740 Mac Namara
740 Mac Namara
740 Mac Namara
ABSTRACT
H
ypodontia is the developmental absence each with a small effect. Hypodontia may also
of 1 or more teeth.1 Oligodontia is the occur with no hereditary history. An asso-
term conventionally used in cases where ciation between hypodontia and microdontia
6 or more teeth are missing and anadontia, has been found and affects females more than
a much more rare finding, describes the males. 3,9 Conversely, the incidence of super-
developmental absence of all teeth. 2 The preva- numerary teeth is greater in males, with an
lence of hypodontia in the primary dentition association between hyperdontia and macro-
ranges from 0.08% to 1.55%.1 In the perma- dontia. 3,9,10 Hypodontia has been found in asso-
nent dentition, prevalence has been reported ciation with impaction of permanent canines,
to range from 2.3% to 11.3% depending on maxillary canine–first premolar transposition
the population investigated. 3–5 Hypodontia of and taurodontism. 5
third molars has a prevalence of 9% to 37%.6 Although not all reports are in agreement,
Hypodontia in the primary dentition has no it is generally accepted that, excluding third
significant sex distribution, but in the perma- permanent molars, the second mandibular
nent dentition females are affected more fre- premolar is the most frequently missing perma-
quently than males by a ratio of 3:2.5 nent tooth representing 40% to 50% of the
The etiology of hypodontia is unknown7; total number of developing missing teeth.11,12
however, a definite familial trend has been Hypodontia affecting the maxillary lateral
reported.8,9 Brook 9 suggests that most cases incisor is next in terms of frequency (25%), fol-
of hypodontia have a polygenetic inheritance lowed by the maxillary second premolar (20%)
pattern and that the risk of relatives having and the mandibular central incisor (6.5%).11
hypodontia will depend on a combination of These 4 teeth account for 90% of absent teeth
numerous genetic and environmental factors, in hypodontia studies.11,13
Figure 1b: Radiographic views at initial presentation: orthopantomographic view and Figure 1c: Lateral cephalogram at initial
periapical views of incisor area. presentation.
In approximately 80% of reported cases of hypodontia, an oral surgeon and prosthodontist in terms of timing of
only 1 or 2 teeth are missing; in 10%, 4 or more teeth interventions. The timing of extraction of retained primary
are missing, while in fewer than 1%, 6 or more teeth teeth is also critical to the final result. This case report
are absent.5 Permanent first premolars, first molars and shows that it is sometimes better to delay the removal of
canines are very rarely developmentally absent; their retained primary teeth to maintain the surrounding dent-
absence is usually associated with severe hypodontia or oalveolar bone until implants are feasible.
oligodontia.14 A meta-analysis by Polder and colleagues15 Case Report
on reported data from 1936 to 2002 found that the preva-
A girl, aged 12 years 9 months, was referred by her
lence of hypodontia in Europe and Australia was higher
family dentist for orthodontic care to the Graduate
than in North America. Hypodontia may occur in isola- Orthodontic Clinic, University of Western Ontario. The
tion or in association with such syndromes as ectodermal patient’s presenting complaint was “the missing grown-
dysplasia, Down’s syndrome Ellis van Crevald syndrome up teeth and what happens next.” Her general medical
and such conditions as cleft lip and palate. 5,16–19 and dental histories were nonsignificant and she had no
Hypodontia presents significant challenges for the family history of any oral or dental anomaly. The patient
clinician.5 Treatment options will depend on the severity was a regular attendee at dental appointments and had no
of the case. Simple adhesive bridges may resolve mild history of extractions. Extraoral examination revealed a
hypodontia cases or it may be appropriate to close the well-balanced face with normal facial profile and normal
resultant spaces by orthodontic movement of adja- skeletal dental base relations. Intraoral examination
cent teeth. In more severe cases, a combined ortho- revealed a Class I malocclusion in the late mixed denti-
dontic–restorative–surgical approach may be necessary tion (Figs. 1a to 1c, Table 1). A 2-mm maxillary median
with orthodontic treatment needed to relocate space in diastema was present and the maxillary left lateral incisor
preparation for later conventional fixed prostheses or (tooth 22) was microdontic. Oral hygiene and gingival
implants.20–22 status were good and no caries was found. Radiographic
This case report of an adolescent female who presented examination confirmed that 12 teeth were development-
with significant hypodontia illustrates the importance of ally missing: teeth 18, 17, 12, 25, 27, 28, 38, 35, 31, 41, 45
an accurate diagnosis and an effective treatment plan that and 48. Significant external root resorption was found in
relies on appropriate coordination among orthodontist, the retained primary teeth 75 and 85 (Fig. 1b).
