European Archives of Paediatric Dentistry

https://doi.org/10.1007/s40368-019-00476-y

ORIGINAL SCIENTIFIC ARTICLE

Developmental dental anomalies assessed by panoramic radiographs

in a Greek orthodontic population sample
G. Pallikaraki1 · I. Sifakakis2   · S. Gizani3 · M. Makou2 · A. Mitsea4 

Received: 24 April 2019 / Accepted: 27 August 2019

© European Academy of Paediatric Dentistry 2019

Abstract
Purpose  To assess developmental dental anomalies on panoramic radiographs in a Greek orthodontic population.
Materials and methods  The sample consisted of 1200 panoramic radiographs that have been taken as part of routine ortho-
dontic treatment planning in children and adolescents. The following exclusion criteria were applied: systemic disorders
such as syndromes or clefts, previous jaw surgery and poor quality of the radiograph. Dental anomalies were classified as
anomalies of tooth shape, size, eruption-, position- or number anomalies or root alterations.
Results  The age range of the subjects (536 males and 664 females) was 7–17 years with a mean age of 11.78 years. The
prevalence of dental anomalies was assessed with a Chi-squared test. The intraobserver agreement was evaluated by cal-
culating Cohen’s 𝜅 . Among the 1200 digital panoramic radiographs examined, a total of 224 (18.67%) presented dental
anomalies, 92 (7.67%) males and 132 (16.67%) females. Moreover, 203 patients (16.92%) had 1 dental anomaly, whereas
19 (1.58%) and 2 (0.17%) patients had 2 or more than 2 dental anomalies, respectively. Oligodontia was the most prevalent
dental anomaly and was presented in 6.4% of the subjects, while supernumerary teeth were detected in 1% of the patients.
Conclusions  A significant number of orthodontic patients had at least one DDA. The most common DDA in this sample was
oligodontia followed by impaction and supernumerary teeth. Comparison to our data with other studies revealed variation
in their prevalence suggesting genetic and environmental influences.

Keywords  Developmental dental anomaly · Greek population · Panoramic radiography · Prevalence

Introduction however, several environmental etiological factors, in the

prenatal and postnatal development period, may contribute
There is a wide variation of developmental dental anomalies to their development (Kotsomitis et al. 1996). DDA may
(DDA) that might concern tooth shape and structure, root affect size (microdontia, macrodontia); shape (dens invagi-
morphology, tooth number and tooth position. Their occur- natus, talon cusp, dens evaginatus, gemination, fusion, root
rence is related to genetic and congenital causes, as well as dilacerations, taurodontism, concrescence); number such
medical conditions, antineoplastic therapy, local and envi- as hyperdontia, hypodontia (at least one tooth missing),
ronmental factors (Klein et al. 2013; Sharma et al. 2015). oligodontia (at least six missing teeth); and dental tissue
Genetic defects are considered the most influential factors; structures (amelogenesis imperfecta, dentinogenesis imper-
fecta, dentin dysplasia). These anomalies may be the result
of disturbances in the embryological development of teeth
* A. Mitsea at the morphodifferentiation or histodifferentiation stages of
[email protected] development. Positional anomalies such as ectopic eruption
1 may occur as a result of disturbances in the eruption pattern
DDS, Athens, Greece
(Neville et al. 2005). The genetic basis for dental anomalies
2
Department of Orthodontics, School of Dentistry, NKUA, has been well demonstrated by a polygenic model of inher-
Athens, Greece
itance. These polygenic traits enlighten the discontinuous
3
Department of Paediatric Dentistry, School of Dentistry, distributions of tooth morphology and agenesis. They can
NKUA, Athens, Greece
present phenotypic discontinuity, at the end of a constant
4
Department of Oral Diagnosis and Radiology, School distribution (Shokri et al. 2014).
of Dentistry, NKUA, 11527 Athens, Greece

