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Original Article FREQUENCY OF MISSING MAXILLARY PERMANENT LATERAL INCISORS — A STUDY FARWA BATOOL 2 ALIA AHMED 3 SHARAZ AHMED 4 SAMAR E ZAHRA 1 ABSTRACT There are a number of dental anomalies and congenital absence of the teeth is relatively more common. These can cause the patient to seek treatment because of esthetic concern. The aim of this study was to determine the frequency of agenesis of maxillary permanent lateral incisors. A total of 364 outdoor patients, both male and female, were included in the study from age 12 to 40 years. The data was collected and entered in a proforma and was analyzed by using SPSS 17.0. The results showed that only 1.6% of patients had congenitally missing permanent maxillary lateral incisors, with equal distribution within each gender i.e. male 1.7% and in female 1.6%. It was found that all cases have missing permanent maxillary lateral incisors unilaterally with no bilateral distribution. It was concluded that prevalence of congenitally missing maxillary lateral incisor is very low in our population. Key Words: Agenesis, hypodontia, maxillary lateral incisor. INTRODUCTION Smile esthetics is considered critical because of its enormous psychological impact on a person. A pleasant smile boosts an individual's confidence and a good dentition, with a proper soft and hard tissue balance can achieve this goal. Teeth which are visible during smile form the esthetic zone and are vital for achieving esthetic balance. While considering hard tissue dentition any rotated, crowded or missing teeth can lead to unaesthetic smile. A number of causes can lead to missing teeth, for example, either they are impacted or they fail to develop altogether (tooth agenesis). The term ‘hypodontia’ is used for congenital absence of one or more teeth, either in primary or permanent dentition, excluding the third molars.1 It is more prevalent in permanent dentition than the primary dentition2 and females are more frequently affected than males.1,3 Hypodontia can be associated with a syndrome or can occur independently. Dr Farwa Batool, BDS, IIDC, Riphah International University Email: [email protected] Cell: 0336-610-2174 Correspondence Address: House No. 152, Street 1, Sector 1, Airport Employees Housing Society, Rawalpindi 2 Dr Alia Ahmed, BDS, FCPS, Professor Operative Dentistry IIDC, Riphah International University. Address: House No. 124-A, Street 46, I-8/2, Islamabad 3 Dr Sheraz Ahmed, BDS, IIDC, Riphah International University. Received for Publication: April 28, 2016 Revised: June 7, 2016 Accepted: June 7, 2016 1 Agenesis of lateral incisors can occur unilaterally or bilaterally, negatively affecting the smile esthetics. Various syndromic conditions (Ectodermal dysplasia, van der Woude syndrome, Down’s syndrome, Rieger syndrome and Book syndrome) can lead to missing lateral incisors,1,3,4 but mostly the problem is encountered in healthy individuals (non-syndromic hypodontia.3,4 Etiological factors for non-syndromic hypodontia are changes in the dental lamina formation, failure of tooth germ to develop at the optimal time, space limitations and genetic factors.4,5,6 Owais et al evaluated the prevalence of missing maxillary lateral incisors in a sample of 500 orthopantomogram (OPG) and they found that 4.16% maxillary lateral incisors missing.7 Similarly another study revealed that the ratio of bilateral to unilateral absence of maxillary lateral incisor teeth was 2:3.8 The present study was aimed to establish the frequency of missing maxillary lateral incisors at hospital setting in order to acquire prevalence in general population of the city and to reach early diagnosis and carry out management at an early age. METHODOLOGY The prospective cross sectional study was carried out at outdoor patients department of Islamic International Dental Hospital, Islamabad, from June 2015 to Pakistan Oral & Dental Journal Vol 36, No. 2 (April-June 2016) 301 Frequency of missing maxillary lateral incisors November 2015. Non-probability purposive technique was applied. Before the start, study was approved by ethical review committee of the institute. Subjects were selected according to inclusion and exclusion criteria (Table 1). A Proforma was designed for data collection. 364 subjects, both male and female, of age from 12 to 40 years were examined and results were filled on this proforma. The lower age limit of 12 years was taken so, as to allow lateral incisors to fully erupt into oral cavity. Informed consent was taken from the patients. The examination was carried out by using routine diagnostic instrument i.e. dental mirror, which was used to retract upper lip of the patient by the researcher. A periapical radiograph was taken if permanent maxillary lateral incisor was found missing on clinical examination. Panoramic radiograph had been advised to patient if required. SPSS (statistical package for social sciences) 17.0 was used to enter and analyze the data. Frequencies and percentages were described for qualitative variables (gender, missing