Management of mandibular second premolar … 10.1051/odfen/2014037 J Dentofacial Anom Orthod 2015;18:105 1 Article received: 31-07-2014. Accepted for publication: 25-08-2014. Management

DOI: 10.1051/odfen/2014037 J Dentofacial Anom Orthod 2015;18:105

1

Article received: 31-07-2014.Accepted for publication: 25-08-2014.

Management of mandibular secondpremolar agenesis

M. Medio1,2, A. Popelut3, M. De La Dure Molla2,4

1 CECSMO 4, Paris 7 Denis Diderot University, Pitie Salpetriere Hospital, AP-HP (Paris Hospitals

Board), France

2 Orofacial Deformities Reference Center, Rothschild Hospital, Paris, France

3 Private periodontal and implantology practice, Courbevoie, France

4 Pediatric odontologist, Paris 7 Denis Diderot University, Odontology Center, Rothschild Hospital,

AP-HP (Paris Hospitals Board), France

ABSTRACT

In Europe, dental agenesis affects 5.45% of the population. Apart fromthird molars, the mandibular second premolars are most often affected. Foreach clinical situation, the orthodontist must select the best treatment optionto manage the edentulous space.

This space can be closed or left open.If the space is to be closed, the goal is to achieve stable and functional

occlusal relationships without negative impact on profile.If the space is to be left open, the goal is to create a space suitable for

future prosthetic restoration, render the dental axes parallel, and maintainoptimal bone volume, especially if the deciduous molar is in infra-occlusion.

In this paper we present various treatment options for managingmandibular second premolar agenesis.

KEY WORDS

Dental agenesis, mandibular second premolars, infra-occlusion of deciduous molars,orthodontics, decision-making

INTRODUCTION

Dental agenesis is the most commonhereditary dental pathology. Prevalence inEurope is 5.45%28. All teeth, deciduous anddefinitive, may be involved, and it may be iso-lated or associated with multiple deformitysyndromes. In most cases (83%), only oneor two teeth are involved; oligodontia (>6ageneses) is much rarer (0.14%).

The genetic origin is now established38.Mutations in the Msx1, Pax9 and Axin2

genes have been reported in isolatedforms, but do not explain all cases. Genesimplicated in syndromic forms, such asEda1 and Wnt10a, have been reported inectodermal dysplasia as well as in isolateddental agenesis.

Polder’s meta-analysis described distribu-tion, with certain teeth often missing andothers rarely: apart from 3rd molars, theteeth most frequently concerned are the

Address for correspondence:

Marie Medio14 rue Le Brun75013 Paris;[email protected]

© The authors

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mandibular 2nd molars (41%), fol-lowed by the lateral maxillary incisors(23%) (Fig. 1).

Dental agenesis has frequently beenfound to be associated with other den-tal morphogenetic abnormalities: lat-eral maxillary incisor microdontia,maxillary canine palatine inclusion, de-layed development or deciduous molarinfra-occlusion3. Peck described this asa ‘‘pattern of dental anomalies’’, moreoften associated than isolated, sug-gesting a shared genetic origin. Suchpatients constitute 25% of the ortho-dontic population27.

In case of agenesis of at least 1 pre-molar, deciduous molar infra-occlusionis more frequent, at 24.6%8. It resultsfrom arrested deciduous eruption with-out physical obstacle after emer-gence2: the infra-positioned toothremains stationary while surroundinggrowth continues (Fig. 2). It may occurwith or without an underlying definitivetooth germ17.

Etiology is little known. There aretwo main theories. Biederman hy-pothesized impaired alveolodental li-gament metabolism, inducing dentalankylosis4. Kurol suggested a familialgenetic origin, with prevalence vary-ing between populations21. At allevents, the pathophysiology of decid-uous molar infra-occlusion involvesdental ankylosis19. Histologic studiesreported ankylosis areas in theseteeth, which is confirmed by the diffi-culty of extraction.