�����
JCDA • www.cda-adc.ca/jcda
�� • October 2006, Vol. 72, No. 8 • 741
––– McNamara –––
Vertical
Mandibular plane angle; º 26 ± 4 31 31
Facial axis; º 90 ± 3 89 90
Y axis to SN; º 64–68 69 69
SN/GoGn; º 32 ± 4 38 39
Maxillary/mandibular plane; º 28 ± 4 32 32
Lower vertical face height; % 55 57 57
Upper vertical face height; % 45 43 43
Dental
Maxillary incisor to sella–nasion; º 103 ± 5 98 104
Maxillary incisor to palatal plane; º 110 ± 5 104 112
Maxillary incisor to A vertical; mm 5±1 4 5
Mandibular incisor to Md plane; º 90 ± 5 86 85
Mandibular incisor to APg line; mm 1±2 1 2
Mandibular incisor to NB line; mm 3–4 3 4
Interincisal angle; º 130 ± 5 140 131
Maxillary incisal edge display; mm 2–3 6 4
Jarabak analysis
Saddle angle (N-S-Ar); º 123 ± 5 123 125
Articular angle (S-Ar-Go); º 143 ± 5 148 144
Gonial angle (Ar-Go-Me); º 128 ± 7 126 128
Upper gonial angle (Ar-Go-N); º 52–55 51 52
Lower gonial angle (N-Go-Me); º 70–75 75 76
Anterior cranial base (S-N); mm 68–74 72 73
Mandibular corpus (Go-Me); mm 64–76 75 77
ACB: corpus ratio 1:1 1 : 1.04 1 : 1.05
Posterior cranial base (S-Ar); mm 30–36 34 35
Ramus (Ar-Go); mm 39–49 40 42
continued
a b
Figure 2: Pretreatment diagnostic setup: (a) labial view; (b) occlusal views.
Given the patient’s presenting malocclusion, a multi- treatment plan was agreed to involving all 3 special-
disciplinary team approach involving orthodontics, oral ties (Fig. 2). The orthodontic treatment took a non-
surgery and advanced restorative dentistry was essen- extraction approach using a pre-adjusted fixed appliance
tial in the consultation process, treatment planning system (Figs. 3a, 3b). Treatment commenced when the
and later clinical management of this case. The various patient was 13 years and 1 month old. The patient was
treatment options open to the patient were considered. reviewed regarding her prosthodontic–restorative needs
Nonintervention was not an option. Selective extrac- during orthodontic treatment and before debonding
tion of the retained primary teeth or their retention (Fig. 3c). Debonding was completed when the patient
with buildups were also inappropriate options, given the was 15 years and 5 months old (Figs. 4a and 4b, Table 1).
severity of the hypodontia, the resultant poor esthetics Due to poor esthetics, teeth 71 and 81 were extracted
and the malocclusion and poor root formation in 2 of the following debonding (Fig. 4a). Conventional ortho-
3 retained primary molars. Limiting treatment to just 1 dontic retainers with replacement dental units were
dental specialty, such as orthodontics, was also unreal- fitted initially with a view to the long-term insertion of
istic. Orthodontics alone could not close the spaces or implants and placement of final suprastructure fixtures
deal appropriately with the anterior occlusal asymmetry (Fig. 5). The orthodontic goals during both the active
arising from the absent tooth 12. and retentive phases were achieved with good treatment
In consultation with the patient, a combined ortho- outcome.
dontic–restorative–surgical team approach to care The patient was followed in the Graduate Orthodontic
was adopted. The objectives of orthodontic treatment Clinic until maturation of her gingival unit and comple-
were to correct the malocclusion and align the teeth in tion of her skeletal growth. Two years after debonding,
preparation for later prosthodontic care. To assist the the patient was assessed in the fixed prosthodontic and
multidisciplinary consultation process, a diagnostic oral surgery departments for final management of the
setup was prepared and, with the patient’s consent, a edentulous spaces. When she was 19 years old, 3 implants
�����
JCDA • www.cda-adc.ca/jcda
�� • October 2006, Vol. 72, No. 8 • 743
––– McNamara –––
Figure 3a: Clinical view of orthodontic Figure 3b: Orthopantomographic view Figure 3c: Lateral cephalogram at
appliance in situ before debonding. before debonding. debonding.
Figure 4a: Clinical views of occlusion following debonding and before buildup of the microdontic maxillary left lateral incisor.
Figure 4b: Radiographic views following debonding: orthopantomographic view Figure 5: Orthodontic Hawley
and periapical views of incisor area. retainers with dental units used in the
interim period between debonding
and placement of final crowns.
Figure 6a: Clinical views of occlusion, patient aged 21 years, 2 years following placement of implants and final crowns.
�����
JCDA • www.cda-adc.ca/jcda
�� • October 2006, Vol. 72, No. 8 • 745
––– McNamara –––
18. Ribeiro LL, Das Neves LT, Costa B, Ribeiro Gomide M. Dental anomalies
THE AUTHORS of the permanent lateral incisors and prevalence of hypodontia outside
the cleft area in complete unilateral cleft lip and palate. Cleft Palate
Craniofac J 2003; 40:172–5.
