Download Treatment of supernumerary teeth - European Journal of Paediatric

M. F. Mathias1, R. G. Lobo-Piller2, M.S.N.P. Corrêa
Universidade Cruzeiro do Sul
Universidade de Guarulhos
Universidade de São Paulo
1
2
e-mail: [email protected]
Treatment
of supernumerary teeth
ABSTRACT
Background The finding of supernumerary teeth in the
oral cavity is a common occurrence, and they are
interesting because of their potential to lead to aesthetic
and functional alterations. When they are present in the
anterior area of the maxilla, they may cause
complications, such as late tooth eruption or impaction of
the central incisors. They affect from 0.5 to 3.8% of the
population, with men being more affected.
Case reports This article describes two cases of impaction
of the permanent maxillary left central incisor, due to the
presence of a supernumerary tooth in the parasagittal
area of the pre-maxilla, as well as the surgical and
orthodontic procedures adopted.
Keywords:
Diastemas;
Supplementary teeth.
Supernumerary
teeth;
Introduction
Supernumerary teeth are considered to be a numerical
anomaly, characterised by an excessive number of teeth.
Morphologically, they are classified as supplementary and
rudimentary teeth [Srivatsan and Aravindha, 2007]. They
are usually associated with different syndromes such as
Gardner’s syndrome, cleido-cranial dysosthosis or with
facial fissures. However, they may appear in patients with
no pathologies, as an isolated finding. Prevalence ranges
between 0.5 to 3.8% in patients with permanent teeth
and 0.35 to 0.6% in patients with primary dentition
[Fernández et al., 2006; Salcido-Garcia et al., 2004; Van
Buggnhout and Bailleul-Forestier, 2008].
This anomaly is usually detected in routine exams,
mainly affecting permanent teeth. The majority of these
teeth are asymptomatic and 90% of the cases are located
in the anterior region of the maxilla [Almeida et al.,
1997].
In the maxilla, they most frequently occur in the area of
the lateral incisor or as middle teeth, between the two
central incisors [Roberts et al., 1997]. They may be
supplementary (looking like natural teeth), peg-shaped,
tubercular or molar-shaped [Ray et al., 2005], affecting
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men more than women (2:1) [ Bhat, 2006]. According to
Bhat [2006] and Cho [2006], supplementary mandibular
central incisors are a rarer phenomenon. Salcido-Garcia et
al. [2004] studied 2241 radiographs of patients of both
sexes. The middle teeth were the most common finding
(48.6%), followed by supernumerary molars (26.4%),
supernumerary lateral incisors (11.1%) and fourth molars
(9.7%). According to the authors, the results point
towards the need for a panoramic radiogram of all the
patients attended at faculties, clinics and private and
public consulting offices to diagnose undetected
pathologies.
The study of Fernández Montenegro et al. [2006]
assessed a total of 36,057 case records between 1991
and 2003, of which the following factors were reviewed:
age, sex, number of supernumerary teeth extracted,
location and morphology. Of these, 102 patients had 147
supernumerary teeth extracted. The most frequent were
the middle teeth (46.9%), followed by premolars (24.1%)
and fourth or distal molars (18%). As regards location,
74.5% of the supernumerary teeth were in the maxilla
and 46.9% were in the palatine region. Peg-shaped teeth
were the most frequent, and were found in two thirds of
the sample. The authors concluded that the middle teeth
are the greatest cause of retention of permanent incisors,
but they erupted spontaneously after extraction of the
supernumerary teeth, if there was sufficient space in the
dental arch and if they had eruptive force.
According to the literature, supernumerary teeth may
cause functional (malocclusion) and aesthetic alterations
(interincisal diastemas), in addition to other complications
that may affect the quality of life, among them:
impaction of maxillary central incisors, dental retention or
late eruption of the permanent incisors, crowding,
eruption in the nasal cavity, formation of diastemas,
intraoral infection, root anomalies, root resorption of
adjacent teeth, formation of cyst accompanied by bone
destruction [Cogulu et al. 2008], rotations and pulp
necrosis [Giancotti et al., 2008].
