Indian Journal of Dental Research

REVIEW ARTICLE
Year
: 2013  |  Volume : 24  |  Issue : 1  |  Page : 117--122

Supernumerary teeth: Review of literature and decision support system


Deepti Amarlal1, MS Muthu2,  
1 Department of Pediatric Dentistry, Meenakshi Ammal Dental College, Maduravoyal, Chennai, India
2 Department of Pediatric Dentistry, Saveetha Dental College and Hospital, Vellapanchavadi, Chennai, India

Correspondence Address:
Deepti Amarlal
Department of Pediatric Dentistry, Meenakshi Ammal Dental College, Maduravoyal, Chennai
India

Abstract

Supernumerary teeth are those which are additional or in excess of the normal number. They can be either single or multiple, unilateral or bilateral and can be present anywhere in the dental arch with predilection for the premaxilla. Supernumerary teeth are mostly classified on position and form. Timing of surgical intervention of supernumerary teeth has been controversial with various authors having different opinions. Hence a new decision support system is put forward which can help in the treatment planning of supernumerary teeth.



How to cite this article:
Amarlal D, Muthu M S. Supernumerary teeth: Review of literature and decision support system.Indian J Dent Res 2013;24:117-122


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Amarlal D, Muthu M S. Supernumerary teeth: Review of literature and decision support system. Indian J Dent Res [serial online] 2013 [cited 2021 Jun 20 ];24:117-122
Available from: https://www.ijdr.in/text.asp?2013/24/1/117/114911


Full Text

Supernumerary teeth are those that are present in excess of the normal set of teeth and was first described between 23 and 79 AD. [1] A supernumerary tooth can be defined as one that is additional to the normal series and can be found in almost any region of the dental arch. [2] Mesiodens is defined as a supernumerary tooth located in the maxillary central incisor region. Mesiodens can occur either individually or as multiples known as Mesiodentes which may be unilateral or bilateral. [3]

 General Characteristics of Supernumerary Teeth



Prevalence

Supernumerary teeth are more commonly found in the Mongoloid racial group with a reported frequency higher than 3%. [4],[5] Koch et al. [6] stated that the prevalence of supernumerary teeth in the permanent dentition is 1-3% and the prevalence in primary dentition according to Primosch [3] is 0.3-0.6%. Rajab and Hamden [7] found the prevalence in the primary dentition as 0.3-0.8% and in the permanent dentition as 0.1-3.8%. Supernumeraries in the primary dentition may be under-reported because spacing present in the primary dentition may allow supernumerary teeth to erupt into reasonable alignment and they remain unnoticed by parents. [8]

Sexual predilection

Rajab and Hamdan reported in their study conducted in Jordan that males were more commonly affected than females, the ratio being 2.2:1. [7] Mitchell [9] reported a 2:1 ratio in favor of males. Hogstrum and Andersson [10] reported a 2:1 ratio of sex distribution, whereas Luten [11] found a sex distribution of 1.3:1. So LLY [12] found a greater male to female distribution of 5.5:1 in Japanese and 6.5:1 in Hong Kong children.

Location

Supernumerary teeth are estimated to occur 8.2 times more frequently in the maxilla than the mandible [13],[14],[15] and commonly affect the premaxilla. [7] Multiple supernumerary teeth are commonly found in the mandibular premolar region. [16] The results of some major prevalence studies on supernumerary teeth are summarized in [Table 1]. [17],[18],[19],[20],[21],[22],[23],[24],[25],[26],[27],[28]{Table 1}

Etiology

Both genetic and environmental factors have been considered to play a role in the etiology of supernumerary teeth. [16] The theories put forward are as follows:

Atavism theory, which suggests that supernumerary teeth are a result of phylogenetic reversion to extinct primates with three pairs of incisors. [3]Dichotomy theory, which suggests that the tooth bud splits into two equal or different-sized parts, resulting in the formation of two teeth of equal size, or one normal and one dysmorphic tooth respectively. [7]Dental lamina hyperactivity theory, which suggests localized, independent, conditioned hyperactivity of the dental lamina. 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. [3] This is the most accepted theory.

Complications

Supernumerary teeth can be detected during a routine clinical or radiographic examination. However, if complications arise, they may include the following: Prevention or delay of eruption of associated permanent teeth; [7],[29] crowding/malocclusion; [16] incomplete space closure during orthodontic treatment; [30] dilaceration, delayed or abnormal root development of associated permanent teeth, root resorption of adjacent teeth; [7],[29],[31],[32] complications with supernumerary teeth itself like cyst formation, [7],[20],[29] migration into the nasal cavity, maxillary sinus or hard palate, and late forming supernumerary teeth. [17] They can also compromise the esthetics, complicate alveolar bone grafting, compromise the sighting of implants, and impinge on nerves leading to paresthesia and/or pain. [2] The most common developmental disorders that show an association with multiple supernumerary teeth are Cleft lip and palate, Cleidocranial dysostosis, and Gardner's syndrome. [7] Other associated syndromes include Fabry - Anderson's syndrome or chondroectodermal dysplasia, [2] Rothmund - Thompson syndrome and Nance - Horan syndrome. [23]

Classification

Supernumerary teeth have been classified mainly based on their morphology and location. Garvey et al. [2] classified supernumeraries as single or multiple. Single supernumeraries were further classified based on morphology as conical, tuberculate, supplemental and, composite odontoma which may be compound or complex. Multiple supernumeraries were classified as those associated with syndromes and those which are not associated with syndromes. [2]

