The document attached has been archived with permission from the Australian Dental Association. An external link to the publisher’s copy is included.A review of the literature relating to supernumerary teeth is presented along with four case reports to illustrate some possible presentations, diagnostic features, and treatment options.Mark A. Scheiner and Wayne J. Sampso

Sampson, W.

Scheiner, M.

Australian Dental Journal

Adelaide Research & Scholarship

AbstractA review of the literature relating to supernumeraryteeth is presented along with four case reports toillustrate some possible presentations, diagnosticfeatures, and treatment options.Key words: Supernumerary teeth, supplemental teeth.(Received for publication August 1995. Revised January1996. Accepted February 1996.)IntroductionSupernumerary teeth may be defined as any teethor tooth substance in excess of the usual configurationof twenty deciduous, and thirty-two permanentteeth.1 Such a surplus can also be accompanied by adeficit of other teeth. For example, thirty-twopermanent teeth may be present with five lowerincisors and only three lower premolars. Super-numerary teeth may occur singly, multiply,unilaterally or bilaterally, and in one or both jaws.Cases involving one or two supernumerary teethmost commonly involve the anterior maxilla, followedby the mandibular premolar region.2 When multiplesupernumerary teeth are present (>five), the mostcommon site affected is the mandibular premolarregion.3 Single supernumeraries occur in 76 to 86 percent of cases, double supernumeraries in 12 to 23 percent of cases, and multiple supernumeraries in lessthan 1 per cent of cases.4A slight difference in the relative frequency ofdifferent supernumerary teeth is reported in theliterature. Luten’s study5 suggests in order of decreas-ing frequency: upper lateral incisors (50 per cent),mesiodens (36 per cent), upper central incisors (11per cent), followed by bicuspids (3 per cent). ShapiraAustralian Dental Journal 1997;42:(3):160-5Supernumerary teeth: A review of the literature andfour case reportsMark A. Scheiner, BDSc*Wayne J. Sampson, BDS, MDS†and Kuftinec6 state the order of decreasing frequencyas being: upper central incisors, molars (especiallyupper molars), premolars, followed by lateral incisorsand canines. Classification of supernumerary teethmay be on the basis of position or form.2 Positionalvariations include mesiodens, paramolars, disto-molars and parapremolars. Variations in form consistof conical types, tuberculate types, supplementalteeth and odontomes. Supernumerary teeth may,therefore, vary from a simple odontome, through aconical or tuberculate tooth to a supplemental toothwhich closely resembles a normal tooth. Also, the siteand number of supernumeraries can vary greatly.Supernumerary teeth are less common in thedeciduous dentition with a reported incidence of 0.3per cent to 1.7 per cent of the population.7 Possibleexplanations for the less frequent reporting ofdeciduous supernumerary teeth include lessdetection by parents, as the spacing frequentlyencountered in the deciduous dentition may beutilized to allow the supernumerary tooth or teeth toerupt with reasonable alignment. Also, manychildren have an initial dental examination followingeruption of the permanent anterior teeth so anteriordeciduous supernumerary teeth which have eruptedand exfoliated normally would not be detected.7The prevalence of supernumerary teeth variesbetween 0.1 and 3.6 per cent of the populationsstudied.3 Methodology for detection and the populationstudied could account for the range of prevalencecited. Luten5 studied the prevalence of supernumeraryteeth in the primary and permanent dentitions of1558 children and found a prevalence of 2 per cent.The methodology included the use of bitewing andperiapical radiographs for detection.A recent study of 2338 randomly selectedpanoramic radiographs of intact dentitions ofAustralian subjects aged seven to twenty years,found 2.3 per cent with supernumeraries (Fuss andSampson, unpublished data). Of those with160 Australian Dental Journal 1997;42:3.*Orthodontic Registrar, Department of Dentistry, The University ofAdelaide.†Professor of Orthodontics, Department of Dentistry, The University ofAdelaide.at the age of eight years. This may be an example ofpost permanent dentition development. Paramolarsand parapremolars would also seem to fit a model ofpost permanent dentition development consistentwith continued dental lamina activity.Effects of supernumerary teeth on the developingdentition vary. There may be no effect with thesupernumerary tooth or teeth discovered either as achance radiographic finding or following theireruption. Crowding may be evident due to anincreased number of erupted teeth. Failure oferuption of adjacent permanent teeth is the mostfrequent occurrence and occurs in 30 to 60 per centof cases.2,11 The supernumerary or adjacent teethmay be displaced and ectopic eruption of either isnot uncommon. Supernumerary teeth may