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DDA anomalies might be isolated or syndromic, of minor prosthodontic treatment, large tooth restorations preventing
or major importance. In most cases, they are asymptomatic observation of the crown morphology, unknown age or gen-
and incidental clinical or radiographic findings. However, der were excluded from the study. Furthermore, third molar
in several cases, these anomalies may have aesthetic or/ evaluation was not included in the study.
and functional implications. They may also cause serious The subjects, ranged in age from 7 to 17 years, with a
complications such as root resorption of adjacent teeth, mean age 11.8 years (SD: 2.1) and were all of white ethnic
interfere with treatment procedures (extractions, root canal origin. The sample was composed of 536 males with a mean
treatments, etc.) or induce pathological changes such as age of 11.8 (SD: 2.1) and 664 females with a mean age of
cysts. Consequently, early diagnosis performed with routine 11.7 (SD: 2.0).
radiographic examinations is important for the evaluation All the images were evaluated by the same observer. Digi-
and treatment planning of these cases (Şener et al. 2011; tal images were saved in jpeg format and observed under the
Temilola et al. 2014; Wright 2016; Fauzi et al. 2017). More same conditions on a diagnostic monitor, without perform-
than one DDA can often be observed in the same patient. A ing any enhancement, compression or magnification.
considerable reciprocal association was found between five There was no time limit on the evaluation session’s
out of seven anomalies, a fact suggesting a common genetic duration, however, 30 images, at most, were observed con-
origin (Baccetti 1998). secutively (without break) to minimise errors due to raters’
Surveys on DDA prevalence may provide valuable infor- fatigue. The observer re-evaluated half of the images after a
mation for phylogenic and genetic studies. Moreover, they 1-month interval. The images’ order was randomly changed
may contribute to the understanding the phenotypic plas- for this second rating.
ticity and the genetic/environmental influences within and Gender and age were recorded for each subject. The
between population (Yaacob et al. 1996; Vani et al. 2016). selected radiographs were reviewed for the following: the
Several DDA epidemiological studies have been conducted presence of dental anomalies consisting of number anoma-
in different populations, demonstrating geographic and eth- lies such as hypodontia, oligodontia, supernumerary teeth,
nic variation in their prevalence (Thongudomporn and Freer eruption anomalies such as ankylosis, ectopic eruption and
1998; Ghaznawi et al. 1999; Osuji and Hardie 2002; Altug- impacted teeth, position anomalies such as migration, trans-
Atac and Erdem 2007; Uslu et al. 2009; Kositbowornchai position, root alteration such as dilacerations, hypercemento-
et al. 2010; Gupta et al. 2011; Nemati et al. 2012; Patil et al. sis, concrescence, residual roots, such as fusion, macrodon-
2013; Vani et al. 2016). The objective of this study was to tia, microdontia. Diagnosis and recording of anomalies were
investigate the presence and distribution of DDA in a Greek made according to the definitions described by Lam (2014).
population sample of orthodontic patients. Dental anomalies were classified as:

• Anomalies of tooth shape: taurodontism, fusion.

Materials and methods • Anomalies of tooth size: macrodontia, microdontia.
• Eruption anomalies: ankylosis, impaction, ectopic erup-
For this retrospective study, a sample consisting of 1200 dig- tion.
ital panoramic radiographs was selected out of 2300 patient • Position anomalies: migration, transposition.
records, during the years 2017–2018. The radiographs were • Root alterations: dilaceration, hypercementosis.
selected from the archives of three private dental practices, • Number anomalies: hypodontia, oligodontia, supernu-
limited to Orthodontics, in Athens, Greece and were taken merary.
as part of the orthodontic treatment planning and not for the • These definitions are in general descriptive only with the
purpose of this study, with the same equipment (Planmeca investigator recognising if a tooth is normal or anoma-
PM2002CC (Planmeca Oy, Helsinki, Finland) and standard- lous.
ised method (67 kV, 5.0 mA, 13.9 s).
Images of patients with free medical history, white ethnic
origin, with sufficient enamel formation for the permanent Statistical analysis
teeth within the selected age range were included in the
study (AAPD 2016). Only good-quality images, accord- Statistical analysis was performed using the STATISTICA
ing to the European Guidelines on Radiation Protection in 12.00 statistical software for Windows (StatSoft Inc.), fol-
Dental Radiology 2004, concerning panoramic radiographs lowed by descriptive analysis (mean and standard deviation).
were accessed (The European Guidelines on Radiation Pro- Intra-rater agreement was assessed by calculating Cohen’s
tection in Dental Radiology 2004). Images from patients Kappa ( 𝜅  > 0.8). The value of significance was obtained
with systemic disorders such as syndromes, or cleft lip and/ using Chi-squared. A p value of < 0.05 was considered sta-
or palate, previous jaw surgery, extracted permanent teeth, tistically significant.