maxillary lateral incisors). Effect modifiers such as gender, tooth position were controlled by stratification. An arbitrary value of p<0.05 was considered significant. RESULTS In the present study 180 male and 184 female were examined from a total of 364 people. This study found that 1.6% of subjects had missing maxillary lateral incisors. Out of 180 males 3 (1.7%) had missing maxillary lateral incisors and out of 184 females 3 (1.6%) had missing maxillary lateral incisors. All 6 missing maxillary lateral incisors were unilateral. No bilaterally missing maxillary lateral incisors were found among 364 subjects. The prevalence of missing maxillary lateral incisor is summarized in Table 2. TABLE 1: INCLUSION AND EXCLUSION CRITERIA Exclusion criteria Inclusion criteria Patients who, has been diagnosed with any syndrome due to which they have • Patient aged 10-40 years. shown feature of hypodontia. First trimester pregnant female, to avoid over dosage of radiation. Both male and female have been included. Patients who has previous history of extraction and radiographic (periapical/ panoramic) evidence of mineralization. Traumatic avulsion Impacted incisors Uncooperative patient Medically compromised patient TABLE 2:PREVALENCE OF UNILATERAL VS BILATERAL MISSING LATERAL INCISORS WITHIN GENDER Gender Missing lateral Unilateral incisors missing Count Female Male 3 3 6 % within gender 50.0% 50.0% 100.0% % of Total 1.6% 1.7% 1.6% % within missing lateral incisors Bilateral present Count .8% .8% 1.6% 181 177 358 % within gender 50.6% 49.4% 100.0% % of Total 98.4% 98.3% 98.4% Count 49.7% 48.6% 98.4% 184 180 364 % within gender 50.5% 49.5% 100.0% % of Total 100.0% 100.0% 100.0% 50.5% 49.5% 100.0% % within missing lateral incisors Total Total % within missing lateral incisors Pakistan Oral & Dental Journal Vol 36, No. 2 (April-June 2016) 302 Frequency of missing maxillary lateral incisors TABLE 3: CHI SQUARE TEST COMPARISON OF PREVALENCE OF MISSING LATERAL INCISORS BY GENDER Value Df Asymp. Sig. (2-sided) Pearson Chi-Square .001a 1 .978 Continuity Correctionb .000 1 1.000 Likelihood Ratio .001 1 .978 Fisher's Exact Test Linear-by-Linear Association .001 N of Valid Cases 364 1 Exact Sig. (2-sided) Exact Sig. (1-sided) 1.000 .647 .978 a. 2 cells (50.0%) have expected count less than 5. The minimum expected count is 2.97. b. Computed only for a 2x2 table When applying chi-square to determine any significant gender difference it was seen that male and female had equal chance of having unilateral missing maxillary lateral incisors (Table 2). And the difference is not statistically significant at a p value of 0.05. Since the p value has been calculated as 0.978, it shows that the association between gender and missing maxillary lateral incisors is very weak (Table 3). DISCUSSION In the maxillary anterior region (esthetic zone), maxillary lateral incisor is the most common congenitally missing permanent tooth, representing approximately 20% of all dental anomalies. 9,10 Muller observed that in a North American population, the maxillary lateral incisor was the most frequently missing tooth in individuals with agenesis of only one or two teeth. The frequency of missing lateral incisors reported by Amin F11 et al was 2.17%. Their study was conducted on 230 orthodontic patients between the chronological ages of 10 and 32 years (mean age 16.6 years), with 84 males and 146 females. They have reported the unilateral tendency of missing maxillary lateral incisor, and females had more tendencies towards hypodontia than males. In studies of Al- Emran and Al-Humayani F12 maxillary lateral incisors agenesis was reported as comparatively low as 0.6% and 0.7%. In another cross sectional study conducted in India prevalence of missing lateral incisors was 0.3%.2 There has been reports on country to country and racial variation in hypodontia.8 The reported prevalence of missing teeth, excluding the third molars in both sexes combined, varies from as high as 10.1% in the Norwegian population13 and as low as 0.3% in the Israeli population. The prevalence of hypodontia investigated in Australian orthodontic patients was 8.1 percent while in Japanese orthodontic patients the prevalence was 8.5 percent.14 The prevalence in Mexican orthodontic patients was 2.7 percent.15 Karadas et al16 studied a Turkish subpopulation for the distribution and frequency of tooth number anomalies. They have reported that the agenesis of maxillary lateral incisors in females (2.54%) were higher as compared to the males (1.93%). There were equal distribution of absent maxillary lateral incisors between bilateral (1.13%) and unilateral (1.13%). Difference between genders according to unilateral or bilateral maxillary lateral incisors was not statistically significant. Current study examined 180 male and 184 female from a total of 364 people. This study had found that 1.6% of subjects had missing maxillary lateral incisors, which was within the range of above mentioned prevalence i.e. 0.3 to 10.1%.2,7,11,12,13,14,15 There was an equal distribution of missing maxillary