J Korean Acad Pediatr Dent > Volume 52(2); 2025 > Article
Lee, Lee, Shin, Jeong, and Park: Anatomical and Dentoalveolar Features of Maxillary First Premolar Abnormal Eruption in Mixed Dentition

Abstract

This study aims to analyze anatomical and structural changes related to abnormal eruption of the maxillary first premolar in children, focusing on the correlation between maxillary sinus pneumatization volume and positional shifts in the premolar and canine. Twenty-nine children, with Hellman dental age IIIA, exhibiting unilateral abnormal eruption of the maxillary first premolar, were selected. Maxillary sinus morphology and the positions of tooth buds were assessed through CBCT images, and 3D-scanned diagnostic models were used to evaluate the upper arch form. The affected and control sides were compared in terms of sinus pneumatization and the positions of the first premolar and canine tooth buds. Maxillary sinus pneumatization on the affected side was significantly increased (p = 0.0202), while no significant difference was found in the total sinus volume (p = 0.9694). On the affected side, the apex of the first premolar was positioned more anteriorly (p = 0.0029) and more palatally (p = 0.0011) than that on the unaffected side. Additionally, the apex of the canine was positioned more posteriorly on the affected side compared to that on the unaffected side (p = 0.0039). Model analysis revealed that the anteroposterior total arch length on the affected side was longer than that on the control side (p < 0.0001), while the transverse width did not show any statistically significant difference. These findings suggest a potential relationship between maxillary sinus pneumatization and the abnormal eruption path of the first premolar, as well as possible effects on the eruption of canines.

Introduction

Maxillary sinus growth begins in utero; at birth, the sinus exists in a small air pocket [1]. The sinus expands proportionally with the growth of the facial bones and progresses in stages. The first growth stage occurs in the first three years of life and the second occurs between the ages of 6 and 12 years, with lateral expansion toward the zygomatic recess and downward extension to the level of the hard palate by the age of 9 years [2,3]. During the third stage, the alveolar bone undergoes pneumatization, with the eruption of permanent premolars and molars, pushing the floor of the maxillary sinus below the nasal cavity floor by 4 ‒ 5 mm [3,4]. This physiological process is known as maxillary sinus pneumatization (MSP), which continues throughout life at a slower rate post-puberty owing to reduced facial development [5].
Several factors have been reported to influence MSP, including genetics, nasal mucosal aeration, craniofacial structure, bone density, sinus surgery, growth hormone levels, pressure within the maxillary sinus, and agerelated processes [6]. Research indicates that posterior tooth loss can affect MSP, with the sinus floor expanding into the alveolar ridge area, as observed radiographically, where the tooth roots appear to penetrate the sinus floor [7]. Some studies have shown a positive correlation between tooth extraction and increased pneumatization of the sinus floor [8]. In a study of impacted teeth, the volume of the maxillary sinus was smaller on the impacted maxillary canine than on the non-impacted side. However, the volume returned to normal after orthodontic treatment [9]. This suggests that the shape of the maxillary sinus may be influenced by the form or position of developing teeth in the surrounding area.
The maxillary first premolar is anatomically constrained by various structures during its eruption [10]. Anteriorly, the maxillary canine tooth buds; posteriorly, the second premolar tooth buds; superiorly, the inferior border of the sinus cortical bone; and inferiorly, the primary tooth limit the available eruption space for the maxillary first premolar. Consequently, in mixed dentition, abnormal positioning of the first premolar tooth bud can lead to displacement, crowding, tooth rotation, and an abnormal eruption direction [10,11].
Abnormal positioning of the tooth bud is a developmental issue that can arise owing to the complex interplay between various factors. Tooth bud displacement significantly affects both the alignment and functionality of the dentition, making it essential to identify the underlying causes. Genetic factors play a crucial role in tooth development and alignment [12]. Physical obstruction is also a major cause of tooth bud displacement, as the position of adjacent teeth, limited space, and abnormalities in the jaw structure can hinder the tooth bud from following its natural eruption path [13]. Premature loss of primary teeth is another contributing factor, as it can prevent the normal eruption of permanent teeth, leading to tooth bud displacement [10]. Traumatic injuries can alter tooth positioning and negatively affect development. Pathological conditions such as caries and periodontal disease may also disrupt normal tooth bud development [10,14]. Growth and developmental patterns are significant factors that can lead to tooth bud displacement during individual growth processes [14].
Although numerous studies have reported the dental and alveolar features of impacted teeth, most have focused on the third molars or maxillary canines [15]. Reports on eruption pathway obstruction of the first premolar are scarce. Furthermore, studies examining the relationship between maxillary sinus pneumatization and eruption abnormalities of the maxillary first premolars, especially in growing children, are limited.
Cone beam computed tomography (CBCT) is an efficient imaging tool for evaluating the size, position, and relationship between teeth and adjacent structures [16]. It enables accurate visualization of the direction of impacted teeth, assessment of bone quality, and identification of potential complications such as root resorption or proximity to vital anatomical structures [17]. This comprehensive imaging technique improves diagnostic precision and helps with treatment approaches, ultimately enhancing patient outcomes. We aimed to evaluate the dental and anatomical characteristics of first premolars with eruption abnormalities during mixed dentition us-ing CBCT and a diagnostic dental model. In this study, we aimed to clarify the relationship between the maxillary first premolar and maxillary sinus, offering clinical insights into the dental and skeletal development of affected children.

