Exeley Inc.

Elardo, E.

Elbadri, N.

Sanchez, C.

Powell, V.

Smaris, M.

Li, Y.

Jacobson, J.

Hilbert, T.

Hamilton, T.

Wu, D.W.

B subgroup detection in a small hospital transfusion service

MILOŠEVIĆ, Predrag

MILOŠEVIĆ, Vladimir

MILOŠEVIĆ, Grigor

STRIVING FOR SUSTAINABLE ARCHITECTURE IN THE 21ST CENTURY – MAIN ISSUES IN THE DEVELOPMENT OF INNOVATIVE OFFICE SPACE CONCEPTS

AYDIN, Abdulkadir Cüneyt

KILIÇ, Mahmut

MAALI, Mahyar

BAYRAK, Barış

TUNÇ, Erkan

THE TORSIONAL AND SHEAR BEHAVIOR OF STEEL FIBER REINFORCED RC MEMBERS

Guo, Yi

Ruan, Xiaoyi

Calibration of Structured Light Scanning System

Feng, Leijie

Mu, Zehui

Research on Mobile Point Exchange System Based on Collaborative Filtering Recommendation Algorithm

Lu, Ping

Liu, Pingping

Xu, Jiangtao

Design of Intelligent Warehouse Management System Based on MVC

Xiang, Jie

Yin, Yuanyuan

Gan, Ziqi

Shim, Sangbeom

Zhao, Lixing

Mandibular effects of temporary anchorage devices in Class II patients treated with Forsus Fatigue Resistant Devices: A systematic review

Masoud, Ahmed I.

Bindagji, Feras H.