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Results the least common types of abnormalities. The prevalence of

those anomalies was as follows: taurodontism 0.5%, fusion
Among the 1200 digital panoramic radiographs examined, a 0.3%, macrodontia 0.6% and microdontia 0.5%. Intra-rater
total of 224 (18.67%) had DDA, which included 92 (7.67%) agreement was assessed with Cohen’s 𝜅 and was found to be
males and 132 (16.67%) females, 203 patients (around among 0.68–0.81 in different categories which is considered
16.92%) had 1 DDA, whereas 19 (1.58%) and 2 (0.17%) acceptable.
patients had 2 or more than 2 DDA, respectively (Table 1).
Table 2 illustrates the distribution of patients according to
gender and the prevalence of the DDA. In Table 2, oligo- Discussion
dontia was the most prevalent DDA and was presented in
6.9% of the subjects. Mandibular second premolars were DDA are an important part of the problem list in 10–20%
the most commonly missing teeth. Concerning the rest of of patients diagnosed with malocclusion. In most of these
the number anomalies, supernumerary tooth anomalies were cases, these anomalies and their patterns of association
presented in 1% of the sample, while hypodontia was pre- should be taken into consideration in orthodontic treat-
sented in only 0.17% of the sample. Impaction (excluded ment planning. Usually, these malocclusions need earlier
third molars) was observed in 5.7% of the cases. 2.2% of the orthodontic treatment inception and require longer treatment
subjects presented ectopic eruption, more often in maxillary periods (Peck 2009). Patient’s dental history is of major
canines. The least common eruption anomaly was ankylo- importance for the prediction of DDA, since the chance of
sis (0.5%). A total of 64 subjects with impacted teeth were expression of these traits from one generation to the next is
found with a prevalence of 5.3%. Maxillary canines were significant (Ely et al. 2006; Peck 2009). DDA were found in
more often impacted (third molars were excluded). Root about one-third of the present sample of panoramic radio-
alterations–dilacerations (3.4%) were predominant in males graphs. This rather high prevalence underscores the need
(5.2%) compared to females (1.9%). Shape anomalies were for precise diagnosis and intervention to prevent further

Table 1  Distributions of dental Description Males Females Total sample p value

anomalies by gender
No dental anomaly 444 (37.00%) 532 (44.33%) 976 (81.33%) 0.000
One dental anomaly 85 (7.08%) 118 (9.83%) 203 (16.92%) 0.016
Two dental anomalies 7 (0.58%) 12 (1.00%) 19 (1.58%) 0.000
> Two dental anomalies 0 (0.00%) 2 (0.17%) 2 (0.17%) 0.000
Total subjects with dental anomalies 92 (7.67%) 132 (16.67%) 224 (18.67) 0.000

Table 2  Prevalence of dental anomalies in the study group

Dental anomaly Males Females Total Chi-square p value Most affected tooth
n % n % n %

Taurodontism 3 0.56 3 0.45 6 0.5 6.14 0.189 Mandibular second molars

Fusion 2 0.37 2 0.3 4 0.33 4.09 0.129 Maxillary canines
Macrodontia 4 0.75 3 0.45 7 0.58 7.38 0.117 Maxillary central incisors
Microdontia 1 0.19 5 0.75 6 0.5 3.26 0.353 Maxillary lateral incisors
Ankylosis 2 0.37 3 0.45 5 0.42 4.89 0.179 Maxillary second premolars
Impaction 17 3.17 47 3.91 64 5.33 16.79 0.157 Maxillary canines
Ectopic eruption 2 0.37 25 3.77 27 2.25 19.63 0.104 Maxillary canines
Transposition 0 0 4 0.6 4 0.33 3.24 0.518 Maxillary canines and central incisors
Root alterations– 28 5.22 13 1.96 41 3.42 32.63 0.026 Maxillary lateral incisors
dilacerations
Hypodontia 2 0.37 0 0 2 0.17 2.48 0.115 Mandibular first premolars and
Maxillary premolars
Oligodontia 31 5.78 46 6.93 77 6.42 39.84 0.016 Mandibular second premolars
Supernumerary 7 1.31 5 0.75 12 1 12.72 0.048 Mesiodents

