Abstract
Background:
The early tooth loss has an adverse effect on the overall well-being of an individual. The aim of the current study was to highlight the orthodontic complications of long-term tooth loss in the city of Najran.
Materials and Methods:
This was a cohort study of patients presenting for orthodontic rehabilitation. A total of 326 patients that presented for orthodontic rehabilitation were examined clinically and data such as age, gender, number of missing teeth, missing teeth, duration of missing teeth, tipping, and overerupted and rotated teeth were recorded. Patients that can be treated with orthodontic space closure were excluded from the study. Patients’ data were analyzed using IBM SPSS Statistics and results were presented as simple frequencies and descriptive statistics.
Results:
Out of 326 patients that presented for orthodontic rehabilitation, 259 patients had missing teeth with its sequelae that will demand prosthodontic rehabilitation with a prevalence rate of 79.4%. There are 97 (37.5%) males and 162 (62.5%) females with M:F ratio of 1:1.7. The age ranged from 15 to 52 years with mean ± standard deviation (28.5 ± 8.5). The age group 21–30 years constitutes the group with the highest number of missing teeth. A total number of 595 (60.2%) teeth were missing, 173 (17.5%) teeth were tipped, and 124 (12.5%) teeth were overerupted, whereas only 97 (9.8%) teeth were rotated (n = 989). Fixed orthodontic appliances (FOAs) were used for all cases with rotation and FOAs + Mini Screws were used for all cases with tipping, overeruption, and/or combinations. The dental loss was managed by prosthesis depending on patients’ choice and financial capability ranging from removable/fixed prosthesis and dental implants.
Conclusion:
Orthodontic consequences of early tooth loss include tipping and rotation of adjacent teeth and overeruption of opposing teeth. Early acknowledgment of tooth replacement after tooth loss is essential in preventing long-term orthodontic adverse effects.
Keywords: Missing teeth, orthodontics, tooth rotation, tooth tipping
Introduction
The impact of oral diseases on the quality of life (QoL) is obvious.[1] The psychosocial impact of such diseases on the daily life of individuals is of considerable importance.[1] Any disease that could interfere with daily activities may have an adverse effect on the general QoL. Tooth loss which is a sequela of oral diseases can be very traumatic and harrowing in which societal activities may be disrupted and may require readjustment psychosocially.[1] Authors have recognized the importance of tooth replacement in the upkeep of oral health.[2] The sequelae of not replacing missing teeth include inappropriate speech, inefficient mastication, improper digestion, occlusal stability changes, overeruption of opposing dentition, tipping of adjacent teeth, alveolar bone loss, and temporomandibular joint disorders.[3-7]
The World Health Organization has recommended a minimum of 21 adult functional teeth to experience a good dietary intake without a need for a prosthesis.[8] Tooth loss leading to partial or total edentulism exhibits a wide range of long-term feelings and such underlying feelings may explain dissatisfactions observed in dental prosthesis wearers.[9-11] Many patients attending dental clinics for the replacement of missing teeth have done so to either restore esthetics or functions.[12]
Long-term tooth loss with its antecedent sequelae may also affect treatment modalities and choice of orthodontic rehabilitation. It may require removable, fixed, or functional appliances. Overerupted tooth may have to be intruded and[13] tipped tooth may need uprighting.[14,15] Depending on the choice and mechanics of orthodontic treatment, these patients may need prosthetic replacements for these missing teeth to prevent relapse.[16] The present study hopes to highlight the consequences of long-term tooth loss in the city of Najran.
Materials and Methods
This is a cohort study of patients presenting for orthodontic rehabilitation in our center over 3 years (2017–2019) after obtaining ethical approval from the Ethics and Research Committee of the Center, in the city of Najran, Kingdom of Saudi Arabia. A total of 326 patients that presented for orthodontic rehabilitation were examined clinically and data such as age, gender, number of missing teeth, missing teeth, duration of missing teeth, tipping, and overerupted and rotated teeth were recorded. Excluded are patients with less than 1-year history of tooth loss and patients not requiring prosthetic rehabilitation after the orthodontic therapy. Fixed orthodontic appliances (FOAs) were used for all cases with rotation and FOA + Mini Screws (FOA + MS) were used for all cases with tipping, over-eruption, and/or combinations.
