Mesiodens- A common supernumerary tooth: Report of management of a case with two mesiodens

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1 41 CASE REPORT Mesiodens- A common supernumerary tooth: Report of management of a case with two mesiodens Dr. ZeeshanSheikh 1,2,3,4 (Dip.Dh, BDS, MSc, PhD, Post-Doctoral Fellow) Dr. Amir Manzoor 5 (BDS,MSc) Dr. Nida Amir 5,6 (BDS, MSc, MSc-Paed-DentResident) 1 Faculty of Dentistry, Division of Biomedical Sciences, McGill University, Montreal. Quebec, Canada 2 Faculty of Dentistry, Matrix Dynamics Group, University of Toronto. Ontario, Canada. 3 Department of Material Sciences & Preclinical Dentistry.Altamash Institute of Dental Medicine (AIDM), Karachi, Pakistan 4 Department of Oral Anatomy.Altamash Institute of Dental Medicine (AIDM), Karachi, Pakistan 5 Faculty of Dentistry, Division of Oral Health and Society, McGill University, Montreal Quebec, Canada 6 Department of Paediatric Dentistry, Nobel Biocare Oral Health Centre, University of British Columbia, Vancouver, British Columbia, Canada Corresponding Author Dr. Zeeshan Sheikh address: zeeshan.sheikh@mail.mcgill.ca Tel: Access this Article Online Quick Response Code Use the QR Code scanner to access this article online in our database Article Code: IDJSR 0114 Abstract Supernumerary teeth can be present in both the primary and the permanent dentitions, however, they are almost five times more frequently observed in the permanent dentition. The supernumerary teeth are also reported to be more common in the male, rather than thefemale population. The most commonly occurring supernumerary tooth is the mesiodens, occurring in 0.15% to 1.9% of the population. The exact etiology of supernumerary teeth remains largely unknown. Early diagnosis of mesiodens allows prompt management and prevents the need for extensive treatment and development of associated complications. Spontaneous eruption and alignment of incisors can be potentially initiated by extracting the mesiodens in the early mixed dentition stage. However, if the incisors fail to erupt even after extraction, surgical and orthodontic interventions may be required. Key Words: Tooth; Supernumerary; abnormalities; Diagnosis. Incisor Preamble Hyperdontia is a condition of having supernumerary teeth, whichare defined as extra teeth present in addition to the normal dentition number(1). The prevalence of hyperdontia is reported to be between 0.15% and 3.9% (2-7). Supernumerary teeth can be present in both the primary and the permanent dentitions, however, they are almost five times more frequently observed in permanent dentition (8-10). Also supernumerary teeth are reported to be more common in the male rather than in female population (11). The most commonly occurring supernumerary tooth is the mesiodens, which means middle tooth (12, 13). A mesiodens is located in the maxillary central incisor region, having an overall prevalence between 0.15% and 1.9%(1, 8-11, 14). The occurrence of mesiodens may be single, multiple, unilateral or bilateral, and they may often fail to erupt. Mesiodentes is the name given to the presence of multiple supernumerary teeth in the same dentition (14). The presence of mesiodentes has the potential to affect patient appearance and occlusion by the alteration of the natural eruption path of permanent incisors(1, 15,16). Incidence Supernumerary teeth mostly occur in the maxilla (~80-90%)(1, 2, 17), and ~50% of them are found in the anterior region(1, 15, 17). Around 85% of all anterior supernumerary teeth do not erupt, and

