Bilateral tooth transposition between maxillary canine and 1st premolar is a rare finding and poses a challenge to any orthodontist to treat. In definitive treatment plan, one of the treatment alternatives can be finishing the case with alignment of involved teeth in their transposed position whereas the other option is to correct the transposition orthodontically and establishing the natural tooth order. Here a case is presented where transposed positions were maintained with the philosophy to treat by minimizing the negative factors

Mahajan, Monika

English

Atharva Scientific Publications (E-Jounals)

Mahajan M                                                              Transposition of bilateral maxillary canine and 1
st
 premolar   
Vol 8| Issue 1| Jan– Mar 2019                                                                                                            J Orofac Res 8 
 Case Report 
Orthodontic treatment of transposition of bilateral maxillary canine and 
1st premolar by maintaining the transposed position: A case report  
Monika Mahajan  
From, Assistant Professor, Department of Orthodontics & Dentofacial Orthopedics, Himachal Pradesh Government Dental 
College and Hospital, Shimla, H.P. India. 
Correspondence to: Dr. Monika Mahajan, Department of Orthodontics and Dentofacial Orthopedics, Himachal Pradesh 
Government Dental College and Hospital, Shimla, H.P. India. Email: monika.hemender@gmail.com  
Received - 15 February 2019                                  Initial Review – 5 March 2019                                         Accepted – 20 March 2019  
ABSTRACT 
Bilateral tooth transposition between maxillary canine and 1
st
 premolar is a rare finding and poses a challenge to any 
orthodontist to treat. In definitive treatment plan, one of the treatment alternatives can be finishing the case with alignment of 
involved teeth in their transposed position whereas the other option is to correct the transposition orthodontically and 
establishing the natural tooth order. Here a case is presented where transposed positions were maintained with the philosophy 
to treat by minimizing the negative factors. 
Keywords:- bilateral transposition , orthodontic treatment 
 
 
ooth transposition is a developmental alteration 
resulting in a deviation in tooth position, clinically 
identified as the interchange of two adjacent teeth, 
that alters the natural order of the dental arch [1-3]. Tooth 
transposition can be complete, when both the tooth crown 
and the root are transposed, or incomplete when only the 
clinical crown is transposed but the root apex remains in 
relatively normal position [4]. The 5 types of tooth 
transpositions observed in upper jaw are classified by Peck 
and Peck according to the teeth involved as: (1) Canine to 
1
st
 premolar; (2) Canine to Lateral Incisor; (3) Canine to 1
st
 
Molar position; (4) Lateral Incisor to Central Incisor; (5) 
Canine to Central Incisor position [2]. Transpositions 
mostly involve the upper arch and unilateral transposition 
is more common than bilateral transpositions with the left 
side being more often involved [3-5]. 
The canine is one of the most commonly involved teeth 
in the transposition phenomenon, changing its eruptive 
place with the lateral incisor or the 1
st
 premolar in most 
cases [5-7]. Canine transposition has a maxillary 
predilection and is generally associated with other 
anomalies such as agenesis (40%), deciduous canine 
retention (50%) and peg shaped maxillary lateral incisor 
(25%) [1,6,8]. Unilateral canine transposition  happens 
more frequently (79%) and the left side is more frequently 
affected (69%) [1,9]. Bilateral transposition has been 
reported in 5% of cases [2]. Transposition between canine 
and maxillary 1
st
 premolar occurs in 0.135% to 0.510% of 
the population [4,10]. In Japan, the incidence ranges from 
0.065% in general population to 0.660% in orthodontic 
patients [10,11]. Elsewhere occurrence ranges from 
0.380% in a Turkish population to 0.510% in Africa 
[10,12]. 
Tooth transposition can hinder esthetic and functional 
aspects of dentition. Postulated causes of tooth 
transposition include inversion of the tooth buds during 
development, alteration of the tooth eruption pattern, the 
presence of deciduous teeth beyond the maximum time 
limit for the development of the permanent teeth and any 
dental trauma during childhood. A genetic origin also has 
T 
Mahajan M                                                              Transposition of bilateral maxillary canine and 1
st
 premolar   
Vol 8| Issue 1| Jan– Mar 2019                                                                                                            J Orofac Res 9 
been reported as the main etiologic factor thus supporting a 
theory of multifactorial heredity in transposition of teeth. 
Maxillary canine and 1st premolar transposition is 
currently considered a tooth position anomaly caused by 
genetic factors along with a multifactorial inheritance 
pattern. According to Peck and Peck various observations 
corroborate the polygenic inheritance theory such as the 
high prevalence of dental anomalies related to maxillary 
canine -1st premolar transposition, its bilateral occurrence, 
familial occurrence with significant differences in 
prevalence among males and females [3-5,13-18]. We 
hereby present a case to demonstrate complete bilateral 
transposition of maxillary canine to 1st premolar along 
with the treatment option selected. 
CASE REPORT 
The patient, a girl aged 13 years, reported to the 
Department of Orthodontics, with the chief complaint of 
mild crowding along with tooth malposition in upper arch. 
An extraoral examination showed a pleasing face with 
facial symmetry and a straight profile (Fig 1). An intraoral 
examination revealed that she had all her permanent teeth 
erupted except maxillary left canine which had not 
erupted. There were bilateral retained deciduous maxillary 
canines present.  
 