Australasian Orthodontic Journal Volume 37 No. 1 May 2021 121© Australian Society of Orthodontists Inc. 2021
Excluding third molars, the prevalence of tooth agenesis of permanent teeth ranges from 1.6% to 9.6%. The congenital absence 
of maxillary permanent canines is a rare condition with a reported prevalence of less than 0.5%. Case reports describing 
congenitally missing permanent canines are uncommon, and those that involve treatment are even more rare.  
This case report describes the orthodontic treatment of a 12-year-old male patient who presented with a congenitally missing 
upper left permanent canine compounded by a malformed upper right permanent canine. Additionally, the patient had a retained 
upper left deciduous canine, a Class I molar relationship, an anterior open bite, and proclined and protruded incisors.  
Treatment involved upper left first premolar substitution for the congenitally missing canine following the extraction of the upper left 
retained deciduous canine, the upper right first premolar, and both lower first premolars. The upper right malformed permanent 
canine was retained. The total treatment time was 32 months and the result remained stable 19 months later. 
(Aust Orthod J 2021; 37: 121 - 127. DOI: 10.21307/aoj-2021-013)
Received for publication: May 2020
Accepted: January 2021
Orthodontic treatment of a case with a 
congenitally missing maxillary canine and a 
malformed contralateral canine
Ahmed I. Masoud* and Feras H. Bindagji† 
Department of Orthodontics, Faculty of Dentistry* and Faculty of Dentistry,† King Abdulaziz University, Jeddah, Saudi 
Arabia
Introduction
The most common craniofacial congenital malfor-
mation in humans is tooth agenesis, which, excluding 
third molars, ranges in prevalence from 1.6% to 9.6% 
depending on the population studied.1 Tooth agenesis 
may also be seen in the deciduous dentition, but with 
a lower prevalence ranging from 0.5% to 0.9%.2 Tooth 
agenesis of six or fewer teeth (excluding third molars) 
is referred to as hypodontia,1 and 80% of individuals 
with hypodontia have only one or two missing teeth.3 
The most likely teeth to be congenitally missing, other 
than the third molars, are the permanent lower second 
premolars, followed by the upper lateral incisors, and 
the upper second premolars.4 
It is suggested that there are four morphogenic fields in 
each jaw, identified as an incisor, canine, premolar and 
molar fields. Variability is more common at the distal 
end of each morphological field as the most mesial 
tooth appears to be the most stable. The canine is the 
only tooth in its morphogenic field and hence is highly 
stable and rarely missing.5-7 The congenital absence 
of a maxillary permanent canine has a prevalence of 
less than 0.5%, and three recent studies reported the 
prevalence to be zero.8-10 Previous studies have reported 
a greater frequency of congenitally missing maxillary 
canines to occur in females compared to males,11,12 
and in black compared to white populations.13,14
Possible approaches to manage congenitally missing 
teeth include space closure using orthodontic therapy, 
opening the space for implant placement, auto 
transplantation, or prosthetic restoration.15,16 The 
restoration of the missing tooth is often complicated by 
the remaining teeth being in unfavourable positions. 
Common issues faced in treating hypodontia patients 
include aligning displaced teeth, space management, 
tooth uprighting, the management of a possible deep 
overbite, and post-treatment retention.16 Orthodontic 
treatment may facilitate restorative care but the final 
Ahmed I. Masoud: aemasoud@kau.edu.sa;  Feras H. Bindagji: feras.h.b@hotmail.com
brought to you by COREView metadata, citation and similar papers at core.ac.uk
provided by Exeley Inc.
Australasian Orthodontic Journal Volume 37 No. 1 May 2021122
MASOUD AND BINDAGJI
treatment plan will be dependent on factors related 
to patient age, the degree of inherent crowding, the 
condition of the retained deciduous teeth, the type of 
malocclusion, and the patient’s preference.15 
Case reports detailing congenitally missing perma-
nent canines are uncommon,7,17-21 and those that 
involve treatment are even more rare.22 This case 
report describes the orthodontic treatment of a case 
presenting with a congenitally missing upper left 
permanent canine compounded by a malformed 
upper right permanent canine.
Case report
A 12-year-old African American male in good 
general health presented with the chief complaint 
of “I don’t like my upper front teeth”. An extra-oral 
examination revealed a convex soft tissue profile, an 
obtuse nasolabial angle, and lips that were protruded 
and incompetent. Upon intraoral examination, the 
patient had tooth staining, a retained deciduous upper 
left canine, a malformed upper right canine, a Class 
I molar relationship, spacing, an increased overjet 
and an anterior open bite (Figure 1). A radiographic 
examination revealed a congenitally missing upper left 
canine, an upper right permanent canine with a long 