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 European Archives of Paediatric Dentistry

complications. The earlier the diagnosis, the fewer the risks with other anomalies, such as aplasia, peg-shaped lateral
related to treatment. incisor and deciduous tooth retention (Ely et al. 2006).
DDA occur with different frequencies in various popula- This anomaly was observed in 0.3% of the present sample,
tions, suggesting the influence of genetic and environmental only in females. Maxillary canines or central incisors were
factors. These differences may reflect variations in race or the most affected teeth (Fig. 1).
sample selection, the applied methodology, the inclusion or Dental morphology may be involved in the aetiology of
diagnostic criteria and differences in definitions of the den- crowding or spacing in the dental arch. Macrodontia is less
tal anomalies. The present study reported the incidence of common than microdontia (Altug-Atac and Erdem 2007).
DDAs in an orthodontic population while some of the quoted The prevalence of macrodontia and microdontia in the cur-
studies for comparison are in general and not in orthodon- rent study (0.6% and 0.5%, respectively) was similar when
tic population. Wide variations in DDA’s prevalence have compared to some studies (Altug-Atac and Erdem 2007;
been reported in the literature, ranging from 5.6 to 74.7%, Uslu et al. 2009; Patil et al. 2013). However, other authors
within the general population (Thongudomporn and Freer reported higher incidence of microdontia due to the inclu-
1998; Ghaznawi et al. 1999; Osuji and Hardie 2002; Altug- sion of third molars in their sample (Ghaznawi et al. 1999;
Atac and Erdem 2007; Uslu et al. 2009; Kositbowornchai Kositbowornchai et al. 2010). Μaxillary lateral incisor was
et al. 2010; Gupta et al. 2011; Nemati et al. 2012; Patil most commonly affected by microdontia in the present sam-
et al. 2013; Vani et al. 2016). Altug-Atac and Erdem (2007) ple, in agreement with previous research (Thongudomporn
reported 5.6% prevalence in the Turkish population, which and Freer 1998; Altug-Atac and Erdem 2007; Patil et al.
is much lower compared to ours (18.67%). This difference 2013). Although the prevalence of taurodontism was lower
may be attributed to several factors such as sample size and than that observed in most studies (Thongudomporn and
age range. Additionally, in this study, impaction, dilacera- Freer 1998; Ghaznawi et al. 1999; Uslu et al. 2009; Gupta
tion, and taurodontism were not included in the evaluation. et al. 2011), a study in Iran found similar prevalence for this
Moreover, the reason of extractions was not defined for any anomaly (Nemati et al. 2012).
permanent teeth apart from oligodontia or hypodontia. The prevalence of ectopic eruption was considerably
Oligodontia was the most frequent dental anomaly lower compared to other studies, whilst the rate reported by
in the present study. Although several studies evaluated Thongudomporn and Freer (1998) on the Australian popu-
rotations (Osuji and Hardie 2002; Altug-Atac and Erdem lation is quite high (Gupta et al. 2011; Vani et al. 2016).
2007; Patil et al. 2013; Vani et al. 2016), this anomaly On the other hand, the reported prevalence by Uslu et al.
was not included in the present study, beside the fact that (2009) in the Turkish population is even lower. The maxil-
pre-eruptive and post-eruptive disturbances may con- lary canine was the most common ectopically erupted tooth
tribute to its multifactorial aetiology (Kim et al. 1961) supporting the findings of previous studies (Uslu et al. 2009;
which, however, remains obscure and may not be related Gupta et al. 2011). In this study, maxillary canine was also
to developmental changes. Tooth transposition is a rare the most commonly impacted tooth, excluding third molars.
eruption anomaly that involves the permanent dentition The prevalence of impacted teeth was 5.3%, which is much
(incidence 0.3–0.4%) and is more frequently seen in the lower than in the studies of Fardi et al. (2011) who reported
maxilla (Yilmaz et al. 2005). Transposition may occur a prevalence of 13.7% in north Greece.

