Orthodontic management of supernumerary teeth- a case report

Rahman MA1BDS, FCPS, Alam MM2 BDS, FCPS and Hossain MZ3 BDS, PhD

Abstract
Supernumerary tooth is one that is additional to the normal series and can be found in almost any region of the den-
tal arch .Mesiodens is the most common type of supernumerary tooth found in the premaxilla between two central
incisors. They may be single, multiple, unilateral or bilateral, erupted or unerupted in one or, both jaw. It usually
results in oral problems such as malocclusion, food impaction, poor aesthetics, and cyst formation. Early diagnosis
and treatment is suggested to prevent orthodontic and pathologic complications. This article highlights the ortho-
dontic management of a case of twenty five year old Bangladeshi male with two supernumeraries- one is a supple-
mental tooth erupted in the oral cavity causing malocclusion and another impacted mesiodens near the nasal floor.
The case was managed by a joint effort of maxillofacial surgeon and orthodontist. At first, maxillofacial surgeon
removed the two supernumerary teeth. After healing the orthodontic correction was done with fixed appliance using
multiloop edgewise technique. It took nearly 18 months to complete the treatment. The patient was happy with the
new appearance and function.

Key words: Supernumerary teeth, Mesiodens, supplemental teeth. (Ban J Orthod and Dentofac Orthop, Oct 2011;
Vol-2, No. 1, p 30-33)

INTRODUCTION present typically in between the maxillary central incisors

,Paramolar- present beside a molar, Distomolar- present distal to
Supernumerary tooth is one that is additional to the normal series the last molar and Parapremolar- in the premolar region. Cases
and can be found in almost any region of the dental arch1. involving one or two supernumerary teeth most commonly
Etiology of the development of supernumerary teeth is not clear. involve the anterior maxilla, followed by mandibular premolar
Atavism theory suggested that supernumerary teeth were the region. When multiple supernumeraries are present the most
result of phylogenetic reversion to extinct primates with three common site is the mandibular premolar.3,6,7
pairs of incisors. It may be due to dichotomy of the tooth bud2 or
due to localized, independent and conditioned hyper activity of The various problems associated with the supernumerary teeth
dental lamina3. Genetic factor also suggested since many inci- are: failure of the eruption of permanent teeth, or their displace-
dence of recurrence within the same family3,4 ment. They can also cause crowding, loss of tooth vitality due to
root resorption and may also be associated with pathology like
The supernumerary teeth may be single, multiple, unilateral or cyst. Occasionally, supernumerary teeth are not associated with
bilateral, erupted or unerupted and in one or, both jaws. Multiple any adverse effects and may be detected as a chance finding dur-
supernumeraries are rare in individuals with no other associated ing radiographic examination. Early extraction of supernumerary
disease or syndromes. Multiple supernumerary teeth are usually tooth is advocated to reduce treatment time and complications.8,9
associated with conditions such as cleft of the lip and palate or
syndromes like Cleidocranial Dysplasia and Gardner's syn- CASE REPORT
drome.5
A twenty five year old Bangladeshi male reported to the
The prevalence ranges between 0.3-0.8% in the primary denti- Department of Orthodontics and Dentofacial Orthopedics,
tion and 0.1-3.8% in the permanent dentition. Males are affected Dhaka Dental College and Hospital, Dhaka with a complaint of
approximately twice as often as females.1,5 irregular upper front teeth. His reason of attendance was to
improve his esthetics.
Supernumerary teeth are classified according to morphology and
location. In the primary dentition, morphology is usually normal
or conical. There is a greater variety of forms presenting in the
permanent dentition. There are four morphological different
types of supernumerary teeth; Conical( most common with trian-
gular or conical- shaped crown and complete root formation,6
Tuberculate (Barrel shaped appearance and a crown consisting of
multiple tubercles with incomplete or absent root formation ),
Supplemental (morphological resemblance of a normal tooth,
most often a permanent maxillary lateral incisor) and Odontome
(numerous small tooth like structures or a single irregular mass).
They are also classified on the basis of location: Mesiodens-
Figure 1: Pre-treatment extra-oral facial photographs

30
1Lt Col Md. Anisur Rahman, BDS, FCPS (Orthodontics) Department of Orthodontics. Dhaka Dental College, Dhaka, 2Lecturer,
Department of Orthodontics and Dentofacial Orthopedics, Dhaka Dental College and Hospital, 3Professor and Head Department of
Orthodontics and Dentofacial Orthopedics, Dhaka Dental College and Hospital
Rahman MA, Alam MM and Hossain MZ

On extra-oral examination of the patient had a square face form

and a straight profile and a pleasant outlook. Intra oral examina-
tion revealed a supplemental tooth, which was erupted behind the
right upper central incisor and posed obliquely to the incisal edge
of the left upper central incisor tooth. Right upper central incisor
was proclined over the right lateral incisor. While remaining
other teeth were in the normal alignment. He had full set of per-
manent dentition with class I molar and canine relationship and
an overbite and over jet of 1 mm. Midline coincided. Oral
hygiene of the patient was good with little staining of teeth.

