Supernumerary Tooth Associated with an Mesiodens: A Case Report

Supernumerary tooth is an additional entity to the normal series and is seen in all the quadrants of the jaw1 The presence of supernumerary teeth is a dental anomaly of patterning and morphogenesis. Patterning alterations in human dentition often occur and are characterized by alterations in the number, size and shape of the teeth. Supernumerary teeth are developmental alterations of number and morphology that result in the formation of teeth in excess of the usual number2. Supernumerary teeth may occur as single (76–86%) double (12–73%) or multiple (<1%), unilaterally or bilaterally, and in one or both jaws3 The prevalence of supernumerary teeth in permanent teething oscillates from 0.5– 3.8%, in comparison with 0.3–0.6% in primary teething. Supernumerary teeth appear with a higher frequency in males than in females with a 2:1 ratio. Supernumerary teeth also called hyperdontia, occur in both dentitions unilaterally or bilaterally and in one or both jaws. Multiple supernumerary teeth are in individuals with no other associated diseases or syndromes4 Supernumerary teeth are most frequently located in the maxillary incisor region (64.3%) with mesiodens accounting for 32.4% of such presentation5 A mesiodens is the most frequent type of supernumerary tooth. The frequency and prevalence of supernumerary teeth according to dental group is given in [Table 1]6. The literature shows that 76 to 86% of nonsyndromic cases involve only one supernumerary tooth and that 12 to 23% of cases present two ST (2,10,11).


INTRODUCTION
Supernumerary tooth is an additional entity to the normal series and is seen in all the quadrants of the jaw 1 The presence of supernumerary teeth is a dental anomaly of patterning and morphogenesis.Patterning alterations in human dentition often occur and are characterized by alterations in the number, size and shape of the teeth.Supernumerary teeth are developmental alterations of number and morphology that result in the formation of teeth in excess of the usual number 2 .Supernumerary teeth may occur as single (76-86%) double (12-73%) or multiple (<1%), unilaterally or bilaterally, and in one or both jaws 3 The prevalence of supernumerary teeth in permanent teething oscillates from 0.5-3.8%, in comparison with 0.3-0.6% in primary teething.Supernumerary teeth appear with a higher frequency in males than in females with a 2:1 ratio.Supernumerary teeth also called hyperdontia, occur in both dentitions unilaterally or bilaterally and in one or both jaws.Multiple supernumerary teeth are in individuals with no other associated diseases or syndromes 4 Supernumerary teeth are most frequently located in the maxillary incisor region (64.3%) with mesiodens accounting for 32.4% of such presentation 5 A mesiodens is the most frequent type of supernumerary tooth.The frequency and prevalence of supernumerary teeth according to dental group is given in [Table 1] 6 .The literature shows that 76 to 86% of nonsyndromic cases involve only one supernumerary tooth and that 12 to 23% of cases present two ST (2,10,11).

Etiology
Many hypotheses have been proposed to explain the development of these teeth,including atavism, tooth germ dichotomy, hyperactivity of the dental lamina, and genetic and environmental factors 10 .The hereditary factor is believed to be important for the development of ST.There may be transmission of a recessive or dominant autosomal trait with incomplete penetrance, or the condition may be associated with an X chromosome 14 .Some ST are only impacted in the maxillary bones with no harmful effect and are usually identified accidentally during radiographic exams performed for other reasons [4][5][6] .However, in some cases they may cause complications, including retention or delayed eruption of some permanent teeth, diastemas, dislocation, dental rotation, root resorption, periodontal lesions, pulp necrosis of adjacent teeth, and formation of a dentigerous (odontogenic) cyst 7,10,15 .Thus, an early diagnosis and appropriate treatment are essential for a successful solution 2 .

Classification
Classification of supernumerary teeth may be on the basis of position and morphology.

Case Presentation
A 11 year old boy cameto the hospital withthe chief complaint of forwardly placed teeth and psycho social problems.He had no relevant medical history and past dental history.On Extra oral examination,maxillary anteriors were protruberent with incompetent lips (fig 1).
Intra oral examination revealed presence of mesiodens and a mild diffuse swelling in the palatal aspect of maxillary anteriors extending from distal aspect of mesiodens to the distal surface of 12 and from gingival margin of mesiodens,11 and 12 to 2 cm from junction of hard palate and soft palate, measuring 2×2 cm, surface was regular, color was normal with palatal mucosa with no secondary ulcerations.On palapation, swelling was hard and non-tender.The treatment protocol was to remove the mesiodensand impacted supernumerary tooth surgically followed by orthodontic correction of malocclusion.

Treatment done
Surgical removal of the impacted supernumerary tooth was done through palatal

CONCLUSION
Supernumerary teeth can present in any region of the oral cavity.These may erupt or remain impacted and may lead to various complications.In this case the removal of odontome improved the esthestic status of the patient.

Positional variations include: 7 •
Mesiodens: Present in the incisor region • Paramolar: Present beside a molar • Distomolar: Present distal to the last molar • Parapremolar: Present beside a premolar Based on the morphology they can be of four types: 1,8 • Conical: Peg shaped teeth Tuberculate: Made of more than one cusp or tubercle.They are barrel shaped, usually invaginated • Supplemental: Resemble normal teeth may incisor, remolar or molar • Odontome: Does not resemble any teeth but is only a mass of dental tissue.The ability to properly evaluate ST to determine their relation with adjacent teeth and other anatomical structures is important for the decision about treatment, especially when extractions or ortho-surgical interventions are indicated.
On radiographic investigation, both IOPA (fig 2) and occlusal films( fig 3)revealed radiopaque structure mimicking enamel, dentin and pulp of a tooth in between 11 and 12, suggesting the presence of mesiodens.Another radiopaque structure resembling a tooth was present at the root tip of mesiodens extending till 12, suggesting the presence of impacted supernumerary tooth in the palatal region.A computerised tomography scan fig(