Prevalence of deciduous molar in-fra-occlusion varies in the literaturebetween 1.3% and 38.5%, depend-ing on ethnicity35.

The teeth most often involved arethe deciduous mandibular 2nd molars,the mandible being more often af-fected than the maxilla30.

Diagnosis is founded on clinicaland radiological examination. Infra-occlusion may be unilateral (Fig. 3).

Figure 1Distribution of dental agenesis: the mandibular premolars are the most often affected

(apart from the 3rd molars).

M. MEDIO, A. POPELUT, M. DE LA DURE MOLLA

2 Medio M., Popelut A., De La Dure Molla M. Management of mandibular second premolar agenesis

TREATMENT DECISION-MAKING IN MANDIBULAR 2ND MOLAR AGENESIS

Early diagnosis of premolar agen-esis is hindered by delayed calcifica-tion. By the age of 8 years, thedental follicle or germ should be visi-ble on X-ray, but this may not be thecase until around 11 years of age23.

Orthodontic management may notinclude deciduous molar extractionand space closure.

Several authors raised the greatquestion: to open or to close?

Treatment decision-makingfactors

Age

Age at diagnosis influences treat-ment strategy. If diagnosis is earlier

Figure 2Series of panoramic radiographs taken between 8 and 12 years of age at 1-year intervals,

showing relative reinclusion of 75. Following extraction of 85, 45 developed normally.

MANAGEMENT OF MANDIBULAR SECOND PREMOLAR AGENESIS

Rev Orthop Dento Faciale 2015;18:105. 3

than the development of the definitive2nd molar, all options are open14.

If, on the other hand, dentition isdefinitive, closure is liable to have es-thetic repercussions.

Facial typology

Facial typology is a fundamentalfactor in choosing between openingor closure.

In hypodivergent subjects, thetreatment objective is to avoid wor-sening the profile and therefore toavoid extraction but rather retain theagenetic spaces. In hyperdivergentsubjects, on the other hand, it is bet-ter to extract the premolars and per-form mandibular closure to improvelip occlusion at rest.

Bjork described a qualitative analy-sis of the various types of mandibularrotation7. In hypodivergent subjects,the bone is denser and orthodonticmovements to close extraction and/or agenetic spaces are more difficult,notably in the mandible.

Skeletal and dental disorders

Agenetic space closure is the mostattractive solution in young patients,avoiding implants. Treatment options,however, depend on orthodontic diag-nosis29. Usually, closure is indicatedwhen extraction is necessary to re-solve dentomaxillary disharmony: i.e.,bilabioversion and/or crowding (Fig. 4).

Number of dental ageneses

The number of ageneses also deter-mines treatment options. In severe oli-godontia, closure of spaces would leadto very short arcades, impairing masti-cation (Fig. 5).

Deciduous molar integrity

Decay, large obturation, root resorp-tion or infra-occlusion may reducedeciduous molar lifetime. If molar infra-occlusion is severe, the vertical defectwill be large and some authors recom-mend extraction18. If deciduous molarintegrity is unimpaired, the tooth

Figure 3Panoramic radiograph in a 13 year-old girl with agenesis of 14, 15, 18, 25, 35, 38, 45 and48 and moderate infra-occlusion of 85 but not 75.



can usefully be spared, to as a spacemaintainer33.

Extraction of ankylosed deciduousteeth

Ankylosis seems to be associatedwith deciduous molars showing infra-occlusion; alveolar bone-loss following

extraction may be severe, jeopardizingfuture implantation and the wholeorthodontic plan16.

Motivation of patients and parents

Orthodontic treatment involvingclosures can be long, requiring goodcooperation and motivation.

Figure 5Panoramic X-ray of severe oligodontia with all 8 deciduous molars in infra-occlusion.

Figure 4Mandibular casts of 2 patients during constitution of young adult dentition, with persis-tence of 75 and 85 in moderate infra-occlusion. a) Anterior crowding with no room for33 and 43 to develop. b) Diastema generalized from 34 to 44.



