CASE REPORT

Incorporating retained deciduous teeth in

orthodontic therapy
Christian R. Kenworthy, DDS,a and Brent E. Larson, DDS, MS,b
Rochester, Minn
While patients with hypodontia of the permanent dentition constitute a relatively small portion of the general
population, a significant percentage of these patients will require orthodontic therapy. This is a case report in
which the family opted to maintain the retained deciduous teeth rather than seek combined
orthodonticprosthodontic treatment. (Am J Orthod Dentofacial Orthop 2001;119:202-10)

n patients without cleft lip or cleft palate, the presence of hypodontia of the permanent dentition is
reported to be between 1.5% and 10.2%. The
prevalence varies slightly by region and ethnic group.
The most common missing tooth is the mandibular second premolar.1-3 For obvious reasons, this population
of patients is often referred for orthodontic therapy.
There are several treatment options for permanent
tooth hypodontia. With the nearly 90% long-term success rate of dental implants,4 many patients with
hypodontia choose to have the deciduous teeth removed
and the space reduced orthodontically, then filled with
an implant-supported crown. This particular treatment
plan could also include replacing the missing tooth or
teeth with a bridge or partial denture.5 If arch perimeter
needs and profile considerations are acceptable, another
option is to remove the deciduous tooth (or teeth), its
antagonists, and its permanent contralateral counterparts, and then close the extraction spaces, thus avoiding any prosthetic intervention. Finally, one could opt to
use the deciduous dentition in the final occlusion.
Retained deciduous teeth are sometimes thought to be
an unreliable source of long-term occlusion, but case
reports are available that demonstrate more than 50
years of deciduous tooth service.6
Many factors will influence the choice of treatment
plan. One will be the age of the patient at the time of the
initial orthodontic examination. Early detection will
allow all treatment avenues to be explored with the
patient and family. The root form and the crown position

Submitted by Dr Kenworthy in partial fulfillment of the requirements for the masters degree in Biomedical Science at the Mayo Graduate School of Medicine.
aGraduate Student in Orthodontics, Mayo Graduate School of Medicine.
bPrivate Practice.
Reprint requests to: Brent E. Larson, 401 16th St SE, Rochester MN 55904;
e-mail, belarson@home.com.
Submitted, December 1999; revised and accepted, June 2000.
Copyright 2001 by the American Association of Orthodontists.
0889-5406/2001/$35.00 + 0 8/4/112445
doi:10.1067/mod.2001.112445

202

of the retained teeth will influence the orthodontists preferred treatment plan. The orthodontic diagnosis may be
used to predict the acceptability of extraction space closure on soft tissue esthetics. Family preference and specialist availability may also play a role in the choice of a
combined orthodonticprosthodontic treatment plan.
HISTORY

The patient was referred to the Mayo Clinic Division

of Orthodontics in 1991 at the age of 8 years 8 months
with the chief complaint of an impinging overbite and
dental crowding. With the exception of a penicillin
allergy, her medical and dental histories were unremarkable. At the time of her initial examination the maxillary
lateral incisors had not yet erupted. While the patients
family expressed a desire for interceptive therapy,
records were postponed until 1993, when the patient was
10 years old and had all 4 maxillary incisors.
DIAGNOSIS

It was noted radiographically that teeth 1.5 and 3.5

(FDI numbering system) were congenitally absent but
that the root forms and lengths and the crown positions
of teeth 5.5 and 7.5 were favorable. Both skeletal and
dental deepbite were evidenced by an SN-GoGn angle
of 24.8 and 100% overbite of the mandibular incisors.
The molar relationship was one half cusp Class II on the
left and Class I on the right. The mandibular incisors
were retroclined and retrusive and oriented 80 to the
mandibular plane (mean, 95.9 5.7) and 0.7 mm anterior to NB (mean, 5.0 2.5). The maxillary incisors were
also retroclined and retrusive and oriented 103.2 to the
nasal floor (mean, 112.5 5.3) and 1.4 mm anterior to
NA (mean, 4.3 2.8). Contact irregularities were noted
in the maxillary and mandibular incisors, and a mild
curve of Spee was present in the mandibular arch. These
findings produced a diagnosis of transitional Class I
deepbite malocclusion (Figs 1, 2).

American Journal of Orthodontics and Dentofacial Orthopedics

Volume 119, Number 3

Fig 1. Pretreatment facial and intraoral photographs.

