Doi:10.21276/ledent.2018.02.03.02 Review Article Hyperdontia Clinical Aspects and Manifestations Kumari Priyanka Shrivastva, V. Suneel Chandra, Santanu Mukherjee, Rajnish Gakhar Postgraduate Student, Dept. of Oral Pathology and Microbiology, MGS Dental College, Sriganganagar, Rajasthan. Abstract Supernumerary teeth are relatively common and can cause a variety of complications. They are more frequent among men than in women, more common in the maxillary, and surely more prevalent in the permanent dentition. The clinicians need to recognize signs that might be suggesting the presence of supernumerary teeth, especially aberrations in the eruptive pattern, and then perform the relevant investigations. Their treatment depends on the type, position and possible complications detected on clinical and radiographic examination. This article presents a review of the classification, diagnosis and management of this difficult clinical entity. Keywords: Distomolar; Mesiodens; Paramolar; Supernumerary Teeth; Supplemental teeth. Corresponding Author: Dr. Kumari Priyanka Shrivastva, Postgraduate Student, Dept. of Oral Pathology and Microbiology, MGS Dental College, Sriganganagar, Rajasthan. How to Cite: Shrivastva KP, Chnadra SV, Mukharjee S, Gakhar R. Hyperdontia Clinical Aspects and Manifestations. IDA Lud J le Dent 2018;2(3):8-13. INTRODUCTION Supernumerary teeth or Hyperdontia or Polydontia is defined as presence of any extra tooth or teeth in the dental arch, in addition to the normal series of teeth. According to Brook, the prevalence the supernumerary teeth were about 0.8% in primary dentition and 2.1% in permanent dentition.1 Supernumerary teeth occur approximately eight times more frequently in maxilla than in the mandible.2-4 IDA Ludhiana s Journal le Dentistry Vol.2 issue 3 2018 Supernumerary permanent teeth are apparently more common than supernumerary primary teeth. Boys are affected approximately twice as frequently as girls.5 Supernumerary teeth may be single or multiple in numbers, moreover these teeth can be either unilateral or bilateral.6 Supernumerary teeth can be associated with delayed eruption of permanent teeth, retained primary teeth, deflection of roots with unusual inclinations, displacement of 8
teeth, diastemas, overcrowding, abnormal root resorption, and formation of follicular or dentigerous cysts. 7,8 ETIOLOGY The etiology of supernumerary teeth is not completely understood. It can occur either due to genetic factors or due to some environmental factors. 9 Various theories have been postulated to explain their occurrence: Atavism: According to this theory supernumerary teeth were thought to be the result of phylogenetic reversion to extinct primates with three pairs of incisors. This theory has been largely discarded. 10 Dichotomy theory: This theory stated that some factors such as trauma, evolutionary mutations, can cause accidental division of follicle into two or more fragments, of equal or different-sized parts, resulting in the formation of two teeth either of equal size, or one normal and one dysmorphic tooth. 11 Dental lamina hyperactive theory: This theory suggests that supernumerary teeth are formed as a result of localized, independent, conditioned hyperactivity of the dental lamina. 6 According to this theory, a supplemental form would develop from the lingual extension of an accessory tooth bud, whereas a rudimentary form would develop from the proliferation of epithelial remnants of the dental lamina. 10 It is the most accepted theory. Genetic factors: The occurrence of supernumerary teeth in several members of the same family has been observed, indicating a familial pattern. The observation that males are affected approximately twice as often as females, also indicates sex-linked inheritance. 6,10 Supernumerary teeth may be associated with some syndromes, such as Apert syndrome, Fabry s syndrome, cherubism, Gardner syndrome, cleidocranial dysplasia or Crouzon disease, cleft lip, cleft palate and other as hereditary fibromatosis, associated with hearing loss and supernumerary teeth 12 however, mesiodens can occur in individuals with no syndrome. CLASSIFICATION Supernumerary Teeth can be classified based on morphology into conical, Tuberculate, Supplemental variety and Odontomes. Based on location, they can be classified into Mesiodens, Paramolar, Distomolar and Parapremolar. CONICAL TYPE: - This is the most common type. 6 The teeth are usually conical or triangular- shaped crowns and complete root formation and mostly seen in permanent dentition, i.e. mesiodens. 10 They can cause rotation or displacement of the permanent incisor, but rarely delays eruption. 