CASE REPORT

Concomitant permanent maxillary canine

agenesis and transposition treated with
extractions and lingual brackets
~es,b Octavio Cintra,b
Isabela Parsekian Martins,a,b Renato Parsekian Martins,a,b Graça Guimara
a
and Ary Santos-Pinto
Araraquara, S~ao Paulo, Brazil

This case report describes the successful orthodontic treatment for a healthy woman with maxillary canine-
premolar transposition associated with rare hypodontia of the contralateral canine. The treatment included
extraction of the transposed maxillary right and deciduous maxillary left canines and 2 mandibular second pre-
molars. The objectives of the treatment were to (1) correct the upper midline deviation and the occlusal plane
cant, (2) move the maxillary first premolars into the canine position, (3) retract the mandibular incisors to improve
the facial profile, and (4) reduce the labial protrusion. Orthodontic treatment was carried out with the lingual tech-
nique in the maxillary arch and esthetic ceramic brackets in the mandibular arch. The segmented mechanics
were effective, fast, and consistently promoted the necessary movement without side effects. The smile line
was improved, resulting in an ideal and esthetic gingival exposition, with the borders of the maxillary teeth
following the lower lip smile curvature. The patient achieved ideal dentofacial esthetics, achieved better dental
and functional occlusion, was pleased with her improved facial contour, and as a result, showed an improved
self-image. (Am J Orthod Dentofacial Orthop 2020;157:550-60)

D
ental transposition is a rare condition that in- unilateral transpositions, although the bilateral occur-
volves positional interchange of 2 teeth.1-6 rence is most prevalent (11%-27% of dental anoma-
Maxillary canine–first premolar transposition af- lies).7,10,11 Another rare condition is the congenital
fects approximately 0.3% of the population3,5,7 and absence of canines. The teeth that most commonly
constitutes the most common dental transposition, exhibit hypodontia are the most distal teeth of each
with an incidence of about 58%-70%.3,7,8 Genetic and dental morphologic class, namely the third molars, the
multifactorial factors have an important etiologic role lateral incisors, and the second premolars. Previous
in this type of transposition. Environmental factors studies have shown that the prevalence of permanent
such as space discrepancy, deciduous alterations (cav- maxillary canine agenesis varies between 0.07% and
ities, periodontal problems, or abnormal root resorp- 0.13%. This condition has negative functional and
tion), and dental trauma can also contribute to the esthetic repercussions.12,13 From a functional point of
ectopic eruptions of the canines. Females show a greater view, the lack of a canine guide can interfere with ob-
prevalence of transposition, and this condition can be taining a mutually protected occlusion in the mastica-
associated with other dental alterations such as agenesis tory movements and with a proper function of the
or alterations in the shape of the lateral incisors.5,9,10 The temporomandibular joint. In addition, dentofacial es-
left side seems to be the more frequent location of thetics are impaired by the lack of one of the most
important components in the upper anterior region for
a
Department of Pediatric Dentistry and Orthodontics, Araraquara School of the definition of the harmony and beauty of the smile.
Dentistry, S~ao Paulo State University, Araraquara, S~ao Paulo, Brazil. Treatment alternatives for maxillary canine–first pre-
b
Private Practice, Araraquara, S~ao Paulo, Brazil.
All authors have completed and submitted the ICMJE Form for Disclosure of Po- molar transposition are dependent on the dental arch
tential Conflicts of Interest, and none were reported. space condition, the stage of dental development, the
Address correspondence to: Isabela Parsekian Martins, Department of Pediatric root position of the involved teeth, periodontal condi-
Dentistry and Orthodontics, Araraquara School of Dentistry, S~ao Paulo State Uni-
versity, Rua Humaita, 1680, Araraquara, S~ao Paulo, 14801-903, Brazil; e-mail, tions, and the type of malocclusion. The objective of
[email protected]. this case report is to describe the successful treatment
Submitted, August 2018; revised and accepted, December 2018. for a patient with maxillary canine-premolar transposi-
0889-5406/$36.00
Ó 2019 by the American Association of Orthodontists. All rights reserved. tion associated with rare hypodontia of the contralateral
https://doi.org/10.1016/j.ajodo.2018.12.026 canine.
550
Martins et al 551

Fig 1. Pretreatment facial and intraoral photographs.