root, an upper right first premolar with a short root, 
proclined and protruded upper and lower incisors 
and a high mandibular plane angle (Figures 2 and 3; 
Table I).
Figure 1. Facial and intraoral photographs taken at the initial visit (age 12 years, 0 months). 
Figure 2. Panoramic radiograph taken at the initial visit (age 12 years, 
0 months). 
Australasian Orthodontic Journal Volume 37 No. 1 May 2021 123
CONGENITALLY MISSING MAXILLARY CANINE 
Treatment objective
The treatment objectives were to: (1) eliminate 
the anterior open bite; (2) close the upper and 
lower spaces; (3) obtain an ideal occlusion with an 
appropriate overjet; (4) reduce the incisor proclination 
and protrusion; (5) reduce the lip protrusion and lip 
incompetence; and (6) achieve a premolar-canine 
substitution in the upper left quadrant. 
Treatment plan
The treatment plan involved the substitution of 
the upper left first premolar for the missing canine 
following the extraction of the retained upper left 
deciduous canine, the upper right first premolar, 
and both lower first premolars. Alternatively, the 
malformed upper right permanent canine could 
have been extracted. However, the upper right first 
premolar had a short root and therefore was selected 
for extraction. A non-extraction treatment plan was 
considered but discarded because, although several 
of the treatment objectives would be achieved, a 
reduction in lip protrusion, lip incompetence, incisor 
proclination, and incisor protrusion would be greater 
with extractions. The retention plan included full-
time wear of modified upper and lower removable 
Hawley retainers with ball clasps and labial bows 
extending distal to the premolars.
Figure 3. Lateral cephalogram taken at the initial visit (age 12 years, 
0 months). 
Measurement Initial taken at initial visit (12 y 0 mo) Final taken at debond visit (15 y 3 mo)
   Facial Angle (FH-NPo) (◦) 84.2 83.9
   Convexity (NA-APo) (◦) 6.8 2.3
   SNA (◦) 79.5 78.1
   SNB (◦) 76.7 77
   ANB (◦) 2.8 1.1
   AB - NPo (◦) 2.8 1.3
   FMA (MP-FH) (◦) 32.8 34.3
   Y-Axis -- Downs (SGn-FH) (◦) 64.5 66.6
   Occ Plane to FH (◦) 12.7 14.7
   Interincisal Angle (U1-L1) (◦) 96.3 127
   L1 to Mand Plane -90 (◦) 13.8 -3.9
   U1 - SN (◦) 119 105.7
   U-Incisor Protrusion (U1-APo) (mm) 15.8 9.5
   L1 Protrusion (L1-APo) (mm) 11.3 6.2
   FH - SN (◦) 8.1 6.9
   Wits Appraisal (mm) -3.2 -5.4
   Lower Face Height (ANS-Me) (mm) 72 80.1
   LFH/TFH (ANS-Me:N-Me) (%) 58.1 61.8
   Upper Lip to E-Plane (mm) 2.4 2.1
   Lower Lip to E-Plane (mm) 10.2 7.7
   Nasolabial Angle (Col-Sn-UL) (◦) 83 82.8
Table I.  Cephalometric measurements before and after treatment.
Australasian Orthodontic Journal Volume 37 No. 1 May 2021124
MASOUD AND BINDAGJI
Treatment progress
Treatment was initiated after the extraction of the 
recommended teeth. Banding and bonding were 
completed using 0.018″ × 0.025″ brackets of Roth 
prescription. Both arches were levelled and aligned 
using 0.014″ nitinol wire. The wires were upgraded to 
0.016″ stainless steel wires, and power chains were used 
to retract the upper right canine and consolidate the 
lower canine-to-canine region to prepare for lower en 
masse retraction. After the lower anterior spaces were 
closed, a 0.016″ × 0.022″ nitinol wire with a reverse 
curve was inserted. The lower canine-to-canine region 
and the lower first molar to second premolar on both 
sides were consolidated using a stainless steel ligature 
wire, and a power chain was stretched from the lower 
second premolar to the lower canines. Due to its long 
root, a prefabricated upper lip bumper was inserted 
to reinforce upper arch anchorage during upper 
right canine retraction (Figure 4). Once the upper 
right canine was retracted, the upper lip bumper was 
removed, and an upper 0.016″ × 0.022″ stainless steel 
wire with keyhole loops was activated to retract the 
upper incisors. Palatal root torque was added to achieve 
bodily retraction of the upper incisors. After all space 
closure, upper and lower 0.016″ × 0.022″ nitinol wires 
were placed followed by 0.016″ × 0.022″ stainless steel 
wires for finishing and detailing using class II elastics 
as needed. To improve the aesthetics of the upper left 
first premolar, labial root torque was applied along 
with enameloplasty of the palatal cusp. Interproximal 
reduction of the upper incisors was performed to 
Figure 5. Facial and intraoral photographs taken at the debond visit (age 15 years, 3 months).
Figure 4. A prefabricated upper lip bumper inserted to reinforce the 
upper anchorage during upper right canine retraction due to its long 
root.
Australasian Orthodontic Journal Volume 37 No. 1 May 2021 125
CONGENITALLY MISSING MAXILLARY CANINE 
manage a Bolton discrepancy and improve overjet and 
overbite. Because fixed retainers were refused by the 
patient’s mother, modified upper and lower Hawley 
retainers were provided for retention. The patient was 
referred for aesthetic restoration of the upper right 
canine but chose not to proceed. The total treatment 
