Prevalence of Dental Anomalies in Brazilian Children and Adolescents: Implications for Optimal Radiographic TimingABSTRACT
Objective: To evaluate the prevalence of dental anomalies (DA) in panoramic radiographs (PR) of Brazilian children and adolescents and to provide evidence to guide the appropriate timing of PR prescription.
Material and Methods: This retrospective observational study analyzed 1,027 PR of patients aged 6 to 18 years, obtained from the electronic records of an Oral Radiology Service. DA in the primary and permanent dentitions were assessed by sex, age group, and tooth number. A trained professional with over 20 years of radiology experience performed radiographic evaluations. Data were evaluated using chi-square and Fisher's exact tests.
Results: A total of 91.7% of patients presented at least one DA, with no correlation to sex or age. The anomaly rate per patient was higher in adolescents (>12 years) than in children (2.48 vs. 1.86). The mandible was more frequently affected in both dentitions. Adolescents exhibited significantly higher rates of microdontia, hypercementosis, agenesis, root dilaceration, taurodontism, retained deciduous teeth, and impaction. In contrast, tooth rotation was more frequent in children (p<0.05). Canines and third molars were the most affected permanent teeth; in primary teeth, canines and second molars were most involved.
Conclusion: The high prevalence of dental anomalies highlights the importance of prescribing panoramic radiographs for early diagnosis. Timely detection enables preventive interventions and supports better clinical and developmental outcomes.
Keywords:
Radiography; Panoramic; Diagnostic Imaging; Tooth Abnormalities; Child; Adolescent
Introduction
Panoramic radiography (PR) is a valuable diagnostic tool for dental surgeons in children and adolescents, providing a comprehensive view of the maxillomandibular complex. As an extraoral technique, it is well accepted by younger patients and facilitates clinical procedures. Additionally, it serves as a complementary initial exam to confirm the correct chronology of tooth eruption [1,2]. This imaging method is effective at detecting dental anomalies (DA), defined as deviations that occur during tooth development, which may result from environmental factors, genetics, or systemic conditions. Such anomalies can affect the number, size, shape, and position of teeth, directly influencing clinical management [3,4]. These conditions increase the risk of caries and periodontal disease due to bacterial plaque accumulation and may also interfere with occlusal function, speech, and mastication [5,6].
Prevalence studies show considerable variability across populations. In Italy, the prevalence of dental anomalies among individuals aged 8 to 12 years was 20.9%, with a male-to-female ratio of 1:1, indicating no statistically significant difference between sexes. In Brazil, a retrospective cross-sectional study analyzing 663 digital panoramic radiographs from children, adolescents, and adults found that 31% of individuals presented at least one dental anomaly (DA), a rate consistent with previous Brazilian findings [7]. Eruptive anomalies were the most frequent (46%), followed by numerical (29%) and morphological anomalies (18%) [8].
Approximately 5% of children are born with a hereditary anomaly, and among them, around 60% present with dental, maxillary, or facial abnormalities [4]. Adolescents, in particular, may experience greater psychological distress due to the aesthetic impact of DA, which can negatively impact self-esteem [6].
Prevalence studies are essential for understanding the occurrence of DA within specific populations. The School of Dentistry, Araçatuba - São Paulo State University (UNESP), offers free multidisciplinary dental care to a population of approximately 800,000 residents across 47 municipalities. The institution maintains an extensive database of PR exams, providing a valuable resource for analyzing individual characteristics and identifying dental anomalies (DA).
Nevertheless, there is insufficient evidence to guide prescribing PR in pediatric patients. Few studies have established the optimal ages for early detection of DA, limiting dentists' ability to make timely diagnoses [9]. Early detection enables simpler, less invasive treatments and leads to better prognoses by supporting proper maxillary and mandibular development and improving functional, occlusal, and aesthetic outcomes [5,6].
This study aims to analyze the prevalence of DA in PR among Brazilian children and adolescents to understand its distribution across age groups and between sexes. The findings are expected to assist clinical decision-making regarding the appropriate timing for PR prescriptions, enhancing diagnostic accuracy and improving treatment planning.
Material and Methods
Study Design and Ethical Clearance
This analytical, descriptive, comparative, and retrospective observational study was approved by the Human Research Ethics Committee of the School of Dentistry, Araçatuba - São Paulo State University (UNESP) (Approval number: 4.456.006), in accordance with STROBE and RECORD guidelines.
Sample
The Digital PR analyzed in this study was obtained at the Oral Radiology Service between 2015 and 2018, and all images were archived in the institutional image database. A total of 1,027 panoramic images were selected, comprising 667 from patients aged 6 to 12 years and 360 from patients aged 12 to 18 years. The images were anonymized and coded, and information such as age and sex was recorded in electronic spreadsheets. All radiographs were acquired using the PaX-400 Digital Panoramic X-ray system (Vatech Co., Ltd., Gyeonggi-do, Korea).
