Supernumerary teeth- A Report of 6 different Cases

INTRODUCTION

Supernumerary teeth or hyperodontia is defined as the existence of an excessive number of teeth in relation to the normal dental formula. They can be present in the maxilla or in the mandible and can be only one, multiple, uni or bilateral. The reported prevalence of this abnormality varies between 1.5% and 3.5% in the permanent dentition in comparison with 0.3 to 0.6% in the deciduous dentition. Supernumerary teeth are more frequent in males than in females in a proportion of 2:1. The most frequent locations for supernumerary teeth are: the midline of the maxilla, palatal area of upper incisors, lower premolar area and distal of the upper and lower third molars. Regarding their morphology, supernumerary teeth are classified as supplementary (they duplicate the anatomy of anterior or posterior teeth) or rudimentary (dysmorphic, tubercular or conoid). Multiple hyperodontia can be associated with Gardner's syndrome, Fabry-Anderson syndrome, Ehlers-Danlos syndrome, labial palatal cleft or cleidocranial dysostosis¹ .

The exact etiology of supernumerary teeth is unknown, however, several theories have been postulated to try to explain their presence: the phylogenetic theory as a regression to the anthropoids whose dental formula had more teeth, the autonomic recessive inheritance or linked to the X chromosome, an abnormal reaction to a local traumatic episode, environmental factors, dichotomy of the tooth germ and the theory of hyperactivity of the dental lamina, are the most accepted¹ .

Morphology of teeth can be altered due to perturbations in the genetic process of odontogenesis. Developmental alterations in tooth shape include concrescence, gemination and fusion. Concrescence represents a rare developmental anomaly in which two fully formed teeth are joined along the root surfaces by cementum² . The incidence of concrescent teeth is reported to be highest in the posterior maxilla complicating exodontia and influencing endodontic, orthodontic, periodontal and even prosthodontic diagnosis and treatment planning as well³ . Concrescence may occur during root formation or after the radicular phase of development is complete. If the condition occurs during development, it is called true concrescence; if it occurs later, it is acquired concrescence⁴ . Although the exact aetiology of concrescence has not yet been explained, many authorities suspect that space restriction during development, local trauma, excessive occlusal force, or local infection after development play an important role. The union may vary from one small site to a solid cemental mass along the entire extent of approximating root surfaces⁴ . Concrescence can occur between normal molars, a normal molar and a supernumerary molar, and in both erupted and impacted teeth³ .

This article reports six different cases of supernumerary teeth with positional variability and their management.

CASE REPORTS

CASE 1

A 38-year-old male patient visited a private clinic with a chief complaint of pain in the left maxillary posterior tooth. Examination of the patient was done after obtaining an informed consent. There was no significant medical and family history. Intraoral examination revealed full set of permanent teeth in association with a completely erupted supernumerary molariform tooth (paramolar) found palatal to 28 (Figure 1A). The paramolar was causing discomfort to the patient but did not interfere with occlusion. 28 was periodontally compromised showing grade 1 mobility.

Intraoral periapical radiograph revealed a supernumerary emphasising the need for early management.tooth that was superimposed on 28 (Figure 1B). There was widening of periodontal ligament space on the mesial aspect of 28. Since the patient was not willing for periodontal therapy and due to inaccessibility, the tooth was planned for extraction. After radiographic and clinical examination, there was a suspicion of either fusion or concrescence of 28 with paramolar. Under local anesthesia, the third molar was extracted without difficulty. The third molar was found fused to the paramolar along the cementum (Figures 2A & 2B). On examination of the extracted specimen, the roots of both the teeth were fused from the cementoenamel junction throughout the root length.

CASE 2

A 28 year old male patient came with the complaint of decayed 47 and 48. On examination, a supernumerary tooth resembling premolar was present in the position of mandibular first molar (Figure 3A). Patient gave a history of extraction of 46, 10 years back due to dental caries. The supernumerary premolar was rotated buccolingually such that the buccal surface faced mesially and lingual surface distally with spacing between adjacent teeth, 45 and 47 (Figures 4A & 4B). The tooth was not in occlusion with opposing molar. ntraoral periapical radiograph showed single root with root nd length 2 mm shorter than the adjacent 2 premolar, but the overall morphology resembled mandibular first premolar (Figure 3B). There were no other supernumerary teeth or other anomalies noted.

CASE 3

A 42 year old male patient came to a private clinic, with the complaint of pain in the right lower third molar and rotated upper anterior teeth. The third molar was planned for extraction as it was pulpally involved. A mesiodens was found between 11 and 21 which was conical in shape causing rotation of 11 (Figure 5A). Intraoral periapical radiograph showed periodontal bone loss between mesiodens and 11 (Figure 5B). Patient was advised for extraction of mesiodens followed by orthodontic treatment to correct misalignment and improve aesthetics.

CASE 4

A 24 year old male patient came to a private clinic with a complaint of halitosis and sensitivity in his teeth. Patient gave a history of road traffic accident 6 months back which had caused fracture of some of his posterior teeth. On routine intraoral examination, a conical supernumerary tooth was found between 12 and 13 which was in line with the adjacent teeth, and was not malpositioned (Figures 6A & 6B). As the tooth was asymptomatic and the patient was unaware of this extra tooth, aesthetic correction was advised. Since the posterior teeth showed Elli's Class 2 fracture, they were restored with composite and GIC.