Figure-2: Pre treatment intraoral photograph

A panoramic x-ray confirmed the presence of an impacted

mesiodens between the root apices of upper two central incisor
Figure 3c : Pretreatment ,lateral cephalogram tracing
tooth and a supplemental tooth along with normal complement
of teeth present (Fig. 3a). X-ray lateral cephalogram (Fig. 3b)
along with tracing was done as routine orthodontic pre treatment Table-1: pre treatment lateral cephalometric tracing results
procedure (Table-1).
Parameter Reference Patient's
Measurement8 Measurement
(± 2°)

SNA (angle) 82° 83°

SNB (angle) 80° 80°
ANB (angle) 2° 3°
Upper 1 to NA (mm) 4mm 4 mm
Upper 1 to NA (angle) 22° 23°
Lower 1 to NB (mm) 4mm 6mm
Lower 1 to NB (angle) 25° 27°
Figure 3a : Pretreatment OPG Inter incisal angle 131° 125°

Interpretation-A Class I skeletal jaw relationship with average

inclinations of the maxillary and mandibular incisors.

Figure - 4: Pre treatment intra oral photographs of models

Figure 3b : Pretreatment cephalogram

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Bangladesh Journal of Orthodontics and Dentofacial Orthopedics (BJO and DFO)
Vol. 2, No. 1, October 2011
Orthodontic management of supernumerary teeth- a case report

Tooth jaw discrepancy Post treatment OPG ( fig.7) shows space closure, root paral-
lelism and absence of supernumeraries.
Upper arch
Arch perimeter -Total tooth material

= 74mm - 79mm
= -5 mm

Lower arch
Arch perimeter -Total tooth material

=63mm - 65mm
= -2mm

Pre treatment model analysis shows crowding in both the arches

due to tooth jaw discrepancy. He was diagnosed as a case of class Figure-7: Post treatment OPG
I malocclusion with supplemental tooth in between upper central
incisor teeth and an impacted mesiodens near the root apices of
upper central incisors. A multidisciplinary approach was adopted
for the management of the case. The patient was referred to max- Table-2: post treatment lateral cephalometric tracing results
illofacial surgeon for extraction of the impacted mesiodens along
with the supplemental tooth. After that he was supervised for Parameter Reference Patient's
orthodontic intervention (fig.5) Measurements Measurement
(± 2°)

SNA (angle) 82° 83°

SNB (angle) 80° 80°
ANB (angle) 2° 3°
Upper 1 to NA (mm) 4mm 4 mm
Upper 1 to NA (angle) 22° 23°
Figure-5: Extracted supernumeraries and post extraction upper jaw
photograph Lower 1 to NB (mm) 4mm 6mm
Lower 1 to NB (angle) 25° 27°
Standard edgewise appliance was fitted and a standard arch wire Inter incisal angle 131° 125°
sequence of 0.014-inch multi loop SS wire. A segmented arch
wire of 0.016-inch SS wire with closing loop was incorporated Post treatment lateral cephalometric tracing shows Class I
between the upper central incisors. A stop loop was given distal skeletal pattern with average incisor inclination.
to left upper central incisor. The left side of the arch wire was
engaged in bracket channel upto first molar, while on the right
side it was engaged only to the central incisor tooth to facilitate
its movement without putting pressure on anchor teeth. Once the
arches were fully aligned and space was closed, finishing and
detailing of teeth was done with 0.016 inch round wires.
Following debonding, upper Hawley retainers were used to
maintain. The patient was advised to wear the retainers full time
for six month, then night-time use might be sufficient as long as
he could. He was instructed for a quarterly follow up schedule.

Figure-8: Post treatment intra oral photographs

Figure-6: Treatment progression (closing space and detailing occlusion) of models

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Bangladesh Journal of Orthodontics and Dentofacial Orthopedics (BJO and DFO)
Vol. 2, No. 1, October 2011
Rahman MA, Alam MM and Hossain MZ

Figure-9: Post treatment intra oral photographs of both jaws

DISCUSSION REFERENCES

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Early diagnosis and appropriate management can minimize the
potential complications caused by supernumerary tooth.
Whatever the etiology is, it is the duty of the practitioner to rec- Corresponds to:
ognize the signs suggesting the presence of supernumerary tooth.
Extraction in mixed dentition helps spontaneous alignment of the Dr. Md. Anisur Rahman
adjacent tooth. Orthodontic intervention in time is immensely BDS, FCPS (Orthodontics)
Department of Orthodontics.
beneficial to patients from esthetic and functional point of view.
Dhaka Dental College, Dhaka

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Bangladesh Journal of Orthodontics and Dentofacial Orthopedics (BJO and DFO)
Vol. 2, No. 1, October 2011