Data were analyzed using IBM SPSS Statistics for IOS Version 25 (Armonk, NY, USA: IBM Corp) and results presented as simple frequencies and descriptive statistics. Pearson’s Chi-square was used to evaluate the association and level of significance among categorical variables such as age group of patients, gender, and number of missing teeth. P ≤ 0.05 was considered statistically significant.
Results
Out of 326 patients that presented for orthodontic rehabilitation, 259 patients had missing teeth with its sequelae that will need prosthodontic rehabilitation giving a prevalence rate of 79.4%. There are 162 (62.5%) females and 97 (37.5%) males with F:M ratio of 1.7:1. The age ranged from 15 to 52 years with mean ± standard deviation (28.5 ± 8.5). When the age group was compared with gender of patients, there was no statistically significant difference (P = 0.132) [Table 1]. The age group 21–30 years constitutes the group with the highest number of missing teeth with a statistically significant difference when compared (P = 0.034) [Table 2]. Most of the patients suffered the loss of one or two teeth (91 [35.2%] and 76 [29.4%]), respectively, whereas only 3 (1.1%) patients suffered a loss of eight teeth. This was not statistically significant (P = 0.320) [Table 2].
Table 1.
Distribution of age group and number of missing teeth according to the gender of patients
| Gender | Statistics (%) | |||
|---|---|---|---|---|
|
| ||||
| Male (%) | Female (%) | Total (%) | ||
| Age group | ||||
| 11-20 | 11 (4.2) | 36 (13.9) | 47 (18.1) | χ2=7.07, df=4, P=0.132 |
| 21-30 | 50 (19.3) | 74 (28.6) | 124 (47.9) | |
| 31-40 | 26 (10.0) | 35 (13.5) | 61 (23.5) | |
| 41-50 | 10 (3.9) | 14 (5.4) | 24 (9.3) | |
| 51-60 | 0 (0.0) | 3 (1.1) | 3 (1.1) | |
| Total | 97 (37.5) | 162 (62.5) | 259 (100.0) | |
| Number of missing teeth | ||||
| One | 38 (14.7) | 53 (20.5) | 91 (35.2) | χ2=7.01, df=6, P=0.320 |
| Two | 30 (11.6) | 46 (17.8) | 76 (29.4) | |
| Three | 10 (3.9) | 27 (10.4) | 37 (14.3) | |
| Four | 14 (5.4) | 29 (11.2) | 43 (16.6) | |
| Five | 4 (1.5) | 2 (0.8) | 6 (2.3) | |
| Six | 1 (0.4) | 2 (0.8) | 3 (1.1) | |
| Eight | 0 (0.0) | 3 (1.1) | 3 (1.1) | |
| Total | 97 (37.5) | 162 (62.5) | 259 (100.0) | |
Table 2.
Distribution of number of missing teeth according to the age group of patients
| Number of missing teeth | Age group (%) | Total (%) | ||||
|---|---|---|---|---|---|---|
|
| ||||||
| 10-20 | 21-30 | 31-40 | 41-50 | 51-60 | ||
| One | 16 (6.2) | 44 (17.0) | 22 (8.5) | 9 (3.5) | 0 | 91 (35.2) |
| Two | 17 (6.6) | 37 (14.3) | 17 (6.6) | 5 (1.9) | 0 | 76 (29.4) |
| Three | 4 (1.5) | 17 (6.6) | 9 (3.5) | 4 (1.5) | 3 (1.1) | 37 (14.3) |
| Four | 9 (3.5) | 20 (7.7) | 12 (4.6) | 2 (0.8) | 0 | 43 (16.6) |
| Five | 1 (0.0) | 3 (1.1) | 1 (0.4) | 1 (0.4) | 0 | 6 (2.3) |
| Six | 0 | 2 (0.8) | 0 | 1 (0.4) | 0 | 3 (1.1) |
| Eight | 0 | 1 (0.4) | 0 | 2 (0.8) | 0 | 3 (1.1) |
| Total | 47 (18.1) | 124 (47.9) | 61 (23.5) | 24 (9.3) | 3 (1.1) | 259 (100.0) |
χ2=38.120, df=24, *P=0.034
A total number of 595 (60.2%) teeth were missing, 173 (17.5%) teeth were tipped [Figure 1], 124 (12.5%) teeth were overerupted [Figures 2a and b], whereas only 97 (9.8%) teeth were rotated [Figure 3] (n = 989) [Table 3]. Regarding specific individual tooth that was missing, tooth number 46 was the most lost tooth in the study population (70 [7.1%]). This was quickly followed by tooth number 24, 14, and 36 (65 [6.6%]), 63 (6.4%), and 58 [5.9%]), respectively (n = 989). Tooth number 35 was the least missing tooth (38 [3.8%]). Other distributions are as shown in Table 3.
