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Case Report
Clinical and surgical considerations
for impacted mesiodens in young
children: An update
Ritu Jindal, Sunila Sharma1, Kanupriya Gupta

Department of Pedodontics and Preventive Dentistry, National Dental College and Hospital, Dera Bassi, Mohali, Punjab,
1
Department of Pedodontics, Bhojia Dental College and Hospital, Baddi, Himachal Pradesh.

ABSTRACT

Background: Most supernumerary teeth are located in the anterior maxillary region and are
classified according to their form and location. Their presence may give rise to a variety of
clinical problems. Detection of supernumerary teeth is best achieved by thorough clinical and
radiographic examination. Supernumerary teeth may be encountered by the general dental
practitioner as a chance finding on a radiograph or as the cause of an impacted central incisor.
Design: This article presents an overview of the clinical problems associated with
supernumerary teeth and includes a discussion of the classification, diagnosis, and
management of this difficult clinical entity.
Conclusion: The most common supernumerary tooth, which appears in the maxillary midline,
is mesiodens. Their diagnosis and management should form part of a comprehensive treatment
plan. Treatment depends on the type and position of the supernumerary tooth and on its
effect on adjacent teeth. The article throws a light on various modalities for investigation and
treatment of supernumerary teeth, which is important for an early intervention in children to
avoid major complications.

Key words: Mesiodens, radiographic examination, supernumerary teeth, surgical extraction

Introduction respective population.[6,7,10,11] An even gender

Address for Correspondence:
Dr. Sunila Sharma,
H. No. 124‑ E, Kitchlu Nagar,
Ludhiana, Punjab, 141 001, India
E‑mail: drsunilasharma@ymail.com
Date of Submission: 28‑06‑2012
Date of Acceptance: 12‑07‑2012
Access this article online
Website:
www.indjos.com
DOI:
10.4103/0976-6944.106462
Quick Response Code:
Definition
A supernumerary tooth is one that is
additional to the normal series and can be
found in almost any region of the dental arch.
Supernumerary teeth can occur either as
isolated events or multiple, unilaterally,
or bilaterally in both jaws or as part of
a syndrome or disease.[1‑5] The treatment
decision is based on the individual case and
may require interdisciplinary cooperation.
The prevalence rates of supernumerary
teeth reported in the literature vary between
0.1% and 3.6% in the permanent dentition
depending on the respective population.[6,7]
In deciduous teeth, prevalence is lower,
amounting to 0.3–0.8%. [8,9] Males are
affected more frequently in the second
dentition, with literature reporting rates
of between 2:1 and 6:1, depending on the
distribution appears in the first dentition.[6,9]
Single supernumerary tooth are still common
(76‑86%), but multiple supernumeraries are
rather rare (less than 1%).[1,12,13] Eruption
frequency is reported to vary between 15%
and 34% in the permanent dentition,[14]
while in the milk dentition, about two‑thirds
of the supernumeraries erupt.[14,15] Hence,
the importance of timely diagnosis and
treatment planning for these mysterious
teeth is clearly justified.
The reasons for development of these
supernumerary teeth are not completely
understood. Various theories exist for the
different types of supernumerary. One
theory suggests that the supernumerary
tooth is created as a result of a dichotomy
of the tooth bud. [16] Another theory,
well supported in the literature, is the
hyperactivity theory, which suggests that
supernumeraries are formed as a result of

