|Year : 2012 | Volume
| Issue : 2 | Page : 94-98
Clinical and surgical considerations for impacted mesiodens in young children: An update
Ritu Jindal1, Sunila Sharma2, Kanupriya Gupta1
1 Department of Pedodontics and Preventive Dentistry, National Dental College and Hospital, Dera Bassi, Mohali, Punjab, India
2 Department of Pedodontics, Bhojia Dental College and Hospital, Baddi, Himachal Pradesh, India
|Date of Submission||28-Jun-2012|
|Date of Acceptance||12-Jul-2012|
|Date of Web Publication||24-Jan-2013|
H. No. 124- E, Kitchlu Nagar, Ludhiana, Punjab, 141 001
Source of Support: None, Conflict of Interest: None
Background: Most supernumerary teeth are located in the anterior maxillary region and are classified according to their form and location. Their presence may give rise to a variety of clinical problems. Detection of supernumerary teeth is best achieved by thorough clinical and radiographic examination. Supernumerary teeth may be encountered by the general dental practitioner as a chance finding on a radiograph or as the cause of an impacted central incisor.
Design: This article presents an overview of the clinical problems associated with supernumerary teeth and includes a discussion of the classification, diagnosis, and management of this difficult clinical entity.
Conclusion: The most common supernumerary tooth, which appears in the maxillary midline, is mesiodens. Their diagnosis and management should form part of a comprehensive treatment plan. Treatment depends on the type and position of the supernumerary tooth and on its effect on adjacent teeth. The article throws a light on various modalities for investigation and treatment of supernumerary teeth, which is important for an early intervention in children to avoid major complications.
Keywords: Mesiodens, radiographic examination, supernumerary teeth, surgical extraction
|How to cite this article:|
Jindal R, Sharma S, Gupta K. Clinical and surgical considerations for impacted mesiodens in young children: An update. Indian J Oral Sci 2012;3:94-8
|How to cite this URL:|
Jindal R, Sharma S, Gupta K. Clinical and surgical considerations for impacted mesiodens in young children: An update. Indian J Oral Sci [serial online] 2012 [cited 2017 Jul 25];3:94-8. Available from: http://www.indjos.com/text.asp?2012/3/2/94/106462
| Introduction|| |
A supernumerary tooth is one that is additional to the normal series and can be found in almost any region of the dental arch.
Supernumerary teeth can occur either as isolated events or multiple, unilaterally, or bilaterally in both jaws or as part of a syndrome or disease. ,,,, The treatment decision is based on the individual case and may require interdisciplinary cooperation.
The prevalence rates of supernumerary teeth reported in the literature vary between 0.1% and 3.6% in the permanent dentition depending on the respective population. , In deciduous teeth, prevalence is lower, amounting to 0.3-0.8%. , Males are affected more frequently in the second dentition, with literature reporting rates of between 2:1 and 6:1, depending on the respective population. ,,, An even gender distribution appears in the first dentition. ,
Single supernumerary tooth are still common (76-86%), but multiple supernumeraries are rather rare (less than 1%). ,, Eruption frequency is reported to vary between 15% and 34% in the permanent dentition,  while in the milk dentition, about two-thirds of the supernumeraries erupt. , Hence, the importance of timely diagnosis and treatment planning for these mysterious teeth is clearly justified.
The reasons for development of these supernumerary teeth are not completely understood. Various theories exist for the different types of supernumerary. One theory suggests that the supernumerary tooth is created as a result of a dichotomy of the tooth bud.  Another theory, well supported in the literature, is the hyperactivity theory, which suggests that supernumeraries are formed as a result of local, independent, conditioned hyperactivity of the dental lamina.  Heredity may also play a role in the occurrence of this anomaly, as supernumeraries are more common in the relatives of affected children than in the general population.  However, the anomaly does not follow a simple Mendelian pattern. 
Supernumerary teeth are classified according to morphology and location. In the primary dentition, morphology is usually normal or conical. There is a greater variety of forms presenting in the permanent dentition. [Figure 1] Four different morphological types of supernumerary teeth have been described. ,
Problems associated with supernumerary teeth
Failure of eruption
The presence of a supernumerary tooth is the most common cause for the failure of eruption of a maxillary central incisor or may cause retention of the primary incisor.
Displacement of the crowns of the incisor teeth is a common feature in the majority of cases associated with delayed eruption. 
Erupted supplemental teeth most often cause crowding. 