Materials and Methods

This study was approved by the Institutional Review Board (IRB) of Pusan National University Dental Hospital (Approval No.: PNUDH 2024-09-001-003).

1. Study Subjects

The participants of this study were selected from 2,970 patients who visited the Department of Pediatric Dentistry at Pusan National University Dental Hospital between March 2015 and June 2023. Using panoramic radiographs for screening, children who met the following inclusion criteria were selected. The study involved 29 children aged 7 ‒ 12 years, all of whom had Hellman dental age IIIA and presented with abnormalities in the eruption direction of the first premolars. Patients with congenital craniofacial anomalies (such as cleft lip or palate, Down syndrome, or ectodermal dysplasia) or a history of maxillofacial trauma or surgery or those who had received prior prosthetic or orthodontic treatment, were excluded from the study.
Inclusion Criteria
  • ˙ Unilateral abnormal eruption of the maxillary first premolar (defined as an abnormal eruption with a non-ankylosed first deciduous molar, where the first premolar had a downward displacement of within 5 mm and an axial inclination of within 55° relative to the erupted permanent molar) (Fig. 1) [10,11].

  • ˙ Availability of radiographic records (CBCT) and a diagnostic model suitable for analysis.

Exclusion Criteria
  • ˙ Eruption abnormalities related to systemic diseases.

  • ˙ Abnormal eruption pathways of both the left and right maxillary first premolars.

  • ˙ The absence of usable radiographic records (panoramic, CBCT), diagnostic models, or radiographs with errors or low resolution that were unsuitable for analysis.

For the 29 selected participants, the quadrant with abnormal eruption of the maxillary first premolar was designated as the experimental group, whereas the quadrant with normal eruption was designated as the control group (Fig. 2).

1) Maxillary Sinus Volume Assessment Using CBCT

Three-dimensional analysis of the maxillary sinus volume was conducted using CBCT imaging with a Viso G7 device (PLANMECA, Helsinki, Finland). The scan settings included a voxel size of 0.3 × 0.3 × 0.3 mm, 110 kV, 11.0 mA, and a scan duration of 3.272 seconds. The resulting DICOM files from the CBCT scans were processed for 3D analysis using the ITK-SNAP software (version 3.0; Cognitica, Philadelphia, PA, USA).
An experienced dentist with over 10 years of CBCT expertise, blinded to patient identities, performed the CBCT analysis. The scans were analyzed twice, with an interval of one week between assessments. For each patient, the anatomical structures were reoriented to align the anterior nasal spine (ANS), posterior nasal spine (PNS), and nasion (Na) in a single reference plane to ensure consistent and accurate orientation. The right and left orbitales (Or) were also considered to maintain precision across reconstruction.
To measure the maxillary sinus volume, a semiautomatic segmentation tool (ITK-SNAP 3.0) was utilized, following a method similar to that described by Gomes et al. [18]. The examiner outlined the region of interest (ROI) by delineating the anterior, posterior, lateral, medial, superior, and inferior walls of the maxillary sinus in the multiplanar reconstructions. A threshold range between ‒1000 and ‒400 was set to capture the relevant voxels necessary for building the 3D model. “Seeds” were placed within the ROI to initiate the segmentation process. After completing the process, the software generated a 3D reconstruction of the segmented maxillary sinus and provided its volume in cubic millimeters (mm³) (Fig. 3). The left and right maxillary sinuses were segmented individually and their volumes were compared.
The volume of the maxillary sinus pneumatized infe-riorly to the alveolar bone, relative to the nasal floor, was divided into sections for comparison of the left and right volumes (mm³) (Fig. 4).

