Download Tooth transposition–A literature review and a clinical case

Braz J Oral Sci. January-March 2006 - Vol. 5 - Number 16
Tooth transposition – A literature
review and a clinical case
Beatriz Silva Câmara Mattos1*
José Carlos Mesquita Carvalho1*
Márcio Matusita2*
Ana Paula Pereira Pinheiro Alves2*
1
D.D.S., Ph.D.
D.D.S.
*Department of Maxillofacial Surgery,Prosthesis
and Traumatology, School of Dentistry,
University of São Paulo, São Paulo, Brazil.
2
Received for publication: July 15, 2005
Accepted: December 14, 2005
Abstract
Tooth transposition is an anomaly in the position of teeth where two
teeth of the same maxillary quadrant change their position in the
dental arch. There are different types of transposition, classified
according to the involved teeth. The review of the etiology of tooth
transposition aims at identifying the factors related to its occurrence,
and the purpose of this study is to report a case of cleft lip. Studies
indicate higher prevalence of upper Canine – First Premolar
transposition compared to other types of transposition, as well as a
higher prevalence among females and of its unilateral occurrence.
Mx.C.P1 is also related to anomalies in tooth number, especially
with the agenesis of the lateral incisor. The clinical case of cleft lip
and upper Canine – First premolar transposition presented in this
study enables the discussion of aspects regarding the etiology of
tooth transposition and of predisposing factors. Both the Mx.C.P1
transposition and cleft lip and palate are related to genetic factors
and present a multifactorial inheritance pattern. The importance of
prevention and early detection of tooth transposition is reaffirmed,
aiming at minimizing the disturbances caused by tooth transposition.
Further research on the prevalence of tooth transposition in
populations with cleft lip and palate would yield a better insight
about the simultaneous occurrence of these dental and oral anomalies.
The therapeutic procedures for functional and cosmetic rehabilitation
of the reported patient are described.
Key Words:
tooth transposition, cleft lip and palate, tooth agenesis
Correspondence to:
Beatriz Silva Câmara Mattos
Faculdade de Odontologia - Universidade de
São Paulo
Av. Lineu Prestes, 2227
05589-900 Cidade Universitária, São Paulo,
SP - Brazil
Phone: (011) 55479547
Fax: (011) 51812229
E-mail: [email protected]
886
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Braz J Oral Sci. 5(16):953-957
Introduction
Tooth transposition is an anomaly described as the positional
interchange of two teeth in the same quadrant, altering their
normal position in the dental arch. Tooth transposition can
be complete, when both the tooth crown and the root are
transposed, or incomplete, when only the clinical crown is
transposed, but the root apex remains in relatively normal
position1. The five types of tooth transposition observed in
the upper jaw were classified by Peck and Peck2 according
to the teeth involved: 1. Canine – First premolar (Mx.C.P1);
2. Canine – Lateral incisor (Mx.C.I2); 3. Canine to first molar
position (Mx.C.M1); 4. Lateral incisor – Central incisor
(Mx.I2.I1); 5. Canine to central incisor position (Mx.C.I1).
Tooth transposition can hinder esthetic and functional
aspects of dentition. For this reason, it is important to know
the variables related to the etiology and prevalence of this
anomaly in order to establish possible preventive measures.
The etiology of tooth transposition is not yet clear, and the
various existing theories point to etiologic factors related to
the location of the transposition and to the dental elements
involved.
The position of the tooth crypt in the maxilla is determined
by the shape of adjacent structures, particularly of the teeth
located in the anterior maxilla3. Physiologic tooth migration
and tooth eruption path are extremely influenced by the
morphology and growth pattern of local bone tissues. The
eruption path, which generally follows root orientation, can
be influenced and altered by maxillary spaces, mechanical
obstructions and variations in the speed of growth3. The
upper canine, in its pre-eruptive stage, occupies a relatively
high position, adjacent to the apertura piriformis and above
the position occupied by pre-erupted premolars. Therefore,
upper canines present increased risk of ectopic eruption4.
Traumatic injuries to primary teeth and bone pathologies
such as cyst formation may cause displacement of permanent
tooth germs and lead to an abnormal eruption path. Yet, the
observation of a high incidence of retained deciduous canine
and permanent canine transposition has pointed towards a
cause-effect relationship. It is a matter of speculation whether
the retention of a deciduous tooth may cause the
displacement of its permanent successor or whether an
altered path of eruption may lead to the retention of the
deciduous tooth 5.
