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Year : 2023  |  Volume : 12  |  Issue : 1  |  Page : 13

Prevalence of mesio-distal dilaceration in patients presenting for initial orthodontic care: A retrospective study

1 Department of Adult Restorative Dentistry, Oman Dental College, Muscat, Oman; Department of Restorative Dentistry, Dundee Dental Hospital and School, University of Dundee, Dundee, Scotland, UK
2 Department of Adult Restorative Dentistry, Oman Dental College, Muscat, Oman
3 Department of Oral Biology and Diagnostic Sciences, Dawson Dental, Toronto, Canada
4 Department of Orthodontics, Oman Dental College, Muscat, Oman

Date of Submission09-Aug-2022
Date of Decision12-Oct-2022
Date of Acceptance01-Nov-2022
Date of Web Publication18-Mar-2023

Correspondence Address:
Abubaker Qutieshat
Department of Adult Restorative Dentistry, Oman Dental College, PO Box 835, Mina Al Fahal, Postal Code 116, Muscat

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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jos.jos_75_22

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OBJECTIVE: To determine the prevalence of dilaceration in a sample of patients presenting for initial orthodontic care.
METHODS: Examining radiographs from a random sample of orthopantomogram images was used to acquire the data. In all, 2,801 dental records were evaluated at Oman Dental College (ODC), Oman. A dental X-ray processing software was utilized to view the images. A tooth was classified as having a mesial/distal dilaceration if its long axis exhibited an angle of 90 degrees or greater. Dilacerated roots in the buccal/lingual direction were diagnosed by observing the appearance of a spherical opaque area with a dark shadow in its central region, projected by the apical foramen, which gave the root canal a “bull's-eye” appearance.
RESULTS: Dilacerations were found in 17.32% of the records examined. The maxillary second molars (22.71%) were the most commonly affected, followed by the mandibular third molars and mandibular lateral incisors (21.90% and 17.23%, respectively). The central incisors and canines were the least affected, with dilaceration affecting less than 0.2% of the teeth. The mandible was found to have more dilacerations than the maxilla (53.78% and 46.22%, respectively). 61.03% of dilacerations occurred in molars, 43.12% of which occurred in third molars.
CONCLUSION: Dilaceration is a notable dental anomaly that can affect any tooth, with some teeth being more affected than others. Dilaceration in maxillary second molars and mandibular lateral incisors is more common in the population of this study than in other populations reported in the literature. Recognizing the condition will allow for more effective orthodontic treatment.

Keywords: Dilaceration, initial orthodontic care, prevalence, tooth impaction, Oman

How to cite this article:
Qutieshat A, Al Harthy N, Javanmardi S, Singh G, Chopra V, Aouididi R, Al Hanashi O, Al Arabi A. Prevalence of mesio-distal dilaceration in patients presenting for initial orthodontic care: A retrospective study. J Orthodont Sci 2023;12:13

How to cite this URL:
Qutieshat A, Al Harthy N, Javanmardi S, Singh G, Chopra V, Aouididi R, Al Hanashi O, Al Arabi A. Prevalence of mesio-distal dilaceration in patients presenting for initial orthodontic care: A retrospective study. J Orthodont Sci [serial online] 2023 [cited 2023 Oct 3];12:13. Available from: https://www.jorthodsci.org/text.asp?2023/12/1/13/371973

  Introduction Top

A distortion of a tooth causing the normal axial relationship between the crown and root to be disrupted during development is termed dilaceration. The condition most commonly arises in permanent teeth as a consequence of trauma to the apex of the primary predecessor, which lies close to the permanent tooth germ, but may also occur as a result of unidentified developmental factors.[1],[2] The slightest displacement of a primary tooth may disrupt the follicles of new permanent teeth, but the incidence of dilacerations affecting the permanent dentition following trauma to the primary dentition is relatively low.[3]

Diagnosis of dilacerated teeth is usually based on clinical and radiographic findings. If the crown is dilacerated, it is almost always clinically obvious. If the root was dilacerated, only a radiographic examination would reveal the presence of dilaceration, which is frequently associated with tooth impaction, prompting the clinician to take a diagnostic radiograph. Clinical manifestations of a dilacerated tooth include primary tooth retention, delayed eruption, atypical soft tissue elevation, and a boneless feel to the gingival mucosa (i.e., dehiscence or fenestration).