alsocause diastemata, root resorption of adjacent teeth,malformation of adjacent teeth such as dilaceration,and loss of vitality of adjacent teeth.9Case reportsThe following four cases were referred to theOrthodontic Clinic, Adelaide Dental Hospital fororthodontic assessment and treatment and representsome of the possible presentations of supernumeraryteeth. They include a case where there was anobvious excess in the number of teeth erupted, onewhere lack of eruption of a permanent tooth was theobvious feature, one where the supernumerary teethwere found by chance as part of a comprehensiveorthodontic examination, and one of interest in thatno treatment was sought or suggested until adult agewith consequent complications.Case 1An 11-year-old female presented with a chiefcomplaint of delayed eruption of a lower permanenttooth. Medical and family histories were non-contrib-utory. Examination revealed a Class I mixed dentitionwith a well aligned upper arch and irregularity of thelower arch associated with an unerupted lower centralincisor (Fig. 1a).Radiographic examination showed tooth 41 to beunerupted, lingually positioned and associated withtwo supernumeraries that were also lingually placed(Fig. 1b, c).Both supernumeraries were extracted and theincisal tip of tooth 41 was exposed. Orthodontictreatment comprised bracketing of 42-32 and asectional arch wire to erupt tooth 41 and align thelower incisors. This mixed dentition treatment wasuneventful and the patient is now under regularreview regarding future fixed orthodontic treatment.Note the dilaceration of 42 root (Fig. 1d) posttreatment.Australian Dental Journal 1997;42:3. 161supernumeraries, 68.6 per cent had single, 20.3 percent had double, and 11.1 per cent had multiplesupernumeraries. The supernumeraries were mostfrequently located in the maxillary incisor region(64.3 per cent) with mesiodens accounting for 32.4per cent of such presentations. In decreasing orderof frequency came supernumeraries in the maxillarythird molar region (29.6 per cent), mandibular thirdmolar region (7.0 per cent), mandibular premolarregion (7 per cent), mandibular incisor region (4.2per cent), and maxillary premolar region (4.2 percent). Supernumeraries were encountered morefrequently in males than females in a ratio of 2:1.Sexual dimorphism is reported by most authors2,5,8with males being more commonly affected. Mitchell2suggested no difference with the sex distribution incases with deciduous supernumeraries, but a 2:1ratio in favour of males in cases exhibitingpermanent supernumerary teeth. Hogstrum andAndersson9 also reported a 2:1 ratio of sex distributionwhile Luten5 found a sex distribution of 1.3:1. A studyof supernumerary teeth in Asian school childrenfound a greater male to female distribution of 5.5:1for Japanese, and 6.5:1 for Hong Kong children.4Multiple supernumerary teeth are more commonwhen a syndrome is involved. Yusof3 suggests that itmay be rare to find multiple supernumerary teethwithout an associated syndrome. Commonsyndromes showing multiple supernumerary teethalong with other conditions include Gardiner’ssyndrome, cleidocranial dysostosis, and cleft lip andpalate. Acton8 advises checking for evidence ofsyndromal involvement in all cases exhibitingmultiple supernumerary teeth. A careful check for afamily history of supernumerary teeth could point tothe presence of a genetically determined syndrome.As inferred above, the aetiology of supernumeraryteeth may be partly genetic as supernumerary teethare more commonly found in relatives of affectedindividuals than the general population; however theinheritance pattern does not follow Mendelianprinciples.2 Environmental factors must also beconsidered in the aetiology of supernumerary teeth,as Shapira and Kuftinec6 propose hyperproductivityof the dental lamina and dichotomy of tooth germsas aetiological factors, which have been supportedby in vitro experiments. They also suggest thephylogenetic process of atavism, syndromes, and thelate development of some supernumerary teeth or a‘post permanent’ dentition may also be aetiologicalfactors.Becker, Bimstein and Shteyer10 reported a case ofmultiple, anterior and posterior, maxillary andmandibular supernumerary teeth which were detectedin a 12-year-old. The supernumeraries were in thecanine-premolar regions and developed afterremoval of a maxillary midline supernumerary tooth162 Australian Dental Journal 1997;42:3.Fig. 1.