2 42 ~65% of them interfere with the natural eruption pathway of maxillary permanent incisors(7). The supernumerary teeth that do erupt can do so at any age, but usually this eruption is observed between the ages of 3 and 7 (18). This usually results in the resorption of primary central incisors and eruption in their place or in the palate (18). Roughly 25% of all patients who present with a mesiodens have other supernumerary teeth also present. Conversely some patients also present with mesiodentes, along with congenitally missing teeth(16, 19). Etiology Supernumerary teeth have been found and reported in ancient human skeletons from the Lower Pleistocene era (20) and in the remains of an Australian aboriginal human years ago (21). The exact etiology of supernumerary teeth remains largely unknown.patients with craniofacial anomalies (cleft lip and palate) and having conditions such as Gardner s syndrome and cleidocranial dysplasia frequently present with having mesiodentes(22, 23). The theory of dichotomy proposes that two teeth are created from the splitting of a single tooth bud, one of which is a mesiodens(10). Another theory suggests that the origins of mesiodentes is related directly to the hyperactivity of dental lamina (1). The dental lamina or palatal extensions of active dental lamina are guided via cell induction towards development of the extra tooth bud (1). Mesiodentes have also been seen to be present in siblings, twins and subsequent generations of a single family with inter marriages hence providing the possibility of a role of genetics(5, 24). The proposed genetic theory is that of autosomal dominant inheritance with partial infusion (10). Since males are twice as frequently affected with the presence of supernumerary teeth than females, a sex-linked pattern has been proposed as well(2, 17, 25). Types Mesiodentes are classified on the basis of their occurrence in the primary dentition (supplementary mesiodentes)or the permanent dentition (rudimentary mesiodentes) (1, 25). Supplementary mesiodentes resemble natural teeth in both shape and size, whereas rudimentary mesiodens are characterised by having an abnormal shape and smaller size(1). According to shape, the mesiodens can be conical, tuberculate or molariform(1, 12, 25). Conical or peg shape is usually associated with single occurring mesiodentes. These are usually present palatally between the deciduous maxillary central incisors and displace the erupting permanent incisors(1, 17, 25). Mesiodentes having completely formed roots often erupt into the oral cavity(1, 26, 27). Conversely, if they are inverted, they are less likely to erupt in the oral cavity and occasionally erupt into the nasal cavity(28). Tuberculatemesiodentes are usually drum-shaped having multiple tubercles or cusps with abnormal roots. They are commonly associated with other supernumerary teeth and may develop unilaterally or bilaterally occupying a more palatal position in comparison with conical mesiodens(17, 29). These supernumerary teeth rarely erupt but delay the eruption of permanent incisors(1, 25). Molariformmesiodentes are rare and have a premolar-like crown shape with a completely formed root(1). Diagnosis Asymmetry in the eruption pattern of the maxillary incisors and retention of maxillary primary incisors should alert the clinician towards the possibility of the presence of mesiodentes. This should especially be suspected if the over-retention is asymmetric or there is an ectopic eruption of one or both permanent maxillary incisors(1, 16, 23, 30). Panoramic, periapical and maxillary occlusal radiographs assist in the diagnosis of the existing mesiodentes. Since only ~25% of them ever erupt, it is imperative to utilise and obtain radiographic evidence of their presence in order to manage them in a systematic manner (30). Although, panoramic radiographs help provide additional information about the associated supernumerary or congenitally missing teeth, these alone often give limited evidence of mesiodens because of lack of clarity in the midline region. The mostaccurate radiographic method to locate a mesiodens is by using 2 periapical or maxillary occlusal films, which are analyzed according to the parallax rule (31). This permits identification of the path of eruption and the location of the impacted mesiodens relative to adjacent structures(32). Complications and Management Maxillary incisor eruption and alignment is commonly affected by the presence of mesiodens(33-36). Erupted mesiodens often result in crowding of teeth(37). Eruption can be prevented in roughly 26 to 52% of cases, rotation of a central incisor in 28 to 63% of cases, ectopic eruption can take place along with labial displacement of incisors in 83% of cases(1, 34). Dilaceration of the developing roots, loss of tooth vitality and root resorption is also occasionally observed. The mesiodens can erupt into the nasal cavity(38, 39) and development of dentigerous cyst is also a distinct possibility(16, 24, 26-28, 40-43). An 11- year retrospective study reported 11% cases had cyst formation when supernumerary teeth were observed(44).

3 43 The type and positioning of the mesiodentes dictate the management. Mesiodens can be extracted early, before root formation or late, after root formation of the central incisors(22). Some authors have recommended extraction of mesiodens in the early mixed dentition stage, in order to encourage spontaneous eruption and alignment of the central incisors(42, 45, 46). Case Report Patient with two mesiodens teeth A 28-year, 4-monthold male presented to the dentist s office with the complaint of being dissatisfied with his appearance and wanted to get his smile fixed as he was getting married in a few months. Hismedical history was unremarkable, and there was no history of dental trauma. Oral examination revealed a complete secondary dentition in Class I occlusion with 2 conical shaped supernumerary teeth in between the maxillary central incisors (Fig. 1). ~8mm. After extraction of the two mesiodens (Fig. 2), elective root canal treatments were performed for the right and left central incisors along with enameloplasty(fig. 2) to use these teeth as abutments for the four unit porcelain fused to metal (PFM) bridge to be constructed. Figure2. Intraoral-view after extraction of bothmesiodens teeth. Diastema of 8 mm after extraction is exhibited. The pontics of this bridge would serve as central incisors and the original central incisors would become lateral incisors (Fig. 3). Figure1. Facial view of patient showing mesiodens. No restorations or caries were evident and the periodontal status was satisfactory. Heconsented to a periapical radiograph (not available to show), which revealed twomesiodens that had fully erupted between the left and right maxillary incisors. No signs of root resorption were observed for the incisor teeth. The left maxillary incisor appeared to be slightly rotated (Fig. 1). A subsequent panoramic radiograph revealed no other abnormalities (not available to show). The patient indicated that he did not have any dental insurance and previously did not have the resources to get the required treatment during his childhood and adolescent years. It was decided and explained to the patient that one option for treatment was to extract the two mesiodens teeth and provide him with a fixed prosthesis to improve his appearance. The patient consented to the proposed treatment and subsequently full mouth impressions were taken to develop study casts. Closer evaluation of the study casts revealed that upon extraction of the two mesiodens there would be a midline diastema of Figure3. Fixed, tooth supported prosthesis (bridge) showing central incisors as pontics and natural central incisors shaped into lateral incisors working as abutments. The existing lateral incisors where shaped to resemble canines and the original canine teeth were rounded to reduce the sharpness resembling first premolar shape (Fig. 4).. Figure4. Intraoral-view showing natural left maxillary lateral incisor shaped as left maxillary canine and the natural left maxillary canine shaped into maxillary left first premolar.