Figure 1.
Intraoral clinical photograph showing mesial tipping of 35 due to missing 34
Figure 2.
(a) Intraoral clinical photograph showing overeruption of 25 and 36 due to missing 35 and 26, respectively (b) Intraoral clinical photograph showing overeruption of 16 due to missing 46
Figure 3.
Intraoral clinical photograph showing rotation of 25 due to missing 26
Table 3.
Distribution of number of missing, tipping, rotated, and overerupted teeth
| Tooth number (FDI) | Tooth feature (%) | Total (%) | |||
|---|---|---|---|---|---|
|
| |||||
| Missing | Tipping | Rotation | Overeruption | ||
| 11 | 4 (0.4) | 1 (0.1) | 0 | 2 (0.2) | 7 (0.7) |
| 12 | 7 (0.7) | 2 (0.2) | 2 (0.2) | 0 | 11 (1.1) |
| 13 | 10 (1.0) | 3 (0.3) | 4 (0.4) | 2 (0.2) | 19 (1.9) |
| 14 | 63 (6.4) | 2 (0.2) | 1 (0.1) | 4 (0.4) | 70 (7.1) |
| 15 | 18 (1.8) | 4 (0.4) | 5 (0.5) | 3 (0.3) | 30 (3.0) |
| 16 | 31 (3.1) | 8 (0.8) | 2 (0.2) | 12 (1.2) | 53 (5.3) |
| 17 | 5 (0.5) | 8 (0.8) | 1 (0.1) | 3 (0.3) | 17 (1.7) |
| 18 | 0 | 1 (0.1) | 0 | 0 | 1 (0.1) |
| 21 | 4 (0.4) | 3 (0.3) | 0 | 0 | 7 (0.7) |
| 22 | 9 (0.9) | 4 (0.4) | 4 (0.4) | 0 | 17 (1.7) |
| 23 | 12 (1.2) | 6 (0.6) | 3 (0.3) | 2 (0.2) | 23 (2.3) |
| 24 | 65 (6.6) | 2 (0.2) | 2 (0.2) | 1 (0.1) | 70 (7.1) |
| 25 | 19 (1.9) | 3 (0.3) | 13 (1.3) | 8 (0.8) | 43 (4.3) |
| 26 | 32 (3.2) | 9 (0.9) | 3 (0.3) | 31 (3.1) | 75 (7.6) |
| 27 | 6 (0.6) | 7 (0.7) | 1 (0.1) | 8 (0.8) | 22 (2.2) |
| 28 | 0 | 0 | 0 | 1 (0.1) | 1 (0.1) |
| 31 | 0 | 0 | 0 | 2 (0.2) | 2 (0.2) |
| 32 | 1 (0.1) | 0 | 0 | 1 (0.1) | 2 (0.2) |
| 33 | 7 (0.7) | 5 (0.5) | 1 (0.1) | 1 (0.1) | 14 (.4) |
| 34 | 41 (4.1) | 2 (0.2) | 3 (0.3) | 2 (0.2) | 48 (4.8) |
| 35 | 38 (3.8) | 8 (0.8) | 10 (1.0) | 4 (0.4) | 60 (6.1) |
| 36 | 58 (5.9) | 18 (1.8) | 1 (0.1) | 2 (0.2) | 79 (8.0) |
| 37 | 14 (1.4) | 21 (2.1) | 3 (0.3) | 1 (0.1) | 39 (3.9) |
| 38 | 0 | 3 (0.3) | 0 | 0 | 3 (0.3) |
| 41 | 0 | 0 | 0 | 2 (0.2) | 2 (0.2) |
| 42 | 1 (0.1) | 0 | 0 | 2 (0.2) | 3 (0.3) |
| 43 | 1 (0.1) | 5 (0.5) | 2 (0.2) | 5 (0.5) | 13 (1.3) |
| 44 | 41 (4.1) | 2 (0.2) | 2 (0.2) | 5 (0.5) | 50 (5.0) |
| 45 | 20 (2.0) | 7 (0.7) | 30 (3.0) | 8 (0.8) | 65 (6.6) |
| 46 | 70 (7.1) | 5 (0.5) | 1 (0.1) | 4 (0.4) | 80 (8.1) |
| 47 | 18 (1.8) | 29 (2.9) | 2 (0.2) | 2 (0.2) | 51 (5.2) |
| 48 | 0 | 5 (0.5) | 1 (0.1) | 6 (0.6) | 12 (1.2) |
| Total | 595 (60.2) | 173 (17.5) | 97 (9.8) | 124 (12.5) | 989 (100.0) |
FDI: Federation dentaire internationale
In terms of orthodontic treatment, all cases with tipping and overeruption were treated by FOA + MS, whereas cases with rotation were managed with only FOA. When there is a combination of tipping, rotation, and overeruption, an FOA + MS was used. The dental loss was managed with prosthesis (removable/fixed prosthesis and dental implants) depending on patients’ choice and financial capability.
