Clinical management of supernumerary teeth: A

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Case Report

Clinical management of supernumerary teeth: A report of two cases Abstract Supernumerary tooth may closely resemble the teeth of the group to which it belongs, i.e. molars, premolars or anterior teeth, or it may bear little resemblancein size or shape to which it is associated. Many complications can be associated with supernumeraries, like impaction, delayed eruption or ectopic eruption of adjacent teeth, crowding, development of median diastema and eruption into floor of the nasal cavity. This may also cause the formation of follicular cysts with significant bone destruction. Early intervention to remove it is usually required to obtain reasonable alignment and occlusal relationship. This article will present the clinical management of an (i) impacted supernumerary tooth impeding the eruption of maxillary central incisor and (ii) erupted supernumerary tooth with midline diastema.

Key words Management, mesiodens, supernumerary, supplemental

Introduction Presence of an extra tooth in the dental arch in addition to the normal series of teeth is called supernumerary tooth. It may closely resemble the teeth of the group to which it belongs, i.e. molars, premolars or anterior teeth, or it may bear little resemblance in size or shape to which it is associated.[1] Supernumerary teeth can occur anywhere in the dental arch, but are found most commonly in the maxilla.[2,3] The single midline supernumerary tooth is the most common finding.[4] Supernumerary teeth can be classified according to their form and location. Primosch [5] classified supernumeraries into two types according to their shape: supplemental and rudimentary. Supplemental refers to supernumerary teeth of normal shape and size

Mittal M, Sultan A1

Professor, 1Reader, Department of Pedodontics, SGT Dental College, Budhera, Gurgaon, Haryana, India. Correspondence: Dr. Meenu Mittal, A-4/16, Paschim Vihar, New Delhi - 110 063, India. E-mail: [email protected]

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and may also be termed incisiform. Rudimentary defines teeth of abnormal shape and smaller size, including conical, tuberculate and molariform.[5-7] It has been found that approximately 25% of the permanent supernumerary teeth are erupted and the remainder are unerupted, whereas 73% of the primary supernumerary teeth are erupted.[6,8] Many complications can be associated with supernumeraries, like impaction, delayed eruption or ectopic eruption of adjacent teeth, crowding, development of median diastema and eruption into the floor of the nasal cavity. This may also cause formation of follicular cysts with significant bone destruction and root resorption of the permanent incisors.[7,9] When any of the above complication occurs or is anticipated, surgical removal of the supernumerary tooth is indicated. This article will present the clinical management of an impacted supernumerary tooth impeding the eruption of maxillary central incisor and erupted supernumerary tooth with midline diastema

JOURNAL OF INDIAN SOCIETY OF PEDODONTICS AND PREVENTIVE DENTISTRY | Jul - Sept 2010 | Issue 3 | Vol 28 |

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Mittal and Sultan: Supernumerary teeth management

Figure 2: Case 1, pre-operative OPG

Figure 1: Case 1, pre-operative

Figure 4: Case 1, post-operative

Figure 3: Case 1, pre-operative IOPA

Case Reports Case 1 A 12-year-old girl reported to the Department of Pedodontics, SGT Dental College, Gurgaon, with a complaint of missing upper central incisor. There was no history of trauma or decay causing the tooth loss. On clinical examination, late mixed dentition with missing upper right central incisor was seen [Figure 1]. There was a firm bulge palpable in the upper right central incisor area intra oral periapical radiograph and orthopantomograph were taken. On examining the radiographs, a dense opaque mass was seen in the right central incisor area, which was provisionally diagnosed as an odontome/supernumerary tooth with an impacted central incisor [Figures 2,3]. An exploratory surgery was planned. On surgical exposure, a supplemental tooth was found palatal to the impacted central incisor. The supernumerary tooth was extracted and the flap was closed with the central incisor left to erupt on 220

its own. A regular follow-up was performed and, at the end of 10 months, a bulge was seen close to the alveolar margin, and the crown of the incisor was exposed conservatively. The tooth is now visible in the oral cavity and its periapical radiograph shows no root resorption [Figures 4,5].