Hansen and Kjaer [2004] analysed the radiographic
records of 8 children, who presented supernumerary
teeth located in the parasagittal region of the premaxilla,
and followed them up from the age of 1 year and 5
months through to the age of 11 years and 5 months.
The anomalies found were: invagination of permanent
teeth, resorption of incisor roots, incisors with curved
roots, late eruption, and late formation of roots. The
authors concluded that in the region with supernumerary
teeth, the adjacent incisors showed late eruption after
removal.
Gündüz et al. [2008] studied 23,000 children in Turkey,
and verified the presence of non-erupted supernumerary
teeth located between the two central incisors, or as a
unilateral tooth or bilateral teeth situated in the midline
of the maxilla. The majority of the complications found
were late eruption of permanent teeth (38.8%),
diastemas in the midline of the maxilla (17.6%), axial
rotation or inclination of erupted permanent incisors
(16.4%), and resorption of adjacent teeth (4.7%). As
regards sex, the proportion was 2.1:1 (men and women,
respectively). Prevalence of middle teeth in the population
was estimated at 0.15% and 2.2%.
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MATHIAS M.F., LOBO-PILLER R.G. AND CORRÊA M.S.N.P.
FIG. 1 - Surgical access; location of supernumerary tooth in the lingual region of non-erupted tooth 21.
FIG. 2 - Supernumerary tooth removed (tubercular shape).
FIG. 3 - Bonding of button on tooth 21 and traction wire in position.
FIG. 4 - Suture with silk
thread.
FIG. 5 - Orthodontic
treatment concluded
after 3 years; gingival line
visibly higher in the
region of tooth 21.
Tyrologou et al. [2005] assessed 11,500 children, and of
this total, 97 individuals presented 123 middle teeth. In
this study, the predominant location was in the palatine
region with 39% in an inverted position. The most
frequently found alterations were late eruption of the
permanent teeth, diastema between the incisors, and
change of incisor rotation. No follicular cyst, resorption of
middle or adjacent teeth was found. The authors
concluded that the risk of complications caused by middle
teeth is very small and therefore, a more restrictive
attitude with regard to surgical removal could be
recommended.
Lo Giudice et al. [2008] emphasised that aesthetics and
function are two important parameters to be taken into
consideration when treating supernumerary teeth.
Particularly, in young patients, invasive and surgical
techniques may be replaced by interceptive orthodontic
treatments.
Case reports
Case report 1
The child JMS, caucasian, was sent to the authors at the
age of 11 years by the orthodontist from the BuccoMaxillo-Facial Surgery Service of the Secretary of Health
of the Municipality of Barueri, SP, Brazil, to remove a
supernumerary tooth in the region of tooth 21. Periapical
radiographs confirmed the presence of the image of the
supernumerary tooth superimposed on the image of the
tooth 21 (parasagittal position). Planning involved surgical
procedure to remove the supernumerary tooth and
orthodontic traction of tooth 21.
276
Surgery was performed by means of a linear incision on
the ridge in the region of 21; releasing incision between
teeth 22 and 23; interpapillary incision between 11 and
22; divulsion and detachment of the flap; location of
supernumerary and tooth 21 (Fig. 1); removal of
supernumerary tooth (Fig. 2); bonding of orthodontic
button to tooth 21 with traction wire (Fig. 3); flap
replacement; suture with simple stitches using silk thread
3.0 (Fig. 4).
In the postoperative period of 7 days, healing was
good, with removal of the suture and the patient was
referred again to the orthodontist. After 3 years of
follow-up, orthodontic treatment was concluded with
satisfactory results from a functional and aesthetic point
of view (Fig. 5).
Case report 2
The child D., mulatto, 8 years old, sought the Pediatric
Dentistry service to explain the non-eruption of tooth 21.
A periapical radiograph revealed the presence of a
supernumerary tooth superimposed to the crown image
of tooth 21 (Fig. 6). On clinical examination, it was
verified that tooth 61 had not exfoliated. A surgical
procedure was performed to remove the supernumerary
tooth. As there was adequate space for tooth 21 to erupt
and because rhizogenesis of this tooth was not complete,
the option was to wait for it to erupt. However, 10
months after surgery, a panoramic radiograph showed
that tooth 21 was not yet in the initial intraosseous
position (Fig. 7).
