A

GNIESZKA

N

ĘCKA

, J

OANNA

A

NTOSZEWSKA

Management of Double Supernumerary Teeth
– Case Report

Postępowanie z podwójnymi zębami nadliczbowymi – opis przypadku

Department of Dentofacial Orthopedics and Orthodontics, Silesian Piasts University of Medicine in Wroclaw, Poland

Dent. Med. Probl. 2007, 44, 2, 271–274
ISSN 1644−387X

CLINICAL CASE

© Copyright by Silesian Piasts University of Medicine in Wrocław
and Polish Stomatological Association

Supernumerary teeth are qualified as a disorder

of odontogenesis, relatively common in an oral cav−
ity and characterized by an excess number of teeth.
The term mesiodens describes a supernumerary
tooth located between maxillary central incisors.
There is an evidence supporting concept of mesio−
dens being the most commonly appearing supernu−
merary tooth, followed by supernumerary premo−
lars, supernumerary laterals and fourth molars [1].
Such an anomaly, located in premaxilla, is usually
recognized as a single extra−tooth. Revealing bilater−
ally located mesiodentes is relatively rare.
Supernumerary teeth prevail in males and, most fre−
quently, they are conically shaped, although tuber−

culate−shaped ones were also reported [2]. The com−
plications associated with untreated supernumerary
teeth – despite their shape and number – include:
overretention of primary teeth, delayed eruption of
permanent incisors, rotations, impaction, diastema,
pulp necrosis and root resorption [3].

The present case describes another risk factor

associated with delayed removal of a mesiodens,
such as intrusion of maxillary permanent incisors,
development of class II division 1 and increased
overjet. In such cases surgical treatment of premo−
lar−resembling, palatally placed supernumerary
teeth was unavoidable, what was also emphasized
in the presented report.

Abstract

Supernumerary teeth are qualified as a disorder of odontogenesis characterized by an excess number of teeth pos−
sibly causing different dental and occlusal irregularities. The authors presented a case of premolar−resembling
supernumerary teeth located bilaterally in premaxilla, causing: shortening of clinical crowns of upper permanent
incisors, class II division 1 malocclusion and an increased overjet. Extraction of supernumerary teeth performed at
one surgical procedure not only enabled eruption of central incisors but also resulted in the overjet decrease.
Impacted centrals appeared in the oral cavity a week after surgery, what led to the conclusion that early diagnosis
and surgical treatment of premolar−resembling, palatally placed couple of mesiodentes are essential to support nor−
mal occlusion (Dent. Med. Probl. 2007, 44, 2, 271–274).

Key words: orthodontics, supernumerary teeth.

Streszczenie

Zęby nadliczbowe zalicza się do zaburzenia odontogenetycznego charakteryzującego się zwiększeniem liczby
zębów, czego następstwem mogą być nieprawidłowości zębowe i okluzyjne. Autorki opisały przypadek dwóch
zębów nadliczbowych znajdujących się w przednim odcinku szczęki, które były przyczyną: skrócenia górnych
stałych zębów siecznych oraz II klasy z grupą 1 i 3 powiększonego nagryzu poziomego. Jednoczasowa ekstrakcja
obu zębów dodatkowych nie tylko umożliwiła wyrzynanie się przyśrodkowego zęba siecznego, ale również
doprowadziła do zmniejszenia nagryzu poziomego. Zatrzymane przyśrodkowe zęby sieczne pojawiły się w jamie
ustnej zaledwie tydzień po zabiegu, co pozwoliło wnioskować, że wczesna diagnostyka i chirurgiczne usunięcie
pary zębów dodatkowych położonych podniebiennie w obrębie zębów siecznych są istotne do utrzymania prawi−
dłowej okluzji (Dent. Med. Probl. 2007, 44, 2, 271–274).

Słowa kluczowe: ortodoncja, zęby nadliczbowe.