2) First Premolar and Canine Position Analysis: CBCT Analysis

Using CBCT, the sagittal reference plane was aligned based on the ANS-PNS-Na plane, and the horizontal reference plane was aligned to a plane passing through the ANS and PNS perpendicular to the sagittal plane. The anteroposterior and transverse widths were measured from the root apex and cusp tip of the first premolar and canine, relative to the contact point of the maxillary central incisors and mid-palatal suture, respectively. In patients with a wide apex, measurements were obtained based on the central points of the buccolingual and mesiodistal axes (Fig. 5).

3) Diagnostic Model Analysis

Diagnostic models obtained for orthodontic evaluation were scanned using a 3D scanner (Medit T710, Medit Corp., Seoul, Korea), and the resulting STL files were uploaded to DentOne software (DIORCO Co., Ltd., Yongin, Korea). The maxillary models were reoriented based on the mid-palatal sutures and central fossae of the left and right first molars. Measurements were then taken based on the central fossae of the first deciduous molar (the predecessor to the first premolar) and the first molar. These included the anteroposterior length (from the contact point of the maxillary central incisor to the first molar) and horizontal width (from the mid-palatal suture to the central fossae of the first deciduous molar and first molar) (Fig. 6 and Table 1). The AAW, PAW, AAL, and TAL were measured separately on the right and left sides.

2. Statistical Analysis

Data collection and analyses were performed by a single dentist. Data were categorized and arranged using Excel 2018 (Microsoft Corporation, Redmond, WA, USA), and all statistical analyses were conducted using IBM SPSS Statistics software (version 27.0; IBM Corp., Armonk, NY, USA). The Mann-Whitney U test was applied to analyze subject distribution, and the Shapiro-Wilk test was used to verify the normality of the data distribution. For continuous data that met normality, paired t-tests were performed, and for data that did not meet normality, the Wilcoxon signed-rank test was used to analyze the differences between paired samples. A p-value of less than 0.05 was considered statistically significant. Categorical variables were presented as frequencies and percentages, while continuous variables were presented as either mean and standard deviation (mean ± SD) or median and range based on data normality.

Results

1. Study Subjects

Among the final 29 participants, 19 were female and 10 were male. The overall average age of the participants was 9.47 ± 1.04 years, with the average age of females being 9.53 ± 1.22 years and that of males, 9.35 ± 0.63 years. There was no statistically significant difference in age between the sexes (p= 0.595, Mann-Whitney U test).
Regarding the location of the abnormal eruption, 12 participants (41.38%) had abnormalities on the left side and 17 (58.62%) had abnormalities on the right side. There was no statistically significant difference in the distribution of abnormal eruption locations between sexes (p= 0.774). Specifically, 7 females (36.84%) and 5 males (50.00%) had abnormal eruptions on the left side, whereas 12 females (63.16%) and 5 males (50.00%) had them on the right side (Table 2).

2. CBCT Analysis

1) Maxillary Sinus Evaluation

Regarding the total volume of the maxillary sinus, the average volume on the side with abnormal eruption was 11,466.36 ± 3,197.55 mm³, and on the control side, it was 11,478.80 ± 3,186.62 mm³, with no significant difference between the two groups (p= 0.9694). However, the degree of pneumatization of the maxillary sinus was significantly greater on the side with abnormal eruption (269.17 ± 252.55 mm³) compared to that of the control side (166.22 ± 158.70 mm³) (p= 0.0202) (Table 3).