The following was planned: surgery to bond an
orthodontic button with traction wire and placement of a
fixed appliance in the maxillary arch (Fig. 8). After 15
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SUPERNUMERARY TEETH. TWO CASE REPORTS
FIG. 6 - Periapical radiograph showing image of supernumerary tooth superimposed on image of the crown of tooth 21
(parasagittal location). FIG. 7 - Panoramic radiograph 10 months after removal of supernumerary tooth.
FIG. 8 - Surgical access, bonding of button, and orthodontic traction wire.
FIG. 9 - Tooth 21 positioned in arch; note the high gingival line
of this tooth.
months, tooth 21 assumed its position in the dental arch,
the fixed appliance was removed and the child began
treatment with an orthopaedic appliance to correct the
lack of space and general misalignment of the teeth. Note
the high gingival line in the region of the tractioned tooth
(Fig. 9), which in the future, after completion of the
orthodontic treatment, may be corrected by gingivoplasty
if necessary.
Discussion
The supernumerary tooth results from the formation of
geminated teeth in the regions of the anterior maxillary
teeth, supernumerary molars and duplication of premolars which, in the absence of syndromes, are seen as a
super production of the dental lamina [Pasler and Visser,
2005].
Supernumerary teeth with a tubercular and inverted
shape do not normally erupt, and retard or prevent
eruption of the central incisors [Fricker and Jayasekera,
2001]. The lack of eruption of a permanent anterior tooth
causes concern and directly affects the individual’s
psychological state, being the reason why the two
patients reported in this study sought the professional
help of an orthodontist and paediatric dentist (Case 1 and
2, respectively).
Impaction of maxillary central incisors is mentioned in
the literature [Cogulu et al., 2008; Giancotti et al., 2008],
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however Fernández-Montenegro et al. [2006] affirm that
after extraction of the supernumerary tooth, the
permanent incisors erupt spontaneously if there is
sufficient space in the dental arch and if they have
eruptive force. In case 1, although there was sufficient
space, the option was to perform orthodontic traction of
tooth 21 immediately after removal of the supernumerary
tooth. The patient’s age was taken into consideration (11
years old), and the radiographic exam revealed that
rhizogenesis of this tooth was already completed and this
would make spontaneous eruption difficult.
In case 2, there was sufficient space in the arch and the
radiograph showed that rhizogenesis of tooth 21 was not
yet complete, which would favor spontaneous eruption.
Nevertheless, after the observation period of 10 months,
the panoramic radiograph showed that the tooth had not
moved, perhaps because the adjacent lateral incisor was
erupting, causing a mechanical barrier to tooth 21. The
hypothesis that this tooth had lost eruptive force was not
discarded. Thus, a new surgical procedure was performed
to bond the orthodontic button.
In both cases, surgical procedures associated with
orthodontic treatment were needed. Tyrologou et al.
[2005] and Lo Giudice et al. [2008] mention that invasive
and surgical techniques can be replaced by a more
restrictive attitude in cases in which complications
resulting from supernumerary teeth can be controlled.
In case 1 there was a satisfactory result from an
aesthetical and functional point of view, and the
important role of a multidisciplinary team in managing
situations which involve supernumerary teeth and their
complications is relevant. In case 2, tooth 21 was already
present in the dental arch, but it was observed that the
gingival line had a very high insertion. Therefore, it is
necessary to wait for the orthodontic treatment to be
concluded, in order to assess the final aesthetic result and
adopt corrective measures if necessary.
Conclusion
Frequently a multidisciplinary team is required to
manage situations that involve supernumerary teeth and
their complications.
It is important to have panoramic radiographs taken in
children at the beginning of mixed dentition for an early
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MATHIAS M.F., LOBO-PILLER R.G. AND CORRÊA M.S.N.P.
detection of
pathologies.
dental
anomalies
and
associated
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