|Year : 2011 | Volume
| Issue : 4 | Page : 288-293
Prevalence of mesiodens among six- to seventeen-year-old school going children of Indore
V Khandelwal1, AU Nayak2, RB Naveen1, N Ninawe3, PA Nayak4, SV Sai Prasad5
1 Department of Pedodontics, Modern Dental College and Research Center, Indore, Madhya Pradesh, India
2 Department of Pediatric and Preventive Dentistry, Mahatma Gandhi Dental College and Hospital, Jaipur, Rajasthan, India
3 VSPM Dental College and Research Center, Nagpur, Maharashtra, India
4 Department of Periodontics, Mahatma Gandhi Dental College and Hospital, Jaipur, Rajasthan, India
5 Indian Agricultural Research Institute, Regional Station, Indore, Madhya Pradesh, India
|Date of Web Publication||21-Oct-2011|
Sr. Lecturer, Modern Dental College and Research Center, Indore
| Abstract|| |
Introduction: 'Mesiodens' are the supernumerary teeth present in the midline of the maxilla between the two central incisors. These mesiodens are the most common supernumerary teeth and are usually responsible for eruption disturbance or delay of the maxillary anterior permanent teeth. The present study seeks to investigate the prevalence of mesiodens among school going children in Indore City, India. Materials and Methods: The study was a retrospective collection of data to evaluate the prevalence of mesiodens among 3896 children, whose ages ranged between six and seventeen years. Results: The results showed that males were affected approximately 1.2 times as frequently as females; 3.18% of the total screened population had mesiodens and among the affected population 4.03% had two or more mesiodens. Most of the mesiodens were conical in shape. The age, sex distribution, number of mesiodens per patient, shape, and direction of the eruption are presented in this study. Conclusions: The present study gives an insight into the prevalence of mesiodens among school going children of Indore city. A coincidental finding in our study has been the high risk of trauma associated with the occurence of mesiodens. This finding makes it mandatory to include mesiodens as a risk factor in traumatic dental injuries. Early diagnosis and management of these otherwise considered mild factors must be made mandatory in pediatric dentistry.
Keywords: Mesiodens, prevalence, prevalence of mesiodens
|How to cite this article:|
Khandelwal V, Nayak A U, Naveen R B, Ninawe N, Nayak P A, Sai Prasad S V. Prevalence of mesiodens among six- to seventeen-year-old school going children of Indore. J Indian Soc Pedod Prev Dent 2011;29:288-93
|How to cite this URL:|
Khandelwal V, Nayak A U, Naveen R B, Ninawe N, Nayak P A, Sai Prasad S V. Prevalence of mesiodens among six- to seventeen-year-old school going children of Indore. J Indian Soc Pedod Prev Dent [serial online] 2011 [cited 2014 Mar 12];29:288-93. Available from: http://www.jisppd.com/text.asp?2011/29/4/288/86369
| Introduction|| |
Supernumerary teeth are defined as any teeth in excess of the normal number. Mesiodens are un-erupted supernumerary teeth, in the central region of the premaxilla, between the two central incisors. The most common type of supernumerary tooth as indicated by Alberti  is mesiodens. Mesiodens may occur as single, multiple, unilateral or bilateral. The presence of multiple supernumerary teeth is called 'mesiodentes'.  Mesiodens are the most common supernumerary teeth and are usually responsible for the eruption disturbance / delay of the maxillary anterior permanent teeth.
The prevalence of hyperdontia is reportedly between 0.15 and 3.9%.  The prevalence of mesiodens varies between 0.09 and 2.05% in different studies and it is reported to be more common in males than in females.  Extra teeth may present in both permanent and primary dentitions, but are five times less frequent in the primary dentition. The literature reports that 80 to 90% of all supernumerary teeth occur in the maxilla, of which half are found in the anterior region .
The presence of mesiodens often results in complications including, retention of primary teeth and delayed eruption of permanent teeth, closure of the eruption path, rotations, retention, root resorption, pulp necrosis, and diastema, as well as nasal eruption and formation of dentigerous and primordial cysts. Less common complications involving the permanent incisors include dilacerations of the developing roots and loss of tooth vitality. Therefore, early diagnosis of mesiodens has particular importance in terms of preventing such complications. However, with respect to the surgical removal of mesiodens, the ideal time for intervention - immediate or delayed intervention - remains a highly controversial issue.