Mx.C.P1 transposition is currently considered a tooth
position anomaly caused by genetic factors, and presents a
multifactorial inheritance pattern2,6-8. According to Peck and
Peck 2, various observations corroborate the polygenic
inheritance theory, such as the high prevalence of dental
anomalies related to Mx.C.P1, its bilateral occurrence, familial
occurrence and the significant difference in prevalence among
males and females.
1. Prevalence
The overall prevalence of this anomaly has been reported to
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Tooth transposition – A literature review and a clinical case
be 0.4%, the incidence in males and females varied according
to the type of transposition considered 7,9-10 , with both
unilateral and bilateral occurrence 11 . The simultaneous
occurrence in both dental arches was not reported; neither
was the incidence in primary dentition.
Tooth transposition is more frequent and varied in the upper
jaw and canines are the teeth most frequently involved1,12-13.
Mx.C.P1 transposition is the most prevalent one4, with an
incidence of approximately 0.13% in the population,
representing 71% to 89.2% of the cases observed in the
maxilla10,12. A higher prevalence in females is reported, and
the following proportions have been observed: M1: F21, M1:
F1.552, M1: F3.86 and M2: F312. Similar frequencies in both
genders have also been described11. Although the bilateral
form may occur, the unilateral occurrence is more prevalent
(4: 1), and the left side is the most affected1,4-5. The incidence
varies according to the different populations studied, and a
higher prevalence of Mx.C.P1 is observed among Caucasian
subjects6. However, in a study of the Turkish population,
the maxillary canine-lateral incisor was the most frequent
transposition, and the same incidence for both sides of the
arch and for both sexes was also observed14.
The studies show a relation between Mx.C.P1 and variations
in the shape, size, number and position of teeth 4-5. The
absence of one or more permanent teeth was observed in
26% of the patients with one of the various types of tooth
transposition2 and high incidences of tooth agenesis, conoid
lateral incisors and/or supernumerary teeth are related to
canine transposition 15 . These anomalies are observed in
36.5% of the cases of canine transposition12. Tooth agenesis
(except for third molar agenesis) and conoid lateral incisors
were reported in 49% of the subjects with Mx.C.P1
transposition 6 . Budai et al. 13 reported the simultaneous
occurrence of tooth transposition and dental anomalies as
follows: tooth transposition and agenesis in 40% of the cases,
tooth transposition and conoid lateral incisors in 25% of the
cases and tooth transposition and retention of deciduous
teeth in 50% of the cases. The absence of one lateral incisor
or both was reported in about 25% of the Mx.C.P1 cases8. A
significant relation (p < 0.001) between lateral incisor
agenesis and Mx.C.P1 transposition was observed16.
2. Cleft lip and palate and tooth transposition
The related literature has thoroughly reported a higher
prevalence of variations in the shape, number and position
of teeth in subjects with cleft lip and palate, particularly in
teeth adjacent to the alveolar cleft17. Tooth agenesis is, for
the most part, determined and transmitted by autosomal
dominant inheritance with incomplete penetrance and
variable expression. The impact of environmental factors also
affects the etiology of these anomalies18-19.
Agenesis of the permanent lateral incisor is more frequent in
subjects with cleft lip and palate. According to Damante et
al.20, agenesis of the permanent lateral incisor is directly
Braz J Oral Sci. 5(16):953-957
related to the complexity of the cleft, and the permanent lateral
incisor is the most frequently absent tooth in cases of cleft
lip and palate. A higher incidence of agenesis is not limited
to the teeth in the alveolar cleft region; a significantly higher
incidence of agenesis of the upper second premolar has been
observed in cases of cleft lip and palate1,21. In a study of
eruption anomalies in canines adjacent to the alveolar cleft it
was observed that canines positioned distally to their primary
predecessors were always related to the presence of a
supernumerary incisor and, in one case, to the agenesis of
the first premolar22.
The related literature reports a delay of 0.5 years in the
development of teeth in patients with cleft lip and palate23,
as well as asymmetric tooth development between the healthy
and the affected maxillary segment. In addition, the teeth in
the affected segment present delayed development24-27. This
delay is more severe among young subjects, and, with age,
tooth development in these patients becomes progressively
similar to that in normal patients28.
