SRM Journal of Research in Dental Sciences

CASE REPORT
Year
: 2018  |  Volume : 9  |  Issue : 3  |  Page : 125--129

Double mesiodens in mixed dentition period: Report of 3 cases


Sukhvinder Singh Rana, Neera Ohri 
 Department of Dentistry, Dr RPGMC, Kangra, Himachal Pradesh, India

Correspondence Address:
Neera Ohri
Department of Dentistry, Dr RPGMC, Ohri Market, Kangra, Himachal Pradesh
India

Abstract

Mesiodens is a supernumerary tooth present in the midline of maxilla, between central incisors, occurring in 0.15%–1.9% of populations. Mesiodens is the most commonly found supernumerary teeth on many occasions. Mesiodens is paired, single, unerupted, and sometimes impacted. These mesiodens cause many complications, such as midline diastema, displacement, rotation, root resorption, unpleasing esthetics, and cyst formation. In the present cases, mesiodens is found bilaterally in the anterior maxilla. In these cases, both mesiodens are prophylactically extracted to prevent its adverse effects on permanent dentition.



How to cite this article:
Rana SS, Ohri N. Double mesiodens in mixed dentition period: Report of 3 cases.SRM J Res Dent Sci 2018;9:125-129


How to cite this URL:
Rana SS, Ohri N. Double mesiodens in mixed dentition period: Report of 3 cases. SRM J Res Dent Sci [serial online] 2018 [cited 2018 Dec 18 ];9:125-129
Available from: http://www.srmjrds.in/text.asp?2018/9/3/125/242453


Full Text

 Introduction



A mesiodens is a supernumerary tooth located in the maxillary central incisor region; the overall prevalence of mesiodentes is between 0.15% and 1.9%. Mesiodens can occur individually or as multiples (mesiodentes), may appear unilaterally or bilaterally, and often do not erupt. Mesiodentes can significantly alter both occlusion and appearance by altering the eruption path and the position of the permanent incisors.[1]

Primosch classified supernumeraries into two types according to their shape: supplemental and rudimentary. Supplemental refers to supernumerary teeth of normal shape and size and may also be termed incisiform. Rudimentary defines the teeth of abnormal shape and smaller size including conical, tuberculate, and molariform.[2]

The most common complications of mesiodentes are the delay or prevention of eruption (26%–52%) and displacement/rotation (28%–60%) of maxillary permanent incisors. Relatively less common complications include crowding, diastema, dilaceration of permanent teeth, cyst formation, and eruption into the nasal cavity.[3]

Mesiodens can be diagnosed through clinical and radiographic examinations using the maxillary anterior periapical and occlusal radiography. In addition to these, orthopantomograph and lateral cephalograph can also aid in the diagnosis. Usually, mesiodens is associated with eruption disturbances, midline diastema, or other malocclusions in the premaxillary region such as rotation or axial inclination of permanent central incisors, dilaceration of roots of incisors, resorption of roots of adjacent teeth, and sometimes even dentigerous cyst formation.[4]

 Case Reports



A series of three males of mix dentition period with double mesiodens is presented.

Case 1

A 10-year-old male patient reported to the dental department, with a chief complaint of extra tooth in the upper front region. The familial, medical, and dental history was noncontributory. The clinical examination revealed mixed dentition with malalignment of the upper anterior region along with double conical supernumerary teeth erupted palatally [Figure 1] and [Figure 2].{Figure 1}{Figure 2}

Case 2

A 9-year-old male reported with spacing between permanent incisors with extra tooth palatally. Clinical and radiographically examination revealed mixed dentition with diastema formation between the upper anterior along with one erupted and one impacted supernumerary teeth palatally [Figure 3], [Figure 4], [Figure 5].{Figure 3}{Figure 4}{Figure 5}

Case 3

A 7-year-old male reported with teeth erupting palatally [Figure 6], [Figure 7], [Figure 8]. Clinically and radiographically examination revealed early mixed dentition with one erupted and one impacted supernumerary teeth palatally.{Figure 6}{Figure 7}{Figure 8}

Treatment

Surgical removal under local anesthesia was performed for all cases with uneventful healing.

