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Posterior Teeth Mesialization With Mini-implants In An Oligodontia Patientpassive anterior bite plane in order to maintain verticalspace required for future prosthodontic replacements.Removal of the remaining deciduous teeth was to bepostponed until patient is ready for more permanentprosthodontic replacements. Resizing of deciduous teethwas planned together with the prosthodontists in order tomaintain optimum space for a normal-sized permanentreplacement in future. Hygienist referral was done formaintenance of oral hygiene, prosthodontist for temporarycomposite build-up of upper canines during treatment,assessment of space required interocclusally and mesiodistallyfor prosthodontic replacement of missing teeth andperiodontist for possibility of crown lengthening procedureon short clinical crowns.TREATMENT PROGRESSTreatment started at 15 year 9 month and ended 18years of age. Orthodontic treatment started with referral tothe oral surgeon for removal of #85, placement of fixedappliances with initial levelling and alignment wires.Prior to placement of AbsoAnchor ® mini-implants, allrepositioning of permanent teeth are done on 017” x025” SS. Gradual stripping of deciduous teeth to resizeto permanent replacement and to allow mesialization ofposterior teeth was carried out (Fig 8). 1.4mm x 8mmand 1.5mm x 6mm mini-implants were first placed by theorthodontist in the first and fourth quadrants respectively,distal to permanent canines. Location was determined withthe help of periapical radiographs and with considerationof amount of movement required. Mesialization of #13and #46 was done immediately using the mini-implantwith aid of extended steel hooks on 019” x 025” SS withthe aid of extended steel hooks on molar bands (Fig 9).After placement of mini-implants on the second and thirdquadrants, mesialization of posterior teeth was commencedon the related quadrants, in conjunction with gradualstripping of deciduous teeth (Fig 10).COMPLICATIONS ENCOUNTERED DURINGTREATMENTOverall, the patient was compliant with oral hygieneand tolerant with all aspects of treatment. Anchoragecontrol after placement of the mini-screws was better andtreatment progressed much faster and more predictably.However, two out of the four mini-implants loosened anddislodged midway of treatment and had to be replaced.During movement of upper right canine mesially, frequentdislodgement of the bracket on lower right first premolaroccurred due to the biting of the upper canine, and it wasdecided to rebracket it after the upper canine has beenmesialized.TREATMENT RESULTSPost-treatment record shows that lateral profile hasbeen maintained with no overt flattening (Fig 11). Extraoralappearance is pleasing and the smile greatly improvedwith redistribution of teeth and acrylic teeth replacementof upper lateral incisors. Class I molar relationship wasachieved (Fig 12). Post-treatment overjet and overbite arewithin normal limits. Overbite stability is good as long aspatient wear upper removable retainer. <strong>Dental</strong> midlinescoincide with facial midline. Composite build-up of uppercanines and central incisors has been placed as intermediateplan prior to definitive prosthodontic treatment.Lateral cephalogram analysis showed slightretroclination of upper and small retraction of lowerincisors and lips (Table 2). Individual superimpositionon maxilla (Fig 13) and mandible (Fig 14) showed molarmesialization. Panoramic radiographs reveal adequate rootparallelism except for #44, with some blunting of lowerright first molar root tips (Fig 15). Bodily mesialization offirst permanent had been successfully carried out. Rootsadjacent to planned future implants have been positionedwith sufficient bone space vertically and mesio-distally.The position of the developing #28 and #38 needs to bereviewed. Although interincisal angle