The inclusion criteria were as follows: (1) patients with a clinical indication for a panoramic radiograph and dental care; (2) those treated at the Dental Radiology Service. The exclusion criteria were: (1) patients who underwent only non-panoramic radiographic examinations; (2) patients with panoramic radiographs taken in multiple years (only the earliest image was considered, and later images were excluded); (3) Patients with syndromes.
Radiographic evaluation was performed by a single trained examiner in a low-light environment, using a Dell notebook (One Dell Way, Round Rock, TX, USA) running Windows 10, equipped with an Intel® Core™ i5-8265U CPU at 1.60GHz and 1.80GHz. Regular breaks were included during the diagnostic sessions to minimize visual fatigue. Dental anomalies in primary and permanent dentitions were analyzed and classified into four types and sixteen subtypes: Shape (hypercementosis, root dilaceration, taurodontism, gemination, fusion, structural anomaly); Size (microdontia, macrodontia); Number (agenesis, retained deciduous tooth, supernumerary, supernumerary roots); Position (impaction, rotation, transposition, ectopia). For each patient, the type and total number of anomalies were recorded.
Data Analysis
Data were tabulated in Microsoft Excel (Microsoft Corporation, Redmond, WA, USA) and analyzed in SPSS 22.0 (SPSS Inc., Chicago, IL, USA), with patients categorized into two age groups: 6-12 years and 12-18 years. Statistical analysis was conducted using the chi-square and Fisher's exact tests at the 5% significance level to assess differences in dental anomaly prevalence by age and sex.
ν Results
Of the 1,027 panoramic radiographs initially selected, 35 were excluded due to noncompliance with the inclusion criteria, resulting from motion artifacts during image acquisition that compromised the accuracy and reliability of the diagnostic interpretation. The final sample comprised 992 radiographs, with children aged 6 to ≤12 years accounting for 65.5% of the study population. At least one DA was identified in 910 patients (91.7%) with no statistically significant differences by sex (p=0.41) or age group (p=0.13).
Among patients with DA, the mean anomaly rate was similar between sexes (2.06 in females and 2.09 in males). However, adolescents (ages 12 to 18 years) had a higher anomaly rate per patient (2.48) than children aged 6 to 12 years (1.86).
Table 1 presents the distribution of patients with anomalies by age group (children and adolescents) and sex. The proportions of male and female patients were similar overall, though there was a slight predominance of males (50.5% vs. 49.5%). A total of 590 children and 320 adolescents with anomalies were evaluated, corresponding to 64.8% and 35.2%, respectively. Regarding the number of anomalies, males presented a higher number compared to females (50.7% vs. 49.2%). A total of 1,099 anomalies were recorded in the pediatric population, and 794 were observed among adolescent patients (58.1% vs. 41.9%).
Distribution of patients with dental anomalies and rate of anomaly/patient according to sex and age group.
As shown in Table 2, a total of 1,893 DA were identified, including children (1,099) and adolescents (794). The adolescent group exhibited a higher anomaly rate per person (2.48). No statistically significant differences between sexes were found for any of the anomaly types or subtypes analyzed.
Among the 1,893 anomalies identified, in the distribution of anomaly subtypes according to sex, the most frequent subtypes were rotation (42.84%- female 80.5% vs. male 82.9%) and impaction (30.42%- female 61.5% vs. male 54.9%), followed by hypercementosis (10.46%- female 21% vs. male 19%). These were the most frequent anomalies in both sexes. Other frequent anomalies included agenesis, root dilaceration, and retained deciduous teeth, none of which showed a statistically significant difference by sex.
Table 2 also highlights significant differences in the distribution of anomalies by age group. Microdontia, agenesis, retained deciduous teeth, root dilaceration, hypercementosis, taurodontism, and impaction were significantly more frequent in adolescents. In contrast, rotation was more common in children.
Figure 1 illustrates the percentage distribution of dental anomalies by permanent tooth, while Figure 2 presents the distribution by primary tooth (FDI two-digit notation). In both dentitions, the mandible was the most affected arch, with 57% of permanent teeth and 72% of deciduous teeth affected.
The permanent teeth most frequently affected by anomalies were teeth 13, 33, and 43, whereas tooth 16 was affected in only one case. In the primary dentition, the most affected teeth were teeth 73 and 83; tooth 52 presented no anomalies in female patients. Among permanent teeth, anomalies were most frequently observed in canines and third molars, including rotation, impaction, hypercementosis, agenesis, dilaceration, and supernumerary teeth. In the primary dentition, canines and second molars were the most affected, with prevalent anomalies including rotation, impaction, and a retained deciduous tooth.