2) Evaluation of the Position of Canine and Premolar Tooth Buds

In comparing the eruption positions in the anteroposterior and horizontal directions, the crown position of the first premolar in the anteroposterior direction on the side with abnormal eruption was 15.37 mm (range: 11.45 - 25.04 mm), while on the control side, it was 14.84 mm (range: 11.63 - 20.19 mm), showing no significant difference (p= 0.0917). In the horizontal direction, the crown position measured 17.33 ± 1.79 mm on the side with abnormal eruption and 17.58 ± 2.15 mm on the control side, also showing no significant difference (p= 0.0947). However, the position of the root apex of the first premolar differed significantly between the two sides. The apex was positioned more anteriorly (12.23 ± 2.88 mm) and more palatally (15.51 ± 2.32 mm) on the affected side compared to the control side (anteroposterior: 13.97 ± 2.04 mm; transverse: 17.11 ± 1.51 mm) (p= 0.0011).
For the canine, only the anteroposterior root position was significantly more posterior on the affected side (15.71 ± 4.21 mm) compared to the control side (13.19 ± 4.29 mm) (p= 0.0036). The anteroposterior and transverse positions of the crown, as well as the transverse position of the root apex, did not show any statistically significant differences between the two sides (p= 0.4382, p= 0.1363, and p= 0.1639, respectively) (Table 4).

3. Diagnostic Model Analysis

In comparing the anteroposterior length and width of the first permanent molar and the first deciduous molar, the anterior width on the side with abnormal eruption measured 18.50 mm (range: 15.40 - 21.60 mm), while on the control side, it measured 18.45 mm (range: 15.55 - 20.95 mm), showing no significant difference between the two groups (p= 0.5165). Similarly, the posterior width was 23.97 ± 1.60 mm on the side with abnormal eruption and 24.14 ± 1.66 mm on the control side, also showing no significant difference (p= 0.4047). However, in terms of the total length, the side with the abnormal eruption measured 31.28 ± 2.35 mm, which was significantly more posterior than the control side, where the total length measured 24.14 ± 1.54 mm (p < 0.0001). This indicates that the first molar was positioned significantly further posteriorly on the side with abnormal eruption (Table 5).