DIAGNOSIS AND ETIOLOGY noticeable (Figs 1 and 2). The permanent right canine
showed a gingival recession and a thin osseous alveolar
A 16-year-old female sought orthodontic treatment covering. The deciduous maxillary left canine was well
in order to correct her anesthetic canine position and positioned but had a high degree of tooth wear. The
mandibular dental crowding. The patient exhibited a maxillary midline deviated to the right. The etiology of
Class I malocclusion, with the maxillary right canine this transposition has a significant genetic influence
transposed in the labial position and located the distal because it is associated with a rare absence of contralat-
position of the second premolar. In addition, the maxil- eral left canine.3,7,14
lary first premolar was mesially located in a distal posi- Complementary observation showed that the
tion to the right lateral incisor. Absence of the mandibular second premolars were in a lingual position
permanent maxillary left canine with prolonged pres- with other minor tooth irregularities resulting in a nega-
ence of the corresponding deciduous canine was also tive lower arch discrepancy.

American Journal of Orthodontics and Dentofacial Orthopedics April 2020
Vol 157
Issue 4
552 Martins et al

Fig 2. Pretreatment dental casts.

The panoramic radiograph showed a rare absence of TREATMENT ALTERNATIVES

the maxillary left canine and an unusual position of the Treatment alternatives for maxillary first premolar
right canine with an extremely distal root position (Fig transposition are based on the dental arch space condi-
3). The root of the deciduous left canine was short tion, stage of dental development, root position of the
because of physiological resorption. All third molars involved teeth, and type of malocclusion. The dental
were present with compatible age development. Cepha- arch discrepancy is usually present, and to correct the
lometric and facial analyses indicated that the patient arch space deficiency, extractions are recommended.
had a hyperdivergent growth pattern associated with a Furthermore, the extraction of the 4 first premolars is
convex profile and a shallow mentolabial fold, small the usual treatment choice for patients with Class I
labial protrusion, normal nasolabial angle, and a favor- malocclusion. The extraction of the transposed teeth
able sagittal maxillomandibular relationship (Table). represents a good option in some instances, reducing
the treatment time and complexity of the dental move-
TREATMENT OBJECTIVES ments required. When the dental arch discrepancy is null
Treatment options included the extraction of the or positive, and the roots are incomplete transposition, it
transposed maxillary right canine, deciduous maxillary is seldom preferred to leave the teeth in their original po-
left canine, and 2 mandibular second premolars. The ob- sition. This solution has a minor esthetic disadvantage,
jectives of the treatment were to (1) correct the upper but is significantly easier and faster, preventing root
midline deviation and occlusal plane caused by the resorption and gingival recession, and it is associated
canine transposition, (2) place the maxillary first premo- with low risk of failure compared with correction of
lars in the canine position, (3) retract the mandibular in- the order of the teeth. However, if the roots are partially
cisors to improve the facial profile (specifically the transposed, the correction of the transposition will
mentolabial angle), and (4) reduce the labial protrusion. depend upon the gingival condition (ie, the presence
Mandibular second premolars were indicated for extrac- of a sufficient amount of mucous tissue and on the
tions to facilitate the alignment of the mandibular teeth osseous thickness [large dentoalveolar process] when at-
and a slight retraction of the incisors to reduce the lower tempting to move the teeth to their correct positions). In
labial protrusion, and to improve the facial contour. Class II malocclusion, extraction of the 2 maxillary first
Because of esthetic concerns and wishes of the pa- premolars is often required, a situation that is favorable
tient, we proposed an orthodontic treatment with the toward correcting the transposition.
lingual technique in the upper arch and the use of After discussing the treatment alternatives with the
esthetic ceramic brackets in the lower arch. patient and explaining the benefits and expected

April 2020
Vol 157
Issue 4 American Journal of Orthodontics and Dentofacial Orthopedics
Martins et al 553

Fig 3. A, Pretreatment panoramic radiograph; B, pretreatment lateral cephalogram; C, pretreatment

cephalometric tracing.

