontal
position rates of the lateral incisor, canine, and first premolar, respectively.
*Statistically significant at P \0.05; yKruskal-Wallis test; zANOVA.

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530 Barros et al

Table III. Group comparisons regarding horizontal, vertical, and angular changes of canines and adjacent teeth (T2-
T1)
EEC group (n 5 49) NEC group (n 5 27) UC group (n 5 54)

Variables Mean 6 SD Mean 6 SD Mean 6 SD P

Horizontal sector –0.81a 6 0.63 0.07b 6 0.26 0.33b 6 0.51 \0.0001*y
Canine position (" )
a –7.45a 6 8.68 –8.16a 6 6.58 –2.05b 6 4.86 \0.0001*z
u 6.40a 6 7.45 9.25a 6 8.48 2.78b 6 5.45 0.0010*y
q 8.04a 6 8.80 10.01a 6 7.32 3.01b 6 5.45 \0.0001*z
Lateral incisor position (" )
a 2.17a 6 5.54 –1.32b 6 5.12 1.63a 6 4.47 0.0125*z
u 1.15 6 8.01 –1.14 6 5.87 1.58 6 5.85 0.1298y
q 2.78a 6 5.91 –0.36b 6 5.79 1.82ab 6 4.04 0.0426*z
First premolar position (" )
a –4.64 6 7.86 –3.33 6 8.45 –2.33 6 7.25 0.3220z
u 6.02ab 6 7.54 8.48a 6 9.00 2.91b 6 8.16 0.0118*z
q 7.63a 6 78.54 9.26a 6 9.01 3.15b 6 7.87 0.0029*z
Vertical position rate of canine and adjacent teeth
3VPR 0.14a 6 0.09 0.16a 6 0.09 0.08b 6 0.04 \0.0001*y
2VPR 0.04a 6 0.05 0.03ab 6 0.05 0.01b 6 0.02 0.0118*y
4VPR 0.11a 6 0.09 0.13a 6 0.07 0.06b 6 0.06 0.0001*y
Horizontal position rate of canine and adjacent teeth
3HPR –0.03a 6 0.06 –0.03a 6 0.03 0.001b 6 0.04 0.0003*z
2HPR –0.02a 6 0.05 –0.002ab 6 0.03 0.006b 6 0.03 0.0089*z
4HPR –0.04a 6 0.07 –0.05a 6 0.05 –0.01b 6 0.04 0.0009*z

Different letters represent statistically significant differences.

2VPR, 3VPR, and 4VPR, Vertical position rates of the lateral incisor, canine, and first premolar, respectively; 2HPR, 3HPR, and 4HPR, horizontal
position rates of the lateral incisor, canine, and first premolar, respectively.
*Statistically significant at P \0.05; yKruskal-Wallis test; zANOVA.

group, making it similar to the UC and NEC groups at T2
(Tables II and III). The first premolar was more distally
displaced in the expanded groups (Tables II and III).
The expanded groups had greater angular, vertical,
and horizontal canine improvements (Table III; Figs 4
and 5). These results agreed with the greater horizontal
and vertical improvement rates in the expanded groups,
using score evaluation (Table I). Thus, RME had a posi-
tive impact on the eruption path of both the ectopically
and normally erupting canines.
DISCUSSION
The evaluation performed on panoramic radiographs
showed consistent intraobserver reliability and repro-
ducibility. Despite this, inherent distortions of the pano-
ramic radiograph can produce misleading data. Linear
measurements of panoramic radiographs seem to be
less reliable than angular evaluations.27-29 To minimize
this limitation, a dual method of panoramic evaluation
was used. Thus, scores11 (Table I) and proportional mea-
surements30 (Tables II and III) were used to evaluate the
vertical and horizontal tooth positions with agreement
of results. These resources have been successfully used
to reduce the shortcomings of radiographic images
taken with less accurate standardization.11,30,31
Since the selection criteria of the ectopically erupting
canines were focused on horizontal sectors II, III, and IV,
with a sector mean score of 2.41 (Tables I and II), canines
closer to the midline in the EEC group were an expected
condition (Table II). However, the canines were also more
mesially angulated (mean angulation, .15" 19,20) and
farther from the occlusal plane in this group (Table II),
suggesting an association between canine ectopic hori-
zontal position and a disadvantageous angular and verti-
cal status, which should be considered an additional risk
for canine impaction.8,10 After RME, 70% of the canines
in the EEC group had some ectopic position
improvement, but less than half of them had achieved
sector I (Table I). In general, the canines of the NEC group
kept an excellent eruption prognosis after RME (Table I).
However, a noticeable percentage of the nonexpanded
normally erupting canines (UC group) showed mild wors-
ening in canine sector rank (Table I). These results should
not be interpreted as many impacted canines occurring in
the EEC and UC groups because at T2 most canines were
in sector I or II, and both groups had favorable angular
and vertical canine positions (Tables I and II). This

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Barros et al 531

Fig 4. Canine improvement. Changes in angular and proportional measurements (vertical and hori-
zontal position rates) show that the canines were significantly more uprighted, closer to the occlusal
plane and farther from the midline in the expanded groups (EEC and NEC) than in the nonexpanded
group (UC).