Discussion
The presence of dental anomalies (DA) often results in significant changes in patients' occlusal alignment. Therefore, early diagnosis and preventive treatment are essential to achieving favorable clinical outcomes. Detecting anomalies at the onset of mixed dentition (around age 6) enables dental professionals to implement preventive strategies that address aesthetic and functional issues before they affect normal development. Radiographic evaluation during school age is recommended to support planning of preventive therapies [10].
Due to their clinical relevance, dental anomalies have been the focus of numerous prevalence studies. Although reported rates vary across populations and regions [3,6], the proper development and eruption of 32 permanent teeth are expected under normal conditions. However, teeth affected by anomalies can lead to malocclusion and interfere with oral function, speech, and facial aesthetics [11].
In the present study, 910 out of 992 patients (91.7%) presented at least one DA, a prevalence higher than previously reported in the literature [3,8]. This discrepancy may reflect differences in genetic background or in diagnostic criteria. Drenski Balija et al. [12] and Bakhurji et al. [13] found no significant association between sex and dental anomalies, consistent with our results. However, Silva Junior et al. [6] reported a higher prevalence among female patients, possibly due to greater participation by female students in school-based screenings.
A significant difference was observed between age groups in relation to the types of anomalies. The most frequent were positional anomaliesrotation and impaction, in both groups. Only positional anomalies - rotation - were more prevalent in children aged 6 to ≤12 years. All other anomalies that showed statistically significant differences (microdontia, hypercementosis, agenesis, dilaceration, retained deciduous tooth, taurodontism, and impaction) were more frequent in adolescents (ages 12-18). One possible explanation is that younger children may not yet have all their teeth erupted or fully formed roots. Shokri et al. [8] found a higher prevalence of positional anomalies in individuals aged 15 years or older, in a sample that included patients up to 35 years old.
Among the 1,893 anomalies identified in this study, the most frequent were rotation, impaction, hypercementosis, and agenesis, findings consistent with those of recent publications [6,14]. In the results, 91.7% of patients had anomalies, with a dental anomaly rate per patient of 2.08, higher than the 45.1% prevalence (396 patients) reported by Afify and Zawawi [15], who were affected by dental anomalies, mainly dental absences and impactions.
The research found that dental anomalies are more prevalent in the mandible than in the maxilla. This finding was contrary to Olatosi et al. [3], who documented prevalence rates of 7.53% in the maxilla and 4.26% in the mandible in pediatric patients aged 0 to 16 years, and Shokri et al. [8], who presented similar results in Iranian populations.
Lower canines were the most affected teeth, likely due to the complexity of their eruption path. This susceptibility may be linked to the complexity of the eruption path, and factors such as supernumerary teeth, insufficient space in the dental arch, and trauma to deciduous teeth [16]. In our study, 1,635 teeth were impacted, most of them permanent. This aligns with findings from Reis et al. [2], who identified impaction as the most prevalent anomaly (26.63%).
Hypercementosis was more prevalent in the region of the lower incisors and canines. This finding corroborates the higher incidence in the lower area, particularly on the left [17]. Castro-Silva et al. [18] observed a higher prevalence of hypercementosis among females in a sample of 723 panoramic images from Ceará, Brazil. Our results support this finding, indicating that the anomaly is more prevalent in females, although no significant difference was observed between the sexes. Additionally, hypercementosis was most common in mandibular incisors and canines, with a slight predominance on the right side.
Root dilaceration was observed in 57 cases, a finding consistent with that reported by Reis et al. [2] and Gonçalves-Filho et al. [19]. The observed difference in the prevalence of the anomaly between males and females was not statistically significant. The analysis revealed that the incisors (anterior and lateral) and the first molars were the teeth most frequently affected, accounting for 24.5% and 17.9% of cases, respectively. As indicated by Martins Neto et al. [20], the teeth most commonly affected by root dilaceration are the incisors and third molars. Reis et al. [2] similarly noted that the first molars were the most affected. Consequently, the data from this study align more closely with the findings of Martins Neto et al. [20].
Taurodontism, characterized by an enlarged tooth body and shortened roots, was among the least prevalent anomalies. Microdontia also had a low prevalence, primarily affecting the upper incisors and third molars. Only one case of macrodontia was identified.
Regarding supernumerary roots, only three patients exhibited this anomaly, all affecting the lower right first molar. There was no significant association with sex or age, in contrast with the previous findings [21], which indicated a higher prevalence of supernumerary roots in the upper premolars (0.6%) and the lower premolars (0.4%). The low prevalence of this anomaly may be related to the two-dimensional nature of panoramic radiographs, which can hinder accurate identification because of overlapping anatomical structures.
