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Prevalence and distribution of dental anomalies in

pretreatment orthodontic Thai patients
Suwadee Kositbowornchai* Chutimaporn Keinprasit** Nusara Poomat***

Abstract
The aim of this study was to evaluate the prevalence and distribution of dental anomalies, including
other pathologic findings in the pre-treatment records of Thai orthodontic patients at the Faculty of
Dentistry, Khon Kaen University. Two observers retrospectively examined 570 panoramic radiographs, study models and pre-orthodontic records. Dental anomalies were recorded using panoramic
radiographs and study models. The prevalence and distribution of the anomalies were assessed and
reported as descriptive statistics. Patients were between 12 and 40 years of age(mean 19.38+4.23).
Persons between 16 and 20 years of age comprised the most common age group (51.1%) requiring
for orthodontic treatment. The patient types included: class I (25.3%), II (27.4%), III (13.2%) and
superclass I (34.0%). Crowding and spacing were found in 89.6% and 73.2% of patients, respectively.
It was found that 38.6% of patients had at least one dental anomaly: hypodontia being the most
common (26.1%), followed by microdontia (13.7%), root shape abnormality (3.4%), hyperdontia (2.7%),
transposition (1.6%), macrodontia (1.4%) and fusion 0.7%. In conclusion, the developmental dental
anomalies found in Thai orthodontic patients were comparable with other research.

Keywords: dental anomaly, panoramic radiograph, tooth abnormality, orthodontics

Correspondence author
Associate Professor Suwadee Kositbowornchai
Department of Oral Diagnosis,
Faculty of Dentistry Khon Kaen University,
Amphur Muang, KhonKaen, 40002
Tel: ++66-4320-405 ext. 11154
Fax: ++66-4320-862
E-mail: suwadee@kku.ac.th
* Associate Professor, Department of Oral Diagnosis, Faculty of Dentistry Khon Kaen University
** Assistant Professor, Department of Orthodontics, Faculty of Dentistry, Khon Kaen University
*** Assistant Professor, Department of Community Dentistry, Faculty of Dentistry, Khon Kaen University

KDJ. Vol.13 No.2 July - Desember, 2010

93

INTRODUCTION

MATERIALS AND METHODS

Dental anomalies, and their influence on

malocclusions,have long been a concern to the dental
profession.Ben-Bassat and Brin1 found that multiple
congenitally-missing teeth affected the skeletal
pattern. Endo et al.2 reported the association of
hypodontia and craniofacial morphology in Japanese
orthodontic patients. Uslu et al.3 found no statistically
significant correlations between having a dental
anomaly and the type of malocclusion, except having
an impacted tooth or a short blunt root. An increased
prevalence of an occlusal deep bite was reported
in palatally-displaced maxillary canine subjects.4
Whether the prevalence of dental anomaly causes
any orthodontic problem has not, however, been fully
understood.
The difference in the prevalence of dental
anomalies in orthodontic patients reported over
the past 10 years of publications was very high.
Altug-Atac and Erdem5 reported 5.46% of the
orthodontic patients in a group of 3,043 had at least 1
developmental dental anomaly, while Thongudomporn
and Freer6 investigated 111 orthodontic patients and
found that 74.8% had at least 1 dental anomaly.
The possible cause of the variance in these reports
might be due to race, sample selection and size,
type of dental anomalies and malocclusion. Indeed,
most of the publications reported the prevalence of
hypodontia in orthodontic patients more than any other
type of dental anomaly and no type of malocclusion
was reported.7-9 These informational gaps limit our
understanding of dental anomalies in persons with
orthodontic problems.
Our purpose8, therefore, was to investigate
the prevalence and distribution of dental anomalies
in panoramic radiographs of Thai orthodontic patients
and evaluate whether the result was comparable with
other studies among orthodontic groups published
over the last decade.

Pre-orthodontic study models and panoramic

radiographs of 570 orthodontic patients were
retrospectively evaluated. All of the patients had been
seen at the Orthodontic Clinic, Faculty of Dentistry,
Khon Kaen University, between 1999 and 2006.
Detailed medical, dental and family histories were
obtained for all subjects. The selection criteria follow:
1. No significant medical history, such as
significant trauma to the jaw bones.
2. No history of metabolic disorders or syndrome
affecting bone metabolism and/or tooth formation.
3. No history of extraction or previous
orthodontic treatment.
4. No cleft lip and/or palate, craniofacial
anomalies and diagnosed syndromes.
5. Required good quality of study models
with stable occlusion and good quality panoramic
radiographs.