Even as the predisposing factors of dental trauma, such as, open bite, increasing overjet with protrusion of upper incisors, and insufficient lip closure have been well-documented in literature, there is limited evidence indicating mesiodens as a risk factor in trauma. 
| Materials and Methods|| |
The study was a retrospective collection of data to evaluate the prevalence of mesiodens, conducted in the Department of Pedodontics and Preventive Dentistry, Modern Dental College and Research Center, Indore. The study was carried out on 3896 school going children aged six to seventeen years, in Indore. A simple random sampling was done. Radiographs were not taken as this was a field survey.
| Results|| |
[Table 1] shows that the prevalence of mesiodens was estimated to be 3.18% among the observed population. It occurred more frequently in boys than in girls, with the ratio being approximately 2 : 1 [Table 2]. In this study, the male : female ratio was 1.2 : 1.5. Out of the 124 patients, five had two mesiodens (4.03%), whereas, 119 out of 124 had one mesiodens (95.96%) [Table 3]. [Table 4] shows that 21.77% of those who had mesiodens had some kind of traumatic dental injury to their adjacent teeth.
| Discussion|| |
The first documented report of supernumerary teeth has been found in the ancient human skeletal remains of the Lower Pleistocene era.  Until recently, the most primitive evidence of the presence of mesiodens goes back to 13,000 years, when it was found among the remains of an Australian aborigine.  Mesiodens account for 45 to 67% of all supernumerary teeth. Balk (1917) defined mesiodens as the most common among supernumerary teeth, located mesial to both central incisors; appearing peg shaped, in a normal or inverted position.  Regezi and Sciubba  mentioned that the anterior midline of the maxilla is the most common site of the supernumerary tooth, hence the supernumerary tooth is known as mesiodens. Very few supernumerary teeth have been reported in the primary dentition. 
Reports of supernumerary teeth are quite common in dental literature. It may occur individually or in multiples (mesiodentes). These are discovered on a complaint by a patient or when the patient seeks treatment for malocclusion. The impacted mesiodens are often diagnosed by radiographic examination. 
Presence of mesiodens may be seen as an isolated finding or are frequently associated with various craniofacial anomalies, including cleidocranial dysostosis, Gardner's syndrome, cleft lip and palate, Fabry-Anderson's Syndrome or chondroectodermal dysplasia (Ellis-van Greveld Syndrome). 
The prevalence of mesiodens in the present study was 3.18%, which was on the higher side when compared with the studies of Stafne  (0.41%; 1932), Thilander  (1.2%; 1973), Gabris K  (1.9%; 2001), and Clayton  (0.89%; 1956), but was much lower in comparison to that of Tay  (5.8%; 1984). Five (4.03%) out of the 124 patients had two mesiodens.
It occurs more frequently in boys than in girls.  In the present study, a male : female ratio of 1.2 : 1 was observed. The present study was a retrospective collection of data, to evaluate the prevalence of mesiodens. As radiographs were not taken, as this was a field survey, inverted and impacted mesiodens were excluded in this study. Kaan  found 37.6% in the inverted position and 7% in a horizontal position in a radiographic study.
Few studies on the prevalence of mesiodens involving certain ethnic or racial populations have been published to date.  The prevalence of mesiodens has been estimated to be 0.45% in Caucasians, 0.4% in Finnish, 1.43%in Norwegians, 2.2% in Hispanic populations, and 8.3% in a group of Turkish children. In a study by Kaan,  the prevalence in Turkey has been found to be 0.3%. The prevalence of supernumerary teeth in the permanent dentition of the Caucasian general population has been reported to be between 0.1 and 3.8%.  The estimated prevalence in the sub-Saharan Africa and Asian population is reported to be between 2.7 and 3.4%. The general prevalence of mesiodens in Iranian children has been seen to be 1.6%, as reported by Mieghani.  In our study, we have found the prevalence of mesiodens to be 3.18%.
