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The Effects of Primary Canine Loss on Permanent Lower Dental Midline Stability Robert T

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The Effects of Primary Canine Loss on Permanent Lower Dental Midline Stability Robert T PEDIATRIC DENTISTRY V 40 / NO 4 JUL / AUG 18 O COHORT STUDY The Effects of Primary Canine Loss on Permanent Lower Dental Midline Stability Robert T. Christensen, DDS1 • Henry W. Fields, DDS, MS, MSD2 • John R. Christensen, DDS, MS, MS3 • F. Michael Beck, DDS, MA4 • Paul S. Casamassimo, DDS, MS5 • Dennis J. McTigue, DDS, MS6 Abstract: Purpose: The purpose of this study was to compare changes in the lower dental midline position after premature unilateral loss of a primary mandibular canine with dental midline position after normal primary mandibular canine exfoliation. Methods: Dental casts were identi- fied from growth studies at the University of Iowa and the University of Toronto. Two groups of dental casts were identified: (1) premature uni- lateral loss; and (2) normal asymmetric exfoliation of a single primary mandibular canine. The first set of casts displaying unilateral primary canine loss (time one) and the second set of casts displaying full permanent dentition (time two) were collected. The palatal rugae and palatal raphe were used to construct a median palatal plane (MPP). Dental midline position at each time point was measured from the MPP. Results: A total of 56 cases (15 premature, 41 normal) were identified. The mean lower dental midline changes from time one to time two for the premature and normal loss groups were 1.32±0.83 mm and 0.97±0.91 mm, respectively. This difference was not statistically significant regarding group (P=0.62), gender (P=0.91), or the interaction effect of group and gender (P=0.85). Conclusions: There was no significant difference in midline shift between the 15 individuals with premature unilateral primary canine loss and the 41 individuals with normal, asymmetric unilateral loss of a pri- mary canine. (Pediatr Dent 2018;40(4):279-84) Received June 26, 2017 | Last Revision April 4, 2018 | Accepted May 17, 2018 KEYWORDS: CHILD, CUSPID, DENTAL MIDLINE, TOOTH EXFOLIATION, TOOTH DECIDUOUS Previous studies have noted that lower incisor crowding can be cisor inclination changes were similar.6 These two studies had a normal stage of development, although the presence and some overlapping subject types but different changes. severity of crowding cannot be fully gauged until the perma- Alternatively, the erupting permanent incisors may be nent lateral incisors erupt.1,2 blocked by the primary canines, leading to resorption of their Multiple factors influence eruption and alignment of lower mesial root surfaces. This ectopic eruption of the permanent incisors. These factors include dental variables, such as inter- lateral incisors can lead to premature unilateral or bilateral loss dental spacing, intercanine distance and change, arch perimeter of primary canines. Premature loss of primary canines is not changes, and size ratios between primary and permanent teeth.3 limited to cases of ectopically erupting lateral incisors. Caries, Other factors, such as sucking habits and muscle imbalances, trauma, and extraction can also result in early loss of the pri- can change the position of the lower teeth.1,4 mary canine. In cases when arch perimeter and intercanine distance are Regardless of the how the tooth was lost, premature loss inadequate, there may be insufficient space mesiodistally for of a primary mandibular canine and the need for treatment eruption of permanent mandibular incisors. The extraction of have been a topic of debate for many years. By some, it has primary canines in the face of crowding can have variable out- been accepted as fact that the loss of a primary canine leads comes. Sayin and Turkkahraman5 looked at two groups with to an immediate midline shift.7 greater than or less than 1.6 mm of lower incisor crowding Several studies and pediatric dental and orthodontic text- (incisor width compared to available space between the mesial books discuss lower incisor crowding and treatment of the surfaces of the primary canines); they found that, with extrac- lower dental midline shift in the early mixed dentition.1,4,7 Most tions, the lower anteriors retruded but did not affect the arch recommend interceptive treatment for the crowding to mini- length or width compared to the nonextraction group. In a mize or correct the midline shift. While this is appealing to different study, a sample of children with greater than six mm the practitioner and parent, little evidence exists to support of incisor crowding, as determined by Little’s irregularity index, these recommendations. were randomly assigned extraction or nonextraction treatment Generally, recommended treatment is removal of the con- of the primary canines. The extraction group lost more arch tralateral primary canine.7,8 Gianelly stated that the removal of length and had less incisor crowding, but the mandibular in- the opposing canine and placement of a lingual arch will control for symmetry and arch length.8 Others, like McDonald