Closure of mandibular 2nd

premolar agenesis space

In dentomaxillary disharmony, thespace corresponding to the absentpremolar allows correction of crowd-ing or incisor axis; but closure shouldbe avoided if it would impair profileor occlusion.

Extraction and spontaneous closure

The deciduous molar may be ex-tracted at a very early point, allowingphysiological closure. Joondeph andMcNeill recommend extraction be-fore the age of 11 (i.e., before erup-tion of the definitive 2nd molar) so asto allow such spontaneous closure11.

The mandibular 2nd premolarcrown mineralizes between 2 and 7years of age. Before the deciduousmolar is extracted, it should bechecked that the premolar is indeedlacking, with a differential diagnosisof late development. Before extrac-tion, a slice may be performed, to re-duce the mesiodistal diameter of thedeciduous molar37.

Hemisectioning of the deciduousmolar

Some authors recommend initialhemisectioning of the distal part ofthe deciduous molar, to promotespontaneous mesialization withoutversion of the definitive 1st molar, fol-lowed by extraction of the mesialpart of the deciduous molar in a sec-ond step25. This allows control ofmolar anchorage loss without impair-ing the profile.

Extraction and orthodontic closure

An orthodontic apparatus is oftenrequired for agenesis space closure,to restore arcade continuity. If neces-sary, anterior anchorage can be rein-forced by conjoining the anteriorsector and exerting active radiculo-lin-gual torque on the mandibular inci-sors. Canine tip-forward can beassociated, to prevent distal version.

In mandibular agenesis space clo-sure, impact on the profile can behard to avoid: anchorage can be rein-forced, for example by mini-screws.

Closure may require extraction ofpremolars in other sectors, to im-prove occlusion: either contralaterallyto restore arcade symmetry, or an-tagonistically to improve molar rela-tions, or both. In class II or IIItherapy, occlusion balance may beconsidered.

It is, however, often a mistake toextract the deciduous molars andclose the spaces when there is nodentomaxillary disharmony, especiallyin hypodivergent patients (Fig. 6).

Retaining mandibular 2nd

premolar agenesis spaces

When there is no crowding, thetreatment decision is harder to make,especially when prognosis for the de-ciduous molar is poor22.

Intact deciduous molar

If it is decided to retain the agene-tic premolar spaces, it is preferableto conserve the deciduous molar aslong as possible, despite a risk ofinfra-occlusion or root resorption.



Sabri considers the deciduous molarto be the best means of maintainingthe space and bone volume29. Manystudies have shown that deciduousmolars can be conserved for severalyears; their lifetime is hard to predictat an early stage, when decisionshave to be taken, but root resorptionis very slow. If the deciduous molarpersists at 20 years of age, its prog-nosis is very good5.

Deciduous molar root resorption isnegligible for several years; conserva-tion often proves a more lastingsolution that implantation33.

Conserving the deciduous molarconserves bone volume ahead of im-plantation. However, mesiodistal dia-meter should be reduced, as thedeciduous molar is wider than a1.2-mm premolar, so as obtain aspace suited to future implantation15.

Arranging for a 7-mm space allowsclass I molar relations34. Reduction,however, is guided by the divergenceof the roots and size of the pulp, toavoid inflammatory reaction29; other-wise a compromise has to be struckregarding molar occlusion. Accordingto Kokich, when the alveolus of the

Figure 6Decision tree in premolar agenesis. Medio et al., International Orthodontics 2014;12(3):291-302.



adjacent tooth is in contact with theroot of the deciduous tooth, the latteris resorbed.

The deciduous molar may appearin infra-occlusion, but this is not aproblem for its survival5.

