Transverse Discrepancies

Dr. Tassneem Elagib, M.S

(Orthodontics, Korea), B.D.S
(Sudan)
 Hypodontia
• Hypodontia is a word used to describe missing teeth. The term is used
when there is congenital absence of one or more primary or secondary
teeth.
• In Caucasians the most common absent teeth within the dentition are:
●● L5s = lower second premolars
●● U2s = upper lateral incisors
●● U5s = upper second premolars
●● L1s = lower central incisors
 Classifying Hypodontia
Mild cases would present with one to two missing teeth.
Moderate cases would present with three to five missing teeth.
Severe cases would present with six or more missing teeth.
 Other than hypodontia, there are two other terms that are used when
describing missing teeth, depending on how many missing teeth there
are:
●● Hypodontia: fewer than six missing teeth.
●● Oligodontia: more than six missing teeth.
●● Anodontia: a total loss of teeth.
Aetiology of Hypodontia
Genetic factors:
●● Family pattern/history of hypodontia.
●● Not always necessarily the same tooth/teeth.
Local factors:
●● Cleft lip and palate due to disruption in the dental lamina.
Syndromes:
●● Down’s syndrome.
●● Hemifacial microsomia.
Other Medical Conditions (Cleft lip and palate, Ectodermal dysplasia).
 Factors Associated with Hypodontia
• Delayed dental development: on the lower arch the mandibular second
premolars are the last teeth to form, followed by the maxillary second
premolars. Radiographically these teeth are not visible until the age of
9, so it is important that their absence should be treated with care.
• Microdontia: peg laterals can be seen with hypodontia and all small
teeth, which is known as dento‐alveolar disproportion.
• Impacted canines: impacted canines can occur due to missing laterals or
microdontia laterals.
• Abnormal tooth positions: teeth can migrate into any available space,
which can lead to tipping and rotation.
Missing UR2 with peg lateral.
• Alveolar atrophy: in hypodontia spaces alveolar bone shrinks, which
makes tooth movement and implant placement in adult patients more
difficult.
• Retained deciduous teeth: patients who have gone past the normal
sequence of eruption of the second permanent dentition and still
present with retained deciduous teeth should be taken with care.
 Treatment of Hypodontia in Deciduous
Teeth
• is used mainly for psychological reasons. This can be in the form of a
denture to help with and improve aesthetics and function.
Treatment of Hypodontia in Permanent Teeth

 Second premolars: two options can be considered when it comes to

missing second premolars:
• –– Close spaces and bring forward the first and second permanent
molars (6s and 7s) and allow the wisdom teeth to erupt if present.
• –– Open space for prosthetics such as an implant or a bridge.
 Upper lateral incisors:
• Close spaces and modify the canine to look like a lateral incisor.
• Open space for prosthetics such as an implant or bridge.
Hawley with pontic for UR2
 Lower central incisors: two options can be considered when it comes to
missing lower central Incisors
• Close space, especially in Class III, as it will help to retract lower teeth.
• Open space for prosthetics such as an implant or bridge.
 Supernumeraries
• A supernumerary tooth is an extra tooth. A supernumerary tooth is
found when there are excess teeth in the normal series.
• Prevalence of Supernumeraries:
• Affect 4% of Caucasians.
• ●● Males are twice as commonly affected as females.
• ●● The most common area in which supernumeraries are found is the
premaxilla region (80%).
• ●● The second most common area is the mandibular premolar region.
Aetiology of Supernumeraries

• Genetic factors: there could be a family history of supernumeraries.

