Introduction G. F. Ferrazzano*, T. Cantile*, L. Roberto*, S. Baldares**, P. Manzo**, R. Martina ** Hyperdontia is a disorder of odontogenesis characterised by the formation of excess teeth [Capozzi et al., 1987]. University of Naples “Federico II”, Naples - Italy Supernumerary teeth can be defined as “supplementary” *Department of Paediatric Dentistry if they closely resemble the teeth of the group to which **Department of Orthodontics they belong (molars, premolars or anterior teeth) and as “rudimentary” if they are teeth of abnormal shape and e-mail: [email protected] smaller size (conical, tuberculate and molariform teeth) [Batra et al., 2005; Garvey et al., 1999]. The scientific literature also classifies supernumerary teeth according to their intraoral position (mesiodens, paramolar, distomolar and parapremolar) [Mason and Rule, 1995]. An impacted central The reported prevalence of supernumerary teeth ranges from 0.3% to 0.8% in the primary dentition, and from incisor due to 0.1% to 3.8% in the permanent dentition, with a male to female ratio of 2:1 [Srivatsan and Aravindha Babu, 2007; supernumerary teeth: Parolia et al., 2011]. The presence of supernumerary teeth in the primary a multidisciplinary dentition is generally overlooked by parents. In fact, supernumerary teeth in the deciduous dentition are often approach of normal shape (supplemental type), erupt normally, and appear to have a proper alignment. Approximately 80% to 90% of all supernumerary teeth are found in the maxilla; half of these are located in the anterior region [Russell and abstract Folwarczna, 2003]. The most common supernumerary tooth is a mesiodens, which occurs between the maxillary Background Hyperdontia is a disorder of central incisors. Mesiodens can occur individually or as odontogenesis characterised by excess teeth. Many multiples, and may appear unilaterally or bilaterally [Hyun complications can be associated with supernumerary et al., 2009]. Supernumerary teeth are often impacted teeth, such as crowding, tooth displacement, diastema, (88.7%) and are often found in the palatal area. More deep caries, retention or impaction, delayed eruption or rarely, they can be located in the superior distomolar, ectopic eruption of adjacent teeth, aesthetic problems, inferior premolar, superior premolar, inferior distomolar, neuralgic manifestations, root resorption of adjacent superior canine, and inferior incisor zones [Grimanis et al., teeth, and dentigerous cyst formation with significant 1991; Hurlen and Humerfelt, 1992]. bone destruction. Treatment of hyperdontia depends on Although several theories have been postulated to the area and number of supernumerary teeth, and also explain their development (including atavism, tooth on the presence of pathologic processes that can affect germ dichotomy, hyperactivity of the dental lamina, and them and/or the teeth of the normal series that could be genetic and environmental factors), the aetiology of erupted, retained or impacted. supernumerary teeth is still uncertain [Liu, 1995; Primosch, Case report The present case report describes the 1981; Rajab and Hamdan, 2002; Saarenmaa, 1951;Wang clinical management of two impacted supernumerary and Fan, 2011]. Supernumerary teeth have been teeth, which impeded the eruption of the maxillary right associated with a number of developmental disorders central incisor in a paediatric patient. A multidisciplinary and syndromes, such as cleidocranial dysplasia, Gardner´s treatment approach was planned, including the surgical syndrome and lip and palatal fissures [Rajab and Hamdan, removal of the supernumerary teeth and the orthodontic 2002; Stahl et al., 2006]. Multiple supernumerary teeth correction of the unerupted permanent maxillary right unrelated to any syndrome or systemic illness are very central incisor. Combined surgical and orthodontic uncommon; in such cases, they are normally found in the treatment resulted in an aesthetically pleasant and inferior premolar area [Moore et al., 2002]. balanced occlusion. Thus, early multidisciplinary treatment Many complications are associated with supernumeraries, is required for greater hard and soft tissue preservation. such as crowding, tooth displacement, , diastema, deep caries, retention or impaction, delayeeruption or ectopic eruption of adjacent teeth, aesthetic problems, neuralgic Keywords Hyperdontia; Impacted teeth; manifestations, root resorption of adjacent teeth and Orthodontic treatment. Retained teeth; Surgery; dentigerous cyst formation with significant bone Supernumerary teeth. destruction [Mittal and Sultan, 2010]. In particular, the presence of supernumerary teeth in the anterior area of