It was observed in our study that those children who had mesiodens had a high prevalence for traumatic injury (21.77%) in the maxillary region; as these mesiodens could further cause the forward positioning of the arch, making the facial profile more prone to traumatic injuries.
The etiology of the supernumerary teeth is not completely understood. Evidence regarding the etiology of mesiodens indicates that genetic susceptibility together with environmental factors might increase the activity of the dental lamina leading to the formation of the extra tooth / teeth. The observation that supernumeraries are more common in family members suggests heredity as an etiological factor; however, it does not follow a simple Mendelian pattern. It has been suggested that environmental factors might have an influence on genetic susceptibility. 
Various theories exist for the different types of supernumerary teeth. It was originally postulated that mesiodens represented a phylogenetic relic of extinct ancestors who had three central incisors.  A second theory known as dichotomy suggests that the tooth bud is split to create two teeth, one of which is the mesiodens.  The third theory involving hyperactivity of the dental lamina is the most widely supported. According to this theory, remnants of the dental lamina or palatal offshoots of the active dental lamina are induced to develop into an extra tooth bud, which results in a supernumerary tooth. 
It has been reported that single supernumeraries were observed in 76 to 86% of the cases, while double supernumeraries in 12 to 23%, and the multiple supernumeraries were observed in less than 1% of all cases.  If positioned in the anterior location, more problems would be caused due to altered growth and development in the area. Delayed eruption of permanent central incisors is quite common if mesiodens are present. They erupt spontaneously once the mesiodens are extracted.  Most of the mesiodentes (55.2%) were found in the vertical position, followed by inverted position (37.6%), and horizontal position (7%). 
The classifications of supernumerary teeth are usually based on their morphology together with their location in the dental arches. According to the shape and size, two subclasses are considered in the classification of mesiodens; namely, eumorphic and dysmorphic. The eumorphic subclass is usually similar to a normal-sized central incisor, whereas, the dysmorphic teeth have different shapes and sizes and are categorized into conical, tuberculate, supplemental, and odontomes. Therefore, supernumerary teeth might vary from a normal tooth to a dysmorphic mass.  The conical shape is found to be the most commonly observed morphology in various studies.
Presence of mesiodens that may cause over retention of primary teeth, delayed eruption of permanent incisors, impaction of permanent teeth, displacement or rotation of the central incisors, space loss, median diastema  that may lead to open bite, increasing overjet with protrusion of upper incisors, and insufficient lip closure have been well-documented in the literature. According to Tashima, the prevalence of inter-incisal diastema is seven times higher in the presence of mesiodens.  There is limited evidence indicating mesiodens as a risk factor in trauma. The only case suggesting mesiodens as a risk factor was reported by Kupietzky  and more recently by A. Alacam,  where the mesiodens was considered as a risk factor for causing as well as complicating dental trauma.
The most common complication associated with mesiodens (or mesiodentes) is the eruption disturbance/ delay in the maxillary anterior region. Impaction of the permanent incisors due to the presence of mesiodens is common. These teeth usually erupt spontaneously after extraction of the mesiodens.  Also, this type of supernumerary tooth often prevents the maxillary incisors from contacting each other, resulting in the formation of a mid-line diastema. About 25% of the mesiodentes presenting in the maxilla erupt into the oral cavity. The majority of un-erupted teeth are observed in the permanent dentition and are relatively common in the early-mixed dentition age.
Mesiodens may affect the dentition in various ways. Some of the problems these teeth can cause are:
Children who sustained accidental damage to their maxillary incisors had protrusion and incompetent lips at rest. This has also been demonstrated previously by S Petti,  ML Gauba,  Chandra S and Chawla TN,  qne Rai S and Munshi AK. 
- Crowding or abnormal diastema
- Displacement and / or rotation
- Failure of eruption
- Hindrance to orthodontic movement
- Enlargement of the follicle and possible cystic change
- Root abnormalities - dilacerations of the developing root
Glendor Ulf  presented an international review of well-known as well as less well-known unintentional and intentional causes of traumatic dental injuries (TDIs). The maxillary teeth are more frequently traumatized than mandibular teeth and this probably relates to the more vulnerable position of the maxillary incisors.