The occurrence of Mx.C.P1 was reported in six cases of cleft
lip and palate (CLP), where two cases of bilateral CLP
presented bilateral tooth transposition, two cases of unilateral
CLP presented tooth transposition on the same side of the
cleft, and two cases of cleft of the secondary palate presented
unilateral tooth transposition1.
The case of incomplete, unilateral cleft of the primary palate
on the right side with transposition of the right canine
reported in this study presents bilateral agenesis of the
permanent lateral incisors and of the upper second premolars.
Tooth agenesis, the most frequent anomaly in human
dentition, is described as an autosomial dominant
characteristic. The simultaneous occurrence of lateral incisor
agenesis and Mx.C.P1 is reported as evidence of the influence
of genetic factors in tooth transposition2,6-7,16.
Clinical Case
The patient, a boy aged 12 years and 6 months, who had
undergone corrective surgery for unilateral cleft of the
primary palate on the right side, sought treatment at the
Outpatient Clinic of Oral and Maxillofacial Prosthesis, School
of Dentistry, University of São Paulo. Upon clinical analysis,
we observed bilateral absence of the upper lateral incisors,
retention of both the upper left primary canine and second
molar, and ectopic eruption of the upper right canine. The
upper central incisors were asymmetric, and the central
incisor adjacent to the alveolar cleft presented shape
anomaly, with converging proximal surfaces and reduced
width of the incisal third 29 (Figure 1). The panoramic
radiograph showed bilateral agenesis of the upper lateral
incisor, of the upper second premolars and of the upper and
lower third molars (Figure 2). Based on the concept of a
multidisciplinary approach and aiming to improve aesthetics,
oral health and function, and to attain stable results, the
Tooth transposition – A literature review and a clinical case
fundamental objectives of any treatment, the patient was
referred to orthodontic treatment.
Fig. 1 - Bilateral absence of the upper lateral incisors, retention of
the upper left primary canine and second molar, and ectopic eruption
of the upper right canine. Central incisor adjacent to the alveolar
cleft with shape anomaly (converging proximal surfaces and reduced
width of the incisal third).
Fig. 2 - Panoramic radiograph showing bilateral agenesis of the
upper lateral incisor, of the upper second premolars and of the upper
and lower third molars.
Discussion
The patient presented a very harmonic facial profile.
Orthognathic surgery was not considered because no
maxillomandibular discrepancy was observed. The
occurrence of bilateral anodontia of the upper permanent
lateral incisor and of the second premolar is in accordance
with observations of a higher prevalence of variations in the
number of teeth related to cleft lip and/or palate17,21. The
simultaneous occurrence of variations in the shape and
number of teeth corroborates the existence of a relation
between these two anomalies and Mx.C.P1 2,5-6,12, even in
cases of cleft lip and palate1. It is noteworthy that Mx.C.P1,
in particular, is today considered a tooth position anomaly
which results from the influence of genetic factors and
presents a multifactorial inheritance pattern, similarly to cleft
lip and palate.
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Braz J Oral Sci. 5(16):953-957
The location of tooth germs in the maxillary anterior region
and their eruption path are influenced by bone morphology
and development in this region and by spatial conditions3
and this may explain how the eruption path of the canine
was distally deviated in this cleft lip patient, causing the
observed tooth transposition. The ectopic eruption of the
upper right canine observed in this case characterizes
Mx.C.P1 in the maxillary quadrant where the cleft is located,
made more severe by the second premolar agenesis. The
canine transposed with the first premolar, whose eruption
and development were chronologically delayed, and erupted
mesially to the permanent first molar. The left canine was
located in the position of the lateral incisor and mesially to
the primary canine. However, this does not characterize
Mx.C.I2, because of the agenesis of the lateral incisor. In this
case, it is possible that the eruption path of the left canine
was mesially deviated due to the agenesis of the lateral
incisor. This led to the eruption of the canine where the lateral
incisor should be, and to the persistence of the primary canine.
