Download Supernumerary and supplemental teeth

Supernumerary and supplemental teeth:
case report
G. LO GIUDICE, V. NIGRONE, A. LONGO, M. CICCIÙ
ABSTRACT. Aim is to report the case of a ten year old child affected by a numeric dental anomaly showing the
pathologic condition characterised by the simultaneous presence of supernumerary and supplemental teeth. The
anomaly was analysed to plan the best surgical and orthodontic treatments. Case report Dental history, clinical
and instrumental examinations were made to perform a correct orthodontic examination and diagnosis. A young
patient was affected by numeric dental anomaly in the upper jaw. We observed a high number of teeth, specifically
two normally formed supplemetary lateral permanent incisors and an unerupted mesiodens placed between the
upper central incisors. Firstly, the supplemental lateral teeth were extracted. This surgical therapy and the
application of a space maintainer were made to permit the eruption of the permanent canines. Then the mesiodens
also underwent surgical treatment (i.e. extraction). Eventually, physiologic eruption of permanent teeth was
allowed by the planned surgical-orthodontic treatment. Discussion Aim of the surgical-orthodontic treatment was
extraction of the unerupted supernumerary teeth to obtain the physiologic eruption of the permanent ones.
Orthodontic treatment is important to solve malocclusions and maintaining the space for the eruption of
permanent teeth. Conclusion Aesthetics and function are two important parameters in modern dentistry. All
clinicians should try to make a correct and rational diagnosis for both simple and complex dental pathologies.
Particularly in young children, invasive and surgical disinclusive techniques can be substituted by interceptive
orthodontic treatments.
KEYWORDS: Dental anomaly; Hyperdontia; Supplemental and supernumerary teeth.
Introduction
Numeric dental anomalies can be defined as high
frequency diseases, and young children are often
affected. Therefore an early diagnosis is important to
plan a correct therapy. The increase of this pathology
over the last years should be associated with a higher
attention paid by paediatricians and dentists.
Numeric dental anomalies are characterised by an
increased or reduced number of teeth in the jaws.
Capozzi et al. [1987] in a work about hyperdontia
defined two different pathologic conditions: real
hyperdontia (increased number of both primary and
permanent teeth) and false hyperdontia, with the
concomitant presence of deciduous teeth near the
corresponding permanent teeth. Other studies confirm
the same results [Capozzi et al.,1987; Cassetta et al.,
1994; De Michelis et al., 1992; Orlando et al., 1966;
Pezzoli et al., 1969].
Department of Dentistry, University of Messina, Italy
E-mail: [email protected]
EUROPEAN JOURNAL OF PAEDIATRIC
DENTISTRY • VOL. 9/2-2008
A classification of numeric dental anomalies was
published by Tomes [1873], who defined the
following.
- Supplemental: tooth characterised by the same
form and function of adjacent teeth with no
anatomical differences.
- Supernumerary: tooth characterised by an atypical
anatomic form; often these teeth are smaller than
normal.
Bush classification [1897] analysed the different
morphology of supernumerary teeth:
- Conic: tooth of a small volume and conic form, its
root is short and palatine.
- Tubercolate: tooth with several cusps. Its root is
short and hooked.
- Infundibulform: tooth with a funnel form. Its root is
short and conic.
A study showed that supernumerary teeth are
characterised by regular form and structure. Only
conic teeth are affected by different mineral
concentrations with irregular dentine [Pezzoli et al.,
1969].
Different authors classified supernumerary teeth
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according to their position and location. Mesiodens
can be defined a tooth located between central upper
incisors; paramolar a tooth placed in molar region;
distomolar a tooth that lies distal to the third molar
[Bolk, 1914; Sfasciotti et al., 1991].
Supernumerary position was investigated by
Capozzi [1987] and De Michelis [1992] in two
different scientific works, showing that tooth position
can be normal, inverse, transverse or ectopic.
A statistic analysis of the supernumerary teeth
orientation was made by Tay et al. [1984], concluding
that 16.8% of the analysed sample were in the correct
position, 77.6% were inverted, and 5.6% were in
transverse position.
The pathogenesis of this anomaly is still debated.
Familiarity is considered the main factor, while
phylogenetic theories have only historical value..
Levine, Di Biase, Mckibben, Sykaras, Primosch and
Liu studied in their works the high activity of the
primitive dental lamina as a possible cause of dental
numeric anomaly [Levine, 1961; Di Biase, 1969;
Mckibben et al., 1971; Sykaras, 1975; Primosch, 1981;
Liu, 1995].
Cleidocranial disostosis is a genetic syndrome
characterised by numeric dental anomalies.
For this reason genetic factors are highly associated
with the real genesis of the disease. Orlando, Capozzi,
and Cassetta underlined that numeric dental anomalies
can be present also in other genetic syndromes like
ectodermic displasy, Crouzon’s disease and orofacial
syndromes (Sture–Weber, Anderson, Gardner, Down)
[Orlando et al., 1966; Capozzi et al., 1987; Cassetta et
al., 1994].
The frequency of this disease was analysed by
Orlando, Mckibben, Primosch, Goaz, Capozzi, NikHussein and Roberts. Those epidemiological reports
show that there is high frequency of supernumerary
teeth in permanent dentition (3.8%). Frequency in
primary dentition is lower (1.8%) [Orlando et al.,
1966; Mckibben et al., 1971; Primosch, 1981; Goaz et
al., 1986; Capozzi et al., 1987; Nik-Hussein et al.,
1996; Roberts et al., 2005].
In 2005, Bryan et al published an investigation on
delayed eruption of permanent due to the presence of
supernumerary teeth in relation to: root maturity,
degree of vertical impaction, and degree of angle of
impaction [Bryan et al., 2005].