Galea  observed that the severity of the injuries appeared to increase when the accidents occurred in subjects with some form of malocclusion (Galea observed that the severity of injuries appeared to increase when there was an associated injury to the lower lip, while a third of the accidents occurred in subjects with some form of malocclusion).
A radiological examination is of basic importance here for proper treatment planning; however, it can be imprecise due to interference of dental structures in an X-ray. An atypical clinical or radiological picture can cause difficulties in diagnosing this dental anomaly. A thorough radiographic examination at various angles may help us in the estimation of the exact location of the tooth, especially in cases of impacted mesiodens. 
Radiographs are recommended to assist the process of diagnosis of mesiodens. Although a panoramic radiograph is the best screening tool, clarity in the midline region is still limited for the diagnosis of mesiodens. For a precise view in the incisor region, an anterior occlusal or a periapical radiograph is also helpful. With the parallax technique (horizontal tube shift technique), the buccolingual position of the un-erupted mesiodens can be evaluated.  Removal of mesiodens is indicated in the following situations; inhibition or delay of eruption, displacement of the adjacent tooth, interference with orthodontic appliances, presence of a pathological condition, or spontaneous eruption of the supernumerary tooth.
Only 25% of all mesiodentes spontaneously erupt into the oral cavity. If un-erupted, the tooth can alter both the eruption of the permanent incisors and the resulting occlusion. 
Therefore, once a mesiodens has been diagnosed, the clinician must decide on the treatment to minimize further sequelae. In children and adolescents, extraction of mesiodens has been recommended in order to avoid the possible effects on occlusion as well as cyst formation.
There are two methods for extraction of mesiodens; early extraction before root formation of the permanent incisors and late extraction after root formation of the permanent incisors. There is a controversy in the literature regarding the time of removal of any un-erupted mesiodens. The immediate removal versus delay in surgical intervention following root development of the central incisor and the lateral incisor, at about the age of eight to ten years, has been mentioned.
Yagüe-García  emphasized that the early removal of the supernumerary teeth in order to prevent complications is the treatment of choice. Solares  recommended extraction of mesiodens in the early mixed dentition in order to facilitate spontaneous eruption and alignment of the incisors. Henry  suggested delayed extraction of the mesiodens, at about the age of 10, when the apex of the central incisor nearly formed. If treatment is postponed after this age, more complex surgical and orthodontic treatment may be necessary. The type and position of the un-erupted tooth, the space available in the dental arch, in addition to the stage of root development may influence how long it takes for an impacted tooth to erupt after surgical removal of the mesiodens.
In cases where eruption of the permanent central incisors was hampered, extraction during the early mixed dentition stage allowed the normal eruptive forces to promote spontaneous eruption of the permanent central incisors after the extraction. Extraction of a mesiodens at a time appropriate for promoting self-eruption in the early mixed dentition may result in better alignment of the teeth and may minimize the need for orthodontic treatment. Close monitoring of the dentition is required after the extraction of a mesiodens. It might take six months to three years for an un-erupted tooth to erupt after removal of the mesiodens.  Approximately six months after extraction of a mesiodens, clinical and radiographic reassessment is recommended to determine if the tooth has erupted.
Also, if the un-erupted supernumeraries exhibit no pathology and do not interfere with the orthodontic movement of the adjacent teeth, they are usually left in situ. Periodic radiographic control is essential, as degeneration of the follicle may lead to development of a dentigerous cyst. 
| Conclusions|| |
Mesiodens, as the most prevalent form of supernumerary teeth in permanent dentition is quite a common condition. Early detection and management of all supernumerary teeth is a necessary part of preventive dentistry. Extraction of mesiodens in the early mixed dentition helps spontaneous alignment of the adjacent teeth. In this way orthodontic problems and traumatic dental injuries to adjacent teeth and / or dental pathology associated with this dental anomaly can be avoided. The importance of early radiographic investigation of the suspected cases cannot be understated. However, symptomless cases could be left untreated along with regular check-ups. It can be concluded that early diagnosis is important for the preservation of the dentition and the development of the occlusion.
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[Table 1], [Table 2], [Table 3], [Table 4]
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