Discussion

The eruption abnormality of the maxillary first premolar is a critical issue in dental arch alignment. When the maxillary first premolar fails to follow its normal eruption path, it may deviate or encounter positional issues due to collisions with adjacent teeth or structures. In this study, eruption disturbances of the first premolars were observed on both the right and left sides, with no significant differences (p= 0.774).
Kjær investigated etiological research on premolars with eruption abnormalities by focusing on the resorption pattern of the preceding primary molars [10], while Ismail et al. classified ectopic eruption of premolars according to depth of impaction and inclination [11]. In this study, to reduce errors and establish criteria for each case, we defined standards for various eruption abnormalities of the first premolars based on previous research and conducted the study accordingly.
The maxillary sinus, which is an air-filled bilateral space in the maxillary complex, is the largest paranasal sinus [19]. It plays essential roles, such as humidifying air, regulating air pressure, and reducing skull weight [20]. The floor of the maxillary sinus is formed by the alveolar ridge of the maxilla, and when the sinus is large, or the space between the teeth and the sinus is narrow, the roots of the teeth may be positioned close to the floor of the sinus [21-23]. In this study, the volume of the maxillary sinus on the side with the eruption abnormality showed a statistically significant increase in pneumatization compared with the volume of the control group. This suggests that the spatial relationship between the maxillary sinus and the first premolar is closely associated with the eruption abnormality. Specifically, when the canine is displaced or impacted, it forms a closer relationship with the maxillary sinus, and the changes in sinus volume and root position may mutually influence each other.
Previous studies examining the relationship between the maxillary sinus and eruption abnormalities have mentioned that the volume of the maxillary sinus can decrease due to inflammatory or infectious diseases [24]. Research by Ikeda et al. reported that the maxillary sinus volume can be reduced by inflammatory diseases, and pediatric chronic rhinosinusitis (CRS) is closely related to the occurrence of maxillary sinus hypoplasia or chronic maxillary atelectasis [1,25]. In cases of CRS, the likelihood of maxillary sinus hypoplasia increases, with some studies reporting rates of 4% to 7%. However, in this study, only patients without symptoms of sinusitis or inflammatory diseases were included to ensure that pathological factors did not influence the results. This allowed for a clearer analysis of the relationship between maxillary sinus volume changes and eruption abnormalities.
This study found that when the maxillary first premolar exhibited an eruption abnormality, the degree of maxillary sinus pneumatization was significantly greater. This suggests that the relationship between tooth eruption paths and the maxillary sinus may play a significant role, with the size and pneumatization of the maxillary sinus potentially affecting both eruption abnormalities and tooth transposition. Previous studies on maxillary sinus development have shown that the sinus grows most rapidly between ages 0 and 4 years [26], with gradual size increases occurring between ages 4 and 8 years. By age 9 years, the sinus extends to the level of the hard palate, and its height continues to increase until around age 18 years [2]. However, the width and length (anteroposterior dimension) of the maxillary sinus reach adult proportions by around age 12 years [27]. Given that the average age of the subjects in this study was 9.47 years‒during a period of ongoing vertical sinus growth‒changes in the position of developing tooth buds and eruption pathways may significantly influence the shape and size of the maxillary sinus. Findings of the studies on growth and morphological changes of the dental arch can be compared with the findings of this study [28,29]. During dental arch growth, vertical, sagittal, and transverse dimensions exhibit distinct growth patterns. The vertical dimension, in particular, continues to grow the longest and is linked to changes associated with tooth eruption throughout life. The sagittal and transverse dimensions vary according to the timing of tooth eruption, with the anterior portion stabilizing relatively early [29], while the posterior portion tends to grow for a longer period. The transverse dimension of the dental arch, independent of the overall skeletal growth, is influenced by tooth eruption and alignment, suggesting that eruption abnormalities may interact with maxillary sinus pneumatization. This study also suggests that the relationship between dental arch width and maxillary sinus pneumatization may be closely linked, offering deeper insights into the connection between eruption abnormalities and the maxillary sinus.
In conclusion, this study indicates that maxillary sinus pneumatization may be closely related to tooth eruption abnormalities. The positional changes of teeth and the maxillary sinus may present clinically significant issues, particularly in orthodontic treatment planning, where variations in sinus volume and tooth alignment could play a role. However, as the size and volume of the maxillary sinus are still developing during childhood, additional studies involving diverse age groups and populations are necessary to further clarify the relationship between the maxillary sinus, tooth transposition, and eruption abnormalities. Based on the results of this study, problems that may arise due to the eruption abnormality of the maxillary first premolar during the mixed dentition period include midline deviation and lateral crossbite. In cases where crossbite is present or likely due to maxillary growth, maxillary arch expansion may be necessary to establish normal occlusion and prevent negative outcomes. Therefore, clinicians must recognize and diagnose eruption abnormalities of the maxillary first premolar early, intervening with appropriate treatment to mitigate potential complications.
One limitation of this study is the restrictive selection criteria for the subjects, which may not fully reflect the general distribution of maxillary first premolar impaction cases. Furthermore, the study was limited to children undergoing orthodontic treatment at a single institution, which may not represent the broader population of individuals with maxillary first premolar eruption abnormalities. Moreover, it was impossible to confirm whether the skeletal changes observed in this study were consistent with those observed in previous studies involving post-growth patients. Therefore, future research should involve multiple institutions and a broader population base with a long-term follow-up of children with maxillary first premolar eruption abnormalities to better understand craniofacial development and changes.

Conclusion

This study confirmed that in cases of abnormal eruption of the premolar, there is an increase in maxillary sinus pneumatization, a significant difference in the position of the tooth bud compared to the control group, and a discrepancy in the anteroposterior length of the dental arch. These anatomical and dentoalveolar changes may impact the occlusion and orofacial function of growing patients, suggesting the necessity of proactive intervention.

NOTES

Acknowledgments

This study was supported by a New Faculty Research Grant of Pusan National University, 2023.

Conflicts of Interest

The authors have no potential conflicts of interest to disclose.

Funding information

This study was supported by a New Faculty Research Grant of Pusan National University, 2023.