Demographic data
Age, sex and type of malocclusion were
recorded for each patient. Panoramic radiographs and
study models were examined for dental anomalies
and pathologic findings, with agreement between an
orthodontist and a radiologist. Descriptions of anomalies
used the criteria presented by Langland et al.10.
The following dental anomalies were assessed:
1. Number abnormalities (hypodontia and
hyperdontia);
2. Size abnormalities (macrodontia and
microdontia);
3. Shape abnormalities (fusion, gemination);
4. Location (transposition of tooth);
5. Other fidings.
Statistical analysis
Descriptive analysesusing the Statistical
Package for Social Science (SPSS 9.0)was used

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to calculate the prevalence and distribution within the

dental anomaly data. Percentages and means were
also calculated.

RESULTS
The sample group comprised 124 males
(21.8%) and 446 females (78.2%). Age ranged
between 12 and 40 years (mean, 19.38+ 4.23);
the average for the male and female groups was
18.1 and 19.0, respectively. Most of those seeking
orthodontic treatment were between 12 and 25 years
of age (94.3%), with the largest group being between
16-20 years of age (51.1%).
The patients were grouped into: class I
(25.3%), II (27.4%), III (13.2%) and superclass I
(34.0%). Crowding and spacing problems were found
in 89.6% and 73.2% of patients, respectively. It was
found that 38.6% of patients had at least one dental
anomaly. The prevalence and distribution of dental
anomalies follow:

Hypodontia
Of the 570 subjects, 149 (26.1%) had 350
missing teeth. The prevalence and distribution of
hypodontia is presented in Table 1. The most common
missing tooth was the third molar (68.9%), followed
by the lateral incisor (15.1%) and the second premolar
(8.6%). Except for the third molar, the other missing
teeth occurred in mandible (17.4%) more often than
in the maxilla (13.7%) and were distributed fairly
evenly between the right and the left side. Among
the hypodontia group, the percentage of patients with
one, two, three, four or five congenitally missing teeth
were 11.4, 6.5, 3.3, 3.0 and 0.7 respectively. The
prevalence of six or more congenitally missing teeth
was 1.4 % The highest number of congenitally missing
teeth was 14 but in only one subject (0.2% of the
total number of subjects)

Table 1 Prevalence and distribution of hypodontia

Number of tooth missing (% of missing tooth)
3 M
2ndM
2nd PM 1st PM
C
2nd I
1stM
Arch
R L R L
R
L R
L
R
L R L
R
L
80 60 0 1
0
1
7
3
4
4
1 1 11 13
Maxilla
(40.0%) (0.3%) (0.3%) (2.9%) (2.3%) (0.6%) (6.9%)
52 49 1 2
0
2 10 10 0
2
0 1 16 13
Mandible (28.9%) (0.9%) (0.6%) (5.7%) (0.6%) (0.3%) (8.3%)
241
4
3
30
10
3
53
Total
(68.9%) (1.1%) (0.9%) (8.6%) (2.9%) (0.9%) (15.1%)
(M=molar, PM=premolar, C=canine, I= incisor, R=right, L=left)
rd

Hyperdontia refers to one or more extra teeth.

Mesiodens is the extra tooth in the maxillary midline.
Our study reports extra teeth, either supernumerary
teeth or mesiodens, separately. A total of 15 subjects
(2.6%) presented; 12 with supernumerary teeth and
9 with mesiodens (Table 2). Six subjects presented
1 supernumerary tooth and three with 2 extra teeth.
Nine mesiodens were found in 6 subjects. Three

1st I
Total
R
L
188
1
1
(0.6%) (53.7%)
2
2
162
(1.1%) (46.3%)
6
350
(1.7%) (100.0%)

subjects had 2 cone-shaped mesiodens. The ratio of

upper to lower and anterior to posterior supernumerary
teeth was 2 to 1 and 3 to 1 respectively.
Regarding shape, the extra tooth shape resembled
the adjacent permanent tooth, such as the incisor
(2 cases), a cone shape (2 cases) or a canine
(5 cases) at the anterior sextant and the premolar
(1 case) or the molar shape (2 cases) at the
posterior sextant.

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Table 2 Prevalence and distribution of supernumerary tooth and mesiodens (% of the subjects)

Supernumerary tooth
- maxilla
- mandible

Patient's right sextant

Anterior sextants

Patient's left sextant

Total

1
(0.2%)
1
(0.2%)

6
(1.1%)
3
(0.5%)

1
(0.2%)
0
(0.0%)

9subjects
12 teeth
(1.6%)

Mesiodens
- maxilla

Macrodontia and microdontia The occurrence of

macrodontia was less common than microdontia.
Eight subjects had macrodontia (1.4% of the total
570 cases), including 5 cases of 1 macrodontia, 2
cases of 2 macrodontia [#28 (the maxillary left third
molar) & #48(the mandibulary right third molar) and
#25 (the maxillary left second premolar) & #34
(the mandibulary left first premolar)] and 1 case of 3
macrodontia [#15 (The maxillary right second premolar,
#35 ( the mandibulary left second premolar & #45
the mandibulary right second premolar)]. Macrodontia
did not appear in the anterior sextant. The most
common type of macrodontia presented at the third