13 TUBERCULATE TYPE: - They usually possess more than one cusp or tubercle and are frequently described as barrel shaped and may be invaginated. 6,10 Tuberculate types have either incomplete or absent root formation and are more commonly seen in the incisor area, usually found in a palatal position relative to the maxillary incisors and the teeth are often impacted. 13 SUPPLEMENTAL TYPE: - These teeth resemble their respective normal teeth and are formed at the end of a tooth series. The most common supplemental tooth is the permanent maxillary lateral incisor, although supplemental premolars and molars also occur. Majority of supernumerary teeth found in the primary dentition are supplemental and rarely remain impacted. 14 IDA Ludhiana s Journal le Dentistry Vol.2 issue 3 2018 9
ODONTOME TYPE: - Odontoma refers to any tumor of odontogenic origin. Most authorities, however, accept the view that the odontoma represents a hamartomatous malformation rather than a neoplasm. These are hamartomas (benign, disordered overgrowths of mature tissue) comprising all dental tissues and appearing radiographically as well-demarcated, mostly radio-opaque lesions in tooth-bearing areas. There are two different types of odontome: complex and compound. Complex odontome is the diffuse mass of dental tissue which is totally disorganized that has no morphological resemblance to a tooth. Compound odontomes on the other hand are a malformation which bears some superficial anatomical similarity to a normal tooth. MESIODENS: - This is the most common of all the supernumerary teeth (Fig 1). It is located in the midline, on the palatal aspect relative to the upper central incisors. These teeth are either impacted or inverted or horizontal in orientation. Usually, they are small and short, with a triangular or conical crown. 15 Fig. 1: Mesiodens PARAMOLAR: Paramolars (Fig. 2) are usually rudimentary, located either in the buccal or in the lingual aspect of the normal molars. DISTOMOLAR: - They are located on the distal aspect of the third molar teeth in the dental arch but rarely delay the eruption of the associated teeth. Both distomolars and paramolars are often known as the fourth molars. Fig. 2: Paramolar PARAPREMOLAR: - This is a supernumerary tooth that resembles a premolar and forms in a premolar region. DIAGNOSIS Diagnosis is based on the clinical and radiographic findings. In addition, computerized tomography has been introduced recently as a complementary diagnostic method. On clinical examination, one can find the erupted supernumerary teeth in the oral cavity; also do a suppositional diagnosis in cases where unilateral persistence of a deciduous incisor, delay in eruption or ectopic eruption of a permanent incisor, a wide diastema, or rotation of erupted permanent incisors etc are observed. Palpation helps us to find out about the situation and whether the unerupted supernumerary tooth is accessible to the touch. 16,17 Radiological examination informs us about the shape, number, location and relations of the supernumerary teeth with adjacent IDA Ludhiana s Journal le Dentistry Vol.2 issue 3 2018 10
structures. It is also very useful in asymptomatic cases. 6,18 To find the location of the supernumerary tooth the most useful radiographic investigation is the orthopantomography (OPG). In addition occlusal radiographs and periapical radiographs with different horizontal angles are also used to show the incisor region in detail. 19-26 Long-cone periapical radiographs will be useful to rule out the possibility of root resorption of a permanent tooth caused by a supernumerary tooth. In order to localize the bucco-lingual position of an unerupted supernumerary or normal tooth, the parallax method is recommended. 27 Supernumeraries that are lying deeply in the palate are located with the help of a lateral radiograph of the incisor region which will enables the practitioner to decide whether a buccal rather than a palatal approach should be used to remove them. In addition, conebeam computed tomography has recently been used to evaluate supernumerary teeth showing the exact location in the three planes. This technique is very useful in pretreatment evaluation of supernumerary teeth and surrounding structures. 18 MANAGEMENT Different authors have different opinions regarding the treatment of supernumerary teeth, particularly with regard to the right time for extraction. 28 For managing supernumerary tooth comprehensive treatment plan should be made and the condition should not be considered in isolation. This paper provides guidelines based on past research in the form of indications for removal of supernumerary tooth. These include: 1. If there is delayed or inhibited eruption of central incisor. 