time was two years and eight months (Figures 5–8; 
Table I). Figure 9 shows images of the patient 19 
months after active treatment. The result remained 
stable except for some extraction space opening distal 
to the lower canines.
Discussion
The first report of a congenitally missing permanent 
canine was presented in 1952 by Furstman et 
al., describing a case of four congenitally missing 
permanent canines. A clinical examination further 
Figure 6. Panoramic radiograph taken at the debond visit (age 15 
years, 3 months).
Figure 7. Lateral cephalogram taken at the debond visit (age 15 years, 
3 months).
Figure 8. Cephalometric superimposition of before and after treatment
revealed a peg-shaped deciduous canine. The 
treatment chosen was to open space for the restoration 
of the four missing permanent canines subsequent to 
the retention of the deciduous canines for as long as 
possible.22 Mesialisation of the posterior teeth was 
considered but discarded. This was likely due to the 
infrequent use of miniscrews since the first report of 
their application was in 1945.23
Subsequently, several authors have reported cases of 
congenitally missing permanent canines; however, 
no treatment apart from retention of the deciduous 
canines was performed.7,18-21 Retaining a deciduous 
canine beyond the age at which it normally exfoliates 
Australasian Orthodontic Journal Volume 37 No. 1 May 2021126
MASOUD AND BINDAGJI
is a valid treatment option in cases of congenitally 
missing permanent canines. The exfoliation of a 
deciduous tooth results primarily by resorption of 
its root by the permanent successor; however, the 
process is disturbed in cases of agenesis.24 Haselden 
et al. reported that almost 60% of deciduous canines 
with no permanent successors had little or no root 
resorption up to the age of 40 years. In addition, lower 
deciduous canines had a greater predicable life span 
compared to the upper deciduous canines.24 Retaining 
a deciduous canine can help preserve the alveolar bone 
to possibly allow implant placement in the future.7
Several factors require consideration when deciding to 
retain a deciduous canine and relate to the preference 
of the patient, the cost, and the type of underlying 
malocclusion.20 In the present case, the patient had 
protruded and incompetent lips, proclined and 
protruded incisors and an anterior open bite, so 
an extraction treatment plan was chosen. Upper 
arch anchorage was needed because the upper 
right permanent canine had a long root and an 
upper lip bumper was inserted to provide posterior 
tooth support during permanent canine retraction. 
Alternative anchorage considerations were the use 
of miniscrews, a headgear, or a transpalatal arch. 
Although not usually used in the upper arch,25-27 a 
lip bumper was placed since the upper bands were 
already prepared with headgear tubes and no patient 
compliance would be needed.
Previous studies have reported an association between 
hypodontia and other dental anomalies.28 It is 
suggested that hypodontia is often associated with a 
reduction in tooth crown size.29 GunaShekhar et al. 
described a case of three congenitally missing canines 
associated with microdontic maxillary permanent 
lateral incisors (peg-shaped) and incomplete 
root formation.18 Cho et al. reported 32 cases of 
congenitally missing maxillary permanent canines. 
Five cases presented with a microdontic upper lateral 
incisor and one case with a microdontic contralateral 
maxillary canine.17 Similarly, in the present case there 
was a congenitally missing upper permanent canine 
and a contralateral malformed canine presenting with 
a small crown.
Conclusion
Although rare, a permanent maxillary canine can 
be congenitally missing. When this condition is 
encountered, appropriate orthodontic diagnosis and 
treatment planning is required to decide on the best 
treatment approach.
Figure 9. Facial and intraoral photographs taken at the 19 month follow-up visit (age 16 years, 10 months).
Australasian Orthodontic Journal Volume 37 No. 1 May 2021 127
CONGENITALLY MISSING MAXILLARY CANINE 
The present case report described premolar 
substitution and extraction in the three other 
quadrants as the preferred option in the management 
of a congenitally missing maxillary canine. This was 
achieved while maintaining a long-rooted, malformed 
contralateral canine.
Conflict of interest
The authors report no professional or financial conflict 
of interest in relation to this case report.
The patient provided permission for the publication 
of his clinical data and photographs.
All procedures followed were in accordance with the 
ethical standards of the responsible committee on 
human experimentation (institutional and national) 
and with the Helsinki Declaration of 1964 and later 
versions.
Corresponding author
Dr Ahmed I. Masoud
Clinical Assistant Professor
Department of Orthodontics
Faculty of Dentistry
King Abdulaziz University
PO Box 80209
Jeddah 21589
Saudi Arabia 
Email: aemasoud@kau.edu.sa
References
1. Matalova E, Fleischmannova J, Sharpe PT, Tucker AS. Tooth 