Primosch [3] classified supernumeraries into two types according to their shape: supplemental and rudimentary. Supplemental or eumorphic refers to supernumerary teeth of normal shape and size, and may also be termed incisiform. Rudimentary or dysmorphic defines teeth of abnormal shape and smaller size, including conical, tuberculate, and molariform types. [3]

Kalra [33] also classified supernumerary teeth or hyperdontia according to morphology and number. According to morphology, supernumerary teeth may be further classified as accessory and supplemental. Accessory teeth do not resemble the normal form and have a morphology that deviates from the normal appearance of the teeth. Supplemental teeth are extra teeth but have the shape and size of normal teeth. The summary of different classifications given by various authors over the years is listed in [Table 2]. [34],[35],[36],[37]{Table 2}

Treatment

Treatment of supernumerary teeth includes several controversies and varied opinions among authors, particularly with regard to the timing of removal. Rotberg [38] recommended removal of the supernumerary as soon as it has been discovered and ideally before the age of 5 years so that root formation of the associated permanent incisors is incomplete. However Koch [6] stated that immediate removal of supernumeraries is not necessary if no pathology is present. Hogstrum and Andersson [10] suggested two options. The first option involves removal of the supernumerary as soon as it has been diagnosed. This could create dental phobia in a young child and can also cause devitalization or deformation of adjacent teeth. Secondly, the supernumerary could be left until root development of the adjacent teeth is complete. The potential disadvantages associated with this plan include loss of eruptive force of adjacent teeth, loss of space and crowding of the affected arch, and also possible midline shifts. Munns [39] and Shanmugha Devi et al. [40] stated that the earlier the offending supernumerary tooth is removed, better will be the prognosis.

According to Garvey et al., [2] extraction is not always the treatment of choice for supernumerary teeth. They may be monitored without removal in cases if satisfactory eruption of related teeth has occurred, if there is no orthodontic treatment required, if there is no associated pathology and if removal would prejudice the vitality of the related teeth. According to Shah et al., [16] if the supernumerary teeth cause no complications and are not likely to interfere with orthodontic tooth treatment, they can be monitored with yearly radiographic review. The patient should be warned of complications, such as cystic change and migration with damage to nearby roots. If the patient does not wish to risk such complications, it is acceptable to remove the supernumerary teeth. [18] If they are associated with the roots of permanent teeth, it may be apt to wait for the full root development before surgical extraction to minimize the chances of root damage. In a recent article by Omer et al., [41] the authors suggested that if the supernumerary teeth do not cause any discernable adverse effects on adjacent teeth and if no future orthodontic treatment is foreseen, it is reasonable to recommend that immediate surgical intervention is not essential. Several other authors have also recommended a delayed or conditional removal which appears logical. [6] Furthermore Koch et al. [6] suggested that supernumerary teeth have a tendency to resorb and disappear if left untreated. Summary of timings of removal of supernumerary teeth given by various authors is listed in [Table 3].{Table 3}

Omer et al. [41] conducted a study to identify the different changes and complications that occur to the adjacent teeth in relation to their stage of root development at the time of removal of the supernumerary tooth and to identify the optimum time for surgical removal of supernumerary teeth. They concluded that surgical removal of unerupted supernumerary teeth when the permanent teeth are at stage C of Demirijian (4-5 years old) exhibited minimal complications. Arrested root development was most likely to occur when a supernumerary tooth was removed approximately 5 and 6 years of age (stage D). Hence surgical removal of a supernumerary tooth is best delayed if the adjacent permanent teeth are at stage D (5-6 years old), unless the removal is justified due to any existing pathology. Furthermore, surgical removal of a supernumerary tooth when the child is 6-7 years old (stage E) carries minimal risk of arresting the root development of the adjacent permanent teeth. Delayed surgical removal of unerupted supernumerary teeth until after the adjacent permanent tooth has reached stage H caused more developmental defects like resorption of roots. [41] Ease of bone removal in young children and the initial superficial position of the supernumerary tooth makes the procedure less invasive compared to the delayed approach. The only exceptions to early intervention are those supernumeraries that are likely to erupt, such as those in the midline that are normally orientated and conical shaped and those that are located high above the apices of the normal teeth, especially when orthodontic treatment is not envisaged.

Decision support system

Keeping in mind the different controversies, we have put forward a decision support system [Figure 1] to help in the treatment planning of the supernumerary teeth. The goal of the decision support system is to assist the clinician with diagnosis and treatment planning. According to this decision support system, supernumerary teeth can be either erupted or unerupted. Erupted supernumeraries should be preferentially extracted except in cases where the supernumerary teeth need to be retained. For example, in cases of adjacent tooth clinically missing, in cases where the supernumerary tooth is required as an abutment, or in cases where reshaping of mesiodens is done when the primary incisor is lost prematurely and the permanent incisor is not yet erupted. [42] Unerupted teeth can be those associated with complications and those not associated with complications. Those not associated with complications can be kept under periodic review in accordance with Garvey et al. [2] and Shah et al. [16] If the unerupted supernumerary tooth is associated with any complications, then it should be surgically removed. Surgical removal can be delayed in cases if the supernumerary tooth is placed close to the apices of the developing permanent teeth in accordance with Stermer Beyer-Olsen et al. [43] or if the formation of the supernumerary teeth is in the initial stages resulting in chances of recurrence which is in accordance with de Oliveira Gomes et al. [25]{Figure 1}

 Conclusion



This paper puts forward a decision support system which helps in overcoming the controversies regarding the timing of removal of the supernumerary tooth. Clinician should be aware of the presence and associated complications of the supernumerary teeth to make a correct decision regarding the management.

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