4 44 The patient returned 6 months later for a periodic check-up (Fig. 5). He reported that he was very satisfied with the appearance and had no difficulties to report. Figure5. Photograph taken after six months of treatment with the patient s smile showing acceptable aesthetics. Conclusion The most common form of supernumerary teeth arethe mesiodens. In most cases, early diagnosis and treatment can lead to successful management and do not require extensive treatment. In this case, an adult male resented with two mesiodens in place of the natural maxillary central incisors. Despite being in his late twenties, the male patient was successfully managed and rehabilitated functionally and aesthetically with results that pleased him. A fixed prosthesis such as PFM crown was able to provide the necessary aesthetes and functional form that is important for anterior maxillary teeth. The adjacent maxillary central and lateral incisors and canines were shaped accordingly to represent the correct shape and form of the teeth that occur naturally in the maxillary arch, after the placement of the prosthesis. Despite having a diastema of 8 mm after the removal of the supernumery teeth, the patient did not require orthodontic treatment and prosthodontic treatment was deemed suitable to manage this case. In a 6 month post-follow up the patient reported that he was pleased with the treatment and had received the results that he had desired. References 1. Primosch RE. Anterior supernumerary teeth--assessment and surgical intervention in children. Pediatric dentistry. 1981;3(2): Epub 1981/06/ Bergstrom K. An orthopantomographic study of hypodontia, supernumeraries and other anomalies in school children between the ages of 8-9 years. An epidemiological study. Swedish dental journal. 1977;1(4): Epub 1977/01/ Brook AH. Dental anomalies of number, form and size: their prevalence in British schoolchildren. Journal of the International Association of Dentistry for Children. 1974;5(2): Epub 1974/12/ Brook AH. The prevalence of dental anomalies in year old children: a comparison of continuous and discontinuous residents of a natural fluoride area. Proceedings of the British Paedodontic Society. 1974;4:7-12. Epub 1974/10/ McKibben DR, Brearley LJ. Radiographic determination of the prevalence of selected dental anomalies in children. ASDC journal of dentistry for children. 1971;28(6): Epub 1971/11/ Brabant H. Comparison of the characteristics and anomalies of the deciduous and the permanent dentition. J Dent Res. 1967;46(5): Epub 1967/09/ Luten JR, Jr. The prevalence of supernumerary teeth in primary and mixed dentitions. Journal of dentistry for children. 1967;34(5): Epub 1967/09/ Sykaras SN. Mesiodens in primary and permanent dentitions. Report of a case. Oral surgery, oral medicine, and oral pathology. 1975;39(6): Epub 1975/06/ Sykaras SN. Totally inverted mesiodens. Oral surgery, oral medicine, and oral pathology. 1975;39(5):834. Epub 1975/05/ Sedano HO, Gorlin RJ. Familial occurrence of mesiodens. Oral surgery, oral medicine, and oral pathology. 1969;27(3): Epub 1969/03/ Van Buggenhout G, Bailleul-Forestier I. Mesiodens. European journal of medical genetics. 2008;51(2): Epub 2008/02/ Prabhu NT, Rebecca J, Munshi AK. Mesiodens in the primary dentition--a case report. Journal of the Indian Society of Pedodontics and Preventive Dentistry. 1998;16(3):93-5. Epub 2000/01/ Alberti G, Mondani PM, Parodi V. Eruption of supernumerary permanent teeth in a sample of urban primary school population in Genoa, Italy. European journal of paediatric dentistry : official journal of European Academy of Paediatric Dentistry. 2006;7(2): Epub 2006/07/ Gallas MM, Garcia A. Retention of permanent incisors by mesiodens: a family affair. British dental journal. 2000;188(2):63-4. Epub 2000/02/ Marya CM, Kumar BR. Familial occurrence of mesiodentes with unusual findings: case reports. Quintessence Int. 1998;29(1): Epub 1998/06/ von Arx T. Anterior maxillary supernumerary teeth: a clinical and radiographic study. Australian dental journal. 1992;37(3): Epub 1992/06/ Hattab FN, Yassin OM, Rawashdeh MA. Supernumerary teeth: report of three cases and

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