–Case 1. a, Intra-oral view of the mandibular arch. Note 41unerupted. b, Note two supernumeraries (arrow) associated withunerupted 41. c, Periapical view showing position of the super-numeraries (arrows). d, Postoperative radiograph showing successfulalignment but root dilaceration is apparent for 42 (arrow).1a 1b1c1dCase 2An 11-year-old male presented with a chiefcomplaint of an extra front tooth. Medical andfamily histories were unremarkable. Examinationrevealed a mild Class II molar relationship in themixed dentition with a well aligned lower arch andincreased overbite and overjet. A supplementalcentral incisor and lateral incisor on opposite sidesof the maxillary arch  were evident (Fig. 2a).Radiographic examination revealed the super-numeraries to be truly supplemental as all threeupper central incisors displayed identical morphologyas did the three lateral incisors (Fig. 2b).Treatment involved extraction of the most distalupper right lateral incisor, the most distal anddisplaced upper central incisor, and placement ofupper and lower bands on first molars and bracketson incisors to reduce the overbite and overjet causedby the excess tooth substance. The early treatmentgoals were achieved without complication and thepatient is under regular review.Case 3A 16-year-old male presented with a chiefcomplaint relating to aesthetic concerns regardinghis crooked teeth. Medical and family histories werenot significant. Examination revealed a Class Imalocclusion with moderate to severe upper andlower incisor crowding. Also noted were super-numerary teeth erupting buccal to the upper secondpermanent molars (Fig. 3a).Radiographic examination revealed the presenceof two conical supernumerary paramolars per upperquadrant (Fig. 3b).Treatment involved the extraction of upper andlower first premolar teeth to relieve the crowding,extraction of the supernumerary teeth and upper andlower full arch banding to correct the malocclusion.Case 4An eight-year-old female presented with displacedupper anterior teeth. Medical and family historiesAustralian Dental Journal 1997;42:3. 1632a 2b3a 3b4a4bFig. 2.–Case 2. a (top left), Intra-oral view of the maxillary arch. Notesupplemental lateral incisor in the right quadrant (arrow) andsupplemental central incisor in the left quadrant (arrow). b (topright), Supplemental teeth (arrows) showing identical morphology topermanent lateral and central incisors respectively.Fig. 3.–Case 3. a (centre left), Intra-oral view of the maxillary arch.Note supernumerary teeth erupting buccal to upper right and leftsecond permanent molars (arrows). b (centre right), Two super-numerary teeth per quadrant associated with upper right and leftsecond permanent molars (arrows). It would be easy to overlookthese supernumeraries had they not been clinically emergent.Fig. 4.–Case 4. a (bottom left), Panoramic radiograph showingsupernumeraries between 11 and 21 (arrows) and agenesis of 35 and45. Note transposing 32. b (bottom right), Periapical radiograph ofthe supernumeraries (arrows) indicating rudimentary forms anddivergent eruption paths.were unremarkable. Examination revealed a Class Idental pattern compensating for a Class II skeletalfacial pattern with upper and lower anterior dentalarch crowding.Radiographic examination revealed two rudi-mentary-type mesiodens supernumeraries andagenesis of 35 and 45 (Fig. 4a, b). The developingtransposition of 32 was also noted.Treatment was instituted to extract the super-numeraries and 72, 73 and 83 to facilitate alignmentand reduce the severity of transposition of 32; theneed for early banding to be reviewed four monthspostoperative.DiscussionThe cases described above represent a smallsample of the possible presentations for cases involvingsupernumerary teeth. It is essential to enumerateand identify the teeth present clinically andradiographically before a definitive diagnosis andtreatment plan can be formulated.Not all situations lend themselves to idealtreatment results. Timing of interceptive treatmentshould be as soon as possible following clinicaldetection of an abnormal eruption pattern. It hasbeen suggested that a tooth delayed in its eruptionby more than six months with respect to its antimereshould be radiographically investigated. A panoramicradiograph is a most useful screening radiograph insuch situations as it shows all areas of the maxillaand mandible.Mitchell and Bennett12 have suggested that differenttypes of supernumeraries have been associated withdifferent effects on the adjacent dentition. Fosterand Taylor13 examined this relationship and foundtuberculate types more commonly produceddelayed eruption, whereas conical types morecommonly produced displacement of the adjacentdentition.Controversy exists regarding the optimal treat-ment of delayed eruption due to supernumeraryinvolvement. The options include removal of thesupernumerary only, removal of the supernumeraryand orthodontic treatment to re-establish sufficientspace for the delayed tooth, with or without surgicalexposure of the unerupted tooth at the time ofsupernumerary tooth removal.Taylor14 described a case where a geminatedmaxillary lateral incisor was seen as unaesthetic.Treatment involved removal of the large, notched,geminated tooth and autogenous transplantation ofa supplemental lateral incisor from the oppositemaxillary quadrant. In this case, the surplus toothmaterial was utilized to replace a malformed tooth.The case report highlighted the need for carefuldiagnosis and treatment planning as in somesituations the surplus tooth tissue may be