Case Report

The patient, a Caucasian 11−year−old male pre−

sented for orthodontic examination due to absence
of permanent upper central incisors, despite pri−
mary incisors exfoliated within normal age.
Objective extraoral examination revealed convex
profile, mainly caused by protrusion of upper lip
resting on overgrown premaxilla (Fig. 1). Lack of
upper centrals and increased, overjet coincided
with excessive development of premaxilla, so
a routine panoramic radiograph was taken in order
to asses possible reason of delayed eruption of
permanent incisors. The orthopantomogram of
early mixed dentition stage showed all the germs
of permanent teeth including third molars,
although delayed eruption of lower premolars and
permanent canines was evident (Fig. 2a). Two
supernumerary teeth were diagnosed in the area of
upper permanent central incisors, causing their
improper angulation: separation of the roots and
mesial inclination of the crowns. Another radio−
logical projection was performed in order to con−
firm initial diagnosis and to find out the precise
location and anatomical features of supernumerary
teeth; thus their palatal position and incomplete
apex formation were observed (Fig. 2b).

Eventually, the upper right incisor showed

symptoms of the delayed eruption, but it was
stopped once it reached half of the crown−length;
the left maxillary incisor was still clinically absent.
Treatment plan called for extraction of both super−
numerary teeth (Fig 3a, b), although the right
supernumerary tooth did not interfere with erup−
tion of its permanent successor. Importance of
obstacles removal in order to facilitate tooth−erup−
tion became evident in this case where the left
upper central incisor appeared in the mouth mere−
ly a week after operation (Fig. 4a) and the right
counterpart showed eruptive activity again. The
overjet was slowly decreasing, nevertheless mal−
occlusion is still to be eliminated, so activator has
been planned in order to correct class II molar rela−
tionship (Fig. 4b, c).

Discussion

Recognition of dental anomalies is essential in

determining appropriate treatment for each patient.
Diagnosis and assessment of mesiodens are essen−
tial for proper management of the patient. Data
derived from diagnostic radiographs, together with
clinical care are important steps in the treatment of
supernumerary teeth. According to Kupietzky et al.
[3], surgical removal of a mesiodens is one of the
best therapeutical options, although the ideal tim−

ing of an operation still seems to be highly contro−
versial. Immediate intervention in young patients
could be very beneficial even in a case demanding
re−treatment with exposition of an incisor’s crown
and its gentle luxation [4]. Early surgical interven−
tion allows avoiding previously mentioned compli−
cations and their sequelae associated with untreat−
ed supernumerary teeth, such as ancylosis of the

A. N

ĘCKA

, J. A

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272

Fig. 1. Extraoral photo: apparently convex profile

Ryc. 1. Zdjęcie zewnątrzustne: ewidentnie wypukły
profil

Fig. 2. Initial radiograms: a – orthopantomogram,
b – occlusal view

Ryc. 2. Radiogramy początkowe: a – pantomogram,
b – projekcja na górną płytkę zgryzową

a

b

maxillary central incisors, cyst formation and – less
common – nasal eruption [5, 6]. Moreover, trau−
matic intrusion of maxillary permanent incisor
must not be neglected as the risk factor favoring
development of root resorption. Considering tran−
sient termination of eruptive potential of the right
incisor and increasing risk of apex injury, surgical
removal of supernumerary teeth was the treatment
option in the case presented.

Orthodontic management of impacted perma−

nent incisors adjacent to surgically removed super−
numerary teeth, also remains a distinct and contro−
versial problem. Foley emphasizes [7] that non−
−erupted permanent maxillary incisors with near
complete apical formation, associated with
palatally placed, tuberculate−shaped supernumer−
ary teeth, may benefit from having an orthodontic
bracket and gold chain placed at the same time as
the surgical procedure to remove the supernumer−
ary tooth to facilitate future orthodontic traction.
Such approach is supported clinically by preva−
lence of rotation, dilacerations of impacted perma−
nent incisors, where the orthodontic treatment
need became evident, especially when two mesio−
dentes interfered with eruption of permanent teeth
[8, 9]. Careful assessment of clinical conditions
after surgical exposure: location of supernumerary
teeth, placement of cingulum of permanent

incisors – those factors allowed predicting possi−
ble need of orthodontic forced eruption even in
case of double supernumerary teeth, thus bonding
of any orthodontic attachment was relinquished.