Fig. 1  Complete transposition
of the upper right permanent
lateral and canine, and the pres-
ence of a retained deciduous
canine in the same quadrant.
Both the permanent canine
and the central incisor remain
impacted

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European Archives of Paediatric Dentistry

Supernumerary teeth or hyperdontia describes an excess Radiographic imaging provides significant information
in tooth number. The reported prevalence of hyperdontia in cases of patients with dental anomalies. The panoramic
lies among 1–3% in the permanent dentition and is rarely radiograph remains the golden standard for the early detec-
seen in the primary dentition (Fig. 2). The aetiology has not tion and diagnosis of DDA; however, it was reported that
yet been clarified, but several theories have been suggested. important pathologies, such as supernumerary teeth, may
Supernumerary teeth were seen in 1% of the present sample, not be well depicted on panoramic radiographs owing to
a finding in accordance with previous studies (0.1–3.8%) the narrow focal trough in the anterior maxillary region
(Bäckman and Wahlin 2001; Fardi et al. 2011). However, (Witcher et al. 2010). Cone-beam computed tomography
Osuji and Hardie (2002) reported a higher rate, due to the (CBCT) provides precise three-dimensional information
inclusion of deciduous dentition. In the study of Bäckman and is required in several cases to establish a more accurate
and Wahlin (2001), supernumerary teeth were present in 14 diagnosis and accordingly an effective treatment (Sharma
cases in the Caucasian population (1.9%). Furthermore, they et al. 2015). However, CBCT should be used only when
reported that the majority of the supernumerary teeth were information provided by conventional radiography is inad-
mesiodens, in agreement with the present study (Fig. 3). equate (Tsolakis et al. 2018).
Most supernumerary teeth were impacted, asymptomatic
and found incidentally during radiographic examinations.
Clinical complications are rather common in patients with Conclusion
supernumerary teeth. Tooth displacement and failure of
eruption are the most frequent complications (Gábris et al. A significant number of orthodontic patients had at least one
2006). The prevalence of hypodontia and oligodontia in the DDA. The most common DDA in this sample was oligodon-
present sample was significantly lower compared to other tia followed by impaction and supernumerary teeth. Compar-
studies, due to the exclusion of third molars. Kositboworn- ison to our data with other studies revealed variation in their
chai et al. (2010) and Uslu et al. (2009) reported a preva- prevalence suggesting genetic and environmental influences.
lence of 26.1% and 21.6%, respectively.

Fig. 2  An unusual case involv-

ing multiple supernumerary
upper primary and permanent
incisors, in addition to the pres-
ence of fusion between the left
primary central incisor and a
primary supernumerary tooth

Fig. 3  A case displaying a mesi-

odens, multiple supernumerary
upper primary and permanent
lateral incisors and impaction
of the permanent left central
incisor

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 European Archives of Paediatric Dentistry

Compliance with ethical standards  Lam EWN. Dental anomalies. In: White WC, Pharoah MJ, editors.
Oral radiology principles and interpretations. 7th ed. St. Louis:
Mosby; 2014. p. 582–611.
Conflict of interest  The authors declare that they have no conflict of
Nemati S, Dalili Z, Dolatabadi N, et al. Prevalence of developmental
interest.
and acquired dental anomalies on digital panoramic radiography
in patients attending the dental faculty of Rasht. Iran. J Dentomax-
Human and animal rights  This is a retrospective study and does not
illofac Radiol Path Surg. 2012;1:24–31.
contain any studies with animals performed by any of the authors.
Neville DW, Damm DD, Allen CM, Bouquot JE. Abnormalities of
teeth. In: Oral and maxillofacial pathology. 2nd ed. Philadelphia,
Informed consent  Informed consent was not required as the study is
PA: Elsevier; 2005. p. 49–89.
a retrospective study.
Osuji OO, Hardie J. Prevalence of dental anomalies. Saudi Dent J.
2002;14:11–4.
Patil S, Doni B, Kaswan S, Rahman F. Prevalence of dental anomalies
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