Position anomalies (eruption disorders) showed a high prevalence as previously reported [6], and rotation and impaction were the most prevalent subtypes in children (81.43%) and adolescents (62.21%). Silva et al. [6] noted a significant prevalence of ectopic eruption, with a decreasing number of maxillaries. In contrast, the present study demonstrated a relatively low prevalence of this anomaly, with only 10 patients exhibiting at least one anomaly, representing 1.10% of the total sample.
Roslan et al. [10] found microdontia in 1.08% and dilacerations in 0.27% of their sample. In contrast, Menini et al. [17] reported microdontia in 12.93% of patients, observed only in individuals over 12 years old and primarily affecting third molars. In the present study, 0.79% of patients with anomalies (15 out of 1893 identified anomalies) presented microdontia, most frequently involving upper incisors and third molars, with no sex differences.
Macrodontia was observed in the upper central incisors, as reported by Yassin [22]. Martucci et al. [23] reported that macrodontia was more common in the upper central incisors or the left upper region. Martins Neto et al. [20] reported that only 0.1% (n=1) of their sample presented macrodontia, a low prevalence already well established in the literature, which aligns with our finding (0.11%). In this analysis, one case occurred in tooth 32, the lower left central incisor, of a male patient. A recent study found that dental anomalies were present in 27.5% of the sample, with hypodontia occurring in 7.3% of cases [6]. The most prevalent dental alteration, affecting mainly female patients aged 5-12 years, was anodontia, present in 55% of the sample [24].
In this study, the most frequently observed anomaly was positional (impaction, rotation, transposition, and ectopia). It is worth noting that rotation was the most commonly observed alteration in the male group, occurring in 81.7% of patients (811 of 992 samples).
Dental agenesis, a multifactorial condition often associated with genetic predisposition, environmental factors, radiation, or syndromes, affects approximately 25% of the population [25]. In our sample, it was found in 7.35% of patients, with hypodontia being the most common subtype.
This study identified 1,893 dental anomalies, affecting 91.7% of the analyzed population. It is important to note that a single patient could be present with multiple types of anomalies. Only 50 cases (2.64%) involved retained primary teeth, with deciduous canines being the most frequently affected.
The prevalence of supernumerary teeth was 3.01% of the total number of DA (1,893). The prevalence of developmental anomalies in this study was comparable to that reported by Drenski Balija et al. [12], Fekonja [1], and Olatosi et al. [3]. These previous studies also reported low rates in relation to their prevalence. In Brazil, supernumerary teeth accounted for 4.09% of the total 513 anomalies [7].
In this study, the occurrence of fusion (0.16%) and gemination (0.11%) was lower than expected for the total number of DA, given that these anomalies are rarely reported in the literature. Fusion has been reported at a rate of 0.19% by Hamasha and Al-Khateeb [26] and 0.27% by Gupta et al. [27], while gemination has been reported at a rate of approximately 0.2% [26,27]. Only two cases of transposition were observed (0.11%), in agreement with the results reported by Olatosi et al. [3], who reported a rate of 0.3%.
Structural anomalies were identified in 10 cases (0.53%), but no statistically significant findings were observed. As in other studies, no cases of amelogenesis imperfecta or dentinogenesis imperfecta were observed [28], consistent with the rarity of these conditions, reported to occur at rates of 1:700 and 1:6,000, respectively [29,30]. In Brazil, structural anomalies accounted for 2% of the total 513 anomalies [7].
As a limitation, this study focused on analyzing the prevalence of dental anomalies by classifying them into types and subtypes; however, it did not include more detailed stratification by patient age, limiting it to only two age groups as references. This limited the ability to identify the specific ages at which anomalies were most prevalent. Furthermore, the radiographic data were based on images taken in selected years, so that some anomalies may have already been present in prior years. Future studies with more narrowly defined age ranges are essential to better identify the key ages for the early diagnosis of dental anomalies.
ν Conclusion
Panoramic radiographs analysis revealed a high prevalence of dental anomalies in children and adolescents, with statistically significant differences between age groups. The positional anomaly - rotation and impactionwere the most frequent in all the groups. Only positional anomalies - rotation was more prevalent in children. These findings highlight the clinical importance of panoramic radiographs in the early detection of dental anomalies. Timely diagnosis enables preventive interventions that are crucial for effective management and for promoting favorable long-term outcomes in dental development.
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Financial Support
None.
Data Availability
The data used to support the findings of this study can be made available upon request to the corresponding author.
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Edited by
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Academic Editor:
Alidianne Fábia Cabral Cavalcanti
