Management of Multiple Supernumerary Teeth Followed by Fixed Appliance Therapy: A Case Report
Corresponding Author: Rabia Ishrat Ullah, Department of Pedodontics & Preventive Dentistry, Career Post Graduate Institute of Dental Sciences & Hospital, Lucknow, Uttar Pradesh, India, Phone: +91 9198658435, e-mail: email@example.com
Received on: 17 May 2023; Accepted on: 13 June 2023; Published on: 23 August 2023
Aim and objective: This case report aims to describe the treatment of a malocclusion resulting from the presence of multiple supernumerary teeth.
Background: Most of the time, the presence of supernumerary teeth does not produce any clinical manifestations; nonetheless, in the case of mesiodens, if left untreated, it can lead to further orthodontic complications.
Case description: This case report presents a case of a 10-year-old child showing multiple supernumerary teeth. Surgical intervention followed by orthodontic therapy was the treatment opted for.
Conclusion: Extraction of supernumerary teeth, followed by fixed appliance therapy, is one of the best available treatment options.
Clinical significance: The importance of recognizing the possible consequences associated with supernumerary teeth and preventing them should be well understood.
How to cite this article: Ullah RI, Dwivedi S, Mishra A, et al. Management of Multiple Supernumerary Teeth Followed by Fixed Appliance Therapy: A Case Report. J South Asian Assoc Pediatr Dent 2023;6(1):77-81.
Source of support: Nil
Conflict of interest: None
Patient consent statement: The author(s) have obtained written informed consent from the patient’s parents/legal guardians for publication of the case report details and related images.
Keywords: 2 × 4 appliance, Case report, Impacted, Mesiodens, Supernumerary teeth.
A supernumerary tooth is an additional tooth to the normal dentition, which can be found in all the quadrants of the jaw. The etiology behind the supernumerary teeth has not been completely understood. It has been put forward that supernumerary teeth arise from a third tooth bud developing from the dental lamina, which is in proximity to the permanent tooth bud or possibly by splitting of the permanent bud itself. Another theory, well established in the literature, is the hyperactivity theory, according to which supernumeraries develop as a result of local, independent, and conditioned hyperactivity of the dental lamina. The development of supernumerary teeth seems to exhibit a hereditary tendency in some cases. Supernumerary teeth can be categorized based on morphology and location. Conical, tuberculate, supplemental, and odontome are the different morphological types of supernumerary teeth that have been described. An increased prevalence of supernumerary teeth is commonly associated with cleft lip and palate, cleidocranial dysplasia, and Gardner syndrome.1
An incidence of 0.3–0.8% is seen associated with deciduous dentition, whereas it accounts for 1.5–3.5% in permanent dentition. It has been observed that the maxilla shows the highest prevalence of supernumerary teeth, with the highest frequency seen in the premaxilla region. Males show a higher predilection as compared to females (2:1). The supernumerary teeth present in the maxillary anterior supernumerary may (25%) or may not erupt into the oral cavity and stay unerupted.
Most of the time, the presence of supernumerary does not produce any clinical manifestations; nonetheless, in the case of mesiodens, if left untreated, it can lead to further orthodontic complications such as the over-retention of deciduous incisors, delayed or ectopic eruption of permanent maxillary incisors, displacement and rotation of anterior teeth, crowding, development of midline diastema, and can erupt in the floor of the nasal cavity. Apart from that, it might as the origin of the development of follicular or primordial cysts, which might further cause massive bone destruction and root resorption of the adjacent teeth.2
Interceptive orthodontics plays an important role in stopping the developing malocclusion. If intercepted at an appropriate age, it will definitely lessen the severity of the malocclusion. Nowadays, there is a surge in the use of 2 × 4 appliances to treat various types of malocclusions. This appliance includes brackets which are bonded to the maxillary incisors, bands on the first permanent molars, and continuous archwires in order to deliver good arch form and control anterior teeth.
This case report presents a case of a 10-year-old child with the presence of two mesiodens (one erupted and one unerupted). Surgical intervention opted for the impacted mesiodens, following which the patient underwent fixed orthodontic therapy. The purpose of this case report is to highlight the importance of intercepting malocclusion at the mixed dentition stage and eliminating its cause at the appropriate age in order to avoid deleterious repercussions.
A 10-year-old patient reported to the Department of Pediatric and Preventive Dentistry with a chief complaint of pain in the lower right back region of the jaw for 10–15 days. On intraoral examination, the 85 was found to be grossly decayed, and mesiodens were also observed (Figs 1A to C).
Radiographic examination revealed multiple supernumerary teeth in the maxillary anterior region (Fig. 2).
On the first appointment, 85 was extracted under local anesthesia. Following this, erupted mesiodens were extracted under local anesthesia in the next appointment. For the impacted mesiodens, a panoramic radiograph and radiovisiography (RVG) were taken to confirm the position of the tooth (Figs 3 and 4).
The surgical procedure was explained to the patient’s parents, and informed written consent was taken. The infraorbital and nasopalatine nerve block was given to the patient. The impacted tooth was palpated on the palate near the permanent right central and lateral incisor. The palatal flap was raised with respect to the above-mentioned teeth starting from 12, 11, and extending to 21. As the crown of the tooth became visible, the tooth was elevated with the elevator and extracted with forceps. The flap was sutured back to its position (Fig. 5). Postextraction instructions were given to the patient, and he was recalled after 7 days.