Dr. C. McNamara is specialist registrar, Bristol Dental 19. Kumasaka S, Miyagi A, Sakai N, Shindo J, Kashima I. Oligodontia: a radio-
graphic comparison of subjects with Down syndrome and normal subjects.
School, Bristol, United Kingdom. Spec Care Dent 1997; 17(4):137–41.
20. Thind BS, Stirrups DR, Forgie AH, Larmour CJ, Mossey PA. Management
Part II. Quintessence Int 2005;
of hypodontia: orthodontic considerations. ���������
Dr. Foley is associate professor in the division of graduate 36(5):345–53.
orthodontics and the division of undergraduate orthodon-
21. Forgie AH, Thind BS, Larmour CJ, Mossey PA, Stirrups DR. Management
tics and pediatric dentistry, University of Western Ontario,
Part III. Quintessence Int 2005;
of hypodontia: restorative considerations. ����������
London, Ontario. Dr. Foley is a Diplomate of the American 36(6):437–45.
Board of Orthodontics.
22. Huang LH, Shotwell JL, Wang HL. Dental implants for orthodontic
anchorage. Am J Orthod Dentofacial Orthop 2005; 127(6):713–22.
Dr. C.M. McNamara is consultant orthodontist in Limerick,
Ireland.
References
1. Whittington BR, Durward CS. Survey of anomalies in primary teeth and their
correlation with the permanent dentition. N Z Dent J 1996; 92(407):4–8.
2. Silva Meza R. Radiographic assessment of congenitally missing teeth in
orthodontic patients. Int J Paediatr Dent 2003; 13(2):112–6.
3. McKeown HF, Robinson DL, Elcock C, al Sharood M, Brook AH. Tooth
dimensions in hypodontia patients, their unaffected relatives and a con-
trol group measured by a new image analysis system. Eur J Orthod 2002;
24(2)131–41.
4. O’Dowling IB, McNamara TG. Congenital absence of permanent teeth
among Irish school-children. J Ir Dent Assoc 1990; 36(4):136–8.
5. Larmour CJ, Mossey PA, Thind BS, Forgie AH, Stirrups DR. Hypodontia
Part 1. Quintessence Int
— a retrospective review of prevalence and etiology. ��������
2005; 36(4):263–70.
6. Egermark-Eriksson I, Lind V. Congenital numerical variation in the perma-
nent dentition. D. Sex distribution of hypodontia and hyperodontia. Odontol
Revy 1971; 22(3):309–15.
7. Goodman JR, Jones SP, Hobkirk JA, King PA. Hypodontia: 1. Clinical fea-
tures and the management of mild to moderate hypodontia. Dent Update
1994; 21(9):381–4.
8. Arte S, Nieminen P, Pirinen S, Thesleff I, Peltonen L. Gene defect in
hypodontia: exclusion of EGF, EGFR, and FGF-3 as candidate genes. J Dent
Res 1996; 75(6):1346–52.
9. Brook AH. A unifying aetiological explanation for anomalies of human
tooth number and size. Arch Oral Biol 1984; 29(5):373–8.
10. Symons AL, Stritzel F, Stamation J. Anomalies associated with hypodontia
and the permanent lateral incisor and second premolar. J Clin Pediatr Dent
1993; 17(2):109–11.
11. Rose JS. A survey of congenitally missing teeth, excluding third molars in
6000 orthodontic patients. Dent Pract Dent Rec 1966; 17(3):107–14.
12. Aasheim B, Ogaard B. Hypodontia in 9-year-old Norwegians related to
need of orthodontic treatment. Scand J Dent Res 1993; 101(5):257–60.
13. Rolling S. Hypodontia of permanent teeth in Danish schoolchildren. Scan
J Dent Res 1980; 88(5):365–9.
14. Hobkirk JA, Brook AH. The management of patients with severe
hypodontia. J Oral Rehabil 1980; 7(4):289–98.
15. Polder BJ, Van’t Hof MA, Van der Linden FP, Kuijpers-Jagtman AM. A
meta-analysis of the prevalence of dental agenesis of permanent teeth.
Community Dent Oral Epidemiol 2004; 32(3):217–26.
16. Kjaer I. Prenatal development of the maxillary primary incisors related
to maturation of the surrounding bone and to postnatal eruption. In:
Davidovitch Z, editor. Biological mechanisms of tooth eruption and root
resorption. Birmingham (AL): EBSCO Media; 1988. p. 233–6.
17. Kjaer I, Kocsis G, Nodal M, Christensen LR. Aetiological aspects of man-
dibular tooth agenesis — focusing on the role of nerve, oral mucosa, and
supporting tissues. Eur J Orthod 1994; 16(5):371–5.