Figure 1: Pre-treatment extra-oral photographs 
The clinical examination revealed Angle’s molar 
relationship as class I on the left side and end on the right 
side. There was a complete transposition of maxillary 
canine and 1st premolar on the right side clinically. The 
maxillary right 1
st
 premolar was rotated mesiopalatally and 
maxillary canine was placed buccally distal to 1st 
premolar. The left maxillary canine was unerupted (Fig 2). 
The panoramic radiograph showed that all permanent teeth 
including the 3rd molars were present with complete 
bilateral transposition of maxillary canines and 1
st
 
premolars (Fig 3). 
 
Figure 2: Pre-treatment intra-oral photographs 
 
Figure 3: OPG showing complete bilateral maxillary 
transposition between canine & 1
st
 premolar 
Treatment objectives were based on multidisciplinary 
approach to improve esthetics, establish oral health and 
function as well as to attain stability forms. The patient 
was referred for the required orthodontic treatment with 
the aim of achieving treatment objectives mentioned 
below: 
a) To relieve the crowding of upper and lower anterior 
teeth. 
b) To establish a functional class I molar and canine 
relationship. 
c) To correct the transposition and establishing the natural 
tooth order if possible. 
Orthodontic treatment was initiated by bonding upper 
lower arches with pre torqued and pre angulated brackets 
with a 0.022 inch slot of MBT prescription. Tooth 
Mahajan M                                                              Transposition of bilateral maxillary canine and 1
st
 premolar   
Vol 8| Issue 1| Jan– Mar 2019                                                                                                            J Orofac Res 10 
movement was started with light forces. Both retained 
deciduous canines were extracted. The 1
st
 premolars were 
moved mesially and the canines were moved distally to 1st 
premolar position bilaterally. Fixed appliances were 
removed after 28 months of orthodontic treatment and 
removable Hawleys retainers were placed in both mandible 
and maxilla to maintain orthodontic correction. The patient 
was suggested to get bilateral odontoplasty of the tip of the 
cusp of canines to mimic the anatomy of premolar but she 
did not feel the need and hence declined but was advised to 
undergo it in near future. 
The post-treatment results showed the patient with a 
very pleasant face and smile (Fig 4). Intraorally the patient 
attained correction of crowding of teeth with maintaining 
Angles class I molar relationship with an ideal overjet and 
overbite (Fig 5).  
 
Figure 4: Post-treatment extra-oral photographs 
 
Figure 5: Post-treatment intraoral photographs 
The challenge of correcting a transposition is to 
accomplish it while maintaining periodontal health. The 
post treatment lateral cephalogram shows maintenance of 
skeletal class I bases (Fig 6). The panoramic radiographic 
view demonstrated normal alveolar contours and no sign 
of root resorption or any other damage to canine or 
premolar was seen (Fig 7).  
 