Discussion
The consequences of early tooth loss with its sequelae are a constant challenge to orthodontics. The majority of cases are adult patients with early loss of the lower first permanent molar with the tipping medially of the second permanent molar into the space of the lost tooth.[17-19] The first permanent molars emerge early in life, around age 6 years, therefore, are more prone to dental caries and possible premature extraction before 15 years of age.[20] The importance of teeth in the mouth lies in its major responsibility of maintaining the usual masticatory functions and dentofacial coordination.[20] Once this tooth is lost early, there is a mesial angulation of the second permanent molar. This is further worsened when there is a third molar.[21] From the current study, most of the tipped teeth are the 47 and 37 as a result of early loss of 46 and 36 which is in tandem with the literature.[17-19]
Despite having a large number of missing upper first molars (16 and 26), there was a less number of tipped upper second molars (17 and 27). The reason for this observation is unclear and will demand further research. Other effects of early loss of a mandibular first molar are premolars tipping distally, extrusion of upper molars, narrowing of the edentulous ridge causing altered gingival form, infra-bony defect mesial to the tipped molar, stepped marginal ridges, food impaction, and posterior bite collapse.[22,23] It was observed from the present study that most of the overerupted teeth were the upper first molars (16 and 17) with corresponding missed lower first molars (46 and 36) which is in agreement with the literature.[20] From the study, it is evident that upper molars will rather overerupt than tipped if there is a corresponding lower missing teeth. This is another area of future research on the consequences of early tooth loss.
Teeth rotation resulting in malocclusion requires derotation orthodontically to achieve stable occlusion, finer esthetics, and functional harmony to the patient.[24] It has been noted in the literature that the most rotated teeth are the canines and bicuspids.[24,25] Similar to the literature, most of the rotated teeth in the current study were the bicuspids. Derotation of a tooth was reported to be easier but difficult to retain without relapsing, and therefore, they are to be overcorrected with supracrestal precision and retained for at least 6 months thereafter.[25,26] The additional use of MS as a temporary anchorage device has been shown to provide stable anchorage for various types of tooth movement including, intrusion, retraction, and protraction which cannot be achieved with conventional orthodontic mechanics.[27,28] However, these MS have some risks and complications which could be encountered during fixing, loading, or removal of the MS.[29] Furthermore, discomfort associated with local anesthesia and the economic burden on patients are other disadvantages and consequences of not replacing missing teeth early.
In all of our cases, the management of the edentulous spaces after orthodontic correction of tipping, rotation, and overeruption was managed by the use of prosthesis depending on patients’ choice and financial ability. This extra cost of initial orthodontic treatment would have been avoided if the tooth loss was replaced immediately after the tooth extraction. The prosthetic treatment of the edentulous spaces in our study is consistent with the literature and includes implant-retained prosthesis,[30,31] fixed bridge, and removable prosthesis.[32]
Conclusion
Orthodontic consequences of early tooth loss include tipping and rotation of adjacent teeth and overeruption of opposing teeth. Early acknowledgment of tooth replacement after tooth loss is essential in preventing long-term adverse orthodontic effects. There should be mandatory public awareness in the community to this effect.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
Acknowledgment
The author gratefully acknowledged Dr. Omar Yahya Al-Amri for his help in the data collection. Also acknowledged is the technical input of Dr. Ramat O. Braimah of the Department of Oral and Maxillofacial Surgery, Najran Specialty Regional Dental Center, Kingdom of Saudi Arabia.
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