Occasionally, supernumerary teeth are not associated with any adverse effects and may be detected as a chance finding during radiographic examination. 
They may grow and appear on the palate as extra teeth, or they may grow into the nasal cavity. The teeth may be asymptomatic or cause a variety of signs and symptoms, including facial pain, nasal obstruction, headache, epistaxis, foul-smelling rhinorrhea, external nasal deformities, and nasolacrimal duct obstruction. Complications of nasal teeth include rhinitis caseosa with septal perforation, aspergillosis, and naso-oral fistula. ,
Dentigerous cyst formation is another problem that may be associated with unerupted supernumerary teeth.  Primosch reported an enlarged follicular sac in 30% of cases, but histological evidence of cyst formation was found in only 4% to 9% of cases. 
In lieu of the potential disturbances/problems associated with erupted as well as unerupted mesiodens, this paper aims at an early diagnosis with treatment planning for these supernumerary teeth reviewing the decision about whether to extract or not and of time when to intervene in a young child, keeping in mind his eruption pattern, eruption status, and the approximation of our supernumerary concerned with these factors.
Clinical findings and case report
A nine-year-old patient presented to the department with chief complaint of extra tooth in upper front region of mouth causing disfigurement. He gave a history of fractured anterior tooth few days before and had no hypersensitivity related to the tooth.
A thorough examination was conducted where medical history and family history was unremarkable. Clinical examination revealed presence of conical mesiodens palatal to 11, displacing it labially [Figure 2]. There was Ellis class 1 fracture with respect to 21.
|Figure 2: Preoperative occlusal view showing an erupted conical mesiodens palatal to 11|
Click here to view
Occlusal radiograph was taken to rule out the possibility of multiple supernumerary tooth. To our surprise, there was another unerupted inverted mesiodens impacted in the palate, quite posterior approaching the permanent first molar area on left side towards the midline.
Radiographic examination revealed two mesiodens, one erupted and one unerupted [Figure 3].
|Figure 3: Preoperative occlusal radiograph showing impacted conical mesiodens|
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The extraction of both mesiodens was planned.
After giving local anesthesia, the extraction of erupted mesiodens was carried out followed by the surgical extraction of the unerupted one. The palatal flap was raised from distal aspect of first permanent molar on left side to distal aspect of canine on right side [Figure 4]. After locating the crown, with minimal bone cutting, extraction of the mesiodens was done and sutures were given. Excellent healing was observed after two weeks. Also, the buccally displaced tooth came into alignment. Composite build up of 21 was done afterwards.
A 10-year-old male patient reported to the dept. of pedodontics and preventive dentistry, with the chief complaint of proclined central incisor on the left side. Patient gave the history of extraction of an extra tooth located just lingually to the central incisor. Based on the history, location, and sequelae, the extracted tooth was diagnosed as mesiodens. Thorough clinical examination revealed a slight swelling, approx. 1 x 1 cm in size on the palate, near 1 st molar on the left side and towards the midline.
Diagnostic maxillary occlusal radiograph revealed an incompletely formed tooth in the same location where the swelling was felt [Figure 5]. The diagnosis was made as impacted mesiodens.
|Figure 5: Preoperative occlusal radiograph showing an impacted inverted mesiodens|
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Surgical extraction was planned. The histopathological examination confirmed the diagnosis of impacted mesiodens surrounded by granulation tissue. The patient remained under follow-up for 2 months, and no complications were observed [Figure 6].
A nine-year-old patient reported to the department of pedodontics and preventive dentistry with chief complaint of missing permanent left central incisor along with delayed eruption. On clinical examination, it was observed that 61, 62 were retained with unerupted maxillary permanent incisors, though 31, 41, 42 were fully erupted [Figure 7]. The diagnostic maxillary anterior occlusal radiograph revealed the presence of two supernumeraries in the anterior region [Figure 8]. Based on the clinical and radiological findings, an observation of two impacted supernumerary teeth was made. As observed from the radiograph, the permanent incisor roots were not fully developed (Demrijian stage F). Therefore, wait and watch treatment option was considered for impacted supernumeraries as surgical intervention is required for their removal, which can lead to obtunded root growth. However, an eruption incision was planned to facilitate the eruption of permanent incisors.
|Figure 8: Preoperative occlusal radiograph showing two|
supernumeraries in the anterior region
Click here to view
| Discussion|| |
Impacted supernumerary teeth either remain clinically silent or are diagnosed as a chance finding during radiographic examination or they are cause of a complication and require an immediate intervention. Unerupted mesiodens may lead to some potential problems that is disturbed tooth eruption, tooth rotation, bodily displacement, crowding, spacing, or diastema of normal teeth. A cystic alteration is detected in 4-9% of the supernumerary cases, with the anterior maxilla being affected in 90%. , Occurrence of the above-mentioned complications indicates surgical removal of the supernumerary tooth. 
