Year : 2006 | Volume
: 24 | Issue : 5 | Page : 20--23
Supplemental mandibular central incisor
Department of Pedodontics with Preventive Dentistry, Jaipur Dental College, Near Kukas Institutional Area, N.H.-8, Dhand, Jaipur, Rajasthan, India
Department of Pedodontics with Preventive Dentistry, Jaipur Dental College, Near Kukas Institutional Area, N.H.-8, Dhand, Jaipur, Rajasthan
Most of the supernumerary teeth are located in anterior maxillary region with their presence giving rise to a variety of clinical problems. Occurrence of supernumerary supplemental mandibular central incisor is a rare phenomenon. This case report describes a rare case of supernumerary supplemental mandibular central incisor which had erupted labially causig mild crowding in the anterior midline region.
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Bhat M. Supplemental mandibular central incisor.J Indian Soc Pedod Prev Dent 2006;24:20-23
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Bhat M. Supplemental mandibular central incisor. J Indian Soc Pedod Prev Dent [serial online] 2006 [cited 2021 Jan 24 ];24:20-23
Available from: https://www.jisppd.com/text.asp?2006/24/5/20/26032
Supernumerary teeth or hyperdontia is defined as excess number of teeth as compared to the normal dental formula. The first report of supernumerary teeth appeared between AD 23 to 79. A Supernumerary tooth either resembles or may not resemble in size and shape to the teeth with which it is associated.
Studies showing prevalence of supernumerary teeth have produced conflicting results which can be attributed to differences in sampling techniques, diagnostic criteria and racial groups examined.
Racial variation has higher frequency in Asian population. A single supernumerary tooth accounts for 76 to 86%, in pairs accounts for 12 to 23% and less than 1% cases with three or more extra teeth.
Multiple supernumerary teeth are rare and often found in syndromes such as cleidocranial dysostosis around 22% in maxillary incisor region to 5% in molar region, Gardner's Syndrome, cleft lip and palate. The frequency of supernumerary permanent teeth in cleft area with unilateral cleft lip or palate or both was found to be 22.2%. The other syndromes associated with supernumerary teeth include.
3. Craniometaphyseal dysplasia.
4. Crouzon disease
6. Ehler's Danlos
14. Oral-facial-digital, Type I and II
15. Sturge weber
A large percentage of anterior supplemental supernumerary teeth remain unerupted (around 75%) or partially (around 2%) or fully erupted., Nonsyndromic multiple supernumerary teeth occur most frequently in the mandible especially premolar region followed by molar and anterior region.
The occurrence of supernumerary teeth in primary dentition is a less common finding, one fifth of that seen in permanent dentition. A supernumerary tooth in primary dentition was reported with presence of mesiodens in one case in between primary maxillary central incisors and with an extra supplemental tooth palatal to primary maxillary central and lateral incisors in an another case. The occurrence of supernumerary teeth in both the primary and permanent dentition has been reported at around 30%. Supplemental lateral incisors in primary dentition occasionally erupt normally.
Sex predilection for occurrence of supernumerary teeth shows male female ratio 2:1 where as in a Hong Kong Chinese study male predilection reached as high as 6.5:1.
A rare case of hereditary multiple impacted normal and supernumerary teeth without any associated syndrome was reported with the 8 year old child showing four supernumerary teeth along with retained primary dentition and the mother showed 8 supernumerary teeth with retained primary dentition. A few cases of non-syndrome multiple impacted teeth was also reported with predilection for mandibular premolar region.
A supernumerary tooth should be removed if the above complications listed are identified. Extraction can be immediate approach or delayed approach, but as far as possible before removal, a comprehensive treatment plan should be considered generally, early surgical intervention is preferred which gives the spontaneous eruptive force of permanent incisors and prevent diastema formation and extensive surgical/ orthodontic treatment. Before surgical removal localization and relation to the roots of primary teeth and erupted permanent, unerupted permanent teeth, floor of the nose, maxillary sinus and other structures must be assessed.
