Peter Ngan* Dean Heinrichs

DMD

DENTAL PRACTICE

Hong Kong Dent J 2011;8:40-5

DDS, MS DDS, MS

Spencer Hodnett

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
*

ABSTRACT
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

Introduction
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 : pngan@hsc.wvu.edu

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 jaws); and the condition of the bone after extraction of the primary tooth.

Age and distance of the primary tooth from the occlusal plane
The age of the patient at the time of diagnosis is important, because vertical growth continues past the pubertal growth spurt and lasts longer than growth in the sagittal and transverse dimensions 3. 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. Primary molars can often appear below the occlusal plane (infraocclusion). However, a step in the occlusal plane does not always mean the tooth is ankylosed 4. The best method to determine this is to compare the bone height to the adjacent molar or premolar on a bitewing radiograph 5. If the bone level between the primary molar and the adjacent first

permanent molar or premolar is level, the deciduous tooth is erupting evenly. In a young patient, if there is an oblique step in the bone height from the primary to the permanent molar or premolar, then the tooth is probably ankylosed. 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, since there is little growth remaining in the vertical dimension 5. 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. The tooth should therefore be extracted to prevent a potential alveolar ridge defect.

Gender
The gender of the patient is also important, because of different maturation rates in males and females. The growth of the facial skeleton continues after puberty, but the rate of growth decreases steadily and, after the second decade of

Figure 1

Diagnostic scheme for treatment options for congenitally missing mandibular second premolars

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life, seems to be clinically insignificant. About 60% to 70% of the increase in anterior facial height (nasion-menton) occurs in the lower anterior part (anterior nasal spine menton) 4. There is also a difference in the amount of growth between the sexes during the second decade of life; in those aged more than 20 years, the inter-gender difference is substantially diminished 4. However, the rate of eruption of the maxillary central incisors in females has been reported to be greater than that in males, despite more growth of anterior facial height in males over the same time 4.

Condition of the bone after extraction of the primary tooth

Once the decision is made to extract the primary molar because of caries, resorbed roots, or ankylosis, the next step is to decide how to manage the space. Ostler and Kokich 6 studied the long-term changes in bone associated with extraction of primary second molars with no permanent successor. They found that the alveolar ridge narrowed by 25% in the first 4 years after extraction of the deciduous tooth; after 7 years it narrowed by another 5% resulting in a total reduction in width of 30%. Kokich 7 described a way to preserve the alveolar ridge after extraction. In one case he moved the first premolar into the position of the missing second premolar. This tooth movement through the alveolar ridge allowed for adequate bone height and thickness, and prevented the need for bone grafting prior to the placement of an implant to restore the first premolar space.

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. If the primary tooth has a large restoration or is severely decayed, the options are limited to removal of the tooth. The same is true of a primary tooth with severely resorbed roots. Also, it is easy to make decision on extraction/non-extraction if there is sufficient crowding, excessive proclination of the incisors, and presence of jaw discrepancies (Figures 2 and 3).

Decision to extract the primary second molar

If the primary tooth is extracted, the next decision is whether to replace the missing premolar or close the space.

(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

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Management of congenitally missing premolar

Historically, conventional bridges or resin-bonded bridges were used to restore the missing teeth. The negative aspects of these options were that conventional bridges could lead to pulp devitalization in younger patients, and that resin-bonded bridges in posterior areas had poor survival rates 8,9. The best option for a congenitally missing mandibular second premolar was to replace it with a single tooth implant 5, which has a 95% 10-year survival rate, but placement must be delayed until growth is complete 10. Replacement with a conventional fixed bridge has a 10-year survival rate of about 84%, but again, placement should be delayed until the pulp chamber allows preparation 11. Autotransplantation is an option if a viable tooth (usually a third molar or premolar with an open apex) is available. This procedure has been popular in European and SouthEast Asian countries, but is rarely performed in North America, because most oral surgeons are unfamiliar with the procedure 12,13. After 4 years, success rates of autotransplantation were 94% and 82% for incomplete and complete root formation, respectively 2.

facial profile, space closure has undesirable side-effects. The introduction of temporary anchorage devices, such as miniscrew implants, has created more options for space closure (Figure 4) 5. By utilizing such implants, the molars can be protracted without side-effects on the anterior teeth of the arch. If the decision is to remove the primary molar at an early age, controlled slicing of the tooth may be an option (Figure 5). This is indicated when the deciduous tooth is not ankylosed and has erupted evenly between adjacent teeth 14. This is best done between the ages of 8 and 9 years. However, good results can be obtained in persons as old as 11 years. The mesiodistal width of a typical primary molar is 13 mm; the normal width of an average mandibular second premolar is 7.5 mm. Although a single-tooth implant may be planned to replace the missing premolar, the patient may be too young and still growing. To preserve the buccolingual bone for an eventual implant, controlled slicing may be indicated; it is a process that removes the distal root and crown of the primary molar, allowing the first permanent molar to drift into approximation with the mesial portion. Once this occurs, the mesial portion is removed and fixed appliances are used to complete the space closure 15. Another option exists if the patient has completed vertical growth. 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, the teeth can be leveled and aligned. Then an endosseous implant can be placed in the position of the missing premolar. After healing, 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.

Decision to close the space

If it is decided to close the space, there are major orthodontic anchorage concerns. Fines et al. 1 reported a case with a unilateral missing mandibular second premolar, in which the decision was to extract the primary tooth and close the space. Class II elastics were employed to close the space. However, a 1-mm midline shift to the affected side was noted after completion. Closing the space of a primary molar, which is often 10 to 11 mm, is difficult at best and may result in a midline shift and flattening of the face 14. If the patient has a protrusive profile or moderate crowding, space closure is favored. However, 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. (b) Placement of a mini-implant between the mandibular canine and first premolar to protract posterior molars. (c) Post-treatment in the patient

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Decision to keep the primary second molar

If it is decided to keep the primary molar, the difference in size between a primary molar and a permanent succedaneous premolar must be addressed. The primary second molar is usually 1.5 to 2 mm wider than the succedaneous premolar. 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. One can decide to accept the end-toend molar relationship and manage it when the patient eventually loses 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 decision to reshape the tooth is made, radiographs need to be examined to determine by how much the extent of reduction may be limited by divergent roots. However, it has been reported that even with widely divergent roots, the socket wall of the permanent tooth will resorb the divergent deciduous roots and be replaced by bone as the space is closed 16. This would be an ideal situation if the space was later to be restored by an implant. Typically the mandibular second primary molars are approximately 10 to 12 mm wide. By reducing the mesiodistal width, the tooth can be narrowed to about 8.0 mm 16. It is usually necessary to add composite to the occlusal surface to obtain occlusal contact; the composite can be added interproximally to cover exposed dentin. If the primary molar is retained, the prognosis for its longterm survival is more than 90%. In a study of 99 subjects with agenesis of one or both mandibular second premolars, only seven of the 99 primary teeth were exfoliated during an observation period from 12 years to adulthood 13.
(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

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Conclusions
There are numerous options for treating a patient with a congenitally missing mandibular second premolar. The key to successful management is to diagnose the problem early in the presence of mixed dentition. 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, the clinician must prevent any detrimental changes to the occlusion and to the facial profile. More treatment options are open to younger patients. The advent of temporary anchorage devices provides new treatment options for managing patients with congenitally missing mandibular second premolars.

References
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