The reported case had one erupted and an unerupted mesiodens in the maxilla. No sign and symptoms were present related to the unerupted mesiodens. When no clinical sign is apparent and the mesiodens is asymptomatic and impacted, it can lead to many pathological findings like granuloma or cyst as already discussed, and no doubt, the young children are more prone to these manifestations. This is because the permanent dentition is not developed yet and occlusion is not established, chances of pathologies in young children is highly associated with unerupted supernumerary teeth because it may act as nidus for cystic transformation or infection propagation. Therefore, the potential detrimental effects in young children make it mandatory to extract unerupted supernumerary teeth.
Radiographic examination of the jaws is, therefore, imperative. In routine analyzes of supernumerary teeth, radiographs required are periapical, orthopantomogram. When suspecting a supernumerary tooth, an upper occlusal film is very much helpful in clarifying the presence or absence of the supernumerary teeth.
The bucco-lingual position of unerupted supernumeraries can be determined using the parallax radiographic principle:  The horizontal tube shift method. Intraoral views may give a misleading impression of the depth of the tooth. A true lateral radiograph of the incisor region assists in locating the supernumeraries that are lying deeply in the palate and enables the practitioner to decide whether a buccal rather than a palatal approach should be used to remove them.  Nasal teeth result from the ectopic eruption of supernumerary teeth. Their clinical and radiologic presentation is so characteristic that their diagnosis is not difficult. CT scanning is helpful in planning their treatment. 
Wait-and-see behavior is also indicated if surgical removal of a complication-free supernumerary would jeopardize the vitality of other permanent teeth.  In such cases, the close topographic relationship between the normal teeth and the supernumerary to be removed may be resolved by orthodontic means prior to the surgical procedure. Although supernumerary teeth may remain in the jaw for years without causing complications, they should be observed as they may as well cause cystic complications. ,, Development of a carcinoma is very rare. , An association of impacted teeth and neuralgia has been reported in sporadic case studies; however, has not yet been proven. ,
| Conclusion|| |
Frequency of supernumerary teeth is 3% and may cause a variety of symptoms and complications. Ectopic presentations of these unerupted teeth are rare. Early diagnosis and timely surgical intervention can reduce or eliminate the need for orthodontic treatment and reduce complications to the regular dentition in such cases. However, their diagnosis is very difficult based on just clinical appearance; the key in diagnosis is radiographic examination. Treatment considerations of hyperdontia depend on the respective case: A surgical intervention to prevent any complications or wait and watch to prevent trauma to the adjacent developing structures in a young child's dentition.
What this paper adds
- Supernumerary tooth is a commonly encountered dental anomaly, with mesiodens presenting as a mysterious tooth as far as diagnosis and location is concerned.
- Impacted mesiodens pose a further challenge to the clinician as they require either a surgical approach or sometimes wait and watch therapy scores over the usual treatment.
- The paper, thus, presents a variety of cases and treatment options taking into considerations all the factors required for the correct intervention.