Radiologic evaluation is required to confirm the presence of dilaceration as well as the level and angulation of the dilacerated portion and is also essential for the diagnosis and planning of orthodontic treatment. Treatment and prognosis for affected teeth vary based on the level and degree of dilacerations. The greater the proximity of the dilacerated portion of the root to the crown–root junction, the poorer the orthodontic treatment prognosis, especially when it comes to orthodontic traction.[4],[5] In contrast, obtuse angle root dilacerations and/or dilacerations that are positioned more apically have a higher success rate.

Several, albeit relatively few, published studies have addressed the prevalence of dilacerations; nonetheless, the results of each study have been heterogeneous and inconsistent with the other reports due to the diversity in defining dilacerations, sample size, and the methodology used.[6],[7],[8],[9] In addition, many reports relied on periapical radiographs, which do not necessarily include a full mouth series that covers the entire dentition, as is the case with orthopantomogram radiographs; consequently, the majority of their reporting for prevalence was specific to a tooth type and not to the general population.

This study aimed to explore the prevalence of dilaceration in dental patients presenting for initial orthodontic care and to record the distribution of this condition within a sample from a previously unstudied community.

  Methodology Top

A retrospective study was conducted in a teaching dental hospital in Muscat, Sultanate of Oman, to investigate the prevalence of dilaceration. Ethical approval to conduct this study was obtained from the Research and Ethics Committee at Oman Dental College (ODC). A random sample of 4000 patients who attended the dental center for an initial orthodontic assessment was chosen from a total of 39305 dental records. Orthopantomograms are routinely taken at the first visit for patients attending orthodontic screening clinics. Patients under the age of 15 at the time of the radiographic examination were excluded, as were those whose records lacked or contained orthopantomograms of poor quality. The final sample included 2801 records, each with at least one orthopantomograms. If a record contained more than one orthopantomogram, the earliest one was used.

A single examiner viewed and evaluated all orthopantomograms using SIDEXIS XG software, version (Sirona Dental Systems GmbH, Bensheim, Germany). A tooth was regarded to have a mesial or distal dilaceration if there was an angle of 90 degrees or greater along the axis of the tooth or root. The long axes and angles were determined using the software's “Measure angle” function. By analyzing the appearance of the apical region of the root, labial/buccal or lingual dilacerations were identified. A dilaceration was documented if there was a spherical opaque patch with a dark shadow in its middle region cast by the apical foramen and the root canal had a “bull's-eye” appearance.[10] This was further confirmed if a periodontal ligament gap was exhibited as a radiolucent halo around the dilacerated region [Figure 1]. On a customized data collection sheet, the dilaceration status of each tooth was noted. Multirooted teeth having more than one dilacerated root were counted as a single case of dilaceration. Four weeks following the initial assessment, the examiner reevaluated a sample of 200 orthopantomograms comprising forty-one dilacerated teeth and found 100 percent agreement. The prevalence of root dilacerations was calculated using percentages, and descriptive statistics were applied to the data for further analysis. Statistical analyses were undertaken using GraphPad Prism (GraphPad Software Inc., version 9, San Diego, USA).
Figure 1: An orthopantomogram radiograph showing the characteristic bull's-eye image and radiolucent halo in a labiolingually directed dilaceration of the root of maxillary central incisor

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  Results Top

Dilaceration was observed in 485 of 2,801 subjects, with a frequency of 17.32%. The prevalence of dilaceration among various types of teeth is shown in [Table 1]. The teeth showing the highest prevalence of dilaceration were maxillary second molars (22.71%), mandibular third molars (21.90%), mandibular lateral incisors (17.23%), and maxillary second premolars (11.43%). The teeth showing the lowest prevalence of dilaceration were maxillary and mandibular central incisors and canines, with dilaceration affecting less than 0.2% of the teeth. The mandible was found to have more dilacerations than the maxilla (53.78% and 46.22%, respectively). 61.03% of dilacerations occurred in molars, 43.12% of which occurred in third molars. The prevalence of dilaceration in anterior teeth was comparable to that in premolar teeth, with each group comprising almost one fifth of the overall reported dilaceration cases. Differences between jaws were reported more noticeably between the maxillary and mandibular second molars (22.71% maxillary cf. 2.09% mandibular) and lateral incisors (1.93% maxillary cf. 17.23% mandibular).
Table 1: Distribution of studied teeth with dilaceration prevalence for each tooth type

