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Hong Kong Dent J 2011;8:40-5
DDS, MS DDS, MS
Early management of congenitally missing mandibular second premolars: a review
Department of Orthodontics, West Virginia University, United States of America † Private Practice, Saskatchewan, Canada Private Practice, North Carolina, United States of America
Mandibular second premolars are the second most common missing teeth next to third molars, and are absent in 2.5% to 5% of the population. There is an assortment of treatment options if the problem is diagnosed early during the mixed dentition phase. A diagnostic scheme is presented to aid clinicians choose the best treatment option. These treatment modalities can be broken down into two main groups, based on the decision to keep or extract the primary molars. If space is left for an eventual prosthetic replacement, the clinician should try to create the exact amount of space required and leave the alveolar ridge in an ideal condition for the future replacement. If the space is to be closed orthodontically, detrimental changes to the occlusion and facial profile must be prevented. This paper reviews the current literature on these various treatment modalities and presents a diagnostic scheme to aid choosing the best treatment option. Key words: Anodontia; Mandible; Molar; Treatment outcome
Management of patients with congenitally missing mandibular second premolars continues to challenge clinicians to find the best treatment options. Next to the absence of third molars, the second most commonly missing teeth are the mandibular second premolars, which anomaly is reported to occur in 2.5% to 5% of the population in the USA and Europe 1,2. Such absence ensues bilaterally in 60% of instances. There is an assortment of treatment options if the problem is diagnosed early during the period of mixed dentition. These treatment modalities can be broken down into two main groups based on the decision to keep or extract the primary molars. Most often, these options require an interdisciplinary team to achieve the best result. This paper reviews the current literature on these various treatment modalities and presents a diagnostic scheme to aid clinicians in choosing the best treatment option.
Correspondence to: Prof. Peter Ngan Department of Orthodontics, West Virginia University, 1073 Health Science Center North, P.O. Box 9480, Morgantown, WV 26506, United States of America Tel : (304) 293 3222 Fax : (304) 293 2327 email : firstname.lastname@example.org
Diagnostic scheme for choosing the best treatment option
Figure 1 shows a diagnostic scheme to guide clinicians choose the best treatment option for congenitally missing mandibular second premolars. Apart from patient age and gender, the decision depends on multiple factors, including: distance of the primary molar from the occlusal plane; the condition of the primary tooth; the orthodontic condition (facial profiles, crowding of the arch, proclination of incisors and protrusion of
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the deciduous tooth is erupting evenly. but the rate of growth decreases steadily and. If the bone level between the primary molar and the adjacent first permanent molar or premolar is level. because of different maturation rates in males and females. The best method to determine this is to compare the bone height to the adjacent molar or premolar on a bitewing radiograph 5. because vertical growth continues past the pubertal growth spurt and lasts longer than growth in the sagittal and transverse dimensions 3. The growth of the facial skeleton continues after puberty.Management of congenitally missing premolar the jaws). The same bone step in a 12-year-old boy would indicate a much higher chance of severe infra-occlusion when growth is complete 5. after the second decade of Figure 1 Diagnostic scheme for treatment options for congenitally missing mandibular second premolars Hong Kong Dent J Vol 8 No 1 June 2011 41 . However. a mildly oblique step in the bone height and a minimal step in the occlusal table in a 25-year-old patient may not be critical. then the tooth is probably ankylosed. if there is an oblique step in the bone height from the primary to the permanent molar or premolar. The tooth should therefore be extracted to prevent a potential alveolar ridge defect. a step in the occlusal plane does not always mean the tooth is ankylosed 4. since there is little growth remaining in the vertical dimension 5. Clinicians need to be aware of the remaining growth potential of the patient and the final position of the primary molar if it is ankylosed. In a young patient. Age and distance of the primary tooth from the occlusal plane The age of the patient at the time of diagnosis is important. Gender The gender of the patient is also important. However. Primary molars can often appear below the occlusal plane (infraocclusion). and the condition of the bone after extraction of the primary tooth.