Parent's informed written consent was taken before the surgical procedure.

Intra-alveolar extraction (forceps technique) of erupted supernumerary teeth was done (in case 1)Surgical extraction (transalveolar extraction) of the unerupted supernumerary tooth was done by raising mucoperiosteal flap (in case 2 and 3): first intracrevicular incision is made from the right deciduous canine to the left deciduous canine on the palatal side than a mucoperiosteal flap was raised. After careful elevation of the flap, the supernumerary teeth was removed surgically, and the extraction socket was inspected for any pathological tissue. The flap was repositioned and sutures placed for a week. The patient is recalled after 1 week and sutures removed. The postsurgical phase was uneventful.

 Discussion



The most common supernumerary tooth which appears in the maxillary midline is called a mesiodens. However, very little literature is available on cases of double supernumerary teeth as they do not occur frequently.[5]

A mesiodens is a supernumerary tooth located in the maxillary central incisor region; the overall prevalence of mesiodentes is between 0.15% and 1.9%. Mesiodens can occur individually or as multiples (mesiodentes), may appear unilaterally or bilaterally, and often do not erupt. Mesiodentes can significantly alter both occlusion and appearance by altering the eruption path and the position of the permanent incisors.[1]

The etiology of mesiodens remains unknown although different theories are formulated. The first theory of atavism (phylogenetic reversion) is widely rejected because of the ectopic development, solitary occurrence, secondary eruption to the central incisors, and dysmorphic shape. A possible etiological explanation may be the dichotomy theory with splitting of the tooth bud resulting in two teeth both resembling normal teeth, or resulting in two different teeth with one normal and one dysmorphic. The most widely accepted hyperactivity theory states that locally induced hyperactivity of the dental lamina results in supernumerary teeth, with the lingual extension of an additional bud leading to a eumorphic mesiodens, while the rudimentary-shaped tooth arises from the proliferation of epithelial remnants of the dental lamina. The last theory includes the combination of genetic and environmental factors in human odontogenesis as dynamic interactions. Familial occurrence of mesiodens is reported to involve more than one sibling or one generation. Sedano and Gorlin suggested an autosomal dominant trait with lack of penetrance in some generations and even an X-linked inheritance was suggested because of sex predominance of males over females. A recent report on three siblings with cleidocranial dysplasia syndrome and supernumerary teeth suggests that the involvement of nongenetic or epigenetic regulation mechanisms in the formation of these supernumerary teeth.[6]

Whittington et al, has said that the sooner the diagnosis the better the prognosis The clinician's knowledge of common anomalies and their location in the primary and mixed dentition will result in early diagnosis and may consequently prevent further complications. The diagnosis may be possible as early as age 2 years, and onward, as recommended by some authors.[7] In case of asymmetry, mesiodens should be suspected. It is also probable that overretention of the maxillary primary incisors, especially if asymmetric or in case of the significant ectopic eruption of one or both permanent maxillary incisors, is due to the presence of mesiodens.[8] In primary dentition, mesiodens often has normal shape and erupt normally, and this is the reason why these teeth are often overlooked. The other possible reason for the less frequent reporting of primary mesiodens might be the difficulty in its detection by the caregiver. It is common that anterior primary mesiodens erupts and exfoliates normally before detection and could be mistaken with germination or fusion anomalies.[9]

In permanent dentition, the diagnosis is much easier following the eruption of the permanent anterior teeth. However, in permanent dentition, the detection of supernumeraries needs thorough clinical and radiographic examination. Panoramic, maxillary occlusal, and periapical radiographs are recommended to assist the process of diagnosis of mesiodens. Although panoramic radiograph is the best screening tool, clarity in the midline region is still limited for the diagnosis of mesiodens. For precise view, in the incisor region, anterior occlusal or periapical radiograph is also helpful.[10]

Mesiodentes are frequently associated with various craniofacial anomalies including cleft lip and palate, Gardner's syndrome, and cleidocranial dysostosis.[1]

The occurrence of multiple supernumerary teeth without any associated systemic conditions or syndromes, however, is a rare phenomenon.[11] In all reported cases of our series, none of the patients were affected by any syndrome.