was reduced frompre-treatment value, post-treatment angle is still morethan the norms, therefore long-term retention of overbiteinvolving a removable retainer with anterior bite plate wasplanned.DISCUSSIONThe pattern of oligodontia presented by this casereport conforms to the findings in a study conducted onthe pattern of severe hypodontia affecting at least 5 teethexcluding the third molars where it was reported to beaffecting mainly maxillary lateral incisors (16%), followedby mandibular second premolar (11%), mandibular centralincisor and maxillary second premolar (10% each) 33 .Different methods of mesializationMesialization of posterior teeth by means ofconventional orthodontics to close spaces often tax theanchorage from remaining teeth and unwanted toothmovement can still happen, therefore in hypodontiapatients with an already retrusive profile as in thispatient, conventional orthodontic space closure would bedetrimental to the facial profile 34,35 . Therefore various othertypes of posterior teeth mesialization have been advocated,such as extra-oral traction with chin cup 35 and gradualself-mesialization via hemisection 34 . Reverse headgear wasalso one of the ways recommended to provide anchoragefor moving upper posterior teeth forward to close theedentulous space or to advance the hypoplastic maxilla inhypodontia patients 36,37 , however this method requires ahigher level of patient’s co-operation.The introduction of “absolute” anchorage systemhelps reduce anchorage control problem and thus havebeen documented for this purpose 35,38,39,40 . Sliding jigs wereapplied on the buccal for distalization of the lower posteriorteeth 41 . Costa et al. 42 placed screws in the mandible formesial movement of the molars. Loading protocols forscrews involve immediate loading or a waiting period of 2weeks to apply forces 43 and only a short waiting period wasrequired before loading 44,45 . This advantage reduces the116
Wey / Wu / Wong / Zamri / Häggtreatment period and, thus, increases patient acceptability.Success rateBernhart et al. 46 placed 21 mini-implants on theparamedian region of the palate for protraction of posteriorteeth, among various other purposes and presented an 86%success rate after 11.6 months of use.CONCLUSIONSAs a conclusion, mesialization of posterior teethwith mini-implants is a worthwhile treatment optionespecially in a severe hypodontia patient in order to reducecost of prosthodontic replacement without overt flatteningof patient’s profile.REFERENCES1. Proffit WR, Fields HW, Contemporary Orthdoontics 3rd edn.Mosby 2000:118.2. Kolenc-Fuse FJ. Tooth agenesis: in search of mutationsbehind failed dental development. Med Oral Patol Oral CirBucal 2004; 9:390-5;385-90.3. Nunn JH, NE Carter, TJ Gillgrass, et al. The interdisciplinarymanagement of hypodontia: background and role of paediatricdentistry. Br Dent J 2003;194:245-51.4. Sarnas KV, Rune B. The facial profile in advanced hypodontia:a mixed longitudinal study of 141 children. Eur J Orthod,1983; 5:133-43.5. Polder BJ, Van’t Hof MA, Van der Linden FP, et al. A metaanalysisof the prevalence of dental agenesis of permanentteeth. Community Dent Oral Epidemiol 2004; 32:217-26.6. Schalk van der Weide Y. Oligodontia: a clinical, radiographicand genetic evaluation. 1992, University of Utrecht: Utrecht.7. Rolling S, Poulsen S. Oligodontia in Danish schoolchildren.Acta Odontol Scand 2001;59:111–112.8. Davis PJ. Hypodontia and hyperdontia of permanent teeth inHong Kong schoolchildren. Community Dent Oral Epidemiol1987;15:218-20.9. Gullikson JS. Tooth morphology in rubella syndrome children.ASDC J Dent Child 1975;42:479-82.10. da Fonseca MA. Pediatric bone marrow transplantation: oralcomplications and recommendations for care. Pediatr Dent1998;20:386-94.11. Vastardis H, Karimbux N, Guthua SW, et al. A human MSX1homeodomain missense mutation causes selective toothagenesis. Nat Genet, 1996;13:417-21.12. Stockton DW, Das P, Goldenberg M, et al. Mutation of PAX9is associated with oligodontia. Nat Genet. 