CASE 5

A 25 year old male patient came with the complaint of stains and deposits in his teeth. On clinical examination, a supernumerary tooth resembling lateral incisor was found located between 12 and 13 with spacing between them (Figure 7). Intraoral periapical radiograph showed root length similar to 12. Since the tooth was in line with the normal alignment of maxillary teeth and asymptomatic, patient was informed about the extra tooth and no treatment was planned.

CASE 6

A 26 year old female patient complained of pain in 47, 48 region. On intraoral examination a cusp was found projecting in the region of 48 giving the clinical impression of erupting 48 (Figure 8A). On intraoral periapical radiograph, horizontally impacted 48 and a conical, single rooted supernumerary tooth between 47 and 48 was found (Figure 8B). Extraction of both supernumerary tooth and 48 were done under local anaesthesia.

DISCUSSION

Supernumerary teeth are teeth in excess of the number found in the normal series. Etiology of development of supernumerary teeth is not clear. It may be due to dichotomy of the tooth bud or due to hyperactivity theory, suggesting that they are formed as a result of local, independent, conditioned hyperactivity of dental lamina. Classification of supernumerary teeth may be on the basis of position or form.

Positional variations include:

a. Mesiodens- present in the incisor region

b. Paramolars- present beside a molar

c. Disto-molars- present distal to the last molar

d. Parapremolars- present beside a premolar

Based on the shape, they are classified as

a. Conical- peg shaped teeth

b. Tuberculate- made of more than one cusp or tubercle. They are barrel shaped, usually invaginated

c. Supplemental- resemble normal teeth. May be an incisor, premolar or molar

d. Odontome- does not resemble any teeth but is only a mass of dental tissue

The supernumerary teeth can cause problems for the eruption and alignment of normal dentition. Associated problems can range from failure of eruption, displacement, crowding, adjacent teeth root resorption, formation of 5 dentigerous cyst or they can be just asymptomatic .

Case 1: Concrescence can occur between normal molars, a normal molar and a supernumerary molar, and in both erupted and impacted teeth. There are very few cases about the concrescence of permanent and supernumerary tooth. Case 1 had similar association with periodontitis, attachment loss including pocket formation and bone loss.

Concrescence is clinically nearly impossible to be detected. Due to lack of enamel involvement, the crowns of the affected teeth, if erupted, appear normal. Concrescence may defy radiographic detection as well; they may be misdiagnosed as simple radiographic overlap or superimposition of teeth. Additionally, a normal amount of cementum involved in the concrescence may also contribute to an inaccurate diagnosis⁶ .

The diagnosis of concrescence may occur only after a surgical mishap. Clinicians should be aware of this dental anomaly and should consider concrescence, if difficulty is encountered while extracting a tooth in the maxillary posterior region, to avoid the complications such as fracture of tuberosity or floor of maxillary sinus. Therefore, it is important for the clinician to consider the possibility of concrescence when planning extractions in which the roots of adjacent teeth are radiographically indistinguishable³ .

When the condition is suspected on clinical examination, a radiograph is necessary to detect the concrescence. Additional radiographic projections at different angles may be obtained to detect the condition more clearly⁴ . In the present case, the suspicion of concrescence was there on radiographic evaluation, but was confirmed only during extraction. Due to inaccessibility and patient's unwillingness for periodontal therapy, extraction was done.

Case 2 was interesting because mandibular premolars usually arise on the lingual aspect in the premolar region, but in the present case, it was exactly in the position of first molar when the patient was examined. With the available patient's history, we assume that initially the tooth was lingually placed, after extraction of first molar, the tooth must have migrated with rotation to the present position.

Case 3 signifies the importance of early recognition and removal of mesiodens with proper correction by orthodontic and aesthetic treatment which can prevent the occurrence of rotation, midline diastema, periodontal pocket formation, etc. Therefore in the present case, patient was advised for extraction of mesiodens, followed by orthodontic and periodontal therapy.

Since Cases 4 and 5 were asymptomatic and the supernumerary teeth were in line with the arch, no treatment was carried out for their correction.

Case 6: To the best of our knowledge and literature review, this is one of the rare cases to be encountered. Clinically it is highly impossible to suspect this case as supernumerary tooth because of its infrequent occurrence both in site and sex predilection wise. From the literature review, we could find many cases in which there was either fusion or non- fusion of lower third molar with a supernumerary tooth which was usually distally placed^{4, 7} . But our case report is different from the usual one which is non-fused and located between 47 and 48.

CONCLUSION

The present article reports six different cases of supernumerary teeth with variable clinical presentation. Complications associated with the presence of supernumerary teeth include malalignment of teeth, functional impairment, unaesthetic appearance, periodontitis, failure of a tooth to erupt, ectopic eruption, displacement of adjacent teeth, diastema, dilacerations, cyst formation, root resorption and loss of pulp vitality. Hence early diagnosis and management of supernumerary teeth helps in preventing unnecessary complications.