Fig 2. Pretreatment dental casts.

Kenworthy and Larson 203

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American Journal of Orthodontics and Dentofacial Orthopedics

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B
Fig 3. Phase I cephalometric tracing comparison.
PHASE I
Plan of treatment

Two treatment plans were offered to the family.

Both consisted of maxillary and mandibular 2 4
appliances for 9 months to address incisor position and
overbite. One plan would maintain the retained deciduous
teeth and accept a compromised posterior interdigitation
until adolescence, when the status of these teeth would be
readdressed during the second phase of treatment. The
second option would remove the deciduous teeth when

the root development of tooth 2.5 was half complete.

Tooth 2.5 would then be transplanted to replace 3.5 and
the remaining malocclusion would be managed as a maxillary premolar extraction case. The family declined the
extraction plan and opted to maintain the deciduous teeth.
Treatment objectives

Soft tissue: Maintain soft tissue facial balance.

Occlusion: Allow the permanent first molar occlusion to remain asymmetric because of the anticipated

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Fig 4. Pre-phase II facial and intraoral photographs.

maxillomandibular tooth-size discrepancy once the

existing permanent dentition erupts. Reduce overbite
and establish an ideal overbite and overjet.
Maxillary dentition: Procline and intrude the maxillary incisors to reduce overbite.
Mandibular dentition: Procline and intrude the
mandibular incisors to reduce overbite while
maintaining ideal overjet.
Maxilla: No maxillary positional change was desired.
Mandible: No mandibular positional change was
desired.

was completed in 11 months, and the patient was given

a maxillary Hawley retainer and a mandibular bonded
retainer to wear during the eruption of her permanent
dentition. After 9 months, the Hawley was discontinued
because of its impact on the eruption of the permanent
canines. The patient returned periodically during the
next 3 years for follow-up examinations. Tooth 8.5 was
extracted during this time because of inadequate resorption. A complete set of updated records was obtained 33
months after the completion of phase I care, when the
patient was 14 years 2 months old.

Treatment progress

Results achieved

The initial force was applied through .016-in nickeltitanium archwires. Two months later, incisor advancement was initiated with advancing loops on round .016in stainless steel wires. After 2 months, the round wires
were replaced with .016 .022-in stainless steel wires
with advancing loops and intrusion mechanics. Phase I

Craniofacial growth was the most obvious change

noted between the records taken when the patient was 10
years old and those obtained when she was 14. Maxillary
and mandibular unit lengths increased. The SNA angle
remained constant, but SNB increased and ANB and the
mandibular plane both decreased. Dentally, the incisors

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American Journal of Orthodontics and Dentofacial Orthopedics

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Fig 5. Pre-phase II dental casts.

were aligned. Her maxillary incisors were proclined 12,

while 8 of proclination was noted in the mandibular
incisors. There was a relative extrusion of the maxillary
molars, which accounted for the decrease in overbite,
even though a mild curve of Spee remained. Three deciduous teeth, 5.5, 6.5, and 7.5, were still present (Figs 3-5).
PHASE II
Plan of treatment

The maxillary left second primary molar was

extracted to facilitate the eruption of tooth 2.5. Several
options were again offered. One was to accept the
improvements achieved during phase I and perform no
further treatment. Another was to extract teeth 5.5 and
7.5, reduce the space, further reduce the overbite,
maintain a Class I molar relationship on the right and
obtain it on the left, and plan for implant-retained single-tooth prosthetic replacement of 1.5 and 3.5. The
parents and patient were informed that the longevity of
teeth 5.5 and 7.5 was unknown and that it was possible
that they would exfoliate or become necrotic or unrestorable and require prosthetic replacement. Still, the
family opted to maintain these teeth and accept any
occlusal or esthetic compromises produced by their
presence.
Thus, the final treatment plan consisted of complete
maxillary and mandibular .018 .025-in edgewise
appliances for 18 months followed by a maxillary
Hawley-type retainer with a passive bite shelf and a
mandibular bonded retainer from canine to canine. The

Table I. Summary

of cephalometric analysis

Measurement

Norm

Pretreatment

SNA
SNB
ANB
Wits
SN-GoGn
Y Axis
U1SN
L1MP
U1L1

82
80
2
1
34
59
102
96
127

84.6
83.4
1.2
1.7
24.8
56.2
100.7
80.0
154.5

Pre-phase
II
84.5
84.8
0.3
3.0
22.7
54.4
112.9
88.2
136.2

Posttreatment
85.5
85.1
0.3
3.6
23.7
55.0
116.3
102.3
117.7

goals of treatment were to reduce the overbite, obtain

Class I canines with the best achievable posterior interdigitation, and esthetically detail the anterior dentition.
Treatment objectives

Soft Tissue: Maintain soft tissue facial balance.