2000;24:18-9.13. Silverman NE, Ackerman JL. Oligodontia: a study of itsprevalence and variation in 4032 children. ASDC J DentChild 1979;46:470-7.14. McKeown H.F, Robinson DL, Elcock C, et al. Toothdimensions in hypodontia patients, their unaffected relativesand a control group measured by a new image analysis system.Eur J Orthod 2002;24:131-41.15. Rune B, Sarnas KV. Tooth size and tooth formation in childrenwith advanced hypodontia. Angle Orthod 1974;44:316-21.16. Peck S, Peck L, Kataja M. Site-specificity of tooth agenesisin subjects with maxillary canine malpositions. Angle Orthod1996;66:473-6.17. Pirinen, S, Arte S, Apajalahti S. Palatal displacement ofcanine is genetic and related to congenital absence of teeth. JDent Res 1996;75:1742-6.18. Garn SM, Lewis AB. The gradient and the pattern ofcrown-size reduction in simple hypodontia. Angle Orthod1970;40:51-8.19. Stenvik, A., B.U. Zachrisson, B. Svatun, Taurodontism andconcomitant hypodontia in siblings. Oral Surg Oral Med OralPathol, 1972;33:841-5.20. Lai PY, Seow WK. A controlled study of the association ofvarious dental anomalies with hypodontia of permanent teeth.Pediatr Dent 1989;11:291-6.21. Ogaard B, Krogstad O. Craniofacial structure and soft tissueprofile in patients with severe hypodontia. Am J OrthodDentofacial Orthop 1995;108:472-7.22. Bondarets N, McDonald F. Analysis of the vertical facial formin patients with severe hypodontia. Am J Phys Anthropol2000;111:177-84.23. Wisth PJ, Thunold K, Boe OE. The craniofacial morphologyof individuals with hypodontia. Acta Odontol Scand1974;32:293-302.24. Lindqvist B. Extraction of the deciduous second molar inhypodontia. Eur J Orthod, 1980;2:173-81.25. Mamopoulou A, Hägg U, Schroder U, et al. Agenesis ofmandibular second premolars. Spontaneous space closureafter extraction therapy: a 4-year follow-up. Eur J Orthod1996;18:589-600.26. Tulloch CJF, Ajunctive Treatment for adults, in ContemporaryOrthodontics. Mosby: St. Louis 2000:626-636.27. Blakey GH, White R, Surgical treatment: Mandibular surgery,in Contemporary Treatment of Dentofacial Deformity.Mosby: St. Louis 2003:312-344.28. Josefsson E, Brattstrom V, Tegsjo U, et al. Treatment oflower second premolar agenesis by autotransplantation:four-year evaluation of eighty patients. Acta Odontol Scand1999;57:111-5.29. Lundberg, Isaksson TS. A clinical follow-up study of278 autotransplanted teeth. Br J Oral Maxillofac Surg1996;34:181-5.30. Kristerson L. Autotransplantation of human premolars. Aclinical and radiographic study of 100 teeth. Int J Oral Surg1985;14:200-13.31. Kristerson L, Andreasen JO. Autotransplantation andreplantation of tooth germs in monkeys. Effect of damage tothe dental follicle and position of transplant in the alveolus.Int J Oral Surg 1984;13:324-33.32. Bolton W. The clinical application of tooth-size analysis. AmJ Orthod 1962:504-529.33. Wong TY, McGrath C, McMillan AS. Oral health of southernChinese children and adolescents with severe hypodontia. IntJ Pediatr Dent 2005;15(4):256–263).34. Northway WM. The nuts and bolts of hemisection treatment:managing congenitally missing mandibular second premolars.Am J Orthod Dentofacial Orthop 2005;127(5):606-10.35. Kokich VG. Kokich VO. Congenitally missing mandibularsecond premolars: clinical options. Am J Orthod DentofacialOrthop 2006;130(4):437-44.36. Goodman J. Hypodontia:1. <strong>Dental</strong> update 1994:381-384.37. Miller JR. A dental Class III malocclusion treated to a fullcuspClass II molar relationship. Am J Orthod DentofacialOrthop 1990;97:10-9.38. Block MS, Hoffman DR. A new device for absoluteanchorage for orthodontics. Am J Orthod Dentofacial Orthop1995;107:251-8.39. Sugawara J, Daimaruya T, Umemori M, et al. Distal117
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