After required investigating procedures, 1-month postsurgery, 2 × 4 appliance was planned for the correction of ectopically erupted maxillary left central incisor because of the mesiodens. After giving a proper explanation to the patient’s parents about the 2 × 4 appliance, informed consent was for the same. Brackets were placed on the maxillary central and lateral incisors and bands on the maxillary permanent first molars. 0.012 nickel-titanium (NiTi) archwire was placed initially as it is stiffer and will bring out a greater degree of movement. A transpalatal arch was given for anchorage (Fig. 6). The archwire was changed at every visit in a sequential manner; that is, it was replaced by a more flexible wire. The patient was recalled monthly for the next 2 months, and the archwire sequence was 0.014 NiTi followed by 0.016 NiTi arch wire (Figs 7 and 8, respectively). After the results were achieved, the appliance was debonded at the end of 3 months. The case was followed up for the next 3 months (Fig. 9).
Multiple supernumerary teeth, in the absence of any syndrome, are not very common. It is necessary to identify and locate the position of supernumerary teeth by clinical and radiographic diagnosis and plan the treatment accordingly. A difference of opinion exists regarding the definitive treatment in case of supernumerary involvement. However, removal of the mesiodens after diagnosis is one of the contemplated treatment options in order to avoid future complications.
As seen in the present case, multiple supernumerary teeth have been observed. Immediate removal of mesiodens was indicated as it had led to ectopic eruption of the maxillary incisors. A conclusive diagnosis and management of supernumerary teeth should be made only after thorough clinical as well as radiographic analysis. An orthopantomagram is one of the indicated radiographs required to screen the entire maxilla and mandible. With the upcoming advanced technologies, the use of cone-beam computed tomography (CBCT) can be done to locate the exact position as well as to analyze the structures in proximity to the tooth. However, in the present case. CBCT was not required as the impacted tooth was palpable on the palate without any difficulty. To determine the exact location (buccal or palatal) of the impacted mesiodens, the buccal object rule is indicated. Gomes et al. showed that the most accepted mode of treatment was surgery followed by orthodontic therapy, that is, in 62.0% of cases. In most cases, after the definitive diagnosis, removal of mesiodens is indicated. Besides, as far as the patient’s well-being is considered, the tooth should be removed except where the surgery might cause damage to the adjacent structures.2 After a complete evaluation of clinical and radiographic outcomes, the risk of iatrogenic damage to the roots of the permanent incisors in the present case was minimal. Also, the surgical procedure was easy to manage under local anesthesia.
In order to achieve an occlusion that is esthetically sound and does not hamper the phonetics, the eruption pattern, position and morphology of the social six, that is, the maxillary anterior teeth, should be monitored throughout the mixed dentition stage.3
Removable appliances during the mixed dentition period are one of the most popular treatment options; although they do not compromise the oral hygiene of the patient and are more comfortable for the patient, they offer certain disadvantages, such as limited control over tooth position and unwanted tipping forces. But, excellent retention and extensive cooperation by the patient is also needed so as to achieve satisfactory results. On the contrary, the fixed orthodontic treatment offers excellent control of overactive forces necessary for appropriate tooth movements with the benefit of maximum patient comfort and the achievement of faster results. At this stage, more desired and efficient tooth movements can be accomplished by employing a sectional fixed appliance, that is, the 2 × 4 appliance, for the alignment of anterior teeth. Hence, this technique can be used to treat diastemas, rotations, and improper inclinations of teeth in an easier and quicker pattern (Dowsing).4 Application of light forces in comparison to strong forces appears to produce more reliable results with minimal number of inconsistencies seen among the gingival levels of the adjacent teeth.3 This particular appliance was chosen for this case as the patient had severe gag reflexes, and thus, compliance was expected to be very poor. Moreover, the patient’s esthetic concern demanded immediate and early results, which were achieved within 3 months. At the end of treatment, there was a difference in the gingival margin levels of both the central incisors. This was not intervened further owing to the fact that after the active eruption of the maxillary central incisors, a phase of passive eruption takes place. In passive eruption, migration of the gingival margin takes place labially up until it stabilizes approximately 1–2 mm from the cementoenamel junction.5 Self-correcting anomalies seen in the mixed dentition stage should be clearly understood and kept under supervision by the clinician before the commencement of any such treatment. In the present case, the ugly duckling stage, a self-correcting anomaly, was taken into consideration, and utmost care was taken to avoid unnecessary forces on permanent centrals and laterals to prevent its root resorption by the permanent canines.
In this case, if the mesiodens would not have been removed, the patient would have been esthetically compromised. Furthermore, the unerupted mesiodens might have caused a hazardous impact on the adjacent structures. Early surgical intervention and intercepting the malocclusion under well-planned conditions prevented further complications.
The presence of supernumerary teeth in the oral cavity should be examined thoroughly during the mixed dentition stage in order to avert further complications. Also, fixed appliance therapy should be outweighed the use of removable appliances as it renders faster and more reliable results. Diagnosing the cause of malocclusion and intercepting it in the mixed dentition stage plays a crucial role in the overall development of the child.
1. Sivapathasundharam B. Developmental disturbances of oral and paraoral structures. Shafer’s Textbook of Oral Pathology E-book. 2020 Jun 23;9:10–11.
3. Godhi BS, Shanbhog R, Chanchala HP. Interceptive management of ectopically erupting central incisor - a case report. J Indian Soc Pedod Prev Dent 2019;37(4):409–413. DOI: 10.4103/JISPPD.JISPPD_193_19
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