| References|| |
|1.||Scheiner MA, Sampson WJ. Supernumerary teeth: A review of the literature and four case reports. Aust Dent 1997;42:160-5. |
|2.||Holzhausen M, Goncalves D, Correa F, de Spolidorio LC, Rodrigues VC, Orrico SR. A case of Zimmermann-Laband syndrome with supernumerary teeth. J Periodontol 2003;74:1225-30. |
|3.||Penkala J, Jasniewicz G. Presence of supernumerary deciduous teeth in children with cleft palate. Czas Stomatol 1986;39:745-9. |
|4.||Richardson A, Deussen FF. Facial and dental anomalies in cleidocranial dysplasia: A study of 17 cases. Int J Paediatr Dent 1994;4:225-31. |
|5.||Duncan BR, Dohner VA, Preist JH. The Gardner syndrome: Need for early diagnosis. J Pediatr 1968;72:497-505. |
|6.||Brook AH. Dental anomalies of number, form, and size: Their prevalence in British Schoolchildren. J Int Assoc Dent Child 1974;5:37-53. |
|7.||Davis PJ. Hypodontia and hyperdontia of permanent teeth in Hong Kong schoolchildren. Commun. Dent Oral Epidemiol 1987;15:218-20. |
|8.||Brabant H. Comparison of the characteristics and anomalies of the deciduous and the permanent dentitions. J Dent Res 1967;46:897-902. |
|9.||Ravn JJ. Aplasia, supernumerary teeth and fused teeth in the primary dentition. An epidemiologic study. Scand J Dent Res 1971;79:1-6. |
|10.||Taylor GS. Characteristics of supernumerary teeth in the primary and permanent dentition. Dent Pract Dent Rec 1972;22:203-8. |
|11.||Luten JR. The prevalence of supernumerary teeth in primary and mixed dentitions. J Dent Child 1967;34:346-53. |
|12.||Niswander JD, Sujaku C. Congenital anomalies of teeth in Japanese children. Am J Phys Anthropol 1963;21:569-74. |
|13.||Rosenzweig KA, Garbarski D. Numerical aberrations in the permanent teeth of grade school children in Jerusalem. Am J Phys Anthropol 1965;23:277-83. |
|14.||Rajab LD, Hamdan MA. Supernumerary teeth review of the literature and a survey of 152 cases. Int J Paediatr Dent 2002;12:244-54. |
|15.||Humerfelt D, Hurlen B, Humerfelt S. Hyperodontia in children below four years of age: A radiographic study. ASDC J Dent Child 1985;52:121-4. |
|16.||Liu JF. Characterstics of premaxillary supernumerary teeth: A survey of 112 cases. ASDC J Dent Child 1995;62:262-5. |
|17.||Levine N. The clinical management of Supernumerary teeth. J Can Dent Assoc 1961;28:297-303 |
|18.||Garvey MT, Barry HJ, Blake M. Supernumerary teeth - An overview of classification, diagnosis and management. J Can Dent Assoc 1999;65:612-6. |
|19.||Mitchell L. An Introduction to Orthodontics.1 st ed. Oxford: Oxford University Press; 1996. p. 23-5. |
|20.||Andlaw RJ, Rock WP. A Manual of Paediatric Dentistry. 4 th ed. New York: Churchill Livingstone; 1996. p. 156. |
|21.||Howard RD. The unerupted incisor. A study of the postoperative eruptive history of incisors delayed in their eruption by supernumerary teeth. Dent Pract Dent Rec 1967;17:332-41. |
|22.||Smith RA, Gordon NC, De Luchi SF. Intranasal teeth: Report of two cases and review of the literature. Oral Surg Oral Med Pathol 1979;47:120-2. |
|23.||Alexandrakis G, Hubbell RN, Aitken PA. Nasolacrimal duct obstruction secondary to ectopic teeth. Ophthalmol 2000;107:189-92. |
|24.||Awang MN, Siar CH. Dentigerous cyst due to mesiodens: Report of two cases. J Ir Dent Assoc 1989;35:117-8. |
|25.||Primosch RE. Anterior supernumerary teeth - assessment and surgical intervention in children. Pediatr Dent 1981;3:204-15. |
|26.||Lustmann J, Bodner L. Dentigerous cysts associated with supernumerary teeth. Int J Oral Maxillofac Surg1988;17:100-2. |
|27.||Mitchell L, Bennett TG, Supernumerary teeth causing delayed eruption - a retrospective study. Br J Orthod 1992;19:41-6. |
|28.||Houston WJ, Stephens CD, Tulley WJ. A Textbook of Orthodontics. 2 nd ed Boston Wright Publications; 1992.p. 174-5. |
|29.||Chen A, Huang JK, Cheng SJ, Sheu CY. Nasal Teeth: Report of Three Cases. AJNR Am J Neuroradiol 2002;23:671-3. |
|30.||Shetty R, Sandler PJ. Keeping your eye on the ball. Dent Update 2004;31:398-402. |
|31.||Som PM, Shangold LM, Biller HF. A palatal dentigerous cyst arising from a mesiodente. AJNR Am J Neuroradiol 1992;13:212-4. |
|32.||Olson JW, Miller RL, Kushner GM, Vest TM. Odontogenic carcinoma occurring in a dentigerous cyst: Case report and clinical management. J Periodontol 20007;1:1365-70. |
|33.||Seidner S. Neuralgia caused by unerupted teeth. ZWR 1975;84:981-2. |
|34.||Pejrone CA, Magnani G. Three cases of trigeminal neuralgia due to impacted teeth. Minerva Stomatol 1968;17:39-44. |
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]