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Hypodontia: Etiology, Clinical Features, and Management

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Hypodontia: Etiology, Clinical Features, and Management Surgery Hypodontia: Etiology, clinical features, and management Parmanand J. Dhanrajani, FRACDS, FDSRCS, FFDRCSP Patients who are congenitaliy missing one tooth or more are Irequently encountered in routine practice. The etiology, classilication, and clinical leatures o! hypodontia are reviewed, and treatment modalities are disoussed. One case ot m i Id-to-mode rate hypodontia and one case of severe hypcdontia are described. Osseointegrated implants have provided encouraging results, especially in patients who are missing ante- rior teeth or who have severe hypodontia. (Quintessence Int 2002:33:294-302) Keywords: hypodontia, osseointegrated implant, prosthesis ypodontia is defined as the developmental ah- The developmental disruption arising from the H sence of one tooth or more. The absence of ali presence of cleft lip and palate involving the alveolus teeth (anodontia) is rare, Hypodontia may present may aiso rcsuit in an ahsence of teeth in that region, with varying degrees of severity, and severe hypodon- notably the maxillary lateral incisors."** tia has been defined as the absence of six teeth or more, excluding third molars.' The term oligodontia is used to define deveiop- CLASSIFICATION mental absence of multiple teeth, usually associated with systemic manifestations.- Partial anodontia, a There is no consensus on classification of hypodontia contradictory term, was once widely used but is now in the literature. It is commonly classified according to obsolete. the severity of the condition'-*: 1. Mild-to-moderate hypodontia: Absence of usu- ETIOLOGY ally two teeth or more but fewer than six teeth, excluding third molars {Fig f). Hypodontia may arise as a familial condition; a high 2. Severe hypodontia: Ahsence of six teeth or more, proportion of affected individuals are members of fam- excluding third molars. It may be associated with ilies with a previous history of the condition.' The na- microdontia (Fig 2). ture of the inheritance is complex and not well under- 3. Oligodontia; Absence of multiple teeth, usually stood."*' Hypodontia may also arise in individuals with associated with systemic manifestations. no hereditary history.^ Hypodontia is aiso a common presenting feature in a numher of systemic conditions, such as hypohidrotic PREVALENCE eetodermal dysplasia, Down syndrome, and chon- droectodermal dysplasia.'^ Hypodontia in the permanent dentition occurs in 'S.i^k to 6-5% of the normal popuiation; females are af- fected more frequently than males by a ratio of 3:2.' Severe hypodontia of the permanent dentition occurs •'Consultant, Oral Surgery and Oral (uledicirie, Riyadh Dehtal Center, Riyadh, Saudi Arabia. in 0.3% of the popuiation. In the primary dentition, Reprint requests: Dr R J. Dhanrajani, Riyadh Dental Center, PO Box 704, the prevaience is O.f/n to 0,9%, and there is no signifi- Riyadh 11373, Saudi Arabia E-mail: [email protected] cant sex distribution. 294 MMmhfir4. 2002 Dhanrajani Fig 1 Miid-to-moderate tiypodontia. Both maxiilary iaterai inoisors and the mandibular ieft central inoiscr (arrows) are missing. Rg 2 Severe hypodontia. Severai teeth are missing, ottiers are afieoted by mt- crodontia. and some primary teeth are re- tained. The teeth most commonly affected arc the maxillary lateral incisors, the mandibular and maxillary second 1. The teeth are often microdontic, conical, or ta- premolars, and the mandibular incisors. Hypodontia pered, presenting esthetic and functional problems. involving the maxillary central incisors, the maxillary Preparation of such teeth for fixed restorations and mandibular canines, or the first moiars is rare and may be difficult, and lack of undercut presents re- mostly occurs in patients with severe hypodontia,' tention problems for removable restorations. 2. Eruption of permanent teeth may be delayed or abnormal.'" CLINICAL PRESENTATION 3. Ii the maxillary lateral incisors are microdontic or absent, the maxiliary canines may follow an A number of features have been shown to be associ- ectopic path." ated with hypodontia. These complicate treatment 4. The retained primary teeth may become infraoc- planning and patient management: cluded, resulting in loss of space because of tilting Quir'' 295 Dhanrajani of the adjacent permanent teeth. Usually these re- Treatment options.