Fig 5. Apex superimpositions of canine long axes to compare the groups regarding mean angular po-
sitions of the canines at T1 and T2 and uprighting degrees. Blue and pink colors indicate each pair of
compared groups according to the color in the heading note.

association among less severe horizontal sector, mesial
angulation, and vertical positioning significantly reduces
the canine impaction risk.8,10 After 1 year, RME had
significantly increased the percentage of canines with
improved eruption prognosis in the EEC group and
made the impaction risk almost negligible in the NEC
group (Table I).
Although excessive distal angulation of the lateral
incisor crown can indicate a mesially displaced or angu-
lated canine against the distal aspect of the lateral
incisor root,2 it is speculated that this clinical signal
could also mean that the canine did not lose its eruption
guidance from the lateral incisor root.32 This speculation
could explain the smaller distal angulation of the lateral
incisors in the EEC group, with canines advancing to
sector II with lost eruption guidance at T1 (Tables I
and II). After 1 year of RME, the distal angulation in-
crease of the lateral incisor in the EEC group may indi-
cate that the canine was recovering its eruption
relationship with the distal aspect of the lateral incisor
root (Tables II and III). In fact, this occurrence was true
for 70% of the canines of the EEC group, which had

American Journal of Orthodontics and Dentofacial Orthopedics October 2018 ! Vol 154 ! Issue 4
532
horizontal sector improvement, with 45% reaching
sector I (Table I). We were not concerned with separating
palatal from buccal impaction because, although the
etiologic factors may be distinct,1,33 they seem to
respond favorably to similar preventive
protocols.18,24,29 There is ample evidence that a
spontaneous change of the eruption path of the
palatally displaced canine occurs because of changes
of the environmental conditions produced by
deciduous tooth extractions, mainly if followed by
transpalatal arch, RME, or cervical headgear.1,16-22,29
Since most of these procedures increase or at least
prevent arch length reduction during occlusal
development, it is not surprising that buccally
displaced canines, often associated with arch length
discrepancy, can also benefit from them.
Deciduous first molar extraction has been added to
the preventive extraction of the deciduous canine
because it could benefit first premolar uprighting and
eruption, providing more intrabony space for physio-
logic movement of the canine crown in a distal direc-
tion.17 Thus, evaluation of RME impact on the first
premolar was considered opportune. After RME, the first
premolars of the expanded groups showed greater up-
righting movements (Tables II and III). In addition, the
first premolars were closer to the occlusal plane and
farther from the midline at T2 (Tables II and III). RME
seems to benefit first premolar uprighting, eruption,
and distal positioning, which can contribute to normal-
izing the canine eruption path.17 More recently, a strong
positive correlation between the preeruptive uprighting
changes of the maxillary first premolar and canine was
demonstrated.34 In addition, a prolonged retention
phase with the expander in place could act similarly to
a transpalatal arch, benefitting normalization of the
canine eruption path.18,19
In general, the changes observed in vertical, horizon-
tal, and angular positions of the canine, lateral incisor,
and first premolar were significantly greater in the
expanded groups (Table III; Fig 4) and had a favorable
impact on the canine's ectopic path (Fig 5). More canines
reached the occlusal level at T2 in the expanded groups.
A high percentage (70%) of the canines in the EEC group
had at least 1 horizontal sector of improvement (Tables I
and III). Horizontal sector improvement produced by
RME in the short term was similar to the changes pro-
duced by extraoral headgear16 and double extraction
involving the deciduous canine and first molar,17 but it
was greater than extraction of the deciduous canines
only, and smaller than the association of extraoral head-
gear with deciduous canine extraction.17,18 It can be
speculated that the worse performance of deciduous
canine extraction only is associated with continuous
October 2018 ! Vol 154 ! Issue 4 American Journal of Orthodontics and Dentofacial Orthopedics
Barros et al
reduction in the maxillary arch perimeter after
extraction.15 Therefore, protocols that include ortho-
dontic devices to prevent maxillary arch shortening or
to increase arch perimeter, such as transpalatal arch, ex-
traoral headgear, and RME, seem to produce a more pos-
itive impact on canine impaction prevention, especially
if deciduous canine extraction is associated with
it.16,18,20,21
The a angle (Fig 2) behavior was similar in the
expanded groups after 1 year of RME and showed a
reduction that was intermediary to the single (deciduous
canine) and double (deciduous canine and first molar)