Table. Cephalometric summary outcomes, it was decided to follow the course of treat-
ment involving the extraction of the transposed maxil-
Variable Pretreatment Posttreatment Average
lary right canine, deciduous maxillary left canine, and
SNA 81.7 81.7 82
SNB 76.4 77.5 80 2 mandibular second premolars.
ANB 5.3 4.1 2
IMPA 100.5 99.9 87 TREATMENT PROGRESS
FMA 24.4 23.4 25
S-N.Gn 71.5 70.9 76 Before the orthodontic treatment began, an oral
S-N.Ocl 15.4 17 14 maxillofacial surgeon extracted the right canine, and
(S-N).(Go-Me) 36.4 34.8 32 4 days after the extraction, lingual brackets were
(Go-Me).Ocl 19 15.1 18 placed on the maxillary teeth. The ORG lingual
1/.1/ 120 127 131
brackets (ORJ, Plano, TX) had a slot dimension of
1/.NS 103.5 98.3 103
1/.NA 21.8 18 22 0.018 3 0.030-inch and were bonded from the right
1/-NA mm 4.5 3.3 4 second molar to the left first molar. Leveling and
1/.NB 33.3 32 25 alignment were done with a 0.014-in nickel-titanium
1/-NB mm 7.4 6 4 (NiTi) archwire.

American Journal of Orthodontics and Dentofacial Orthopedics April 2020
Vol 157
Issue 4
554 Martins et al

Fig 4. A, Intraoral photograph during the second premolar rotation in the maxillary arch; B, intraoral
photograph during the leveling and alignment in the mandibular arch.

Fig 5. Progress photographs during the leveling and alignment.

Additional buttons were bonded in the labial crown In the lower arch, the second premolars were ex-
of the right second molar and second premolar. An tracted. Subsequently, esthetic appliances (Mini Gen
elastomeric chain was used to create a binary force to MBT brackets; ORJ, Hangzhou, China) with a slot
rotate the maxillary right second premolar. The elasto- dimension of 0.018 3 0.030-inch were bonded from
meric chain was placed in the labial buttons of the sec- the right first molar to the left first molar. Leveling and
ond premolar, and the second molar was used to alignment were started with a 0.014-inch NiTi archwire
generate a distal force. The elastic chain was placed (Fig 4, B).
from the lingual button of the second premolar to the Extraction of the deciduous maxillary left canine
lingual bracket of the first premolar to generate a was performed, and a 0.016-inch NiTi archwire was
mesial force. To avoid side effects (rotation) in the placed from the right to the maxillary left
anchorage teeth, the brackets of the first premolar as second molars. After the correction of the second pre-
well as lateral and central incisors were tied together molar rotation, the buttons were removed, and then
with a 0.025-inch stainless steel ligature and the the bracket was bonded. Alignment and leveling of
bracket of the first molar and the button of the the maxillary arch were performed with a sequence of
second molar were tied together with a 0.025-inch 0.016-inch stainless steel and 0.016 3 0.022-inch
stainless steel ligature (Fig 4, A). stainless steel archwire, both with antibowing and

April 2020
Vol 157
Issue 4 American Journal of Orthodontics and Dentofacial Orthopedics
Martins et al 555

Fig 6. Progress photographs during space closure.

Fig 7. Progress photographs of the miniscrew placed.

Fig 8. Progress photographs of the 0.01700 3 02500 beta-titanium cantilever activated.

increased curve of Spee. Build-ups were bonded in the with an elastomeric chain from the right first molar to
occlusal surface of the maxillary first molars to avoid the left first molar (Fig 6).
any bracket interference (Fig 5). Space closure was Toward the end of the treatment, we detected an
done with an elastic chain placed from the right first increase of the occlusal plane cant due to the space
molar to the left. In the lower arch, second molar tubes closure procedures of the extracted deciduous canine.
were bonded, and a sequence of 0.016 3 0.022-inch We installed a 6.0 3 2.5 mm miniscrew (American Or-
and 0.017 3 0.025-inch stainless steel archwires was thodontics, Sheboygan, Wis) to assist in the correction
used. Space closure in the lower arch was executed of the occlusal plane cant (Fig 7). Maxillary second

American Journal of Orthodontics and Dentofacial Orthopedics April 2020
Vol 157
Issue 4
556 Martins et al