Deciduous molar in infra-occlusion

In slight to moderate infra-occlu-sion, the deciduous tooth may beconserved, to prevent bone loss forfuture implantation. The tooth shouldbe reconstituted, to restore occlusaland interproximal contact1 and pre-vent version of the adjacent teethand protrusion of the antagonists36.Several treatment options have beendescribed to restore function13:metal crowns, preformed pedodonticcrowns, or direct or indirect compo-site restoration.

A deciduous molar may begin theprocess of ‘‘relative reinclusion’’ at6-13 years of age. If infra-occlusionappears in a 13 year-old girl withalready well-established craniofacialgrowth, it will not be unduly severeand may be managed by a compositeto restore occlusal contact29. There islittle worsening of infra-occlusion inadolescents, with mean progressionof 0.5±0.26 mm/year22.

Prognosis for infra-occlusion de-pends on the severity of root resorp-tion. Severity tends to increaseduring growth and to plateau withadulthood. In over-12 year-olds withmild infra-occlusion, the deciduousmolar may be conserved with goodprognosis. In under-12 year-olds,prognosis is much more uncertain9.

Extracted deciduous molar

For many years, infra-occludingteeth were considered as a source ofocclusion disorder and were almostsystematically extracted. As thecause is usually ankylosis, extractionmay lead to considerable bone loss,complicating future implantation16.

Nowadays, extraction is recom-mended only in case of abscess orsevere decay or if infra-occlusion issevere and the occlusion line is nearthe gum20.

One should not wait until thedeciduous molar is in excessive infra-occlusion, as this incurs a risk of on-set of severe vertical bone defect10;an implant will then be deeply em-bedded and clinical crown height willbe increased. To avoid such verticaldefect, bone graft may be performedor the bone may be remodeled bydistalizing the 1st premolar towardthe missing 2nd premolar and im-planting in the 1st premolar site34 -although this considerably lengthenstreatment.

Avulsion should be performed non-traumatically, possibly by separatingthe roots so as to maintain the alveo-lar walls.

To avoid excessive bone loss duringgrowth, some authors recommend ex-tracting the deciduous molar while in-fra-occlusion is still moderate. Studieshave demonstrated that the bone levelat the extraction site migrates occlu-sally during growth of the adjacentteeth, which continue erupting26. Peri-osteal stretching stimulates osteoblastactivity, allowing alveolar growth tocontinue in the space.



The drawback with early deciduous2nd molar extraction lies in the thin-ning of the bone crest: alveolar crestthickness in the space is reduced by25% over the first 3 years (from 11.5mm to 8.5 mm), then by 4% overthe following 4 years26, more on thevestibular than on the lingual side15.

If for whatever reason (decay, se-vere infra-occlusion, excessively re-sorbed roots) the deciduous molar isextracted, a space maintainer is re-quired awaiting implantation: band/crown and loop, Nance palatal arch,lingual arch, dental tray; pediatric im-plants can also be created.

Deciduous molar replacementsolutions

There are several replacement so-lutions at end of growth.

• Tooth-borne bridgeTooth-borne bridges require dama-

ging the teeth adjacent to the space;if these are healthy, this solutionseems excessive.

• Extension bridgeSome authors have described can-

tilever bridges for premolar replace-ment, fitted to the occlusal andlingual sides of the definitive 1st mo-lar. Sidhu reported a patient withmoderate or severe infra-occlusion of54, 55 and 65; after extracting the 3deciduous molars, the 55 and 65spaces were closed orthodonticallyto achieve therapeutic class II rela-tions and 14 was restored using aceramic prosthetic element fixed to1631. However, studies of posterior

extension bridges reported poorersurvival than for conventional bridgesor implant-borne restoration.

• AutotransplantationIt is possible to do an autotrans-

plant using a premolar that is beingextracted for orthodontic reasons, toreplace another premolar32.

It is also possible to autotransplantthe maxillary 3rd molar to replace thelacking premolar24.

To achieve the best results, the op-timal age for 3rd molar autotransplantis around 17-18 years. The trans-planted tooth should not be comple-tely edified; the root should bebetween one-half and two-thirds ofradicular height12.