utilizedadvantageously.Spontaneous eruption following supernumeraryremoval is suggested to be in the range of 54 percent15 to 75 per cent.16 DiBiase16 suggests that mostteeth experiencing delayed eruption will spontan-eously erupt within 18 months of supernumeraryremoval alone, providing the delayed tooth is notexcessively displaced.Mitchell and Bennett12 studied spontaneouseruption following supernumerary removal only.Ninety-six patients with 120 teeth exhibiting delayederuption were studied. They found that 78 per centspontaneously erupted with a median time foreruption of 16 months. Only 14 per cent required asecond operation to expose the delayed tooth and thisprocedure was performed at a median time of 30months following supernumerary removal. Ifadequate space was available, or was created early, themedian time for spontaneous eruption was reduced.Timing of surgical removal of supernumeraryteeth has also been contentious. Hogstrum andAndersson8 suggested two alternatives exist. Thefirst option involves removal of the supernumeraryas soon as it has been diagnosed. This could createdental phobia problems for a young child and hasbeen said to cause devitalization or deformation ofadjacent teeth. Secondly, the supernumerary couldbe left until root development of the adjacent teethis complete. The potential disadvantages associatedwith this deferred surgical plan include; loss oferuptive force of adjacent teeth, loss of space andcrowding of the affected arch, and possible midlineshifts. In their study 23 children aged less than 11years and 17 aged greater than 11 years at the timeof supernumerary removal, Hogstrum andAndersson8 found no evidence of root resorption,loss of vitality or disturbance of root developmentduring the three-year follow-up period. Obviouslythe position, size and nature of the supernumeraryand the level of co-operation of the patient willinfluence the surgical difficulty and each case shouldbe individually assessed.From the evidence available it would seemprudent to treat by removal of the supernumeraryonly in cases where adequate space is available forthe adjacent permanent tooth to erupt. The spaceshould be monitored to ensure that it does not close,and the delayed tooth should be given approximately18 months to spontaneously erupt. In cases wherethe delayed tooth is displaced, or where further earlyorthodontic treatment is indicated, concomitantexposure and orthodontic traction may be considered.In young patients who are unlikely to cope well witha second operation, initial exposure and orthodontictraction at the time of supernumerary removal maybe advisable, particularly when incisors are involved.164 Australian Dental Journal 1997;42:3.References01. Schulze C. Developmental abnormalities of the teeth and jaws.In: Gorlin RJ, Goldman HM, eds. Thoma’s oral pathology. StLouis: CV Mosby, 1970:112-22.02. Mitchell L. Supernumerary teeth. Dent Update 1989;16:65-9.03. Yusof WZ. Non-syndromal multiple supernumerary teeth:literature review. J Can Dent Assoc 1990;56:147-9.04. So LLY. Unusual supernumerary teeth. Angle Orthod1990;60:289-92.05. Luten JR, Jnr. The prevalence of supernumerary teeth inprimary and mixed dentitions. J Dent Child 1967;34:48-9.06. Shapira Y, Kuftinec MM. Multiple supernumerary teeth: reportof two cases. Am J Dent 1989;2:28-30.07. Taylor GS. Characteristics of supernumerary teeth in theprimary and permanent dentitions. Dent Pract Dent Rec1972;22:203-8.8. Acton CHC. Multiple supernumerary teeth and possible implica-tions. Aust Dent J 1987;32:48-9.9. Hogstrum A, Andersson L. Complications related to surgicalremoval of anterior supernumerary teeth in children. J DentChild 1987;54:341-3.10. Becker A, Bimstein E, Shteyer A. Interdisciplinary treatment ofmultiple unerupted supernumerary teeth: a case report. Am JOrthod 1982;81:417-22.11. Nik-Hussein NN. Anterior maxillary supernumerary teeth: aclinical and radiographic study. Aust Orthod J 1990;11:247-50.12. Mitchell L, Bennett TG. Supernumerary teeth causing delayederuption – a retrospective study. Br J Orthod 1992;19:41-6.13. Foster TD, Taylor GS. Characteristics of supernumerary teeth inthe upper incisor region. Dent Pract 1969;20:8-12.14. Taylor GS. Autotransplant replacement of a geminated incisor bya supplemental lateral incisor. Br J Orthod 1979;6:195-8.15. Witsenberg B, Boering G. Eruption of impacted permanentincisors after removal of supernumerary teeth. J Oral Surg1981;10:423-31.16. DiBiase D. The effects of variations in tooth morphology andposition on eruption. Dent Pract 1971;22:95-108.Address for correspondence/reprints:Professor W. J. Sampson,Orthodontic Unit,Department of Dentistry,The University of Adelaide,Adelaide, South Australia 5005.Australian Dental Journal 1997;42:3. 165

Supernumerary teeth: a review of the literature and four case reports

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Supernumerary teeth: a review of the literature and four case reports

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