|Year : 2015 | Volume
| Issue : 1 | Page : 47-51
Multiple Impacted Permanent and Supernumerary Teeth in the Anterior Mandible of Nonsyndromic Case: A Systematic Review and Multidisciplinary Approach to Management
Pushkar Gawande1, Manjula Hebbale2, Tushar Patil3, Amit Hindocha4, Rajshekhar Halli5
1 Department of Oral and Maxillofacial Surgery, Sinhgad Dental College and Hospital, Pune, Maharashtra, India
2 Department of Oral Medicine and Radiology, Bharati Vidyapeeth University Dental College and Hospital, Pune, Maharashtra, India
3 Department of Orthodontics and Dentofacial Orthopedics, M.A. Rangoonwala Dental College and Hospital, Pune, Maharashtra, India
4 Department of Prosthodontics and Implantology, Sinhgad Dental College and Hospital, Pune, Maharashtra, India
5 Department of Oral and Maxillofacial Surgery, Bharati Vidyapeeth University Dental College and Hospital, Pune, Maharashtra, India
|Date of Web Publication||19-Oct-2015|
Department of Oral and Maxillofacial Surgery, Bharati Vidyapeeth University Dental College and Hospital, Pune - 411 040, Maharashtra
Source of Support: None, Conflict of Interest: None
Multiple impacted permanent and supernumerary teeth have been associated with the syndromes and metabolic disorders. Approximately, 75% of all the supernumerary teeth are impacted and are asymptomatic. Consequently, most such teeth constitute casual findings in the context of routine X-ray studies. Lack of eruptive force and rotation of tooth buds may cause multiple impactions, and additional examinations may be necessary to exclude systemic and metabolic conditions. We present a rare nonsyndromic case with 11 multiple impacted teeth in the anterior mandible, with systematic literature review and multidisciplinary management.
Keywords: Impacted teeth, multiple teeth, nonsyndromic case, supernumerary teeth
|How to cite this article:|
Gawande P, Hebbale M, Patil T, Hindocha A, Halli R. Multiple Impacted Permanent and Supernumerary Teeth in the Anterior Mandible of Nonsyndromic Case: A Systematic Review and Multidisciplinary Approach to Management. J Dent Allied Sci 2015;4:47-51
|How to cite this URL:|
Gawande P, Hebbale M, Patil T, Hindocha A, Halli R. Multiple Impacted Permanent and Supernumerary Teeth in the Anterior Mandible of Nonsyndromic Case: A Systematic Review and Multidisciplinary Approach to Management. J Dent Allied Sci [serial online] 2015 [cited 2018 Sep 19];4:47-51. Available from: http://www.jdas.in/text.asp?2015/4/1/47/167571
| Introduction|| |
Hyperdontia is an odontostomatologic anomaly characterized by an excess in tooth number, both erupted and nonerupted. It can be described as "real" if determined by an increased number of teeth, otherwise it is "false" if caused by a delay in shedding of deciduous teeth beyond the transition period. 
Multiple impacted teeth may be related to syndromes and metabolic disorders. In some cases, however, impaction of multiple teeth is not accompanied by a fixed complex of symptoms. 
Supernumerary teeth were first reported between AD 23 and 79.  The etiology of supernumerary teeth still remains unclear. One theory suggests that these teeth are formed because of local, independent, and conditioned hyperactivity of the dental lamina. , Another theory states that the supernumerary tooth is formed because of dichotomy of tooth bud.  Hereditary and environmental factors are also considered important etiological factors in the occurrence of supernumerary teeth. Autosomal dominant trait has been suggested by Sedano and Gorlin. 
Brook found that supernumerary teeth were present in 0.8% of primary dentitions and 2.1% of permanent dentitions when 2000 school children were surveyed.  While there is no significant sex distribution in primary supernumerary teeth, males are affected approximately twice as frequently as females in the permanent dentition. 
Multiple supernumerary teeth are reported to be associated with few syndromes such as cleidocranial dysostosis, cleft lip and palate, Gardner's syndrome, and chondroectodermal dysplasia. Multiple supernumerary teeth not being associated with any syndrome are very rare. 
The etiology is unknown, although a number of theories have been proposed: Atavism, tooth germ dichotomy, hyperactivity of the dental lamina, and genetic factors comprising a dominant autosomal trait characterized by low penetrance.  Such teeth can erupt normally, remain impacted, invert, reach heterotopic positions, or show abnormal eruptive patterns.  Likewise, the development of supernumerary teeth can give rise to a broad range of complications, such as delayed eruption of permanent teeth, diastemas, the rotation of adjacent teeth, and cystic lesions or the resorption of contiguous teeth. Therefore, an early diagnosis and adequate treatment are essential. ,,,
Although multiple supernumerary teeth appear to develop more often in patients with some relative with at least one supernumerary tooth, the hereditary trait does not exhibit a simple Mendelian pattern. , A review of the literature yielded 7 families in which at least two individuals presented multiple supernumerary teeth - with no associated complex syndrome. ,,,,,,
Although few such cases have been published, it is important to stress that an exhaustive and detailed family history must be compiled when dealing with patients with multiple hyperdontia, since the dominant autosomal hereditary trait involved implies that all generations are affected. However, although the literature points to a familial predisposition to hyperdontia, in our case, there were no supernumerary teeth in any of the direct relatives of the patients. This was probably due to the low penetrance of dominant autosomal transmission, which implies that some generations are not affected by the disorder. On examining the few published cases of multiple hyperdontia not associated to complex syndromes, a predilection for the mandible and premolar series is observed. 