and Avery, believed the extraction of the contralateral canine 7 1 Dr. Christensen is a dentist in private practice, Durham, N.C. USA. 2Dr. Fields is Vig/ will correct the midline deviation. Foley and Wright have Williams Endowed Chair and professor, Division of Orthodontics; 4Dr. Beck is an asso- created different treatments options based on the amount of ciate professor emeritus, Division of Oral Biology; 5Dr. Casamassimo is a professor, Di- crowding present.3 However, it is important to realize that ex- vision of Pediatric Dentistry; and 6Dr. McTigue is professor emeritus, Division of Pediatric traction of teeth may solve one problem while creating another. Dentistry, all at the College of Dentistry, The Ohio State University, and Department of Despite the general acceptance of contralateral canine ex- Dentistry, Nationwide Children’s Hospital, Columbus, Ohio, USA. 3Dr. J.R. Christensen is an adjunct associate professor, Department of Pediatric Dentistry, School of Dentistry, traction as the standard of care, other perspectives exist. Gellin University of North Carolina at Chapel Hill, Chapel Hill, N.C.; and a dentist in pri- affirmed that the primary incisors and canines are necessary vate practice, Durham, N.C., USA. for the process of alveolar growth and increases in intercanine 9 Correspond with Dr. R.T. Christensen at [email protected] width. Hollander and Full reviewed the literature and believed LOWER DENTAL MIDLINE STABILITY 279 PEDIATRIC DENTISTRY V 40 / NO 4 JUL / AUG 18 the dental midline had the ability to self-correct, although they remain. Does the midline change if a single primary mandi- did not cite any supporting studies.10 Lee argued that prima- bular canine is lost prematurely? Does the midline change over ry canines act as proprioceptors for the erupting permanent time as permanent teeth erupt and is the movement in a direc- lateral incisors and are important for optimal mandibular arch tion back to the facial midline or does the midline continue to shape and size.11 move away from the facial midline? Are the changes significant Evaluation of the dental midline. The position of the enough to influence future orthodontic treatment needs or dental midline plays an important role in treatment planning esthetics? Are changes affected by variables, such as chronological for the pediatric dentist and orthodontist. The presence of a or dental age at the time of tooth loss, or by dental crowding? dental midline discrepancy has been documented in 75 per- Although there are studies that describe the progression of cent of the population12 and is cited as a common cause for crowding over time, none looks at the change of the lower less-than-ideal finishes of orthodontic treatment.13 A midline dental midline over time.2 discrepancy (maxillary or mandibular midline off the facial The purpose of this study was to describe quantitative midline) is much more prevalent in the mandibular arch.12 changes in the lower dental midline position for a sample of Although many factors play a role in treatment decisions, dental casts over time after unilateral loss of a primary mandi- one of the more important is the extent of deviation. Jerrold bular canine either prematurely or within normal limits. By stated that a midline discrepancy can be considered very slight identifying mean changes in the dental midline, this study when it is in the one- to two-mm range.14 These cases can often may provide guidance for treatment planning. be managed, without creating functional problems, by tipping the anterior teeth or by interproximal reduction.1,14 Methods Beyer and Lindauer evaluated how discrepancies between This project was exempt from review by an Institutional Re- the maxillary dental midline and the facial midline affected es- view Board (no. IRB16-00284) at Nationwide Children’s thetics. Their study evaluated the tolerance of midline discre- Hospital, Columbus, Ohio, as it does not fit the definition of pancies by general dentists, orthodontists, patients, and parents human subjects research under 45 CFR part 46 or 21 CFR of patients. The authors determined that a midline deviation part 50. Dental casts and treatment records were obtained of 2.2±1.5 mm was the esthetic threshold for an acceptable from growth studies conducted at the University of Iowa20 midline deviation.15 Ker et al. conducted a similar study, solely and the University of Toronto.21 from the layperson’s perspective, and found mandibular mid- Two types of dental casts were identified. The first group line deviations from the maxillary midline were esthetically included casts with premature (more than one year prior to acceptable until they exceeded 2.1 mm.16 loss of the contralateral tooth) unilateral loss of a primary In spite of divergent opinion, the literature seems to agree canine. The second group included casts with unilateral loss that midline discrepancies less than two mm are not estheti- of a primary canine due to normal but asymmetric exfoliation cally or clinically significant and can be managed without the (less than one year prior to contralateral tooth eruption).
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