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Jindal, et al.: Impacted mesiondens in young children: Treatment considerations
local, independent, conditioned hyperactivity of the dental
lamina.[17] Heredity may also play a role in the occurrence
of this anomaly, as supernumeraries are more common
in the relatives of affected children than in the general
population.[18] However, the anomaly does not follow a
simple Mendelian pattern.[18]
Supernumerary teeth are classified according to morphology
and location. In the primary dentition, morphology is usually
normal or conical. There is a greater variety of forms
presenting in the permanent dentition. [Figure 1] Four
different morphological types of supernumerary teeth have
been described.[19,20]
Problems associated with supernumerary teeth
Failure of eruption
The presence of a supernumerary tooth is the most
common cause for the failure of eruption of a maxillary
central incisor or may cause retention of the primary incisor.
Displacement
Displacement of the crowns of the incisor teeth is a
common feature in the majority of cases associated with
delayed eruption.[21]
Crowding
Erupted supplemental teeth most often cause crowding.[18]
Asymptomatic
Occasionally, supernumerary teeth are not associated with
any adverse effects and may be detected as a chance finding
during radiographic examination.[18]
Nasal teeth
They may grow and appear on the palate as extra
teeth, or they may grow into the nasal cavity. The teeth
may be asymptomatic or cause a variety of signs and
symptoms, including facial pain, nasal obstruction,
headache, epistaxis, foul‑smelling rhinorrhea, external
nasal deformities, and nasolacrimal duct obstruction.
Complications of nasal teeth include rhinitis caseosa with
septal perforation, aspergillosis, and naso‑oral fistula.[22,23]
Pathology
Dentigerous cyst formation is another problem that may
Figure 1: Classification of mesiodens
Indian Journal of Oral Sciences  Vol. 3  Issue 2  May-Aug 2012
be associated with unerupted supernumerary teeth.[24]
Primosch reported an enlarged follicular sac in 30% of
cases, but histological evidence of cyst formation was
found in only 4% to 9% of cases.[25]
In lieu of the potential disturbances/problems associated
with erupted as well as unerupted mesiodens, this paper
aims at an early diagnosis with treatment planning
for these supernumerary teeth reviewing the decision
about whether to extract or not and of time when to
intervene in a young child, keeping in mind his eruption
pattern, eruption status, and the approximation of our
supernumerary concerned with these factors.
Clinical findings and case report
Case 1
A nine‑year‑old patient presented to the department with
chief complaint of extra tooth in upper front region
of mouth causing disfigurement. He gave a history of
fractured anterior tooth few days before and had no
hypersensitivity related to the tooth.
A thorough examination was conducted where medical
history and family history was unremarkable. Clinical
examination revealed presence of conical mesiodens palatal
to 11, displacing it labially Figure 2. There was Ellis class 1
fracture with respect to 21.
Occlusal radiograph was taken to rule out the possibility
of multiple supernumerary tooth. To our surprise, there
was another unerupted inverted mesiodens impacted in
the palate, quite posterior approaching the permanent first
molar area on left side towards the midline.
Radiographic examination revealed two mesiodens, one
erupted and one unerupted Figure 3.
The extraction of both mesiodens was planned.
Figure 2: Preoperative occlusal view showing an erupted conical
mesiodens palatal to 11
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Jindal, et al.: Impacted mesiondens in young children: Treatment considerations

After giving local anesthesia, the extraction of erupted

mesiodens was carried out followed by the surgical
extraction of the unerupted one. The palatal flap was raised
from distal aspect of first permanent molar on left side
to distal aspect of canine on right side [Figure 4]. After
locating the crown, with minimal bone cutting, extraction
of the mesiodens was done and sutures were given.
Excellent healing was observed after two weeks. Also, the
buccally displaced tooth came into alignment. Composite
build up of 21 was done afterwards.

Case 2
A 10‑year‑old male patient reported to the dept. of
pedodontics and preventive dentistry, with the chief
Figure 3: Preoperative occlusal radiograph showing impacted
complaint of proclined central incisor on the left side. conical mesiodens
Patient gave the history of extraction of an extra tooth
located just lingually to the central incisor. Based on the
history, location, and sequelae, the extracted tooth was
diagnosed as mesiodens. Thorough clinical examination
revealed a slight swelling, approx. 1 x 1 cm in size on the
palate, near 1st molar on the left side and towards the midline.
Diagnostic maxillary occlusal radiograph revealed an
incompletely formed tooth in the same location where
the swelling was felt [Figure 5]. The diagnosis was made
as impacted mesiodens.

Surgical extraction was planned. The histopathological

examination confirmed the diagnosis of impacted
mesiodens surrounded by granulation tissue. The
patient remained under follow‑up for 2 months, and no
complications were observed [Figure 6]. Figure 4: Flap raised, tooth located and surgically extracted

Case 3
A nine‑year‑old patient reported to the department of
pedodontics and preventive dentistry with chief complaint
of missing permanent left central incisor along with delayed
eruption. On clinical examination, it was observed that
61, 62 were retained with unerupted maxillary permanent
incisors, though 31, 41, 42 were fully erupted [Figure 7]. The
diagnostic maxillary anterior occlusal radiograph revealed
the presence of two supernumeraries in the anterior region
[Figure 8]. Based on the clinical and radiological findings,
an observation of two impacted supernumerary teeth was
made. As observed from the radiograph, the permanent
incisor roots were not fully developed (Demrijian stage F).
Therefore, wait and watch treatment option was considered
for impacted supernumeraries as surgical intervention is Figure 5: Preoperative occlusal radiograph showing an impacted
required for their removal, which can lead to obtunded inverted mesiodens
root growth. However, an eruption incision was planned
to facilitate the eruption of permanent incisors. or are diagnosed as a chance finding during radiographic
examination or they are cause of a complication and require
Discussion an immediate intervention. Unerupted mesiodens may
lead to some potential problems that is disturbed tooth
Impacted supernumerary teeth either remain clinically silent eruption, tooth rotation, bodily displacement, crowding,