the next step is to decide how to manage the space. the rate of eruption of the maxillary central incisors in females has been reported to be greater than that in males. The same is true of a primary tooth with severely resorbed roots. the next decision is whether to replace the missing premolar or close the space. Kokich 7 described a way to preserve the alveolar ridge after extraction. it is easy to make decision on extraction/non-extraction if there is sufficient crowding. About 60% to 70% of the increase in anterior facial height (nasion-menton) occurs in the lower anterior part (anterior nasal spine– menton) 4. and prevented the need for bone grafting prior to the placement of an implant to restore the first premolar space. Condition of the bone after extraction of the primary tooth Once the decision is made to extract the primary molar because of caries. Condition of the primary tooth and the orthodontic condition The decision to retain the primary molar also depends on the condition of the primary tooth and the orthodontic condition. Also. In one case he moved the first premolar into the position of the missing second premolar. in those aged more than 20 years. excessive proclination of the incisors. (a) (b) (c) (d) Figure 2 (a-c) Pretreatment photographs and (d) panoramic radiograph of a patient presenting with congenitally missing second premolars and sufficient crowding to be treated orthodontically by space closure (after extraction of the primary second molars) (a) (b) (c) Figure 3 (a-b) Post-treatment photographs and (c) panoramic radiograph of the same patient after orthodontic space closure 42 Hong Kong Dent J Vol 8 No 1 June 2011 . Decision to extract the primary second molar If the primary tooth is extracted. However. despite more growth of anterior facial height in males over the same time 4. the inter-gender difference is substantially diminished 4. This tooth movement through the alveolar ridge allowed for adequate bone height and thickness. and presence of jaw discrepancies (Figures 2 and 3). after 7 years it narrowed by another 5% resulting in a total reduction in width of 30%. If the primary tooth has a large restoration or is severely decayed. They found that the alveolar ridge narrowed by 25% in the first 4 years after extraction of the deciduous tooth. seems to be clinically insignificant. the options are limited to removal of the tooth. or ankylosis. resorbed roots. Ostler and Kokich 6 studied the long-term changes in bone associated with extraction of primary second molars with no permanent successor. There is also a difference in the amount of growth between the sexes during the second decade of life.Ngan et al life.
This is indicated when the deciduous tooth is not ankylosed and has erupted evenly between adjacent teeth 14. conventional bridges or resin-bonded bridges were used to restore the missing teeth. Autotransplantation is an option if a viable tooth (usually a third molar or premolar with an open apex) is available. which is often 10 to 11 mm. To preserve the buccolingual bone for an eventual implant. Replacement with a conventional fixed bridge has a 10-year survival rate of about 84%. Another option exists if the patient has completed vertical growth. facial profile. The best option for a congenitally missing mandibular second premolar was to replace it with a single tooth implant 5. This is best done between the ages of 8 and 9 years. (b) Placement of a mini-implant between the mandibular canine and first premolar to protract posterior molars. success rates of autotransplantation were 94% and 82% for incomplete and complete root formation. Then an endosseous implant can be placed in the position of the missing premolar. a 1-mm midline shift to the affected side was noted after completion. Once this occurs. The introduction of temporary anchorage devices. After healing. the normal width of an average mandibular second premolar is 7. Closing the space of a primary molar.Management of congenitally missing premolar Historically. If the patient has a protrusive profile or moderate crowding. in the absence of crowding and a good (a) (b) (c) Figure 4 (a) Pretreatment photograph of a patient presenting with congenitally missing and infra-occluded second premolars.13. in which the decision was to extract the primary tooth and close the space. (c) Post-treatment in the patient Hong Kong Dent J Vol 8 No 1 June 2011 43 . controlled slicing may be indicated. allowing the first permanent molar to ‘drift’ into approximation with the mesial portion. Although a single-tooth implant may be planned to replace the missing premolar. Fines et al. the patient may be too young and still growing. After 4 years. good results can be obtained in persons as old as 11 years. By utilizing such implants. This procedure has been popular in European and SouthEast Asian countries. and that resin-bonded bridges in posterior areas had poor survival rates 8. If the space left by a congenitally missing lower second bicuspid is too small to be restored with two restorations. and too large to be restored with one restoration. However. respectively 2.5 mm. placement should be delayed until the pulp chamber allows preparation 11. the mesial portion is removed and fixed appliances are used to complete the space closure 15. The negative aspects of these options were that conventional bridges could lead to pulp devitalization in younger patients. space closure is favored. but is rarely performed in North America. However. Decision to close the space If it is decided to close the space. but placement must be delayed until growth is complete 10. a bracket can be bonded to a provisional crown and the implant can be used as an absolute anchor to mesialize the lower molar to close up residual space. there are major orthodontic anchorage concerns. controlled slicing of the tooth may be an option (Figure 5). which has a 95% 10-year survival rate. has created more options for space closure (Figure 4) 5. 1 reported a case with a unilateral missing mandibular second premolar. is difficult at best and may result in a midline shift and flattening of the face 14. because most oral surgeons are unfamiliar with the procedure 12. the molars can be protracted without side-effects on the anterior teeth of the arch.9. the teeth can be leveled and aligned. The mesiodistal width of a typical primary molar is 13 mm. but again. If the decision is to remove the primary molar at an early age. such as miniscrew implants. However. space closure has undesirable side-effects. Class II elastics were employed to close the space. it is a process that removes the distal root and crown of the primary molar.