All the patients were male of mix dentition period. This suggested that males are predominantly affected by mesiodentes as discussed by Anthonappa et al. (male: female – 3.1:1)[12]

Munns has stated that early the supernumerary tooth is removed better will be the prognosis.[13] The children in these cases were fit enough to tolerate a surgical procedure under local anesthesia.

Extraction is not the only treatment choice for impacted mesiodentes. If the mesiodens remains in place without symptoms and does not adversely affect the adjacent teeth, it may be left in place and observed periodically.[8] In the present case, the surgical removal of the mesiodentes was judged necessary since these teeth had caused axial rotation of the permanent central incisors.

There are no precise indications concerning the ideal time for the surgical removal of impacted mesiodens. According to Atwan et al., a mesiodens can be the best removed when the permanent central incisors start to erupt, but this may not be always possible.[14]

Early diagnosis and treatment of patients with supernumerary teeth are important to prevent or minimize complications. Treatment depends on the type and position of the supernumerary tooth and its effect on the adjacent teeth.[8]

 Conclusions



In all three cases reported, the surgical intervention was decided as the children were mature enough to take-up the surgery, and it also found that mesiodens affected the permanent maxillary central incisor positions. Early diagnosis of mesiodens reduces the treatment required and prevents the development of associated problems. The diagnosis of mesiodens can be done by clinical and radiographic examination, and the extraction of mesiodens in the early mixed dentition helps spontaneous alignment of the adjacent teeth.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the legal guardian has given his consent for images and other clinical information to be reported in the journal. The Guardian understands that names and initials will not be published and due efforts will be made to conceal patient identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1Russell KA, Folwarczna MA. Mesiodens – Diagnosis and management of a common supernumerary tooth. J Can Dent Assoc 2003;69:362-6.
2Primosch RE. Anterior supernumerary teeth – Assessment and surgical intervention in children. Pediatr Dent 1981;3:204-15.
3Hattab FN, Yassin OM, Rawashdeh MA. Supernumerary teeth: Report of three cases and review of the literature. ASDC J Dent Child 1994;61:382-93.
4Viswanathan R, Pai S. Bilateral impacted inverted mesiodentes in the palatal vault: A rare case report. Pediatr Dent J 2015;25:26-8.
5Gharote HP, Nair PP, Thomas S, Prasad GR, Singh S. Nonsyndromic double mesiodentes – Hidden lambs among normal flock! BMJ Case Rep 2011;2011. pii: bcr0720114420.
6Van Buggenhout G, Bailleul-Forestier I. Mesiodens. Eur J Med Genet 2008;51:178-81.
7Whittington BR, Durward CS. Survey of anomalies in primary teeth and their correlation with the permanent dentition. N Z Dent J 1996;92:4-8.
8Rajab LD, Hamdan MA. Supernumerary teeth: Review of the literature and a survey of 152 cases. Int J Paediatr Dent 2002;12:244-54.
9Humerfelt D, Hurlen B, Humerfelt S. Hyperdontia in children below four years of age: A radiographic study. ASDC J Dent Child 1985;52:121-4.
10Wood GD, Mackenzie I. A dentonasal deformity. Oral Surg Oral Med Oral Pathol 1987;63:656-7.
11Orhan AI, Ozer L, Orhan K. Familial occurrence of nonsyndromal multiple supernumerary teeth. A rare condition. Angle Orthod 2006;76:891-7.
12Anthonappa RP, Omer RS, King NM. Characteristics of 283 supernumerary teeth in southern Chinese children. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2008;105:e48-54.
13Munns D. A case of partial anodontia and supernumerary tooth present in the same jaw. Dent Pract Dent Rec 1967;18:34-7.
14Atwan SM, Turner D, Khalid A. Early intervention to remove mesiodens and avoid orthodontic therapy. Gen Dent 2000;48:166-9.