extraction protocols.17 Extraoral headgear showed
greater reductions in the a angle than did the results
of this study.16,18 However, the extraoral headgear
appliance was preceded by deciduous canine
extraction, and the patients were followed for a longer
time (18 months). Thus, it can be speculated that a
similar a-angle reduction can be expected from RME
under these same clinical conditions.
Although the eruption success rate of ectopic canines
can be increased if deciduous canine extraction is asso-
ciated with other preventive protocols,16,18,20 it has been
demonstrated that RME associated with extraoral
headgearm and extraoral headgear alone, can produce
high success rates without extracting the deciduous
canine.21 The results of this study suggest that RME
alone can also produce a high improvement rate of the
canine eruption path without deciduous extraction
(Tables I and III; Figs 4 and 5). Additional studies should
be conducted to evaluate whether deciduous canine
extraction and RME retention protocol can further in-
crease the advantageous impact of RME on ectopic ca-
nines. Another relevant result of this study was that
the nonectopic canines of the NEC group followed an
eruption path farther from the lateral incisor than the
nonectopic canines of the UC group (Tables I and III).
About 30% of the canines of the UC group advanced
to sector II during the observation period, increasing
the root resorption risk of the lateral incisor.14 These re-
sults can contribute to explaining why lateral incisor
resorption has been found to be associated with approx-
imately a third of normally erupting canines.14 Thus, pa-
tients requiring RME can have a significant improvement
of the canine eruption path and a reduction of root
resorption risk of the lateral incisor, even when the
canine has a low potential for impaction. The short-
term results of this study suggest that patients with
ectopic canines must be radiographically evaluated after
1 year. This is because a complementary approach
involving deciduous extractions and a transpalatal arch
before canine root apex closure can be advantageous
if the ectopic canine remains unchanged. Patients with
Barros et al
a high potential for canine impaction should be aware
that orthodontic-surgical traction may be required.
Several preventive procedures are available to
normalize the canine eruption path. However, the im-
pacts of these procedures on the maxillary dental arch,
canine displacement severity, and total patient orthodon-
tic need seem to be the most determinant factors to
delineate the clinician's conduct and to avoid overtreat-
ment. Considering the results of this study and others
that evaluated several treatment protocols, we suggest
concise guidelines for a preventive clinical practice of
ectopic canines during the mixed dentition.15-22,29
1. For patients with orthodontic need restricted to the
ectopic canine with a mild potential for canine
impaction, deciduous canine extraction should be
considered. For those with moderate to severe po-
tential for canine impaction, deciduous canine and
first molar extractions associated with a transpalatal
arch should be considered.
2. For patients with orthodontic need not restricted to
the ectopic canine with a mild potential for canine
impaction, RME with a transpalatal arch or extraoral
headgear without deciduous canine extraction
should be considered. For those with moderate to
severe potential for canine impaction, RME with a
transpalatal arch or extraoral headgear with decidu-
ous canine extraction should be considered.
CONCLUSIONS
Short-term changes produced by RME had a positive
impact on ectopically and normally erupting canines,
making the challenging eruption path of the maxillary
canine more predictable. The positions of teeth adjacent
to the canine was also significantly affected by RME, and
these changes may be associated with improvement of
the ectopic canine position.
After 1 year of RME, the expanded groups had ca-
nines significantly farther from the midline, causing a
high improvement percentage of the horizontal sector
of ectopically erupting canines. Furthermore, canine
eruption and uprighting changes were significantly
greater in the expanded groups. Horizontal, vertical,
and angular positional changes significantly reduced
canine impaction risk.
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Dental and occlusal features in patients with palatally displaced
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ing maxillary permanent canine: interceptive treatment and long-
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460-6.
 CASO CLÍNICO

Infraoclusão de molares decíduos: definindo condutas

na dentadura mista

Daniela Gamba Garib1 1) Universidade de São Paulo, Faculdade de Odontologia de Bauru (Bauru/SP, Brasil).
2) Hospital de Reabilitação de Anomalias Craniofaciais (Bauru/SP, Brasil).
Olga Benário Vieira Maranhão1
Arthur César de Medeiros Alves1
Marcos Roberto de Freitas1
Renata Carvalho Sathler2