Indications for supernumerary removal
1. Delayed central incisor eruption
2. Altered eruption or displacement of incisors, diastema formation
3. Associated pathology
4. Orthodontic alignment of an incisor in close proximity to supernumerary is envisaged.
5. Compromises bone graft in cleft lip and palate cases.
6. Spontaneous eruption of supernumerary has occurred.
7. Predisposes the area to pericoronitis, gingivitis, periodontitis, abscess formation.
Supernumerary teeth can also be monitored without removal if it is asymptomatic, does not hamper eruption of teeth, no active associated pathology.
Once the supernumerary tooth has been removed 78% of impacted permanent teeth will erupt within 2-3 yrs average provided there is adequate space in the arch. Exposure of the permanent incisor is usually not indicated in early stages where as in late stages it should be done. Occasionally the supernumerary tooth can be approached by palatal mucoperiosteal flap or buccal flap.
If there is adequate space in the arch for the unerupted incisor following supernumerary removal, space maintenance can be done or if there is inadequate space a need for space regainer with interceptive procedures may be required.
In other words, management can be summarized into three groups.
1. Remove supernumerary teeth or tooth only.
2. Remove supernumerary teeth and bone overlying impacted teeth and replacement flap if the tooth is deeply placed or exposure if superficially placed.
3. Remove supernumerary teeth and exposure of an unerupted tooth in all cases with or without bonded attachment for orthodontic traction.
Other methods of management of crowding or impaction due to supernumerary are:
1. Orthodontic forces are delivered to the impacted tooth with steel ligatures directed to fixed appliances after a mucoperiosteal flap was reflected with brackets attached to impacted tooth.
2. Orthodontic treatment for crowding with edgewise brackets and 0.016 S.S archwire with multiple loop.
3. Orthodontic traction after removal of overlying bone.
4. Incision of fibrous tissue over the alveolar ridge to promote the eruption.
The concept for treatment of supernumerary teeth can also be divided into four stages as follows.
a. Serial examination of primary teeth to make way for permanent teeth.
b. Removal of supernumerary teeth.
c. Orthodontic traction or surgical exposure to help the teeth erupt.
d. The tooth which does not erupt after surgical exposure or orthodontic traction needs extraction and replacement.
A thirteen year old male child reported to the department of pedodontics and preventive dentistry with the chief complaint of extra tooth in the lower front region. History given by father suggested that the tooth was erupting since one year. The family and medical history was non contributory. Dental history showed that he visited a dentist around 4 years back for cleaning of teeth. Extra-oral examination did not show any abnormality.
Intra-oral examination [Figure 1],[Figure 2],[Figure 3]
On intra oral examination of the child a complete set of permanent dentition in both the maxillary and mandibular arches were seen with a presence of supernumerary supplemental central incisor with morphology similar to that of permanent mandibular central Incisor in the right region which by itself is a rare condition. There was slight lower anterior crowding with labially placed and rotated central incisor and supplemental twin lingually placed and tilted from alignment with other adjacent teeth.
On soft tissue examination of the tongue, labial, palatal, buccal mucosa, floor of the mouth and palate showed no additional abnormalities. Slight gingival recession was seen in relation to labially placed supernumerary tooth.
O.P.G. could not be taken because the patient was not able to afford it therefore a intra oral periapical radiograph was taken which showed the complete root configuration with sound and healthy periodontium, intact lamina dura in relation to central Incisor and its supplemental win. The crown and root morphology of both teeth were also identical [Figure 4].
It is usually difficult to distinguish the normal tooth from its supplemental 'twin'. The management depends upon the type and position of these teeth and their effects on adjacent teeth. If the tooth is not interfering with the development and eruption with no pathologic changes the correct decision may be observation of the tooth till the child is old enough to undergo surgical procedure. But in present case the child was cooperative and there was crowding of lower incisor along with esthetic problem and oral hygiene maintenance. If both teeth are equally well formed the tooth that is displaced the most is to be extracted. Therefore in this case we extracted the most displaced supplemental supernumerary central incisor twin under local anesthesia [Figure 5],[Figure 6]. Later on the patient was advised for wait and watch policy for correction of ligually placed mandibular central Incisor or undergo orthodontic correction of crowding with simple removable appliances.
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