Fig 9. Posttreatment facial and intraoral photographs.

and first molars were then intruded with a vertical outcome was achieved. Class II elastics were also used
elastomeric chain placed in a segment of in this phase.
0.017 3 0.025-in stainless steel braided wire (D- In the finishing phase, a 0.018 3 0.018-inch beta-
Rect; Ormco, Glendora, Calif), bonded onto the tooth. titanium archwire was placed in the upper arch. With
After molar intrusion, a 0.017 3 0.025-inch beta- the aid of panoramic radiography, proper positioning
titanium cantilever was attached to the miniscrew of all maxillary teeth was accomplished with individual
and extended anteriorly to intrude the first premolar wire bends. A 0.017 3 0.025-inch stainless steel arch-
tied to a transparent button bonded on the cervical wire with an omega loop mesial to the second molars
labial crown surface (Fig 8). was placed in the finishing phase. Again, with the aid
The occlusal plane cant correction was carefully of panoramic radiography, proper positioning of all
monitored by visual inspection of the smile during mandibular teeth was also accomplished with individual
each visit of the patient until the desired esthetic wire bends.

April 2020
Vol 157
Issue 4 American Journal of Orthodontics and Dentofacial Orthopedics
Martins et al 557

Fig 10. Posttreatment dental casts.

After 20 months of active treatment, the appliance protrusion, and maintenance of a proper skeletal rela-
was debonded. A clear retainer was placed in the maxil- tionship.
lary arch and a 3-3 bonded lingual retainer in the
mandibular arch. Periodontal and cosmetic reshaping DISCUSSION
was then carried out to finish the dental occlusion Tooth transposition and agenesis often present a sig-
adjustment and to achieve the desired esthetic results. nificant clinical challenge for orthodontists because, in
The final results are shown in Figures 9-12. many cases, the treatment is multidisciplinary, associ-
ated with prolonged treatment time and increased costs.
TREATMENT RESULTS Consequently, the treatment outcome can be compro-
This treatment resulted in a Class I molar relationship, mised.
maxillary first premolars replacing the canines, normal The choice of treatment is influenced by several
overjet, and overbite, and dental midlines coincident factors such as the canine location, the severity of
with the medial sagittal plane. Compatible upper and the transposition, patient’s age, and other patient-
lower arch widths followed the facial characteristics, specific considerations. The first thing to consider
and a proper buccal corridor resulted in an excellent when treating maxillary canine–first premolar trans-
esthetic smile. There was also an improvement of the position is the condition of the periodontal tissue
profile with a reduction of the labial protrusion and and dentoalveolar process. In the present patient,
the mentolabial enhancement. there was no sufficient amount of mucous tissue
The occlusal plane was corrected to become parallel and osseous thickness to move the canine to its cor-
to the intercanthal line, and we achieved an esthetic rect position. The amount and complexity of the
gingival exposition and a border of the maxillary teeth dental movements required because of the unfavor-
following the smile curvature. The upper and lower able position of the canine roots and the fact that
arch assumed a parabolic form without spaces and the affected teeth were incompletely transposed
dental rotations. Third molars were beginning to erupt endorsed its extraction. On the contralateral side,
(extraction is indicated). The radiographic assessment the rare agenesis of the canine and the need for
showed a parallel orientation of the roots, and excellent space for the maxillary midline correction and
dental, bone gingival margin, and skeletal conditions. improvement of the facial esthetics were favorable
Cephalometric findings showed an improvement in toward the extraction of the long retained deciduous
the anterior dental inclination, a reduction of labial canine.

American Journal of Orthodontics and Dentofacial Orthopedics April 2020
Vol 157
Issue 4
558 Martins et al

Fig 11. A, Posttreatment panoramic radiograph; B, posttreatment lateral cephalogram; C, posttreat-

ment cephalometric tracing.