Figure 6: Post-treatment lateral cepalogram showing class 
I skeletal bases 
 
Figure 7: Post-treatment OPG shows finishing in 
transposed position 
DISCUSSION 
The maxillary canine to 1
st
 premolar transposition is 
clearly the most frequently reported maxillary 
transposition type [5,7]. The treatment of transposition can 
be classified as interceptive or definitive depending on 
when the transposition is diagnosed. Interceptive treatment 
is performed on patients at the age of 6 and 8 years after 
OPG and intra oral examination reveals presence of tooth 
transposition at the initial stage. Interceptive treatment can 
be adapted before transposition is complete, which 
normally occurs around 10 years of age. Hence thereafter a 
definitive treatment approach should be adapted [3,19]. In 
definitive treatment, one of the treatment alternatives can 
be finishing the case, with alignment of involved teeth in 
their transposed position. The other option is to correct the 
Mahajan M                                                              Transposition of bilateral maxillary canine and 1
st
 premolar   
Vol 8| Issue 1| Jan– Mar 2019                                                                                                            J Orofac Res 11 
transposition orthodontically and establishing the natural 
tooth order. Extraction approach is preferred when a severe 
arch deficiency persists. It is not advised to correct 
transposed teeth in permanent dentition because of 
potential risk of damaging the teeth or supporting 
structures. Therefore alignment of the involved teeth in 
their transposed position seems to be the best alternative 
with the positioning of teeth in the new sequence [6,15]. 
In our case, a non-extraction approach was considered. 
Thereafter keeping the transposed order of the teeth or 
recreating the natural tooth order was presented as two 
treatment alternatives to the patient. If it is opted to keep 
the natural tooth order, treatment becomes longer and more 
difficult. However, if it is opted to keep the transposed 
tooth order, different variables such as different root 
prominence, different height of gingival scallops as well as 
the shape and size of the transposed premolar has to be 
considered [20]. Esthetic and occlusal considerations 
suggest that aligning the transposed teeth while keeping 
their transposed positions would be unacceptable but, as a 
general rule it is not advisable to correct a transposed tooth 
order due to insufficient buccopalatal width of bone 
support for the movement of two adjacent teeth in different 
directions, especially after eruption [17]. Many reports 
showed recession at the gingival margins of the 
repositioned canines because of long journey of canines 
through the dense buccal compact bone [17,20]. 
We treated this case with the philosophy to minimize 
the negative factors. The key to success is to diagnose the 
case early and begin the treatment, thereby minimizing the 
possibilities of injuring the surrounding tissues [2,9,13]. 
One must take into consideration the esthetic factors, 
occlusion, canine root apex position, periodontal support, 
patients age along with treatment duration, patient 
cooperation when correcting the transposed teeth. 
CONCLUSION 
Transposition is an anomaly of tooth position which is a 
challenge for an orthodontist. When correcting it different 
factors should be taken into consideration such as age of 
patient, esthetics, occlusion, treatment time, patient 
comfort and periodontal support. The treatment allowed us 
to place the teeth in their transposed order. Our patient was 
satisfied with the esthetic results obtained and has good 
oral health. 
 
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Mahajan M                                                              Transposition of bilateral maxillary canine and 1
st
 premolar   
Vol 8| Issue 1| Jan– Mar 2019                                                                                                            J Orofac Res 12 
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How to cite this article: Mahajan M. Orthodontic 
treatment of transposition of bilateral maxillary canine 
and 1st premolar by maintaining the transposed position: 
A case report. J Orofac Res. 2019;8(1):8-12. 
Funding: None; Conflict of Interest: None Stated. 


Orthodontic treatment of transposition of bilateral maxillary canine and 1st premolar by maintaining the transposed position: A case report

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Orthodontic treatment of transposition of bilateral maxillary canine and 1st premolar by maintaining the transposed position: A case report

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