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1,634 (58.34%) of the investigated orthopantomograms belonged to males, while 1,167 (41.66%) belonged to females. The ages varied from 15 to 49 years, with a mean of 23.70 (SD = 7.43) years. 621 teeth found in 485 patients had dilacerations (17.32%). These were identified in 255 (52.58%) males and 230 (47.42%) females, with no statistically significant difference between the sexes (P = 0.6488). Patients who had more than one dilaceration frequently had them on the same tooth bilaterally, a phenomenon most commonly observed with the mandibular lateral incisors, with 71.03% of reported dilacerations in this tooth being bilateral and 55.88% of patients with more than one dilaceration having both mandibular lateral incisors dilacerated. The majority (86.96%) of the reported dilacerated teeth in this study were erupted, whereas 13.04% were impacted.

  Discussion Top

Orthopantomogram radiography has been widely used in oral health epidemiological studies due to the convenience of covering the entire set of teeth and its reliability in obtaining data, particularly in retrospective studies.[11] Periapical and bitewing X-rays only show a few teeth at a time, so they cannot show the whole mouth at once, which in turn can pose a problem when conducting retrospective epidemiological studies. An orthopantomogram can capture the entire mouth in a single image, but its only drawbacks are that it produces a two-dimensional image and it cannot detect caries reliably.

Identifying and diagnosing a dilaceration is essential for any patient requiring orthodontic treatment. Orthodontic movement of dilacerated teeth may result in irreversible root resorption, which can significantly complicate orthodontic treatment for these teeth.[12],[13] In one study that looked at the incidence and severity of root resorption during orthodontic treatment, it was found that dilacerated teeth had the most root resorption after the conclusion of orthodontic treatment.[14] A dilacerated root can make it difficult or even impossible to extrude a tooth using orthodontic treatment, leaving extraction as the only option in certain cases.[15]

According to some researchers, dilaceration is defined as a deviation from the tooth's normal axis of 90 degrees or more.[6],[7],[16] Dilaceration was defined by others as a deviation of 20 degrees or more from the normal axis of the tooth or root.[17] The former definition was used to classify the samples in this study because it distinguishes between normal root curvatures and dilacerations more clearly.

Previous research found that dilaceration occurs at varying rates across different populations, ranging from 0.002 to 30%.[6],[7],[8],[16],[18],[19],[20],[21],[22],[23],[24],[25] Few studies have looked at the condition from an orthodontic standpoint,[12],[21],[22],[24] and dilacerations were found to be more common in orthodontic patients than in those attending for other reasons.[21] The prevalence of dilaceration in the population studied herein is comparable to that reported by Hamasha et al.[6] in Jordan (17%), Citak et al.[24] in Turkey (18.9%), Ardakani et al.[19] in Iran (15%), and Alhumaid et al.[8] and Alahmed et al.[26] in Saudi Arabia (12.5–30%). Clearly, Middle Eastern populations have higher and nearly identical frequencies.

Because third molars accounted for more than one-quarter of all reported dilacerations, countries that follow the US dental school departments' recommendations regarding prophylactic removal of third molars are expected to have a much lower prevalence of dilacerations than the one reported in this study or other studies conducted in countries that do not follow that approach.[27] Notably, the only study conducted in the USA that addressed dilacerations was an assessment of dental and craniofacial findings in individuals with Smith–Magenis syndrome.[28]

The maxillary second molars and mandibular lateral incisors are two tooth types that have never been previously reported as being commonly affected by dilacerations. As we present findings from a single population within a single country, additional research may determine whether similar frequencies are observed in neighboring countries and whether the maxillary second molars and mandibular lateral incisors are more prevalent in regions with genetic ties to the Omanis, such as Baluchistan, Yemen, Persia, Zanzibar, and Bahrain.[29]