(c) Figure 6 (a-b) Pretreatment photographs and (c) post-treatment panoramic radiograph of a patient with congenitally missing lower second premolars who was treated by reshaping of lower primary second molars (a) (b) Figure 7 (a) Post-treatment photograph and (b) post-treatment panoramic radiograph of the same patient 3 years after reshaping of the primary second molars and space closure 44 Hong Kong Dent J Vol 8 No 1 June 2011 . This would be an ideal situation if the space was later to be restored by an implant. the difference in size between a primary molar and a permanent succedaneous premolar must be addressed. the socket wall of the permanent tooth will resorb the divergent deciduous roots and be replaced by bone as the space is closed 16. Typically the mandibular second primary molars are approximately 10 to 12 mm wide.5 to 2 mm wider than the succedaneous premolar. However. the composite can be added interproximally to cover exposed dentin.Ngan et al Decision to keep the primary second molar If it is decided to keep the primary molar. It is also possible to reshape the tooth to approximate the size of a premolar and restore it as such (Figures 6 and 7). If the primary molar is retained. This makes it difficult to finish the case with proper occlusal Figure 5 A patient with a congenitally missing mandibular second premolar treated by hemisection of a primary second molar to allow for first molar to drift (a) (b) interdigitations. The primary second molar is usually 1. By reducing the mesiodistal width. the tooth can be narrowed to about 8. the prognosis for its longterm survival is more than 90%. It is usually necessary to add composite to the occlusal surface to obtain occlusal contact. only seven of the 99 primary teeth were exfoliated during an observation period from 12 years to adulthood 13. One can decide to accept the end-toend molar relationship and manage it when the patient eventually loses the primary molar.0 mm 16. In a study of 99 subjects with agenesis of one or both mandibular second premolars. radiographs need to be examined to determine by how much the extent of reduction may be limited by divergent roots. it has been reported that even with widely divergent roots. If the decision to reshape the tooth is made.
121:594-5. Contemporary orthodontics. Fines CD. Bjerklin K.30:254-61. Hemisection: one large step toward management of congenitally missing lower second premolars. 6. 16. Brattström V. Wong RW. J Oral Rehabil 2002. Tegsjö U.131(4 Suppl):59S-67S. Kokich VG. Habsha E. Treatment of lower second premolar agenesis by autotransplantation: four-year evaluation of eighty patients. Angle Orthod 2004. Am J Orthod Dentofacial Orthop 2002. 2. Alveolar ridge changes in patients congenitally missing mandibular second premolars.57:111-5. Leroux B. Kokich VG.125:537-43. Longevity of fixed metal ceramic bridge prostheses: a clinical follow-up study. J Prosthet Dent 1994. Kokich VO.79:415-21. Fields HW. Semin Orthod 1997. Northway W. Quintessence Int 2004.75:19-21. 4. Am J Orthod Dentofacial Orthop 2006. Interdisciplinary management of single-tooth implants. 11. 14. Congenitally missing teeth: orthodontic management in the adolescent patient. Ostler MS. Controlled slicing in the management of congenitally missing second premolars. The incidence of pulpal complications and loss of vitality subsequent to full crown restorations. Am J Orthod Dentofacial Orthop 2007. References 1.24. Am J Orthod Dentofacial Orthop 2003. the clinician should try to create the exact amount of space required and leave the alveolar ridge in an ideal condition for the future replacement. If the space is to be closed orthodontically. Spear FM. Proffit WR. 9. Am J Orthod Dentofacial Orthop 2004. Mathews DM.123:676-82. Herdach F. 13. The key to successful management is to diagnose the problem early in the presence of mixed dentition. MO: Mosby Inc. If space is left for an eventual prosthetic replacement. Congenitally missing mandibular second premolar: treatment outcome with orthodontic space closure. et al. Saadia M. the clinician must prevent any detrimental changes to the occlusion and to the facial profile. Salonen-Kemppi MA. 4th ed. 15. Hong Kong Dent J 2007.Management of congenitally missing premolar Conclusions There are numerous options for treating a patient with a congenitally missing mandibular second premolar. Ketabi AR. Retrospective review of 1170 endosseous implants placed in partially edentulous jaws. Ont Dent 1998. Andrén A. Rebellato J. Näpänkangas R.130:437-44.74:792-9.. 2007: 113-4.3:4572. 3. Kokich VG. Valerius-Olsson H. More treatment options are open to younger patients.4:122-7. Louis. Eckert SE. Thirteen-year follow-up study of resin-bonded fixed partial dentures. Eur J Orthod 2008. J Prosthet Dent 1998. Congenitally missing mandibular second premolars: clinical options.71:144-9. Wollan PC. 5. Fudalej P. Kokich VO Jr. Saiar M. Grinberg G. Acta Odontol Scand 1999.29:140-5. St. Valencia R. 12. Shum LM. Hong Kong Dent J Vol 8 No 1 June 2011 45 . Agenesis of mandibular second premolars with retained primary molars: a longitudinal radiographic study of 99 subjects from 12 years of age to adulthood. Determining the cessation of vertical growth of the craniofacial structures to facilitate placement of single-tooth implants. Al-Najjar M. 7. 10. Kokich VG. Kårestedt H. Kaus T. Josefsson E. 8.35:407-10. The advent of temporary anchorage devices provides new treatment options for managing patients with congenitally missing mandibular second premolars. Autotransplantation of premolars with closed root apices: an orthodontic case report. Raustia AM.
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