The extraction of transposed teeth represented a indicated for extraction. A part of this resistance was
good option for reducing the treatment time and pro- based on the belief in the importance of canine guid-
vided an excellent periodontal and dentoalveolar process ance.
condition of the remaining teeth. This treatment strat- Previous studies have demonstrated that in patients
egy had minor esthetic disadvantages but was signifi- with lateral incisor agenesis where the maxillary first
cantly easier and faster, preventing root resorption and premolars are positioned in the place of the canines
gingival recession, and was also associated with low that themselves are placed in the lateral incisor posi-
risk of failure compared with correction of the order of tion, have the conventional periodontal health and
the teeth as had been previously considered by other cli- normal temporomandibular joint function, as
nicians. compared with cases in which canines stay in a Class
To start the orthodontic treatment, the extraction of I relationship.7,15-20
the permanent maxillary right canine and deciduous The absence of a criterial judgment by a professional
maxillary left canine was required. The surgeon who without a risk and benefit assessment of the procedure
was first assigned to the patient did not agree with could delay or affect the proper treatment. The present
this extraction option, which constitutes a frequently patient was referred to another surgeon, and the extrac-
encountered situation when permanent canines are tion was performed without any concerns.

April 2020
Vol 157
Issue 4 American Journal of Orthodontics and Dentofacial Orthopedics
Martins et al 559

Fig 12. Craniofacial, maxillary, and mandibular superimpositions of cephalometric tracings, pretreat-
ment (black) and posttreatment (red).

The occlusal and esthetic results showed that the Although the lingual technique was applied, it was
treatment plan, which was chosen for this patient was necessary to use a miniscrew in the right posterior region
optimal, and ultimately a better decision. The peri- to assist with the molar intrusion. The first and
odontal status of the premolars in the place of the ca- second molars were tied together with a rectangular
nines was normal, with imperceptible esthetical wire that served as a point of support for the intrusive
differences. force. As soon as the molars were leveled (intruded), a
To improve the results and to avoid esthetic interfer- cantilever was used for the intrusion of the premolar.
ence, the lingual cusp of the premolars was reduced in This segmented mechanic is very effective, fast, and
height. In addition, an increased lingual torque was consistently promotes the necessary movement without
incorporated into the archwire to create a canine fossa side effects. The force to intrude the molars and the pre-
effect and to help in the esthetics of the alveolus process, molar should be light and continuous, at about 15 to
mainly during smiling. A posttreatment occlusal equili- 25 g of force. For molar intrusion, we used an elasto-
bration was necessary to provide an optimal group func- meric chain.
tion occlusion at the end of treatment and a proper The patient achieved a better facial contour because
functional balance.15,19-21 of a reduction of the upper and lower labial protrusion
The digital smile design concept (DSD) was used to and mentolabial enhancement, was pleased with the
assist in the visualization of dentogingival discrep- final result, and had an improved self-image. Her smile
ancies that could affect the treatment results, and to was improved and showed an ideal esthetic gingival
define the proposed treatment plan. The DSD pre- exposition with the borders of the maxillary tooth
treatment was a valuable tool and provides excellent following the lower lip smile curvature.
insights into the amount of midline deviation and
the cant of the anterior occlusal plane. It also helped
us to do the proper mechanical planning for the cor- CONCLUSIONS
rections. DSD posttreatment helped in the detection of Tooth transposition and dental agenesis often pre-
gingival disharmonies and allowed the medical staff as sent a significant clinical challenge to orthodontists in
well as the patient to visualize the main goals, ex- the fields of treatment planning and biomechanics and
pected results, and limitations.9,22 No periodontal involve a multidisciplinary approach. The objective of
procedure was necessary for this patient, and the this case report is to present the successful orthodontic
gingival margins were remodeled to an extension treatment of a healthy woman with a rare case of maxil-
that an optimal, natural-looking result was lary canine-premolar transposition associated with hy-
achieved.20 podontia of the contralateral canine.

American Journal of Orthodontics and Dentofacial Orthopedics April 2020
Vol 157
Issue 4
560 Martins et al