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the maxilla may cause the delayed eruption or impaction of Paediatric Dentistry “Federico II” of the University of of the central incisors [Mathias et al., 2011]. When any Naples, Italy, with the chief complaint of a missing maxillary of the above complications occur, surgical removal of the right central incisor. According to the medical history, the supernumerary tooth is indicated. child was physically healthy and had no history of dental The specific clinical findings that may indicate the trauma. Neither systemic disorders nor hereditary patterns presence of supernumerary teeth include: absence of of hyperdontia were reported in his family. permanent teeth in the maxillary arch with the persistence The intraoral examination showed absence of the of the deciduous teeth, malposition of erupted permanent permanent maxillary right central incisor, with no evidence teeth, and presence of a wide interincisive diastema and of eruption (Fig. 1). Radiological investigations, including swelling in the buccal or palatal/lingual area [Garvey et al., an orthopantomogram and a 3D computed tomography 1999; Inchingolo et al., 2010]. Treatment of hyperdontia of the skull, were performed. The panoramic radiograph depends on the area and on the number of excess teeth, revealed the presence of an impacted maxillary right and also on the presence of pathologic processes that central incisor and two supernumerary teeth, which affect the supernumerary teeth and/or the teeth of caused the inclusion of the tooth 11 (Fig. 2). The 3D the normal series, which could be erupted, retained or computed tomography analysis revealed the positions of impacted. A pre-operatory evaluation is necessary. Any the impacted right upper central incisor and of the two contiguity between the supernumerary tooth and important supernumerary teeth (Fig. 3, 4). The eruption status of the anatomic structures should be investigated, and the surgical other permanent teeth was normal. procedure should be planned to preserve the surrounding The diagnosis of non-syndromic supernumerary teeth hard and soft structures [Inchingolo et al., 2010]. was made. The present case report describes the clinical management A multidisciplinary treatment approach was planned, of two impacted supernumerary teeth, which impeded the including the surgical removal of the supernumerary eruption of the maxillary right central incisor. teeth and the orthodontic correction of the unerupted permanent maxillary right central incisor. Prior to the surgical phase, the patient underwent expansion of Case report the maxilla to promote the eruption of the impacted tooth and to treat the right side cross bite (Fig. 5). The An 8-year-old boy was referred to the Department transversal correction was performed by means of the

FiG. 1 Intraoral view, showing the absence of the maxillary right central incisor.

FiG. 2 Panoramic radiograph.

FiG. 3 Panorex showing the impacted right upper central incisor and the two super- numerary teeth. FiG. 4 3D reconstruction.

188 European Journal of Paediatric Dentistry Clinical Supplement to vol. 15/2-2014 supernumerary teeth and impaction: a multidisciplinary approach

FiG. 5 Supernumerary tooth cusp. FiG. 6 Palatal muco-periosteal flap. FiG. 7 Removal of supernumerary teeth.

FiG. 8 Surgical area after the removal of supernumerary teeth. FiG. 9 Suture. FiG. 10 Supernumerary teeth after extraction.

FiG. 11 Occlusal radiograph revealing a partial eruption of the maxillary right central incisor. FiG. 12 Surgical exposition. FiG. 13 Intraoral view showing the alignment of the extruded tooth.

Quad Helix appliance, for the coincidental expansion and Surgical exposure of the permanent right molar derotation. The advantages of the Quad Helix are central incisor the possibility to modify the arch shape and size with The impacted permanent maxillary right central a low load/deflection ratio, thus avoiding application incisor was kept under observation to wait for its natural of a strong force that could potentially damage the eruption; however, after 10 months, it was not clinically periodontium and cause root resorption. evident: a maxillary occlusal radiograph revealed that it Regular follow-ups were scheduled to monitor the was slightly impacted toward the left central incisor, and eruption of the permanent central incisor and the the amount of available space was reduced (Fig. 11). associated supernumerary teeth. One month later, the Therefore, orthodontic correction of the impaction was appearance of a supernumerary tooth cusp was detected, implemented. and the surgical treatment was planned (Fig. 5). Two-thirds of the crown of the permanent maxillary right central incisor were surgically exposed with a closed Surgical extraction of the supernumerary teeth eruption technique. The raised flap, which included the Under local anaesthesia, a muco-periosteal flap was attached gingiva, was fully repositioned in its former raised on the palatal side. After careful elevation of the position and then a bracket was bonded to the labial flap (Fig. 6), the supernumerary teeth were surgically surface of the impacted incisor (Fig. 12). removed with the preservation of the roots of adjacent After surgical exposure of the permanent maxillary right teeth (Fig. 7). The extraction sockets were inspected for central incisor, a Beta-Titanium .016x.022 cantilever was any pathological tissue (Fig. 8). The flap was repositioned applied and activated with extrusive force on 1.1 (Fig. and closed with 3-0 silk suture, which was removed after 13). The cantilever was inserted in 1.6-bonded tube and 1 week (Fig. 9). The impacted central incisor was left to ligated to tooth N. 1.1. erupt on its own. On tooth N. 1.2, was placed a 180° rotated bracket to