Case 2 A 9-year-old male patient reported to the Department of Pedodontics, SGT Dental College, Gurgaon, with complaints of a funny-looking, small tooth between the upper two front teeth. On intraoral examination, a mesiodens was seen between the upper two permanent central incisors. The upper left lateral incisor was palatally placed and was in cross-bite. Minor crowding of the lower arch was also seen. Dentition stage was early mixed, with both primary canines and molars present. Orthodontic consultation was taken. It was decided to extract the mesiodens, followed by orthodontic closure of diastema and correction of cross-bite of lateral incisor. The mesiodens was extracted under local anesthesia [Figures 6-8]. For the alignment of the upper arch, upper permanent first molars were banded and edgewise brackets bonded




Figure 5: Case 1, post-operative IOPA

Figure 6: Case 2 after extraction of mesiodens showing diastema

Figure 7: Case 2 OPG after extraction of mesiodens

Figure 8: Case 2, pre-operative showing left lateral incisor in cross-bite

Figure 9: Case 2 under treatment

on the upper incisors. Ni-Ti wire followed by 016 Australian wire were used. The transpalatal arch was also given to hold first permanent molars and to prevent space loss [Figure 9]. After completion of alignment of the incisors [Figure 10], the patient was referred to the Department of Orthodontics for the completion of orthodontic treatment.

Figure 10: Case 2 showing current status of treatment

Discussion The presence of an extra tooth has great potential to disrupt normal occlusal development, and early


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intervention to remove it is usually required to obtain reasonable alignment and occlusal relationship.[10] If the permanent teeth have been displaced, surgical exposure, adjunctive periodontal surgery and, possibly, mechanical traction are likely to be required. Extraction should be completed as soon as the supernumerary teeth can be removed without harming the developing normal teeth.[10] In the present Cases 1 and 2, complications associated with the supernumerary teeth were: impaction and delayed eruption of permanent central incisor and displacement and rotation of central incisors with diastema formation and subsequent crowding in upper arch. In Case 1, the presence of supernumerary tooth in the region of central incisor was the main cause of impaction of the permanent central incisor. Difficulty may be encountered in distinguishing the normal tooth from its supplemental “‘twin.” If both teeth are equally well formed, the correct extraction is of the tooth that is most displaced.[7] In this case, surgical treatment was performed to extract the supernumerary tooth lying palatal to the impacted permanent upper central incisor to bring the unerupted maxillary incisor into proper alignment. The crown of the unerupted incisor was also surgically exposed. No orthodontic traction was performed in this case. Orthodontic traction should be applied when spontaneous eruption does not occur after surgical exposure of the unerupted incisor crown followed by a period of observation of 6 months. Reports say that a majority of the unerupted teeth (approximately 75%) will erupt once the supernumerary tooth is removed. If surgical exposure is necessary, the prognosis for spontaneous eruption is excellent (85%).[11] In Case 2, the supernumerary tooth was mesiodens. The most common complication of mesiodens is

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displacement of central incisors.[7] The treatment was aimed at extraction of mesiodens followed by extensive orthodontic treatment as the patient also had palatally placed upper left lateral incisor and inadequate arch length. Early diagnosis and treatment of patients with supernumerary teeth are important to prevent or minimize complications. Treatment depends on the type and position of the supernumerary tooth and its effect on the adjacent teeth.[6]

References 1. Shafer WG, Hine MK, Levy BM. A textbook of oral pathology. 4th ed. Philadelphia: W.B. Saunders Co; 1983. p. 47. 2. Graber TM. Orthodontics: Principles and Practice. 3rd ed. Philadelphia: W.B. Saunders Co.; 2001. p. 331-48. 3. Stafne EC. Supernumerary teeth. Dent Cosmos 1932;74:653-9. 4. Hogstrom A, Anderssson L. Complications related to surgical removal of anterior supernumerary teeth in children. J Dent Child 1987;54:341-3. 5. Primosch R. Anterior supernumerary teeth assessment and surgical intervention in children. Pediatr Dent 1981;3:204-15. 6. Rajab LD, Hamdan MA. Supernumerary teeth: Review of the literature and a survey of 152 cases. Int J Paediatr Dent 2002;12:244-54. 7. Hattab FN, Yassin OM, Rawashdeh MA. Supernumerary teeth: Report of three cases and review of the literature. J Dent Child 1994;61:382-93. 8. Humerfelt D, Hurlen B, Humerfelt S. Hyperdontia in children below four years of age: A radiographic study. ASDC J Dent Child 1985;52:121-4. 9. Solares R. The complications of late diagnosis of anterior supernumerary teeth: Case report. J Dent Child 1990;57:209-11. 10. Profitt WR, Fields HW, Sarver DM. Contemporary orthodontics. 4th ed. St Louis: CN Mosby Co; 1986. p. 138, 243. 11. Ohman I, Ohman A. The eruption tendency and changes of direction of impacted teeth following surgical exposure. Oral Surg Oral Med Oral Pathol 1980;49:383-9.

Source of Support: Nil, Conflict of Interest: Nil