3(2cone shape)
3(1cone shape)

6subjects
9 teeth
(1.1%)

molar (7 teeth), followed by the second premolar (4

teeth) and the first premolar (1 tooth).
There were 78 cases (13.7%, 120 teeth)
of microdontia (Table 3). The most commonly
affected teeth fairly equally represented the maxillary
third molar (56 from the whole 120 teeth) and the
maxillary lateral incisors (55). It is very common in
the maxilla (96.7%) and very rare in the mandible
(3.3%). The majority of patients presented one (40
cases) or two microdontias (35 cases). Two cases
presented 3 microdontias and one case presented
4 microdontias.

Table 3 Prevalence and distribution of hypodontia (% of microdontia)

Fusion There were four cases (0.7%) of 7 fused

teeth, one case of single fusion, three cases of double
fusion. Except for one tooth of the maxillary second
premolar, the remaining six teeth had fusion at the
mandible. Most fusion occurred among the lower

canine and lower premolar teeth. There was only one

case of fusion of a lower lateral incisor.
Gemination was not found in this study.

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Transposition Of the 9 transposition cases (1.6%),

five were located between the lateral incisor and the
adjacent canine, two between the canine and the first
premolar and two between the first and second premolar.
The abnormality occurred two times in the maxilla to
the mandible (6/3). There was no transposition at
all of the central incisor and molars.
Other findings
Among the 570 records, other radiographic findings
were present (Table 4). Idiopathic osteosclerosis
represented 10% of the findings followed by bifid
root (1.8%), trifid root (0.2%), three root of the first
mandibular molar (0.2%), and odontoma (0.7%).
Idiopathic osteosclerosis occurred only in the
mandible. Of the 14 bifid roots, 13 showed at the

first mandibular premolars and one at the second

mandibular premolar. Six cases presented single bifid
root and four cases showed two bifid roots. One trifid
of the first mandibular premolars was found.
Of the 4 odontoma cases, three were in the
maxilla and one in the mandible. Hypercementosis
was found in 7 cases (1.2%, 9 teeth); one at the
canine and the first molar and seven at the premolar
teeth. No incisal tooth presented hypercementosis.
Only one subject showed three hypercementosis (#15,
#34, #35).
Dental anomalies were ranked according to
prevalence (Table 5). Missing teeth and microdontia
occurred more often than extra teeth and macrodontia.
Root abnormalities were more common than crown
abnormalities.

Table 4. The other findings by general anatomic location

Findings
Idiopathic osteosclerosis
Bifid root
Trifid root
Three roots
Compound odontoma
Complex odontoma
Hypercementosis

Number (% of case)
54 (10%)
10 (1.8%)
1 (0.2%)
1 (0.2%)
2 (0.4%)
2 (0.4%)
7 (1.2%)

Location (number of tooth)

sextant 4,5,6
lower 1st, 2nd PM(13,1)
lower 1st PM(1)
lower 1st M(1)
quadrant1(3)
quadrant3(1)
upper C,2nd PM(1,3)
lower1st PM,2nd PM,1st M(3,1,1)

(M=molar, PM=premolar, C=canine)

Table 5. Dental anomaly problems according to prevalence order

KDJ. Vol.13 No.2 July - Desember, 2010

DISCUSSION
Although the prevalence and distribution of
dental anomalies has been studied in various groups of
orthodontic patients, the discrepancies in the various
results have been attributed to racial differences,
variable sampling techniques and different diagnostic
criteria including the orthodontic problem selected.
Hypodontia
Hypodontia is a common dental anomaly found in
orthodontic patients. Multiple missing teeth not only
cause malocclusion but also make orthodontic treatment
difficult due to poor occlusal support and stability.
Some missing teeth have been reported in association
with at least one other dental anomaly9,11,12 and may
complicate orthodontic problems.
The prevalence of hypodontia in orthodontic
patients has been reported differently. Excluding the
third molar, hypodontia ranges from 2.6% in Turkey5,
to 5.5% in Mexico13, 6.3% in Brazil9, 8.5% in
Japan7, 11.1% in Korea14, 14.7% in Hungary8,
to 26.4% in Thais (this study). Altug-Atac and
Erdem 5, Uslu et al.3 and our study found tooth agenesis
was the most prevalent dental anomaly among
orthodontic patients.
The most common missing tooth in orthodontic
patients varies among the studied groups. Endo et al. 7
reported the most commonly affected tooth was in
the mandibular second premolar. The maxillary lateral
incisor was the most frequent in many studies.3, 5, 9, 13 -15
In our study, the most commonly missing tooth,
excluding the third molar, was the mandibular lateral
incisor (8.3%), followed by the maxillary lateral incisor
(6.9%) and the mandibular second premolar (5.7%).
There are reported differences in symmetrical
hypodontia: some have predominant symmetry7, 13
while in some unilateral dental agenesis is more
common than bilateral agenesis.16