agenesis: from molecular genetics to molecular dentistry. J Dent Res 
2008;87:617-23.
2. Vastardis H. The genetics of human tooth agenesis: new discoveries 
for understanding dental anomalies. Am J Orthod Dentofacial 
Orthop 2000;117:650-6.
3. Lidral AC, Reising BC. The role of MSX1 in human tooth agenesis. 
J Dent Res 2002;81:274-8.
4. Polder BJ, Van’t Hof MA, Van der Linden FP, Kuijpers-Jagtman AM. 
A meta-analysis of the prevalence of dental agenesis of permanent 
teeth. Community Dent Oral Epidemiol 2004;32:217-26.
5. Butler PM. Studies of the Mammalian Dentition.–Differentiation 
of the Post‐canine Dentition. Paper presented at: Proceedings of the 
Zoological Society of London, 1939.
6. Kieser JA. Odontogenic polarity and Butler’s field theory. Med 
Hypotheses 1986;20:103-7.
7. Kambalimath HV, Jain S, Patil RU, Asokan A, Kambalimath D. 
Permanent Maxillary Canine Agenesis: A Rare Case Report. Int J 
Clin Pediatr Dent 2015;8:242-6.
8. Guttal KS, Naikmasur VG, Bhargava P, Bathi RJ. Frequency of 
developmental dental anomalies in the Indian population. Eur J 
Dent 2010;4:263-9.
9. Gupta SK, Saxena P, Jain S, Jain D. Prevalence and distribution of 
selected developmental dental anomalies in an Indian population. J 
Oral Sci 2011;53:231-8.
10. Shetty P, Adyanthaya A, Adyanthaya S, Sreelatha S. The Prevalence 
of Hypodontia and Supernumerary Teeth in 2469 School children of 
the Indian Population: An Epidemiological Study. Indian Journal of 
Stomatology 2012;3.
11. Fukuta Y, Totsuka M, Takeda Y, Yamamoto H. Congenital absence 
of the permanent canines: a clinico-statistical study. J Oral Sci 
2004;46:247-52.
12. Rózsa N, Nagy K, Vajó Z, Gábris K, Soós A, Alberth M et al. 
Prevalence and distribution of permanent canine agenesis in dental 
paediatric and orthodontic patients in Hungary. Eur J Orthod 
2009;31:374-9.
13. Harris EF, Clark LL. Hypodontia: an epidemiologic study of 
American black and white people. Am J Orthod Dentofacial Orthop 
2008;134:761-7.
14. Muller TP, Hill IN, Petersen AC, Blayney JR. A survey of congenitally 
missing permanent teeth. J Am Dent Assoc 1970;81:101-07.
15. Al-Ani AH, Antoun JS, Thomson WM, Merriman TR, Farella M. 
Hypodontia: An Update on Its Etiology, Classification, and Clinical 
Management. Biomed Res Int 2017;2017:9378325.
16. Carter NE, Gillgrass TJ, Hobson RS, Jepson N, Eechan JG, 
Nohl FS et al. The interdisciplinary management of hypodontia: 
orthodontics. Br Dent J 2003;194:361-6.
17. Cho SY, Lee CK, Chan JC. Congenitally missing maxillary 
permanent canines: report of 32 cases from an ethnic Chinese 
population. Int J Paediatr Dent 2004;14:446-50.
18. GunaShekhar M, Srinivas Rao K, Dutta B. A rare case of congenital 
absence of permanent canines associated with other dental anomalies. 
J Clin Exp Dent 2011;3:e70-2.
19. Koç N, Caćırankaya LB, Akkaya N. Unilateral maxillary canine 
agenesis: a case report and literature review. Case Rep Dent 
2014;2014:685014.
20. Borzabadi-Farahani A. Bilateral agenesis of maxillary permanent 
canines: Review of the literature. J Orthod Sci 2015;4:26-9.
21. Yadav SK, Yadav AB, Kedia NB, Singh AK. Agenesis of permanent 
canines: Rare case report. Dent Res J (Isfahan) 2017;14:359-62.
22. Furstman L. Four congenitally missing canines: A case report. Am J 
Orthod 1952;38:449-52.
23. Gainsforth BL, Higley LB. A study of orthodontic anchorage 
possibilities in basal bone. Am J Orthod Dentofacial Orthop 
1945;31:406-17.
24. Haselden K, Hobkirk JA, Goodman JR, Jones SP, Hemmings KW. 
Root resorption in retained deciduous canine and molar teeth 
without permanent successors in patients with severe hypodontia. 
Int J Paediatr Dent 2001;11:171-8.
25. Subtelny JD, Sakuda M. Muscle function, oral malformation, and 
growth changes. Am J Orthod 1966;52:495-517.
26. Takimoto K, Sakuda M, Ishizawa M, Matsumoto M, Deguchi T. 
[Cases of lip bumper application]. Nihon Kyosei Shika Gakkai 
Zasshi 1968;27:359-71. Japanese.
27. Bjerregaard J, Bundgaard AM, Melsen B. The effect of the 
mandibular lip bumper and maxillary bite plate on tooth movement, 
occlusion and space conditions in the lower dental arch. Eur J 
Orthod 1980;2:257-65.
28. Laganà G, Venza N, Borzabadi-Farahani A, Fabi F, Danesi C, Cozza 
P. Dental anomalies: prevalence and associations between them in 
a large sample of non-orthodontic subjects, a cross-sectional study. 
BMC Oral Health 2017;17:62.
29. Garn SM, Lewis AB. The gradient and the pattern of crown-size 
reduction in simple hypodontia. Angle Orthod 1970;40:51-8.


Orthodontic treatment of a case with a congenitally missing maxillary canine and a malformed contralateral canine

Orhan, Kaan

Serindere, Gozde

Belgin, Ceren Aktuna

Kurt, Mehmet Hakan

Evaluation of the visibility of peri-implant bone defects using ultrasonography with two types of probes

Dakok, Kyermang Kyense

Matjafri, Mohammed Zubir

Suardi, Nursakinah

Oglat, Ammar Anwar

Nabasu, Seth Ezra

A blood-mimicking fluid with cholesterol as scatter particles for wall-less carotid artery phantom applications

Not a member yet