Resumo: A infraoclusão é uma alte-
ração de interesse clínico com pre-
valência considerável na dentadura
mista, podendo se manifestar associa-
damente a outras anomalias dentárias.
Assim, o objetivo do presente trabalho
consiste em descrever um protocolo
de conduta que guie o ortodontista e
o odontopediatra diante de molares
decíduos em infraoclusão. Dois fatores do caso na dentadura permanente.
serão considerados na tomada de de- Cabe, então, ao ortodontista reconhe-
cisão: a presença do sucessor perma- cer essa anomalia e aplicar o proto-
nente e o grau de infraoclusão (suave, colo de tratamento mais adequado
moderado ou severo). O tratamento conforme as necessidades individuais,
de escolha deve ser o mais conserva- priorizando um tratamento preciso,
dor possível a longo prazo, de modo sem sobretratamento. Palavras-chave:
a evitar sobretratamento ou contribuir Dente molar. Anquilose dentária. Orto-
negativamente para a reabilitação dontia Interceptora. 79

Infraocclusion of deciduous molars: defining conducts in mixed dentition

Abstract: Infraocclusion is an alteration of
clinical interest with considerable preva-
lence in the mixed dentition, and may present
in association with other dental anomalies.
Thus, the aim of this study is to describe a
conduct protocol to guide the orthodontist and
pediatric dentist in face of deciduous molars
in infraocclusion. Two factors will be consid-
ered in the decision making: 1) Presence of the
permanent successor; and 2) Degree of infraoc-
clusion (mild, moderate or severe). The treat-
ment of choice should be the most conservative
possible in long term, avoiding overtreat-
ment or conducts that may hinder a possible
rehabilitation of the case in the future. It is
then up to the orthodontist to recognize this
anomaly and apply the most appropriate treat-
ment protocol according to the needs of each
patient, prioritizing a precise treatment, with-
out over-treatment. Keywords: Molar. Tooth
ankylosis. Orthodontics, Interceptive.

Como citar: Garib DG, Maranhão OBV, Alves ACM, Freitas MR, Sathler RC. Infraoclusão de molares decíduos: definindo Os autores declaram não ter interesses associativos, comer-
condutas na dentadura mista. Rev Clín Ortod Dental Press. 2018 Out-Nov;17(5):79-89. ciais, de propriedade ou financeiros que representem confli-
to de interesse nos produtos e companhias descritos nesse
artigo. O(s) paciente(s) que aparece(m) no presente artigo
Enviado em: 15/10/2016 - Revisado e aceito: 27/01/2017
autorizou(aram) previamente a publicação de suas fotografias
DOI: https://doi.org/10.14436/1676-6849.17.5.079-089.art faciais e intrabucais, e/ou radiografias.

Endereço para correspondência: Olga Benário Vieira Maranhão

Alameda Dr. Octávio Pinheiro Brisolla, 07-12, Vila Santa Tereza, Bauru/SP
CEP: 17.012-059 – E-mail: olgamaranhao@hotmail.com

© Dental Press Publishing | Rev Clín Ortod Dental Press. 2018 Out-Nov;17(5):79-89
 Garib DG, Maranhão OBV, Alves ACM, Freitas MR, Sathler RC

INTRODUÇÃO sucessor permanente, o que contribui ainda mais

De interesse clínico relevante, a infraoclusão
de molares decíduos apresenta uma prevalência
que varia de 1,3% a 8,9% na população em ge-
ral. O fator genético participa de forma marcante
em sua etiologia1-4. A prevalência da infraoclusão
de molares decíduos mostra-se aumentada em fa-
mílias de indivíduos com essa irregularidade, de-
monstrando seu caráter genético e hereditário1.
Além disso, a infraoclusão de molares decíduos
associa-se com certa frequência a outras anoma-
lias dentárias hipoplasiantes de origem genética,
incluindo a distoangulação de segundos pré-mo-
lares, a microdontia de incisivos laterais superiores
3-6
e a agenesia de segundos pré-molares . Esse pa-
drão de associação sugere uma origem genética
comum para as referidas anomalias.
A literatura relata que o primeiro molar inferior
decíduo representa o dente mais afetado pela in-
fraoclusão. Os segundos molares inferiores e os
segundos molares superiores decíduos estão em
80
1,7,8
segundo e terceiro lugares, respectivamente
Não raramente, a infraoclusão dos molares de-
cíduos é acompanhada pela agenesia do dente
para evidenciar a etiologia genética comum entre
essas duas anomalias9,10.
A infraoclusão é classificada de acordo com
seu grau de severidade11,12. Como demonstra a
Figura 1, o grau suave representa uma forma de
infraoclusão na qual o molar anquilosado situa-se
1-2 mm aquém do plano oclusal5,11-13. O grau mo-
derado é visualizado quando a superfície oclusal
do dente afetado encontra-se no nível do ponto de
contato dos dentes adjacentes5,11-13. Finalmente, o
grau severo é identificado quando o molar decí-
duo situa-se abaixo do ponto de contato interproxi-
mal dos dentes vizinhos5,11-13.
Muito embora a infraoclusão possa ocorrer
desde estágios muito precoces do desenvolvimen-
to oclusal, ou seja, na dentadura decídua, a maior
frequência da infraoclusão é visualizada na denta-
dura mista14. Essa alteração pode ocasionar uma
redução no perímetro da arcada, extrusão do den-
te antagonista, defeito ósseo vertical no molar em
. infraoclusão e, em casos mais severos, a submersão
gengival do molar decíduo seguida da impacção
do pré-molar sucessor, como ilustra a Figura 211,15.