2. If there is presence of rotation, protrusion or displacement of normal teeth. 3. If there is development of some pathological conditions in the jaw, e.g. Dentigerous cyst. 4. If its presence may create problems in orthodontic correction of the teeth. 5. If its presence would compromise surgical correction of cleft palate. 6. If the tooth is present in bone designated for placement of implant. 7. When incisor root development is complete in order to avoid any disorder in permanent dentition. Few cases however require a watchful waiting without supernumerary tooth removal. Such as: 1. Satisfactory eruption of related teeth has occurred. 2. Not likely to interfere with orthodontic tooth movement. 3. Does not provoke any complication and does not interfere with function or aesthetics. 4. Risk of affecting the vitality of the related teeth. 5. Very young child. After the removal of supernumerary teeth, the time taken for the impacted tooth to erupt can vary between six months and three years. 6 Up to 91% of impacted permanent incisors erupt within 18 months following removal. 29 Factors influencing the time taken include- 13,30 Ø the distance the unerupted tooth was displaced, Ø the space available in the dental arch and Ø the stage of root development of the permanent tooth. If there is no spontaneous eruption of the impacted incisors surgical exposure is IDA Ludhiana s Journal le Dentistry Vol.2 issue 3 2018 11
followed by orthodontic traction using brackets attached directly to the labial surface of the incisor. 33 If there is adequate amount of space in the arch for the eruption of impacted incisor following supernumerary removal, space maintenance can be done by simply fitting a removable appliance. If the space is inadequate for the eruption of impacted incisor, the adjacent teeth will need to be moved distally to create space for incisor eruption. In that case, the primary canines may need to be extracted at the same time as the supernumerary tooth. Finally in cases where supplemental tooth is present and erupted, and there is difficulty in differentiating between the supplemental tooth and the normal dental series. In such circumstances, if both the teeth are healthy, it is wise to extract the tooth most displaced from the line of the arch in order to relieve crowding. done 31,32 REFERENCES 1. Brook AH. Dental anomalies of number, form and size: their prevalence in British school children. J Int Assoc Dent Child1974;5:37-53. 2. Yusof WZ. Non-syndrome multiple supernumerary teeth: literature review. J Can Dent Assoc 1990; 56: 147 149. 3. Stafne, EC. Supernumerary teeth. Dent Cosmos 1932; 74: 653 659. 4. Acikoz A, Tunga U, Otan F. Characteristics and prevalence of nonsyndrome multiple supernumerary teeth: a retrospective study. Dentomaxillofac Radiol 2006; 35:185 190. 5. Kinirons MJ. Unerupted premaxillary supernumerary teeth. A study of their occurrence in males and females. Br Dent J 1982;153:110. 6. Rajab LD, Hamdan MAM. Supernumerary teeth: review of the literature and a survey of 152 cases. Int J Paediatr Dent 2002;12: 244 254. 7. Bayrak S, Dalci K, Sari S. Case report: Evaluation of supernumerary teeth with computerized tomography. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2005;100:e65-9. 8. De Oliveira Gomes C, Drummond SN, Jham BC, Abdo EN, Mesquita RA. A survey of 460 supernumerary teeth in Brazilian children and adolescents. Int J Paediatr Dent. 2008;18:98-106. 9. Hall A, Onn A. The development of supernumerary teeth in the mandible in cases with a history of supernumeraries in the pre-maxillary region. J Orthod 2006; 33: 250 255. 10. Primosh RE. Anterior supernumerary teeth assessment and surgical intervention in children. Pediatr Dent 1981;3:204 215. 11. Fleury J, Deboets D, Assaad C, Maffre N, Caillot M. Dents surpenuméraires. Rev. Stomatol. Chir. Maxillofac 1984;85:142-150. 12. Jensen B, Kreiborg S. Development of the dentition in cleidocranial displasia. J Oral Pathol Med 1990;19:89-93. 13. Foster TD, Taylor GS. Characteristics of supernumerary teeth in the upper central incisor region. Dent Pract Dent Rec 1969; 20:8-12. 14. Liu JF. Characteristics of premaxillary supernumerary teeth: a survey of 112 cases. ASDC J Dent Child 1995; 62: 262 265. 15. von Arx T. Anterior maxillary supernumerary teeth: a clinical and radiographic study. Aust Dent J 1992; 37: 189 195. 16. Escoda GC, Micas MM, Tost EA, Albiol GJ. Otras inclusiones dentarias. Mesiodens y otros dientes supernumerarios. Dientes temporales supernumerarios. Dientes temporales incluidos. En: Gay Escoda C, Aytés Berini L, editores. Tratado de Cirugía IDA Ludhiana s Journal le Dentistry Vol.2 issue 3 2018 12
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