Moore at al. [10] reported sequential develop−

ment of multiple supernumerary teeth, emphasiz−
ing importance of radiological follow−up in any
case of mesiodens localised either in the maxilla or
the mandible. It supports the concept that screen−
ing intraoral radiographs are to be incorporated in
any orthodontic management of individuals with
revealed mesiodens.

Early diagnosis and timely intervention could

either prevent serious complications or limit ortho−
dontic treatment needs. Concluding, any delayed,
ectopic or asymmetric eruption of central incisors
should alert the clinician to the possibility of
a mesiodens always requiring careful monitoring
of the case.

Management of Double Supernumerary Teeth

273

Fig. 3. Surgical procedures: a – intra−operative proto−
col, b – extracted supernumerary teeth

Ryc. 3. Procedury chirurgiczne: a – zdjęcie śródopera−
cyjne, b – usunięte zęby nadliczbowe

a

b

Fig. 4. Intraoral pictures of treatment progress, a week
after surgery: a – en face, b – right side, c – left side

Ryc. 4. Zdjęcia wewnątrzustne z przebiegu leczenia,
tydzień po zabiegu: a – en face, b – strona prawa,
c – strona lewa

a

b

c

References

[1] S

ALCIDO

−G

ARCIA

J.F., L

EDESMA

−M

ONTES

C., H

ERNANDEZ

−F

LORES

F., P

EREZ

D., G

ARCES

−O

RTIZ

M.: Frequency of

supernumerary teeth in Mexican population. Med. Oral Patol. Oral Cir. Bucal. 2004, 9, 407–409.

[2] E

RSIN

N.K., C

ANADAN

U., A

LPOZ

A.R., A

KAY

C.: Mesiodens in primary, mixed and permanent dentitions: a clin−

ical and radiographic study. J. Clin. Pediatr. Dent. 2004, 28, 295–298.

[3] K

UPIETZKY

A., R

OTSTEIN

I., K

ISCHINOVSKY

D.: A multidisciplinary approach to the treatment of an intruded max−

illary permanent incisor complicated by the presence of two mesiodentes. Pediatr. Dent. 2000, 22, 499–503.

[4] M

ORAES

R.S., F

ARINHAS

J.A., G

LEISER

R., P

RIMO

L.G.: Delayed eruption of maxillary permanent central incisors

as a consequence of mesiodens: a surgical re−treatment approach. J. Clin. Pediatr. Dent. 2004, 28, 195–198.

[5] A

TWAN

S.M., T

URNER

D., K

HALID

A.: Early intervention to remove mesiodens and avoid orthodontic therapy. Gen.

Dent. 2000, 48, 378.

[6] R

USSEL

K.A., F

OLWARCZNA

M.A.: Mesiodens – diagnosis and management of a common supernumerary tooth.

J. Can. Dent. Assoc. 2003, 69, 362–366.

[7] F

OLEY

J.: Surgical removal of supernumerary teeth and the fate of incisor eruption. Eur. J. Paediatr. Dent. 2004,

5, 35–40.

[8] G

IANCOTTI

A., G

RAZZINI

F., D

E

D

OMINICIS

F., R

OMANINI

G., A

RCURI

C.: Multidisciplinary evaluation and clinical

management of mesiodens. J. Clin. Pediatr. Dent. 2002, 26, 233–237.

[9] O

CHOA

G

RIJALVA

J.F., K

USTER

C.G.: Supernumerary teeth removal and orthodontic tooth repositioning: a case

report. J. Clin. Pediatr. Dent. 1993, 17, 95–98.

[10] M

OORE

S.R., W

ILSON

D.F., K

IBBLE

J.: Sequential development of multiple supernumerary teeth in mandibular

premolar region – a radiographic case report. Int. J. Paediatr. Dent. 2002, 12, 143–145.

Address for correspondence:

Agnieszka Nęcka
Department of Dentofacial Orthopedics and Orthodontics
Silesian Piasts University of Medicine
Krakowska 26
50−425 Wrocław
Poland
E−mail: [e-mail]

Received: 5.03.2007
Revised: 23.05.2007
Accepted: 31.05.2007

Praca wpłynęła do Redakcji: 5.03.2007 r.
Po recenzji: 23.05.2007 r.
Zaakceptowano do druku: 31.05.2007 r.

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, J. A

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