A B C

Figura 1: Representação dos diferentes graus de severidade da infraocusão de molares decíduos. No grau suave (A), o molar
anquilosado situa-se 1-2 mm aquém do plano oclusal. No grau moderado (B), a superfície oclusal do molar acometido encontra-se no
nível do ponto de contato dos dentes adjacentes. A infraoclusão severa (C) é reconhecida quando o molar decíduo situa-se abaixo do
ponto de contato interproximal dos dentes adjacentes.

© Dental Press Publishing | Rev Clín Ortod Dental Press. 2018 Out-Nov;17(5):79-89
 Infraoclusão de molares decíduos: definindo condutas na dentadura mista

A B C

D E F

81

G H

I J

Figura 2: Paciente do sexo masculino, com 15,5 anos de idade, apresentando infraoclusão severa do dente #55 em uma posição
subgengival. Clinicamente, o dente #15 mostrava-se ausente (A-H). A radiografia panorâmica demonstra que o segundo molar
decíduo esquerdo estava intraósseo, devido a uma infraoclusão severa (I). Como consequência, o segundo pré-molar sucessor ficou
impactado, pela inabilidade de reabsorver o esmalte dentário (J).

© Dental Press Publishing | Rev Clín Ortod Dental Press. 2018 Out-Nov;17(5):79-89
 Garib DG, Maranhão OBV, Alves ACM, Freitas MR, Sathler RC
Ressalta-se que a infraoclusão dos molares decí-
duos, em condições normais, não interfere na erup-
ção do pré-molar sucessor, que irrompe esponta-
neamente, no máximo demonstrando um pequeno
atraso médio de 6 meses em relação à norma16.
Apesar da alta prevalência de infraoclusão, as
condutas clínicas descritas na literatura são diversas
2,12,17,18
e o assunto ainda suscita dúvidas
objetivo do presente trabalho consiste em descrever
um protocolo de conduta que guie o ortodontista, o
odontopediatra e o clínico geral diante de molares
decíduos em infraoclusão. Dois fatores serão consi-
derados na tomada de decisão: a presença do su-
cessor permanente e o grau de infraoclusão.
CONDUTA CLÍNICA NA PRESENÇA DE
SUCESSOR PERMANENTE
Infraoclusão de grau suave ou moderado
Quando o pré-molar sucessor está presente, o clí-
nico deve averiguar o grau de infraoclusão antes da
tomada de decisão13. Quando a infraoclusão é leve
82
ou moderada, o molar decíduo ainda funciona como
mantenedor de espaço na arcada dentária e deve
ser preservado. A conduta é apenas monitorar o de-
senvolvimento da dentição: clinicamente, de 6 em 6
meses, e radiograficamente de 2 em 2 anos13,19,20.
Normalmente, nesses dois graus, ocorre a esfoliação
espontânea do molar decíduo, sem problemas as-
11,12
sociados . A extrusão do dente antagonista não
deve ser uma preocupação se existir oclusão com os
dentes vizinhos ao molar em infraoclusão.
A reconstrução dos molares com resina com-
posta parece representar um sobretratamento, pois
a literatura evidencia que a esfoliação espontânea
do molar decíduo em infraoclusão não depende
9,16,21
da incidência de forças oclusais
A Figura 3 exibe o caso de uma paciente acom-
panhada a partir do período intertransitório da den-
tadura mista. Foi observada infraoclusão suave dos
dentes #74, 84 e 85. Após controle da erupção,
© Dental Press Publishing | Rev Clín Ortod Dental Press. 2018 Out-Nov;17(5):79-89
observou-se que os sucessores permanentes alcança-
ram o nível oclusal de acordo com as condições de
normalidade. A Figura 4 demonstra outro caso de
paciente do sexo feminino com infraoclusão do #74
e do #84, em que o acompanhamento longitudinal
demonstrou o potencial de erupção espontânea dos
sucessores permanentes.
. Assim, o Apesar da conduta conservadora e proservativa,
a ocorrência da infraoclusão dos molares decíduos
pode funcionar como fator de risco para o desenvol-
vimento de outras anomalias dentárias no transcorrer
da dentadura mista. A Figura 3 demonstra um caso
de associação da infraoclusão dos primeiros molares
decíduos inferiores com o atraso eruptivo dos segun-
dos pré-molares inferiores. Observa-se que a ordem
de erupção foi invertida, com os segundos molares
inferiores irrompendo antes dos segundos pré-mola-
res inferiores. As duas ocorrências não devem ser
compreendidas como relação de causa e efeito,
mas sim dois fenótipos distintos decorrentes de uma
origem genética comum5,22.
Infraoclusão de grau severo
Em casos de infraoclusão severa, indica-se a
exodontia do molar decíduo, seguida de mantene-
dor de espaço (Fig. 5 a 7)12,23. Os recuperadores
de espaço também devem ser considerados quan-
do alguma redução significativa do perímetro da ar-
cada dentária for observada no momento do diag-
nóstico5,12. A justificativa para essa conduta mais in-
vasiva centra-se no fato de que os molares decíduos
em infraoclusão severa não podem mais funcionar
como mantenedores de espaço5. Além disso, o
grau de severidade da infraoclusão aumenta o ris-
co da ocorrência de submersão gengival do molar
. decíduo, caso o paciente não retorne às consultas5,
como demonstra o caso ilustrado na Figura 2. A po-
sição subgengival do molar decíduo provoca a im-
pacção do sucessor permanente, pela inabilidade
de reabsorver o esmalte dentário (Fig. 2).
 Infraoclusão de molares decíduos: definindo condutas na dentadura mista

