Case report: non-syndromic multiple supernumerary teeth localized by cone beam computed tomography.
Background: Supernumerary teeth are an infrequent developmental
alteration that can appear in any area of the dental arches and which
are often associated with several syndromes such as cleidocranial
dysplasia or Gardner syndrome. Multiple supernumerary teeth in
individuals with no other associated diseases or syndromes are very
uncommon. CASE REPORT: A 14-year-old male patient presented with 13
unerupted supernumerary teeth distributed in all four quadrants.
TREATMENT: After taking a cone beam computed tomograph (CBCT), surgical
extraction was performed under general anaesthesia in two steps in order
to minimize the risk of airway-constriction by haematoma. FOLLOW-UP:
Follow-up examination was uneventful. Further orthodontic treatment is
planned which will secure the orthodontic alignment and correct
occlusion. CONCLUSION: Cone beam computed tomography is crucial for
exact localization, for treatment planning, and for the surgical
approach in cases of multiple supernumerary teeth.
Key words: multiple supernumerary teeth; non-syndromic hyperdontia; cone beam computed tomography
|Article Type:||Case study|
Tooth diseases (Diagnosis)
Tooth diseases (Care and treatment)
Tooth diseases (Case studies)
|Publication:||Name: European Archives of Paediatric Dentistry Publisher: European Academy of Paediatric Dentistry Audience: Academic Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2010 European Academy of Paediatric Dentistry ISSN: 1818-6300|
|Issue:||Date: Feb, 2010 Source Volume: 11 Source Issue: 1|
|Geographic:||Geographic Scope: Germany Geographic Code: 4EUGE Germany|
Supernumerary teeth, or hyperdontia, are additional teeth in either the primary or permanent dentition [Schulze, 1970]. Very rarely, three or more supernumerary teeth may be seen in the same individual [Fernandez-Montenegro et al., 2006]. The prevalence of multiple supernumerary teeth is 0.06% [Acikgoz et al., 2006]. Multiple supernumerary teeth are usually associated with development disorders or syndromes such as cleidocranial dysplasia or Gardner syndrome. However, occurrence of multiple supernumerary teeth in the absence of any associated syndrome or condition is very uncommon. The aetiology is not clearly understood [Gunduz and Muglali, 2007]. Males are more often affected then females [Rajab and Hamdan; 2002, Asaumi et al., 2004; Acikgoz et al., 2006; Liu et al., 2007; Hyun et al., 2008; Yague-Garcia et al., 2009]. In non-syndrome cases, the mandibular premolar region is the more common site of occurrence [Acikgoz et al., 2006, Hyun et al., 2008].
Supernumerary teeth are usually classified based on their morphology and location in the dental arch. When supernumerary teeth are discovered a decision needs to be made on whether to remove or monitor those [Wang et al., 2007]. In general, supernumerary teeth, especially in the maxillary anterior region, can cause the following clinical problems: failure of eruption, displacement or rotation of a permanent tooth, crowding, abnormal diastema or premature space closure, dilacerations, delayed or abnormal root development of permanent teeth, cystic formation and eruption into the nasal cavity [Rajab and Hamdan, 2002; Asaumi et al., 2004; Hyun et al., 2008]. Surgical removal of impacted teeth may damage adjacent structures, and therefore a thoughtful decision needs to be made with regard to the surgical risks and the benefit of removal [Rajab and Hamdan, 2002, Wang et al., 2007].
In general, conventional radiographs are adequate for localization of supernumerary or supplemental teeth. However, the implementation of cone beam computed tomography (CBCT) has been shown to be of additional benefit as demonstrated by a large study comprising 487 patients, who had solely one, two, or three supplemental teeth [Liu et al., 2007]. In this report, therefore, we report on the application and benefit of CBCT in a case with 13 supernumerary teeth, in a 14-yr-old boy.
A 14-yr-old boy was referred by his orthodontist for surgical removal of numerous supernumerary teeth. Familial, medical and dental history was without pathological findings. Mental development was normal. General examination and extra-oral exploration showed no abnormality. The clinical dental examination revealed that both permanent maxillary central incisors were absent and retention of these teeth was suspected.
As suggested from the referring orthodontist, it was decided to take a CBCT to localize the supernumerary teeth. CBCT (KaVo 3D eXam, KaVo GmbH, Biberach/Riss, Germany) confirmed the presence of all teeth belonging to the permanent dentition, including the 4 third molars, and multiple supernumerary teeth. In total 13 impacted supernumerary teeth were identified (figure 1).
A general physician was consulted and confirmed there was no suspicion of an associated syndrome. Karyotyping was withheld as there was no abnormal development in the individual and the family history was unremarkable. Based on the dental findings and the absence of any associated disorder or syndrome, a diagnosis was made of non-syndrome of multiple supernumerary teeth.
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The digital reconstruction of the CBCT in a lateral view showed the position of the supernumerary teeth in a vertical direction (figures 2a, b). This view was especially helpful to demonstrate and inform the patient and the parents because the localisation of the supernumerary teeth then becomes very clear. The localisation in the premolar region was determined in the horizontal cross sections in oral-vestibular direction. The two supernumerary teeth in the maxilla were in a palatal position (figure 3a). The 5 supernumerary teeth in the premolar region of the mandible jaw were in a lingual position (figure 3b). The frontal three-dimensional reconstruction shows 4 supernumerary teeth and the 2 retained and displaced permanent incisors in the anterior maxilla (figure 4). This view aided the planning for surgical exposition and for the alignment of the 2 permanent maxillary central incisors.
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After the process of informed consent, surgical extraction was performed under general anaesthesia (GA) in two steps in order to minimize the risk of airway-constriction by any possible haematoma. In the region of the anterior teeth a marginal incision was used to expose the 4 supernumerary teeth (figure 5). Furthermore, two brackets were attached to the maxillary central incisors to enable orthodontic alignment and correct occlusion. Antibiotics and NSAIDs were given postoperatively.
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Follow-up examination was uneventful. Orthodontic treatment is continuing and it is planned to eventually secure the correct alignment of the maxillary incisors and occlusion.
Multiple supernumerary teeth are usually associated with syndromes but also can occur in isolation without further abnormality. The surgical-orthodontic management requires accurate diagnosis and precise localization of the supernumerary teeth and the surrounding structures. A close cooperation among dental professionals to define combined surgical-orthodontic management is of great importance.
CBCT is a relatively new three-dimensional imaging technology, which has been specifically developed for imaging of the teeth and jaws [Liu et al., 2007, Dawood et al., 2009]. With imaging by CBCT, it was decided to extract the 13 unerupted supernumerary teeth and to align the permanent maxillary central incisors. Orthodontic treatment was included as part of the long-term treatment plan.
As noted before, CBCT provides accurate evaluation in cases of small numbers of supernumerary teeth [Liu et al., 2007]. In this report the benefit of this new technique in cases with multiple supernumerary teeth has been emphasised. CBCT ensures an adequate surgical approach to the supernumerary teeth and is appropriate for planning the optimal access to minimize surgical risks.
Three-dimensional volumetric imaging using cone beam computed tomograph (CBCT) is clearly advantageous in the management of multiple supernumerary teeth.
The author thanks Dr. G.M. Manegold for critically reviewing the manuscript.
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H.U. Brauer, Private Practice of Oral and Maxillofacial Surgery, Esslingen, Germany
Postal address: Dr. H.U. Brauer. Private Practice of Oral and Maxillofacial Surgery, Kollwitzstrasse 8, 73728 Esslingen, Germany.
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