Occlusion: Create ideal overbite and overjet.
Achieve Class I canines bilaterally. Allow the left
molars to remain in a slight Class II relationship and
the right molars to remain in a slight Class III relationship because of the retained deciduous dentition.
Maxillary dentition: Procline and align incisors.
Make as few and minor adjustments as possible to
tooth 5.5.
Mandibular dentition: Procline, intrude, and align

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B
Fig 6. Phase II cephalometric tracing comparison.

the incisors. Make as few and as minor adjustments as possible to tooth 7.5.
Maxilla: No maxillary positional change was
desired.
Mandible: No mandibular positional change was
desired.
Treatment progress

The appliances were bonded to the entire erupted den-

tition, including the deciduous teeth, and .016-in round

nickel-titanium archwires were placed. After several visits to replace debonded mandibular incisor brackets, a
biteplate was inserted. To express torque, .016 .022-in
nickel-titanium archwires were placed for 1 month, followed by .016 .022-in stainless steel wires in both the
maxilla and mandible. After 7 months of therapy, the
mandibular curve of Spee was leveled and the biteplate
was discontinued. Detailing was continued for the next 8

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American Journal of Orthodontics and Dentofacial Orthopedics

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Fig 7. Posttreatment facial and intraoral photographs.

months. Phase II treatment was completed in 15 months,

with the combined treatment lasting 26 months. At the
patients request, bonded retainers were used in both the
mandible and maxilla. The maxillary retainer had a passive bite shelf designed in composite resin.
Results achieved

The overbite was decreased by both incisor proclination and a relative intrusion of the mandibular
incisors. During Phase II, the interincisal angle was
reduced by nearly 19. The maxillary incisors were proclined 3 and the mandibular incisors were proclined
14. Even with this proclination, the soft tissue profile
remained the same. The SN-GoGn angle increased by
1, and the ANB angle increased just over .5 (Table I).
The patient finished treatment with Class I canines
with a slight mandibular dental midline deviation to the
right. Because of the tooth-size discrepancy of the

retained deciduous teeth, the right posterior occlusion

was slightly Class III, while the left was slightly Class
II. There was, however, no detectable CR-CO shift.
Also, in an effort to move the deciduous teeth as little
as possible, and, as a result of their morphology, some
marginal ridge discrepancies were necessary in order
to maintain occlusion (Figs 6-8).
DISCUSSION

It seems that our perception of retained deciduous

teeth is rooted in a 1948 article by Aisenberg in which
he argues that deciduous teeth cannot withstand the
heavier forces of the adult jaw and will eventually
resorb.7 This uncertain longevity is perhaps the main
reason for orthodontists decisions to have deciduous
teeth removed. Our current understanding is that the
roots of these teeth resorb as the eruption cyst of their
permanent successor approaches, and this ultimately

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Volume 119, Number 3

Fig 8. Posttreatment dental casts.

forces exfoliation. However, without a permanent successor, there is no evidence to predict which roots will
spontaneously resorb. While all teeth are at risk of root
resorption during orthodontic tooth movement, there
has been no evaluation of the differences in resorption
rates or amounts between permanent and deciduous
dentitions. Teeth 5.5 and 7.5 in this patient exhibited
only a small amount of root resorption, even with the
force of orthodontic therapy (Fig 9). In an atraumatic
occlusion, eventual loss of deciduous teeth should be a
topic of discussion, not a predicted sequela.
Another justification for the extraction of retained
deciduous teeth is the ability to create an otherwise
ideal occlusion with the understanding that the restorative dentist will fill the residual space with an appropriate prosthesis. In theory, the posterior occlusion and the
dental midlines for this patient could have been ideal if
the deciduous teeth were removed and the remaining
space reduced. However, the mesiodistal dimension of
these teeth should not be reduced to an ideal dimension
and expected to be used long-term or incorporated in
the final occlusion. This is an anatomical decision based
on the large pulp chambers and the divergent roots that
are especially prominent in mandibular deciduous second molars. Violating the pulp chamber in an attempt to
reduce the size could result in devitalization. Reducing
the width of the crown so that it is less than the width of
the roots could either inhibit proper alignment of the
adjacent roots or increase the risk of resorption because
of the proximity of the roots in this area.