A B Figura 3: Paciente apresentando

infraoclusão suave dos dentes #74, 84
e 85, com a presença dos sucessores
permanentes. Foi realizado o
acompanhamento radiográfico anual (A, B),
no qual se observou o atraso eruptivo dos
dentes #35 e 45 (C), que concluíram seu
processo de erupção depois dos segundos
C D
molares permanentes (D).

A B 83

C D

E F

Figura 4: Paciente do sexo feminino

apresentando infraoclusão dos dentes #74
e 84 (A, B). Ao longo do acompanhamento
clínico e radiográfico, foi observada a
erupção espontânea e adequada dos
G H
sucessores permanentes (C-H).

© Dental Press Publishing | Rev Clín Ortod Dental Press. 2018 Out-Nov;17(5):79-89
 Garib DG, Maranhão OBV, Alves ACM, Freitas MR, Sathler RC
CONDUTA CLÍNICA NA AUSÊNCIA DO
SUCESSOR PERMANENTE
A infraoclusão determina um defeito ósseo
vertical progressivo em torno do molar decíduo.
Esse defeito ósseo é explicado pela tentativa
de manter constantes as distâncias biológicas.
Dessa forma, o molar em infraoclusão apresenta
uma junção amelocementária deslocada para
apical, relativamente aos dentes vizinhos, e a
crista óssea migra para apical em igual propor-
24
ção . Quanto maior a severidade da infraoclu-
são, maior o defeito ósseo vertical visualizado
em radiografais periapicais24,25.
Quando o molar decíduo em infraoclusão
apresenta o sucessor permanente, a erupção do
pré-molar é acompanhada pela migração oclusal
do osso alveolar, normalizando o defeito ósseo
15,25
vertical . Nesse caso, diz-se que o defeito ós-
seo apresenta um carácter reversível. Por outro
lado, quando o molar decíduo em infraoclusão
não apresenta sucessor permanente, o defeito
84
26
ósseo demonstra um carácter irreversível . Tera-
peuticamente, não é possível restabelecer a altu-
ra óssea do rebordo alveolar com enxerto ósseo.
Os enxertos ósseos são bem-sucedidos para res-
tabelecer a largura vestibulolingual do rebordo
alveolar desdentado.
Nas situações em que o paciente ainda se
encontra em fase de crescimento, a exodontia do
molar em infraoclusão sem sucessor permanente
previne a progressão da perda óssea vertical signi-
27
ficativa antes da reabilitação . Em um de seus es-
tudos, Ostler e Kokich avaliaram as alterações em
altura e largura do rebordo alveolar em pacientes
com agenesia de segundo pré-molar inferior e in-
fraoclusão do antecessor decíduo. Quanto mais
© Dental Press Publishing | Rev Clín Ortod Dental Press. 2018 Out-Nov;17(5):79-89
tarde os molares decíduos foram extraídos, maior
a perda óssea alveolar vertical avaliada em radio-
grafias panorâmicas27,28. Por outro lado, a perda
óssea vertical após a exodontia dos molares decí-
duos em infraoclusão foi desprezível (2%). A perda
óssea no sentido vestibulolingual sofreu uma redu-
ção de 25% após 10 anos de acompanhamento
longitudinal, visualizada em modelos dentários28.
Kokich relatou ainda que, devido à complexidade
da exodontia tardia do molar decíduo anquilosado,
torna-se necessário, em alguns casos, desgastar o
osso alveolar durante o procedimento cirúrgico27.
Essa manobra reduz a espessura óssea e aumenta
as chances de necessidade de enxerto ósseo pre-
viamente à reabilitação protética27.
Diante dessas evidências, a conduta mais coe-
rente frente à infraoclusão e agenesia do sucessor