lateral incisors within each gender i.e. (1.7%) in males and (1.6%) in females (Table 3). All 6 missing lateral incisors were unilateral. No bilaterally missing lateral incisors were found among 364 subjects. Limitation of the present study was small sample size and wide range of age which was in contrast to the studies mentioned before, which can have an impact on the result as the actual prevalence of hypodontia in the larger population may be different. The selection of limited age range could be the cause of higher prevalence in previous studies. However the greater age range (12-40 years) was selected for this study. Most of the above mentioned studies have been conducted in orthodontic population of patient which is the reason of their high prevalence rate.7,11 The greater female to male ratio in previous studies showed the more esthetic concern in the female population. In addition, differences between populations of patients seeking treatment may possibly reflect different psycho-social aspects between regions. It is thus probable that in countries where smile aesthetics are highly valued, maxillary lateral incisor hypodontia Pakistan Oral & Dental Journal Vol 36, No. 2 (April-June 2016) 303 Frequency of missing maxillary lateral incisors may motivate parents and patients to seek treatment. The current study was carried out at the local dental hospital setting. Therefore these results represent only the population who is visiting only specific dental hospital, which is a source of bias. Nonetheless, the results give some idea of the situation in the city as a whole. Previous studies which have shown lower percentage of population showing missing maxillary lateral incisors probably because of these studies were conducted on general population instead of orthodontic patients only as well. For future studies a large sample size from whole general population should be used to obtain prevalence and overcome bias. CONCLUSION Following results has been obtained for prevalence of missing maxillary lateral incisors. 4 Liu P-R, Ramp LC. Restoration of congenitally missing lateral incisors after orthodontic treatment. Semin orthod 2013; 19(1): 49-52. 5 Cakan DG, Ulkur F, Taner T. The genetic basis of dental anomalies and its relation to orthodontics. Eur J Dent. 2013 Sep; 7(Suppl 1): S143-7. doi: 10.4103/1305-7456.119092. 6 White SC, Pharoah MJ editors. Oral Radiology: Principles and Interpretation. 6th ed. St Louis: Mosby; 2009. p298. 7 Durrania OK, Bashir U, Shamsher M. Prevalence of tooth agenesis in orthodontic patients at Islamic International Dental Hospital. PODJ. 2010; 2(2): 48-51. 8 Foater TD. Menezes DM: The assessment of Occlusal features for public health planning purposes. Am J Orthod Dentofacial Orthop 1976; 63: 83-90. 9 Fekonja A. Hypodontia in orthodontically treated children. Eur J Orthod. 2005; 27: 457-60. 10 Kavadia S, Papadiochou S, Papadiochos I, Zafiriadis L. Agenesis of maxillary lateral incisors: A global overview of the clinical problem. Orthodontics (Chic) 2011; 12: 296-317. • Prevalence for missing maxillary lateral incisors which has been calculated was very low i.e. 1.6%. 11 Farhat Amin, SA. Agenesis and malformation of maxillary lateral incisors in orthodontic patients, a study. Annals 2011; 17(4): 347-51. • There was equal male to female ratio for missing lateral incisors. 12 Al-Humayani F. Agenesis and malformation of maxillary lateral incisors in Saudi Arabian female students. Egyptian dental journal 2005; 51: 1-6. • All permanent maxillary lateral incisors were unilaterally absent. 13 Nordgarden H, Jensen JL, Storhaug K. Reported prevalence of congenitally missing teeth in two Norwegian counties. Community Dent Health. 2002; 19: 258-61. REFERENCES 14 Endo T, Ozoe R, Kubota M, Akiyama M, Shimooka S. A survey of hypodontia in Japanese orthodontic patients. Am J Orthod Dentofacial Orthop. 2006; 129: 29-35. 1 2 3 Anziani H1, Cole B, Hobson R. An unusual dental anomaly in a hypodontia patient. Dent Update. 2010 Dec; 37(10): 691-2, 694-95. Pushparaja Shetty AA , soniya Adyanthaya, Sreelatha SV. The prevalence of hypodontia and supernumerary teeth in 2469 school children of the Indian population: an epidemiological study. Indian J stomatol 2012; 3(3): 150-52. Stevenson B, Patel D, Ricketts D, Cord A. The orthodontic-restorative interface in patients with hypodontia: the patient's journey. Dent update 2013; 40(5): 354-60. 15 Silva Meza R. Radiographic assessment of congenitally missing teeth in orthodontic patients. Int J Paediatr Dent. 2003; 13: 112-16. 16 Karadas M, Celikoglu M, Akdag MS. Evaluation of tooth number anomalies in a subpopulation of the North-East of Turkey. Eur J Dent 2014; 8: 337-41. CONTRIBUTIONS BY AUTHORS 1 Farwa Batool: 2 Alia Ahmed: 3 Sharaz Ahmed: 4 Samara E Zahra: Main author, designed the work, collection of data, statistical analysis and interpretation of the data ,wrote the article Statistical analysis, final approval of the version. Reviewed the article. Helped in data collection. Pakistan Oral & Dental Journal Vol 36, No. 2 (April-June 2016) 304