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Jindal, et al.: Impacted mesiondens in young children: Treatment considerations
Figure 6: Post operative occlusal radiograph
Figure 7: Preoperative clinical view showing missing 11,12
Figure 8: Preoperative occlusal radiograph showing two
supernumeraries in the anterior region
spacing, or diastema of normal teeth. A cystic alteration
is detected in 4–9% of the supernumerary cases, with the
Indian Journal of Oral Sciences  Vol. 3  Issue 2  May-Aug 2012
anterior maxilla being affected in 90%.[25,26] Occurrence
of the above‑mentioned complications indicates surgical
removal of the supernumerary tooth.[27]
The reported case had one erupted and an unerupted
mesiodens in the maxilla. No sign and symptoms were
present related to the unerupted mesiodens. When no
clinical sign is apparent and the mesiodens is asymptomatic
and impacted, it can lead to many pathological findings like
granuloma or cyst as already discussed, and no doubt, the
young children are more prone to these manifestations.
This is because the permanent dentition is not developed
yet and occlusion is not established, chances of pathologies
in young children is highly associated with unerupted
supernumerary teeth because it may act as nidus for cystic
transformation or infection propagation. Therefore, the
potential detrimental effects in young children make it
mandatory to extract unerupted supernumerary teeth.
Radiographic examination of the jaws is, therefore,
imperative. In routine analyzes of supernumerary teeth,
radiographs required are periapical, orthopantomogram.
When suspecting a supernumerary tooth, an upper occlusal
film is very much helpful in clarifying the presence or
absence of the supernumerary teeth.
The bucco‑lingual position of unerupted supernumeraries
can be determined using the parallax radiographic
principle:[28] The horizontal tube shift method. Intraoral
views may give a misleading impression of the depth of
the tooth. A true lateral radiograph of the incisor region
assists in locating the supernumeraries that are lying deeply
in the palate and enables the practitioner to decide whether
a buccal rather than a palatal approach should be used to
remove them.[18] Nasal teeth result from the ectopic eruption
of supernumerary teeth. Their clinical and radiologic
presentation is so characteristic that their diagnosis is not
difficult. CT scanning is helpful in planning their treatment.[29]
Wait‑and‑see behavior is also indicated if surgical removal
of a complication‑free supernumerary would jeopardize
the vitality of other permanent teeth.[18] In such cases, the
close topographic relationship between the normal teeth
and the supernumerary to be removed may be resolved by
orthodontic means prior to the surgical procedure. Although
supernumerary teeth may remain in the jaw for years without
causing complications, they should be observed as they may
as well cause cystic complications.[26,30,31] Development of a
carcinoma is very rare.[32,33] An association of impacted teeth
and neuralgia has been reported in sporadic case studies;
however, has not yet been proven.[33,34]
Conclusion
Frequency of supernumerary teeth is 3% and may cause
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Jindal, et al.: Impacted mesiondens in young children: Treatment considerations
a variety of symptoms and complications. Ectopic
presentations of these unerupted teeth are rare. Early
diagnosis and timely surgical intervention can reduce or
eliminate the need for orthodontic treatment and reduce
complications to the regular dentition in such cases.
However, their diagnosis is very difficult based on just
clinical appearance; the key in diagnosis is radiographic
examination. Treatment considerations of hyperdontia
depend on the respective case: A surgical intervention to
prevent any complications or wait and watch to prevent
trauma to the adjacent developing structures in a young
child’s dentition.
What this paper adds
• Supernumerary tooth is a commonly encountered dental
anomaly, with mesiodens presenting as a mysterious
tooth as far as diagnosis and location is concerned.
• Impacted mesiodens pose a further challenge to the
clinician as they require either a surgical approach or
sometimes wait and watch therapy scores over the usual
treatment.
• T he paper, thus, presents a variety of cases and
treatment options taking into considerations all the
factors required for the correct intervention.
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How to cite this article: Jindal R, Sharma S, Gupta K. Clinical and
surgical considerations for impacted mesiodens in young children:
An update. Indian J Oral Sci 2012;3:94-8.
Source of Support: Nil, Conflict of Interest: None declared
Indian Journal of Oral Sciences  Vol. 3  Issue 2  May-Aug 2012