97

Hyperdontia
Hyperdontia is detected by chance either during
intraoral examination or on radiographs. In case of
malocclusion, the orthodontist plays a key role in
the diagnosis and therapy through a comprehensive
examination. The treatment decision is based on
the individual case and may require interdisciplinary
cooperation.
The prevalence of supernumerary teeth is
usually lower than that of tooth agenesis.17 The
prevalence of supernumerary teeth in orthodontic
patients ranges between 0.3%-1.37% 3,17,18, while
our study documented 1.6%. The difference in race
significantly affects the frequency of hyperdontia.19
The most common site of supernumerary teeth is in
the maxillary anterior region.3, 8
Mesiodens may cause delay or ectopic
eruption of the permanent incisor or further alter
occlusion and appearance. Early diagnosis is
therefore needed for appropriate treatment, thereby
reducing the invasiveness of surgery, orthodontic
treatment and possible complications.20 Most of the
studies reported mesiodens in terms of supernumerary
teeth. The prevalence of mesiodens in orthodontic
patients ranged between 0.3-1.8 %5, 6, which is
not significantly different from the general population
(0.15-1.9%).20 Our study found mesiodens in 1.1%
of orthodontic patients.
Size abnormalities (macrodontia and microdontia)
Dental morphology is only one of several factors
that may be involved in the etiology of dental crowding
or spacing. Macrodontia is very much less common
than microdontia.5 Compared with other studies3, 5, 6,
the percentage of macrodontia and microdontia in our
study was the highest (1.4% and13.7%, respectively). The most common microdontia was of the
maxillary lateral incisor.5, 6 Maxillary and mandibular

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first and second molars were the only teeth not affected
by macrodontia or microdontia (Table 3).
Shape abnormalities (fusion, gemination)
Fusion requires management for esthetic reasons.
Fusion and gemination in the general population are
reportedly very low (0.19% and 0.22%, respectively)
and extremely limited in orthodontic reports.
Altug-Atac and Erdem5 reported the frequency of
fusion and gemination was 0.23% and 0.07%,
respectively. In our study, fusion occurred in only 0.7%
and no gemination was found. In our study, fusion,
macrodontia and gemination were not found in the
maxillary first premolar, the maxillary and mandibular
first and second molars, or the lower central incisor.
Location abnormalities (transposition)
Teeth transposition is a rare eruption anomaly
that involves the permanent dentition (incidence
0.3-0.4%).21,22 Transposition are more frequently
seen in the maxilla23, as in our study, and affecting
(in descending order) the canines and first premolars,
the canines and lateral incisors and the lateral
and central incisors.23,24 Our study found the most
frequently transposed teeth were the maxillary
canine-lateral incisors. Transposition may occur with
other anomalies, such as aplasia, peg-shaped lateral
incisor and deciduous teeth retention.21 Diagnosis
could be made at the radiological level: the earlier
the diagnosis, the less risks related to orthodontic
treatment.
Other findings
Except for idiopathic osteosclerosis, the number
of root shape, odontoma and hypercementosis
occurred at a very low rate in our study and was hardly
seen in other reports.
The correlation between dental anomalies and

orthodontic problems has not been widely studied.

Chung et al.14 reported the association of a congenitally
missing third molar and skeletal class III malocclusion.
Endo et al.2 evaluated the effect of hypodontia to
craniofacial morphology. Whereas Bauer at al.25
found no statistically relevant correlation between the
location of missing teeth and the craniofacial growth
pattern. The difference in these results reflects the
need for further study on both the prevalence, type of
dental anomaly, location of abnormalities and type of
orthodontic problems, in order to better understand
whether there is a correlation between dental anomaly
and orthodontic problems.

CONCLUSION
Prevalence and distribution of some dental anomalies
in Thai orthodontic patients differed from other studies.
Orthodontists should concern about the difference
in dental anomalies in various group of patients.
Careful diagnosis simplify treatment plan and reduce
complications.

ACKNOWLEDGEMENTS
This study was supported by Faculty of Dentistry,
Khon Kaen University, Thailand. Special thanks to
Mr. Bryan Roderick Hamman for assistance with the
English-language presentation of the manuscript.

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* ** ***

2 570

12 40 ( 19.38+ 4.23 )
16-20 ( 51.1)
( 25.3) ( 27.4) ( 13.2) ( 34)
89.61 73.2 38.6 1
26.1 13.7
( 3.4) ( 2.7) (1.6)
( 1.4) ( 0.7)

: , , ,

. . 40002
0-4320-405 11154
0-4320-862
suwadee@kku.ac.th

*
**
***