Reports of autotransplantation aresparse: the transplanted tooth is sub-ject to ankylosis and survival ispoorer than for an implant; moreover,few surgeons are trained for this pro-cedure.

• ImplantationIn agenesis flanked by healthy

teeth, the most common solution isan implant-borne crown at end ofgrowth39.

In severe infra-occlusion, adjacentteeth may show version, and orthodon-tic treatment is required to correct theiraxes and restore a space suitable forfuture implantation.

Single-unit implantation is reliablein the long term, but cost is a factorto be borne in mind. 5-year survival is93-95%, so that regular follow-up isneeded, with implantation possiblyrepeated at several points over thepatient’s lifetime.



If vertical and/or bone defect is toogreat, autologous or synthetic bonegraft is required to increase bone vo-lume. Support tissue may also needthickening by pre- or intra-operativegingival graft at implantation. If thedeciduous molar is maxillary, sinuselevation may be necessary if resi-dual sub-sinus height is insufficientfor the implant (Fig. 7).

Case report (Fig. 8)

Iona B., aged 20 years, consultedfor esthetic and functional reasons.Esthetically, the lower face was di-minished, her smile unpleasing, andcervico-mental distance was reduced,with double-chin aspect. Dentally, for-mula was incomplete: 15, 25, 35 and45 absent; 55, 65, 75 and 85 totallysubmerged; and 55, 75 and 85 in se-vere infra-occlusion. Malocclusionwas class II.2 with 5-mm class II left

and right molar and canine relation,severe maxillary incisor lingual ver-sion and 6-mm supra-occlusion.

The treatment plan was orthodontic-surgical, with maxillary and mandibularmulti-attachment apparatuses, reopen-ing of 15, 25, 35 and 45 spaces, andmandibular advancement.

The dental arcades were alignedthen straightened and the 1st molaraxes corrected. During orthodontictreatment, teeth in infra-occlusionwere extracted and the spaces con-served. Surgical arches were fittedand 5-mm mandibular advancementwas performed (Dr Deffrennes).Some occlusal finishing was re-quired; the agenetic premolar spaceswere made symmetrical (7 mm).Then 4 implants (Nobel�, Replace,Tapered and NP) were inserted (DrPopelut). Implant-borne crowns werescrewed on 3 months after implantosseointegration.

Figure 7a) Severe 55 infra-occlusion. b) Non-traumatic extraction of 55 with root separation and maximal alveolar wall sparing.c) Sinus elevation on lateral approach; bone filling with resorbable membrane. d) Implant positioning to replace 15.



Figure 8a) Panoramic radiograph show-ing severe 85 infra-occlusionand version of adjacent teeth.b) and c) Reduced space for 45,with mesial version of 46 and5-mm class II molar-canine rela-tion. d) and e) Correction of 46and 44 axes by maxillary andmandibular multi-attachment ap-paratus. Mandibular advance-ment surgery (Dr Deffrennes)restored class I molar relation.f), g) and h) Implantation to 45(Dr Popelut). i) Panoramic radio-graph showing implant repla-cing 45, parallel to mandibularroots.



CONCLUSION

In mandibular 2nd molar agenesis,orthodontics offers several reliablesolutions. The risks associated withagenesis space closure are reducedby the use of skeletal anchors (mini-screws and mini-plates). In the ab-sence of dentomaxillary disharmony,however, retaining the spaces is thebest option. If the deciduous molar isin infra-occlusion, there are severalpossible solutions, according to the

clinical situation. In the long term,the agenetic premolar will be re-placed by an implant-borne crown.Space management is therefore mul-tidisciplinary, and communication be-tween practitioners is essential.

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Management of mandibular second premolar … 10.1051/odfen/2014037 J Dentofacial Anom Orthod 2015;18:105 1 Article received: 31-07-2014. Accepted for publication: 25-08-2014. Management