Fig 1.
Example of how to measure the inclination of the maxillary first premolar (Left). Example of how to measure the impaction depth (Right).
jkapd-52-2-169f1.jpg
Fig 2.
Flow chart showing the process of selecting subjects included in the study.
jkapd-52-2-169f2.jpg
Fig 3.
Measurements of the total maxillary sinus volume. (A) Coronal cut, (B) Right maxillary sinus and left maxillary sinus.
jkapd-52-2-169f3.jpg
Fig 4.
Measurements of the pneumatized maxillary sinus volume. (A) Coronal cut (below nasal floor), (B) Right maxillary sinus and left maxillary sinus (below nasal floor).
jkapd-52-2-169f4.jpg
Fig 5.
The anteroposterior distance and the transverse width were measured from the root apex and cusp tip of the first premolar and canine, relative to the contact point of the maxillary central incisors and mid-palatal suture, respectively.
jkapd-52-2-169f5.jpg
Fig 6.
Dental cast indicating reference points and measurements of the dental arch. Points and measurements of the arch width and length in the dental cast.
MP: The lingual side of the central incisor proximal contact; D4: Central fossa of the first primary molar; P6: Central fossa of the first permanent molar; AAW: Anterior arch width; PAW: Posterior arch width; AAL: Anterior arch length; TAL: Total arch length.
jkapd-52-2-169f6.jpg
Table 1.
Definition of dental points and measurements used in the model analysis
Name Definition
Point MP The lingual side of the central incisor proximal contact
D4 Central fossa of the first primary molar
P6 Central fossa of the first permanent molar
Dimensions AAW Anterior arch width, Width between D4 and the palatal raphe
PAW Posterior arch width, Width between P6 and the palatal raphe
AAL Anterior arch length, Length from the MP to the line connecting each AAW
TAL Total arch length, Length from the MP to the line connecting each PAW
Table 2.
Descriptive statistics of the study group
Female (n = 19) Male (n = 10) Total (n = 29) p-value
Age 9.53 ± 1.22 9.35 ± 0.63 9.47 ± 1.04 0.595
Affected side 0.774
 - Left 7 (36.84%) 5 (50.00%) 12 (41.38%)
 - Right 12 (63.16%) 5 (50.00%) 17 (58.62%)

Mann-whitney U test.

Table 3.
Maxillary sinus volume
Affected side Control side p-value
Mean ± SD (mm3) Mean ± SD (mm3)
Total 11466.36 ± 3197.55 11478.80 ± 3186.62 0.9694
Pneumatization 269.17 ± 252.55 166.22 ± 158.70 0.0202*

Paired t-test (Shapiro-Wilk test for normal distribution of differences)

Asterisk (*) indicates statistically significant differences (p < 0.05).

Table 4.
Anteroposterior and transverse positions of tooth buds
Affected side Control side p-value
Median (Range) (mm) Median (Range) (mm)
Mean ± SD (mm) Mean ± SD (mm)
First premolar
 - Crown (anteroposterior) 15.37 (11.45 - 25.04) 14.84 (11.63 - 20.19) 0.0917
 - Crown (transverse) 17.33 ± 1.79 17.58 ± 2.15 0.0947
 - Apex (anteroposterior) 12.23 ± 2.88 13.97 ± 2.04 0.0029*
 - Apex (transverse) 15.51 ± 2.32 17.11 ± 1.51 0.0011*
Canine
 - Crown (anteroposterior) 6.96 (1.58 - 13.05) 7.31 (4.40 - 11.29) 0.4382
 - Crown (transverse) 15.03 ± 3.67 13.92 ± 1.28 0.1363
 - Apex (anteroposterior) 15.71 ± 4.21 13.19 ± 4.29 0.0036*
 - Apex (transverse) 11.85 ± 2.53 12.51 ± 1.51 0.1639

Paired t-test (Shapiro-Wilk test for normal distribution of differences).

Wilcoxon test (paired sample).

Asterisk (*) indicates statistically significant differences (p < 0.05).

Table 5.
Unilateral arch transverse width and anteroposterior length
Affected side Control side p-value
Median (Range) (mm) Median (Range) (mm)
Mean ± SD (mm) Mean ± SD (mm)
Anterior width (AAW) 18.50 (15.40 - 21.60) 18.45 (15.55 - 20.95) 0.5165
Posterior width (PAW) 23.97 ± 1.60 24.14 ± 1.66 0.4047
Anterior length (AAL) 14.70 (9.03 - 18.60) 14.30 (10.20 - 17.80) 0.3931
Total length (TAL) 31.28 ± 2.35 24.14 ± 1.54 < 0.0001*

Paired t-test (Shapiro-Wilk test for normal distribution of differences).

Wilcoxon test (paired sample).

Asterisk (*) indicates statistically significant differences (p < 0.05).

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