SUPPLEMENTARY DATA 12. Koç N, Ca gırankaya LB, Akkaya N. Unilateral maxillary canine
agenesis: a case report and literature review. Case Rep Dent
Supplementary data to this article can be found on- 2014;2014:685014.
line at https://doi.org/10.1016/j.ajodo.2018.12.026. 13. Polder BJ, Van't Hof MA, Van der Linden FPGM, Kuijpers-
Jagtman AM. A meta-analysis of the prevalence of dental agenesis
REFERENCES of permanent teeth. Commun Dent Oral Epidemiol 2004;32:
217-26.
1. Bocchieri A, Braga G. Correction of a bilateral maxillary canine- 14. Farret MMB, Farret MM, Farret AM, Hollweg H. Unusual ortho-
first premolar transposition in the late mixed dentition. Am J Or- dontic approach to a maxillary canine-premolar transposition
thod Dentofacial Orthop 2002;121:120-8. and a missing lateral incisor with long-term follow-up. Am J Or-
2. Halazonetis DJ. Horizontally impacted maxillary premolar and thod Dentofacial Orthop 2012;142:690-7.
bilateral canine transposition. Am J Orthod Dentofacial Orthop 15. Nordquist GG, McNeill RW. Orthodontic vs. restorative treatment
2009;135:380-9. of the congenitally absent lateral incisor—long term periodontal
3. Maia FA, Maia NG. Unusual orthodontic correction of bilateral and occlusal evaluation. J Periodontol 1975;46:139-43.
maxillary canine-first premolar transposition. Angle Orthod 16. Rosa M, Lucchi P, Ferrari S, Zachrisson BU, Caprioglio A. Congen-
2005;75:266-76. itally missing maxillary lateral incisors: long-term periodontal and
4. Peck S, Peck L, Kataja M. Concomitant occurrence of canine functional evaluation after orthodontic space closure with first
malposition and tooth agenesis: evidence of orofacial genetic premolar intrusion and canine extrusion. Am J Orthod Dentofacial
fields. Am J Orthod Dentofacial Orthop 2002;122:657-60. Orthop 2016;149:339-48.
5. Peck L, Peck S, Attia Y. Maxillary canine-first premolar transposi- 17. Kokich VO, Kinzer GA. Managing congenitally missing lateral inci-
tion, associated dental anomalies and genetic basis. Angle Orthod sors. part I: canine substitution. J Esthet Restor Dent 2005;17:
1993;63:99-109: discussion 110. 5-10.
6. Vitale C, Militi A, Portelli M, Cordasco G, Matarese G. Maxillary 18. Kinzer GA, Kokich VO. Managing congenitally missing lateral inci-
canine-first premolar transposition in the permanent dentition. J sors. part II: tooth-supported restorations. J Esthet Restor Dent
Clin Orthod 2009;43:517-23. 2005;17:76-84.
7. Peck S, Peck L. Classification of maxillary tooth transpositions. Am 19. Kokich VO, Kinzer GA, Janakievski J. Congenitally missing maxil-
J Orthod Dentofacial Orthop 1995;107:505-17. lary lateral incisors: restorative replacement. Am J Orthod Dento-
8. Parker WS. Transposed premolars, canines, and lateral incisors. Am facial Orthop 2011;139:435-45.
J Orthod Dentofacial Orthop 1990;97:431-48. 20. Rosa M, Lucchi P, Ferrari S, Zachrisson BU, Caprioglio A. Congen-
9. Maganzini AL, Schroetter SB, Freeman K. Improvement in smile itally missing maxillary lateral incisors: long-term periodontal and
esthetics following orthodontic treatment: a retrospective study functional evaluation after orthodontic space closure with first
utilizing standardized smile analysis. Angle Orthod 2014;84: premolar intrusion and canine extrusion. Orthod Fr 2017;88:
492-9. 319-32.
10. Shapira Y, Kuftinec MM. Maxillary tooth transpositions: character- 21. Zachrisson BU, Rosa M, Toreskog S. Congenitally missing maxillary
istic features and accompanying dental anomalies. Am J Orthod lateral incisors: canine substitution. Am J Orthod Dentofacial Or-
Dentofacial Orthop 2001;119:127-34. thop 2011;139:434-44.
11. Plunkett DJ, Dysart PS, Kardos TB, Herbison GP. A study of trans- 22. Frizzera F, Tonetto M, Cabral G, Shibli JA, Marcantonio E. Peri-
posed canines in a sample of orthodontic patients. Br J Orthod odontics, implantology, and prosthodontics integrated: the
1998;25:203-8. zenith-driven rehabilitation. Case Rep Dent 2017;2017:1070292.

April 2020
Vol 157
Issue 4 American Journal of Orthodontics and Dentofacial Orthopedics