• Local factors: supernumeraries could be due to hyperactivity within the
dental lamina.
Types of Supernumeraries
• There are four types of supernumeraries:
1. Conical, also known as mesiodens:
• Most common supernumerary.
• Occurs in the premaxilla.
• Looks peg shaped.
• Root formation is complete.
2. Tuberculate: Barrel shaped.
• Consists of multiple tubercles.
• Occurs in the premaxilla.
• Is often paired.
• Forms palatal to upper central incisors.
• Can impede eruption of upper central incisors.
• Root formation is often incomplete.
3. Supplemental:
• Resembles teeth of the normal series.
• Most common area is the maxillary lateral incisor region.
• Second most common area is the mandibular premolar region.
4. Odontome.
Factors Caused by Supernumerary Teeth

• There are two main factors that supernumerary teeth can cause:
●● Displacement of erupted teeth.
●● Impeded eruption, which can lead to impaction.
Clinical Features of Supernumeraries

• Failure of eruption: supernumerary teeth can impede the eruption of

surrounding teeth as they may lie in the path of the eruption.
• Diastema: a mesioden(s) present in the upper midline can cause a
diastema.
• Crowding: an erupted supernumerary can take up arch space, resulting
in crowding.
• Displaced or rotated teeth.
• Root resorption of adjacent teeth.
• Cystic change within the follicle of the supernumerary.
• Prevention of tooth movement.
Medical Conditions Associated with Supernumeraries

●● Cleft lip and palate

●● Cleidocranial dysplasia
●● Gardner’s syndrome.
Management of a Supernumerary

●● Leave it and monitor if there is no orthodontic treatment. In this case

the patient must have routine checks for any root resorption and cystic
change.
●● Extract and expose a permanent tooth if it is impacted.
●● Extract to allow for orthodontic treatment.
Impacted Canines
• Impaction of a canine is where there is failure of eruption due to
crowding or an obstruction within the dental arch. Obstruction could be
due to crowding, a supernumerary, or fibrous tissue.
• Development of the Maxillary Canine:
• Aetiology of Impacted Canine:
• Displacement of the crypt: displaced crypts can result in severely
displaced canines.
• Long path of eruption: the canine can go off course due to the long path
of eruption.
• Short‐rooted or absent upper laterals: the canines use the distal aspect
of the lateral incisors to find their path. If they are absent or small, the
canines can find it difficult to reach their destination.
• Crowding: not enough room for the canines can result in them being
displaced buccally, palatally, or less commonly horizontally.
• Retained deciduous canines: these can result in the permanent canine
losing its way because it is unable to erupt through its normal path.
• Genetics: studies show that impacted canines is an inherited trait.
Clinical Signs of an Impacted Canine

• Canine is unable to be palpated in the buccal sulcus by the age of 10

years.
• Retained deciduous canines are sturdy and not mobile.
• There is severe crowding and inadequate space within the dental arch,
with not enough room for the eruption of canines.
• Increased mobility or non‐vital maxillary central and lateral incisors
could be an indicator of advanced root resorption of these teeth.
Radiographic Signs of an Impacted Canine

• A palatal or buccal displaced canine using the parallax technique.

• The canine overlaps the lateral or central incisor root.
• The long axis of the canine is angled more than 25° to the vertical plane.
Management of Lingual/Palatal and Buccal Canines
• Lingual/Palatal Canines: Surgical Exposure: If the tooth is in a good
position, then an open or closed surgical exposure, prior to orthodontic
alignment, is considered to allow for the tooth to be extruded into the
correct position.
• Buccal Canine: Treatment may differ from palatally positioned canines.
●● Patients may have orthodontic treatment first to create space to see if
the canine will spontaneously erupt itself, as buccal canines have more of
a chance of eruption due to the thin mucosa and bone on the buccal
surface.
●● This is usually done for about six months.
●● If this does not work, surgical exposure is needed.
Surgical Removal

This is advised when:

●● The canine is in a very unfavourable position due to the risk of root
resorption to adjacent teeth if it is left.
●● Patients are poorly motivated.
●● There is severe crowding.
Auto Transplantation
●● This involves surgical removal of an impacted canine and implantation
of this tooth into its normal position within the maxillary alveolus.
●● Space needs to be created to accept the transplant.
●● It is not commonly done due to the risk of ankylosis.
Risks of Impacted Canines
• Resorption
• Transposition
• Ankylosis:
• is the biggest risk that can occur with surgical exposure of a
canine.