Prevention, based on timely detection of variations in the
position of teeth by pediatric dentists, makes early diagnosis
and interceptive treatment possible, especially in cases
where there is retention of the deciduous teeth1,2,30. This is
beneficial to case evolution and reduces the incidence of
tooth transposition 5 . Late diagnosis of complete tooth
transposition, when the canine has already reached the
occlusal plane, prevents any attempt at its orthodontic
correction. Orthodontic correction in these cases would lead
to a greater risk of root interference and damage to both the
roots and supporting structures. Therefore, the tooth should
be positioned in the new sequence presented3,5.
Tooth transposition combined with the ageneses observed
in this case was esthetically and functionally compromising,
requiring orthodontic treatment. When both maxillary caninepremolar transposition and a missing maxillary lateral incisor
are present, the substitution of the premolar for the lateral
incisor may be an option to avoid prosthetic restorations31.
However, in this case, not only was there congenital absence
of the maxillary lateral incisors, but also of the second
premolars. This is what made this case so unique. The
treatment consisted in maintaining the canines in their
transposed position on both sides of the maxillary arch (Figure 3).
The delay in the spontaneous eruption of the right first
premolar led to the surgical exposure of its clinical crown for
orthodontic traction. Because of the reduced dimensions of
the left canine, congenital absence of the lateral incisor and
second premolar and because orthodontic correction of its
position would take longer, we opted for maintaining its new
position in the arch, even though this decision implied in its
prosthetic replacement. The tip of the cusp underwent
odontoplasty to mimic the anatomy of a lateral incisor
(Figure 3). Because of the bilateral impaction of the lower
second premolars, the lack of space32 and the congenital
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Tooth transposition – A literature review and a clinical case
absence of the maxillary second premolars, the orthodontic
planning involved the extraction of the lower second
premolars. Consequently, the patient attained correction of
the deviated maxillary dental midline with Angle’s Class I
relationship.
The prosthetic spaces corresponded to a lateral incisor in
the maxillary segment where the cleft and Mx.C.P1
transposition were located, and to a canine in the normal
segment. After a 6-month period of orthodontic retention,
and when occlusal stability was reached, the prosthetic
treatment was performed by means of resin-bonded bridges,
since the patient refused to be submitted to bone graft in the
alveolar cleft area and have implants placed in the prosthetic
spaces (Figure 4). Resin-bonded bridges were selected in
this case because they conserve the tooth structure of the
abutment teeth and are the best option in case of change of
future acceptance of bone graft and implants; they provide
satisfactory retention and occlusal stability; and they can
be quickly manufactured at a low cost. The treatment aimed
at attaining a group function relationship on the right and
left sides during lateral movements, so that the prosthetic
canine on the left side would not disengage the posterior
teeth during excursive movements of the mandible. The
Fig. 3 - After orthodontic treatment the prosthetic spaces corresponded
to a lateral incisor in the maxillary segment where the cleft and
Mx.C.P1 transposition were located, and to a canine in the normal
maxillary segment.
Fig. 4 - Prosthetic treatment performed by means of resin-bonded
bridges
Braz J Oral Sci. 5(16):953-957
objectives of the treatment were completely fulfilled.
Although the clinical case reported in this study is not a
complex cleft case, the simultaneous presence of bilateral
tooth agenesis of lateral incisors and second premolars, and
tooth transposition characterizes the strong influence of
genetic factors, following a multifactorial inheritance pattern.
It would be interesting to observe the prevalence of tooth
transposition in populations with cleft lip and palate, since
these anomalies are related to the same inheritance pattern.
In addition, the presence of the alveolar cleft alters bone
morphology and spatial conditions, which might influence the
location of the tooth crypt and the eruption path. The unilateral
cleft lip case reported in this study corroborates the higher
occurrence of unilateral Mx.C.P1, but contradicts the tendency
that has been reported in the related literature with regard to
side and gender in populations without cleft lip and palate.
Complete tooth transpositions, as seen in this case, do not
allow prevention or even orthodontic repositioning.
However, incomplete tooth transpositions, especially those
related to the retention of the primary teeth and intraosseous
deviation of permanent teeth might be prevented or
intercepted in order to reduce the complexity of the
orthodontic treatment.
The treatment of the case reported in this study has a threeyear follow-up. The resin-bonded bridges provided stability
of the results attained; the patient showed satisfaction and
good oral health. In addition, bone graft and implants are a
future possibility, since most of the tooth structure of the
abutment teeth has been preserved.
Tooth transposition – A literature review and a clinical case
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