permanente é a exodontia do molar decíduo no
momento do diagnóstico. A exodontia do dente
anquilosado, nesse momento, evita a progressão
do defeito ósseo vertical, quando comparada à
situação em que o dente em questão é mantido
em boca26. Essa conduta é corroborada por ou-
tros autores13,29,30. Em resumo, sempre que houver
agenesia do pré-molar sucessor, independente-
mente do grau de infraoclusão, a exodontia do
molar decíduo deve ser considerada, com o ob-
jetivo de prevenir o incremento do defeito ósseo
vertical determinado pela infraoclusão. Nesses
casos, recomenda-se um mantenedor de espaço
fixo e o monitoramento do paciente até a den-
tadura permanente. O plano de tratamento or-
todôntico corretivo subsequente poderá ter dois
caminhos: o fechamento ortodôntico do espaço
ou a manutenção do espaço para reabilitação
com prótese/implante11,12,31.
 Infraoclusão de molares decíduos: definindo condutas na dentadura mista

A B C

D E F

85

G H I

Figura 5: Paciente do sexo masculino,

encontrava-se no segundo período
transitório ao início do tratamento e
apresentava infraoclusão severa dos dentes
#55, 65 e 75 e moderada do #85 (A-H).
Nessa época, os dentes #15, 25, 35 e 45
J K
se encontravam no estágio 7 de Nolla (I).
Como forma de tratamento, optou-se
inicialmente pela exodontia do #55 e 65,
seguida por uso do aparelho extrabucal
(AEB) com tração alta como mantenedor
de espaço (J-M). Após acompanhamentos
clínicos mensais, foi realizada exodontia do
#75 e instalado arco lingual de Nance como
L M
mantenedor de espaço.

© Dental Press Publishing | Rev Clín Ortod Dental Press. 2018 Out-Nov;17(5):79-89
 Garib DG, Maranhão OBV, Alves ACM, Freitas MR, Sathler RC

A B

C D E

86

F G

Figura 6: A erupção dos dentes #15 e #25 do caso retratado inicialmente na Figura 5
ocorreu após utilização de mola de secção aberta entre o #14 e o# 16 e entre o #24 e o #26.
Não foi necessária nenhuma mecânica ortodôntica para a erupção do #35 e do #45.

© Dental Press Publishing | Rev Clín Ortod Dental Press. 2018 Out-Nov;17(5):79-89
 Infraoclusão de molares decíduos: definindo condutas na dentadura mista

A B C

D E F

87

G H I

Figura 7: Controle de 10 anos após o tratamento do caso apresentado nas Figuras 5 e 6, onde foi observada estabilidade da oclusão.

DISCUSSÃO estudos com animais demonstrou a anquilose em

A infraoclusão é comumente relacionada à an-
quilose dentária e, por isso, não é raro encontrar
na literatura uma associação entre os conceitos
dessas duas alterações12,32. Sabe-se que um den-
te anquilosado não pode mais se desenvolver no
sentido vertical e fica progressivamente em infrao-
clusão. A anquilose dentária nem sempre pode
ser averiguada radiograficamente (dependendo
do grau) ou por meio da tomografia computado-
rizada de feixe cônico. A análise histológica em
dentes em infraoclusão13,32.
A infraoclusão não é o único problema associa-
do à anquilose dos molares decíduos, já que, quan-
to mais tarde essa alteração de erupção for diag-
nosticada, mais graves serão os efeitos deletérios
gerados, em razão da falta de intervenção e plane-
jamento precoce1,5. A infraoclusão abre passagem
para alterações na angulação dos dentes adjacen-
tes, redução do perímetro da arcada, desvio da
linha média e extrusão do dente antagonista15,25.