Our findings show that root dilacerations are common in maxillary premolars, with a prevalence of 14.17%, which may be relevant if the affected individual's initial orthodontic assessment and space analysis point to extraction-based treatment. In such cases, removal of dilacerated premolars would provide a predictable means of providing space to achieve treatment outcomes, especially if crowding relief and overjet correction are required.[30]

Dilacerations are frequently caused by trauma to a primary tooth, which affects the developing permanent tooth bud due to its close proximity to the primary tooth. This causes root curvature to develop in the labio-lingual or medio-distal direction. The position of a tooth dilaceration is determined by the tooth's developmental stage at the time of injury.[31] Some studies, however, support the notion that dilaceration is a true developmental anomaly unrelated to a history of trauma.[10],[16],[32],[33] Other researchers have proposed that dilaceration is likely caused by the ectopic and altered development of tooth buds in an attempt to explain some dilaceration cases that lack any signs of traumatic origin.[34] In light of the higher-than-anticipated prevalence of dilacerations in maxillary second molars and mandibular lateral incisors, reported herein, the findings of this study point to two areas which warrant further research:

1. The effect of the third molar germ on the root formation of the second molars and whether it plays a role in dilaceration

An abnormal position of the germ of a third molar may act as a barrier, altering the pattern the roots of the second molars follow during development and maturation. A similar cause-and-effect relationship was previously observed in the literature, linking the impaction of the second molar to the third molar germ's interference with root formation.[35],[36] An abnormal position of the tooth or an adjacent tooth germ may result in a change in root development or tooth eruption. Furthermore, the presence of a clinically or radiographically detectable physical barrier may alter root development or tooth eruption.[35] If no physical barrier can be identified as the cause of abnormal root development or the cessation of eruption of a normally placed and developed tooth, the cause may be attributed to an overlooked trauma to the site of tooth germ or to developmental factors that might have occurred during maturation and/or eruption.

2. The link between developmental factors and cases of dilaceration that cannot be explained by a history of trauma

Complex anatomic variations in the mandibular lateral incisors have been reported by several researchers, making them one of the most difficult teeth to treat endodontically.[37],[38] The wide range of anatomical variation was attributed to developmental factors, and as a result, the tooth has come to be regarded as one of the most overlooked teeth in terms of anatomical variations within its root/s and/or root canal spaces.[39] It is therefore safe to assume that the developmental factors that may cause anatomical aberrations in this tooth may also play a role in the root's propensity to dilacerate. This was clearly demonstrated in our study when we looked at the mandibular lateral incisor. The bilateral dilacerations identified in this work, particularly in the mandibular lateral incisors, may be linked to previous reports that found symmetrical, bilateral anatomic aberrations in the root morphology and canal configuration of mandibular lateral incisors.[39],[40]

This study backs up the idea that dilaceration is a dental anomaly caused by factors that alter root/tooth development and maturation, and trauma is only one of many potential causes of dilaceration. The majority of dilacerated teeth are located in the posterior region of the mouth, which is less vulnerable to direct trauma than the anterior region. Therefore, trauma alone cannot account for all cases of dilaceration. This notion is consistent with Malčić et al. (2006)[7] and Udoye and Jafazadeh (2009),[16] who suggested that the high prevalence of dilacerations in third molars in their studies may indicate that the development of dilacerations in the posterior region is consistent with ectopic tooth development and lack of space, rather than trauma.

The inability to confirm a history of trauma or the presence of associated syndromes constituted a limitation of this retrospective study. Another limitation was the inability to document the location of the dilaceration on the root and identify the affected root in multirooted teeth.

  Conclusions Top

Dilaceration is seen mostly in maxillary second molars, mandibular third molars, and mandibular lateral incisors. Dilaceration in maxillary second molars and mandibular lateral incisors is more common in this previously unstudied population than in other populations reported in the literature. In all, we consider that the finding of a dilaceration in 17.32% of the patient's records is a prevalence high enough to warrant attention among orthodontists and to call for subsequent investigation into the etiological factors.

Financial support and sponsorship

This research was supported by Oman Dental College, Research grant ODC/REC/RG/2021-4.

Conflicts of interest

There are no conflicts of interest.

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  [Table 1]


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