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FiG. 14 Intraoral views showing the final phases of the alignment of the maxillary right central incisor. provide a buccal root torque to this tooth. Usually, the treatment is required for greater hard and soft tissue upper lateral incisor bracket provides 14° palatal root preservation [Kalaskar and Kalaskar 2011]. torque, and in this case, we inverted the bracket, providing -14° of root torque. Once the correct intercuspation, a satisfactory overjet References and overbite, and alignment of the upper anterior teeth were completed, the appliance was removed, and a › Batra P, Duggal R, Parkash H. Non-syndromic multiple supernumerary teeth transmitted as an autosomal dominant trait. J Oral Pathol Med 2005;34:621– lower canine-canine retainer was bonded. The upper 625. arch retention was managed with a Hawley removable › Capozzi L, Gombos F, Masi P, Modica R, Valletta G. Patologia speciale appliance, to be worn at night for 6 months (Fig. 14). odontostomatologica. Firenze, Italy: USES publisher;1987. › Garvey MT, Barry HJ, Blake M. Supernumerary teeth--an overview of classification, diagnosis and management. J Can Dent Assoc 1999;65(11):612- 616. Conclusion › Grimanis GA, Kyriakides AT, Spyropoulos ND. A survey on supernumerary molars. Quintessence Int 1991;22(12):989-995. › Hurlen B, Humerfelt D. Characteristics of premaxillary hyperodontia. A The presence of supernumerary teeth has the potential radiographic study. Acta Odontol Scand 1985;43(2):75-81. to disrupt the development of normal occlusion, and › Hyun HK, Lee SJ, Lee SH, Hahn SH, Kim JW. Clinical characteristics and complications associated with mesiodentes. J Oral Maxillofac Surg early diagnosis is crucial to minimise complications such 2009;67:2639-2643. as the development of dentigerous cysts, root resorption › Inchingolo F, Tatullo M, Abenavoli FM, Marrelli M, Inchingolo AD, Gentile M, of adjacent teeth, and bone loss [Primosch, 1981; Kessler Inchingolo AM, Dipalma G. 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Management of opted for the preliminary expansion of the maxilla to supernumerary teeth. J Conserv Dent 2011;14(3):221-224. › Primosch RE. Anterior supernumerary teeth—Assessment and surgical promote the eruption of the impacted teeth in the oral intervention in children. Pediatr Dent 1981;3:204-215. cavity. Several factors can have a significant impact on › Rajab LD, Hamdan MA. Supernumerary teeth: review of the literature and a the failure of spontaneous eruption of impacted teeth, survey of 152 cases. Int J Paediatr Dent 2002;12(4):244-254. › Russell KA, Folwarczna MA. Mesiodens - diagnosis and management of a including a tubercolate form of the supernumerary common supernumerary tooth. J Can Dent Assoc 2003;69(6):362-366. tooth, early stages of root formation of this tooth, and › Saarenmaa L. The origin of supernumerary teeth. Acta Odontol Scand space loss. Thus, under unfavourable conditions, an 1951;9:293-303. › Srivatsan P, Aravindha Babu N. Mesiodens with an unusual morphology and interdisciplinary approach with both surgical removal of multiple impacted supernumerary teeth in a non-syndromic patient. Indian J the supernumerary teeth and orthodontic and surgical Dent Res 2007;18(3):138-140. alignment of the impacted tooth may be the best › Stahl F, Grabowski R, Wigger K. Epidemiology of Hoffmeister’s “genetically determined predisposition to disturbed development of the dentition” in choice. In the case reported, the combined surgical and patients with cleft lip and palate. Cleft Palate Craniofac J 2006;43:457-465. orthodontic treatment resulted in aesthetically pleasant › Wang XP, Fan J. Molecular genetics of supernumerary tooth formation. Genesis and balanced occlusion. Thus, early multidisciplinary 2011;49(4):261-277.

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