Fig 9. Pre- and post-phase II bitewing radiographs of

deciduous molars.

There is also the question of implant placement

timing. According to Ostler and Kokich8 there is, on
average, a 25% decrease in arch width in the 3 years
after the extraction of mandibular second primary
molars and an additional 4% decrease over the next 3
years. Seventy-four percent of this change occurs on
the buccal surface. These changes were also noted in
the maxillary posterior region.9 It is also known that
there is a component of vertical alveolar growth that
continues past puberty in association with natural dentition but not with implant-supported prostheses. So, if

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American Journal of Orthodontics and Dentofacial Orthopedics

March 2001

orthodontic treatment is started when the patient is 12

years old and the implant is placed at age 17, there is a
long period of space maintenance accompanied by a
significant amount of expected ridge resorption. A final
consideration is that while the long-term success of
dental implants and bridges in the posterior regions is
generally very high, the availability of a specialist and
the additional cost may eliminate this possibility.
Prosthodontic intervention may be avoided in
patients with retained deciduous teeth by extracting the
retained teeth and closing the residual space. Of course,
treatment time and the effect on both the final occlusion and soft tissue must be considered. This case could
have been treated either by extracting all 4 second premolars and closing all space or by removing only the
deciduous teeth and closing that space. Both of these
options would have increased treatment time and may
have affected facial esthetics.
CONCLUSION

This case report has been presented to illustrate the

possibility of incorporating deciduous teeth in the
orthodontic treatment plan. Along with the rest of the
dentition, these deciduous teeth were bracketed and

aligned with the occlusal plane. The retention of teeth

5.5 and 7.5 in this case resulted in a functional and
esthetic dentition.
References
1. Silverman NE, Ackerman JL. Oligodontia: a study of its prevalence and variation in 4032 children. ASDC J Dent Child
1979;46:470-7.
2. Rolling S. Hypodontia of permanent teeth in Danish schoolchildren. Scand J Dent Res 1980;88:365-9.
3. Shapira Y, Lubit E, Kuftinec MM. Congenitally missing second
premolars in cleft lip and cleft palate children. Am J Orthod
Dentofacial Orthop 1999;115:396-400.
4. Eckert SE, Wollan PC. Retrospective review of 1170 endosseous
implants placed in partially edentulous jaws. J Prosthet Dent
1998;79:415-21.
5. Valinoti JR Jr. The congenitally absent premolar problem. Angle
Orthod 1958;28:36-46.
6. Stanley HR, Collett WK, Hazard JA. Retention of a maxillary
primary canine: fifty years above and beyond the call of duty.
ASDC J Dent Child 1996;63:123-30.
7. Aisenberg MS. The tissues and changes involved in orthodontic
tooth movements. Am J Orthod 1948;34:854-9.
8. Ostler MS, Kokich VG. Alveolar ridge changes in patients congenitally missing mandibular second premolars. J Prosthet Dent
1994;71:144-9.
9. Pietrokovski J, Sorin S, Hirschfeld Z. The residual ridge in par-

The editorial staff of the American Journal of Orthodontics and Dentofacial Orthopedics has chosen the
Fdration Dentaire Internationale (FDI) tooth numbering system as the standard form of tooth notation for
research articles, case reports, and other peer-reviewed materials. We have provided this chart of the FDI system for quick and easy referencing as you read Journal articles.
Permanent teeth
Maxillary right
1.8

1.7

1.6

1.5

1.4

Maxillary left
1.3

1.2

1.1

2.1 2.2

Mandibular right
4.8

4.7

4.6

4.5

4.4

2.3

2.4

4.3

4.2

4.1

3.1 3.2

Maxillary right
5.4

3.3

3.4

5.3

5.2

Maxillary left
5.1

6.1

Mandibular right
8.5

8.4

2.6

2.7 2.8

Mandibular left

Deciduous teeth

5.5

2.5

8.3

8.2

6.2

6.3

6.4

6.5

Mandibular left
8.1

7.1

7.2

7.3

7.4

7.5

3.5

3.6

3.7 3.8