Feng et al. [2007] in their work about oligodontia
and tooth agenesis classified numeric dental anomalies
into syndromic and non syndromic, and they
concluded that aetiological factors can be associated
with genetic mutation.
On the other side, Pardo et al. published [2006] an
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important genetic study of a Chilean family with three
different anomalies. They concluded that genetic
mutations cannot be always associated with dental
numeric anomalies.
The development of supernumerary teeth in the
mandible in cases with a history of supernumeraries in
the pre-maxillary region was analysed by Hall in 2006.
This work presented four cases in which delayed
formation and late eruption of supernumerary teeth in
the mandible occurred in patients with a history of
supernumerary formation in the pre-maxilla region
[Hall et al., 2006].
Chen et al. [2006] published a case report, showing
a supernumerary tooth associated with a genetic
syndrome, and a literature review highlighting the
importance of diagnostic features and treatment
options.
Bayram et al. published [2006] an investigation on
bilaterally impacted maxillary central incisors with
surgical exposure and orthodontic treatment. This case
report underlines that the origin of impacted upper
incisors can be associated with local causes,
supernumerary teeth or odontoma. The surgical
exposure and orthodontic traction of
bilaterally impacted incisors after removal of
impacted supernumerary teeth is presented in this
report.
In the literature the frequency of supernumerary and
supplemental teeth is reported to be higher in males
than females, the proportion in the permanent dentition
is 2:1. However in the primary dentition the ratio is 1:1
[Pezzoli et al., 1969; Brook, 1974; Ravne, 1971; Goaz
et al., 1986; Hogstrum et al., 1987; Berrone et al.,1989;
Goia et al., 1989; Mitchell, 1989; Cassetta et al.,
1994].
Supernumerary primary teeth are found in the
incisors area of both jaws. Orlando, Capozzi and
Cassetta pointed out the central position of the
mesiodens in permanent dentition. Mesiodens is
usually located in the premaxilla (64.3%). Other
positions can be represented by the third upper molar
zone (29.6%), third lower molar area (7.0%),
premolar area (7.0%) and lower incisors area (4.2%)
[Orlando et al., 1966; Capozzi et al., 1987; Cassetta et
al., 1994].
Complications of numeric dental anomalies were
analysed by Orlando, Primosch, Capozzi and Cassetta,
who concluded that malocclusion is the most frequent
complication; it may also be associated with maxillary
cysts and neuralgic manifestations [Orlando et al.,
1966; Primosch, 1981; Capozzi et al., 1987; Cassetta
et al., 1994].
The diagnosis of numeric dental anomaly is
EUROPEAN JOURNAL OF PAEDIATRIC
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SUPERNUMERARY AND SUPPLEMENTAL TEETH
generally easy, and it can be made during a clinical
examination or radiographic analysis. Supernumerary
and supplemental teeth diagnosis was investigated by
Olivera and Cozza [Cozza, 2001; Olivera, 2002].
This case report shows the rare presence of
supplemental and supernumerary teeth. The early non
invasive treatment can be considered the best treatment
option.
A 10 year old male child was observed at the
Department of Dentistry of Messina University.
The case history was negative for systemic and local
genetic diseases. Clinical examination showed a
normal mixed dentition, and the patient was found
caries free.
Intra-oral examination showed two normal-form
supplemental lateral permanent incisors and clinical
evidence of malocclusion (Fig. 1).
Radiographic analysis showed physiologic mixed
dentition and confirmed the presence of two normalform supplemental lateral permanent incisors, and also
an unerupted mesiodens between the upper central
incisors (Fig. 2, 3). For this reason an orthodontic
check-up was performed. Treatment planning was
divided into a first surgical phase and a subsequent
interceptive orthodontic therapy. Correction of
malocclusion aiming to obtain a I molar Class was
considered an important parameter to obtain the
physiologic upper canine eruption. Surgical
extractions of the supplemental teeth and positioning
of a space maintainer were made to allow eruption of
the permanent canines. Then the inverted mesiodens
was also extracted (Fig. 4, 5).
After some months, the canines erupted and a good
dental alignment in the front upper jaw was obtained.
FIG. 1 - Clinical intra-oral view of the two normal-form
twins lateral permanent incisors.
FIG. 2 - OPT.
Case report
Discussion
FIG. 3 - Radiographic view of two normal-form twins lateral
permanent incisors and also a no erupted mesiodens placed
between superior central incisors.
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Case report showed a rare clinical condition: the
concomitant presence of supplemental and
supernumerary teeth.
Robertson et al. reported in 1984 a case of two
supplemental lateral incisors in the upper jaw and
described the therapy underlining the prognosis.
Aim of the therapy was surgical extraction of
supernumerary teeth to obtain the physiologic eruption
of permanent teeth [Foley et al., 2004].
Surgical therapy is often associated with tooth germ
extraction as Sfasciotti et al. showed in 1987
[Sfasciotti et al., 1987]
Orthodontic treatment is important to solve
malocclusions and maintain the space for permanent
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G. LO GIUDICE ET AL.
FIG. 4 - Lateral view Dx e Sn of lateral and central incisors in the upper jaw after treatment.
therapeutic option for promoting physiologic tooth
eruption.
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FIG. 5 - Front view.
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1966; Capozzi et al., 1987; De Michelis et al., 1992;
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2001].
Conclusion
Based on the data from the literature and our
clinical experience, the following can be concluded.
- Dynamic eruptive alterations, influenced by
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- Numeric dental anomalies can be detected by early
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In cases of supernumerary teeth the surgical
orthodontic treatment can be considered the best
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