^" tained teeth are ankylosed, and their surgical and 1, No treatment or simple improvement with resin orthodontic implications must he considered,'^ composite: Patients with minimal spacing may 5. The lack of teeth is often associated with a devel- feel that the appearance of their teeth is satisfac- opmental failure of alveolar bone, resulting in an tory. For others, resin composite may be used to apparent atrophy of the ridge and lack of poste- improve tooth appearance by closing a small di- rior support. astema,^" 2, Space closure: The space corresponding to miss- ing lateral incisors may be closed by protraction TREATMENT MODALITIES of the canines and the buccal segments; the final objective is a Class II buccal occlusion. Selective In general, the options for treatment depend on the grinding and resin composite can he used to alter severity of the hypodontia. Care requires a team ap- the canines and first premolars to simulate the proach, including pédiatrie, orthodontic, and restora- lateral incisors and canines, respectively,^' tive specialists, and the patient must be treated at an 3, Space opening: The alternative to space closure early age.'^ is to maintain or to create the necessary space The patient and parent must be fully informed for a prosthetic replacement of the missing tooth. about the condition and the aims and objectives of Replacement options include removable partial treatment,'^•' A number of factors must be taken into dentures, conventional fixed partial dentures, account at the time of treatment planning: resin-honded fixed partial dentures, and single- tootb i 1, The age of the patient 2, The number and condition of retained teeth Case report. A 17-year-old Saudi girl was treated in 3, The number of missing teeth the orthodontic clinic of the Riyadh Dental Center, 4, The presence of carious teeth She was an intelligent, cooperative, college student 5, The condition of supporting tissues and conscientious about her oral health and esthetics. 6, The occlusion She was undergoing orthodontic treatment to close 7, The interocclusal rest space the diastemas in her maxillary anterior teeth. Examination revealed good facial symmetry. Class I The following procedures may he considered during occlusion on both sides, congenitally missing maxillary treatment planning: lateral incisors, and retained primary lateral incisors. The maxillary arch showed spacing between the ante- 1, Timely extraction of primary teeth in cases of po- rior teeth; in addition, there was minor crowding of the tential crowding can result in spontaneous space mandihular arch. Radiographie examination revealed closure and may lessen the need for intervention an unerupted supernumerary tooth in the region of the later. missing maxillary left lateral incisor (Fig 3a), 2, Ectopic teeth may require surgical exposure to Objectives of the orthodontic treatment were to facilitate eruption and orthodontic traction, provide adequate space for restoration of missing lat- 3, The removal of enlarged frena and crown-length- eral incisors, to close residual spaces in the maxilla, ening procedures may help in provision of fixed and to correct the crowding of the mandibular ante- prostheses, rior teeth. 4, The removal of infraoccluded primary teeth may She was referred to a specialist to determine the be necessary to facilitate orthodontic or restora- possihility of using Implant-retained teeth to replace tive treatment, the lateral incisors, Worldng in a multidisciphnary ap- 5, Orthodontics may contribute to the overall man- proach, the patient, orthodontist, oral surgeon, agement of hypodontia by closing or redistributing restorative dentist, and dental technician agreed on spaces, Tbis may involve a full range of functional, the following treatment goals: removable, and fixed orthodontic appliances, 1, To remove the supernumerary tooth carefully /W/W or moderate hypodontia without damaging the retained primary left lat- eral incisor The most common situation is absence of maxillary 2, To wait for 1 year to allow complete bone heal- lateral incisors. Patients with congenitally missing ing prior to placement of an implant maxillary lateral incisors may seek orthodontic ther- 3, To restore the maxillary lateral incisors with im- apy as a part of a restorative plan,'^-'^ plant-supported crowns 296 • Dhanrajani Fig 3a Management of •r\ .:\--\.- :.:.--.- - p.>j,j iiia Both pei- manent maKillaty lateial I.'"ICIOC:Í ,=1= i.,iio.iiy. botlT pr,i-nary maxil- lary lateral incisors are retained tieft arrow), and a supernumeraty tooth (right arrows) is present in the area of the Iett lateral incisor. Fig 3b Bone healing (arrow) after removal of the supernumerary tooth. Fig 3c Removatüie acrylic resin denture used as a space main- Fig 3d Removable acrylic resin denture m place dJnng the neal- tainer during the healing phase alter stage 1 implant surgery. ing phase. Fig 3f Periapical radiographs at:er cementat'cn ot the crowhs. Fig 3e Periapical radiographs after stage 2 implant surgery Quir*-' 297 D han rai an i Fig 3g Appearance after cementation ot ttie crowns. Fig 3fi Periapical radiographs oí implants atter 7 years of follow- up. Fig 3i Smile 7 years after treatmenl Two weeks after the soft tissue healing, an impres- The supernumerary
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