© Dental Press Publishing | Rev Clín Ortod Dental Press. 2018 Out-Nov;17(5):79-89
 Garib DG, Maranhão OBV, Alves ACM, Freitas MR, Sathler RC

Tabela 1: Protocolo de conduta clínica adotado pelos autores para palatino e as transposições dentárias, tam-
para infraoclusão de molares decíduos na dentadura mista.
bém são “primos” genéticos da infraoclusão dos
GRAU DE PRESENÇA DE AUSÊNCIA DE molares decíduos3,6. Sob esse prisma, crianças
INFRAOCLU- SUCESSOR PER- SUCESSOR
com infraoclusão de molares decíduos devem ser
SÃO MANENTE PERMANENTE
Acompanhamento
monitoradas durante o segundo período transitório
Suave
longitudinal da dentadura mista, para um diagnóstico e inter-
Exodontia do
Acompanhamento venção terapêutica precoce das ectopias dos ca-
Moderado molar decíduo
longitudinal
e instalação de ninos superiores permanentes.
Exodontia do molar mantenedor de
decíduo e instala- espaço
O tratamento de escolha deve ser o mais con-
Severo
ção de mantenedor servador possível em longo prazo, de modo a
de espaço
evitar sobretratamento ou condutas que poderão
contribuir negativamente para a reabilitação futu-
Por isso, é imprescindível que o cirurgião-dentis- ra. Tratamentos alternativos à exodontia do molar
ta saiba diagnosticar corretamente, assim como decíduo em infraoclusão ou ao acompanhamento
escolher a melhor forma de intervenção. Na Ta- clínico e radiográfico (em casos suaves a modera-
bela 1, é possível analisar um breve resumo da dos) podem resultar em maior tempo de tratamento
recomendação de condutas concernentes à e não trazem a certeza de sucesso na interven-
infraoclusão de molares decíduos. Um correto ção. Um exemplo disso é a restauração do molar
diagnóstico clínico e radiográfico é capaz de em infraoclusão visando estimular a esfoliação do
evitar o desenvolvimento de más oclusões e de- dente decíduo, ao promover o contato desse com
feitos ósseos periodontais33. seu antagonista. Essa forma de tratamento pode
88
A infraoclusão de molares decíduos não gera da- gerar dor decorrente da pericementite advinda do
nos ao processo de odontogênese dos pré-molares trauma oclusal; ainda, quando não é realizada
sucessores, e atrasos de até seis meses são consi- em supraoclusão, não garante o sucesso do tra-
5,16
derados aceitáveis . Atrasos maiores no desen- tamento em um período prolongado23. A luxação
volvimento dos pré-molares sucessores não apre- do molar em infraoclusão também foi relatada na
sentam relação de causa e efeito com a infraoclu- literatura como uma alternativa de tratamento12,23.
são dos molares decíduos. As agenesias dentárias Entretanto, seus resultados também não são efeti-
e o atraso eruptivo relevante dos segundos pré-mo- vos e recomendados12,23.
lares são anomalias associadas à infraoclusão dos
molares decíduos, provavelmente devido a uma CONCLUSÃO
4,5
origem genética comum . Essa associação não A infraoclusão de molares decíduos representa
deve ser compreendida de forma distorcida, ou uma anomalia dentária cujo tratamento tem rela-
seja, como uma relação de causalidade onde a in- ção direta com os diferentes graus de severidade
fraoclusão e a anquilose causariam o atraso erup- e com a presença ou ausência dos sucessores per-
tivo do pré-molar sucessor. Na realidade, a infrao- manentes. Cabe ao ortodontista reconhecer essa
clusão, a agenesia e o atraso eruptivo parecem anomalia e aplicar o protocolo de tratamento mais
pertencer à mesma família genética4,6. Aqui, faz-se adequado, conforme as necessidades individuais
importante um adendo: alguns distúrbios eruptivos, de cada paciente, priorizando um tratamento pre-
como a erupção ectópica dos caninos superiores ciso e sem sobretratamento.

© Dental Press Publishing | Rev Clín Ortod Dental Press. 2018 Out-Nov;17(5):79-89

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