We present systematically reviewed literature with search word as "multiple impacted teeth" in the PubMed and related search sites along with our case report managed with multidisciplinary approach.
| Case Report|| |
A 25-year-old male reported to us for correction of his malaligned teeth. The family and medical histories were noncontributory. The general and extra oral examinations were noncontributory to arrive at the diagnosis of any associated syndromes.
Intra-oral examination revealed multiple over-retained deciduous teeth. Hence, an orthopantomogram was advised and it revealed multiple impacted permanent and supernumerary teeth in mandible and maxilla [Figure 1]a. There were eleven impacted teeth in the anterior mandible between 35 and 45 region and four teeth in the maxilla. Few impacted teeth were inverted in position.
|Figure 1: (a) preoperative orthopantomogram, (b) intra-operative intra-oral picture, (c) specimen|
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The patient was informed about the presence of additional number of teeth and was advised surgical removal of the same under general anesthesia before commencing orthodontic treatment. Hence, surgical removal of the impacted mandibular teeth and surgical exposure of the impacted maxillary teeth were planned.
Patient under general anesthesia through naso-endo-tracheal intubation, crevicular incision was placed from 35 to 45 along with two releasing oblique incisions. A trapezoidal mucoperiosteal flap was reflected up till the lower border of the mandible to expose all the impacted teeth [Figure 1]b. Under copious saline irrigation, overlying bone was removed with the help of micromotor and bur. Few teeth were sectioned to prevent damage to the adjacent permanent teeth. All the impacted teeth were removed [Figure 1]c, and flap was sutured to its normal position with the help of sutures. The remaining anterior teeth were stabilized with stainless steel wire reinforced composite splint [Figure 2]a and b. Postoperative course was uneventful with no signs of paresthesia.
Three months later, the patient was subjected to orthodontic treatment for correction of malaligned teeth followed by endodontic/prosthodontic rehabilitation of the anterior mandibular teeth. Now, the patient is on regular follow-up since 1 year [Figure 2]c and d. Complete dental rehabilitation was done after the orthodontic phase [Figure 3].
|Figure 2: (a) Immediate postoperative intra-oral picture with splint in place, (b) orthopantomogram-immediate postoperative, (c) intra-oral 1-year postoperative, (d) orthopantomogram 1-year postoperative|
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|Figure 3: (a) Orthopantomogram during or thodontic phase, (b) orthopantomogram after completion of orthodontic phase, (c) intra-oral picture after complete dental rehabilitation|
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| Discussion|| |
When there is a clinical absence of a number of teeth, and the history indicates that they have not been extracted, partial anodontia and tooth impaction can be considered. , Radiographic examination, however, may reveal multiple impacted teeth, and partial anodontia can be rejected. ,,
Panoramic radiographs may show multiple impacted teeth or in some instances radiopacities scattered throughout the jaws. A detailed description of the positional relationship between each impacted tooth and the neighboring tooth may also be given using three-dimensional computed tomographic images, if surgical or orthodontic treatment is planned. 
Multiple impacted teeth may be related to syndromes and metabolic disorders. Multiple impacted teeth were reported as a feature of cleidocranial dysostosis, Gardner syndrome, and Yunis-Varon syndrome. ,, This condition has also been reported in mucopolysaccharidoses. , After encountering multiple impacted teeth other than third molars or canines, the clinician should then be prompted to look for other features of the syndromes and metabolic disorders that may be present. 
In some cases, lack of space or crowding of dental arches, the premature loss of the primary teeth with subsequent partial closure of the area, and rotation of tooth buds are some of the most common causes contributing to impaction. 
The supernumerary teeth are more likely to be present in patients whose relatives possessed supernumeraries, although the inheritance of these teeth does not follow a simple Mendelian pattern.  It also seems that Asian populations are more affected with supernumeraries than others. ,,
Different studies have reported a prevalence of supernumerary teeth in the permanent dentition of between 0.15% and 3.8%. , Supernumerary teeth are single teeth in 76-86% of cases, while two supernumerary teeth are found in 12-23% of cases, and three or more such teeth in the same individual are only found in 2-8% of cases. However, according to Rajab and Hamdan,  this percentage is <1% when hyperdontia comprises 5 or more supernumerary disease, while Açikgöz et al. report a 0.06% prevalence of multiple supernumerary teeth.  In our case, 11 teeth were impacted in the anterior mandible and 4 teeth in the anterior maxilla.
A review of the literature yielded several studies in which large series of supernumerary teeth were analyzed. , In the case of simple hyperdontia, the supernumerary teeth were most often located in the maxilla - the mesiodens being the most common supernumerary tooth, followed by supernumerary premolars and supernumerary fourth molars. ,,, In contrast, on examining the few published cases of multiple hyperdontia not associated to complex syndromes, a predilection for the mandible and premolar series was observed. 
Supernumerary teeth may erupt or remain impacted within the maxilla. Approximately, 75% of all the supernumerary teeth are impacted and are asymptomatic. Consequently, most such teeth constitute casual findings in the context of routine X-ray studies. ,
It has been reported that supernumerary teeth may be associated to other dental anomalies such as hypodontia, taurodontism, germination, or macrodontia. , However, no such anomalies were observed in our case, in coincidence with the findings of Baccetti,  who recorded no relationship between supernumerary teeth and other dental anomalies.
In contrast to the general opinion that cysts are only rarely formed from a supernumerary tooth, Hopcraft  found such lesions in 9% of all cases. In our case, however, there were no cysts or enlarged dental follicles.
The literature describes different management options for patients with multiple hyperdontia not associated to complex syndromes. Treatment is partly dependent upon the position and clinical manifestations of the supernumerary tooth. Thus, an early diagnosis is very important to decide among extraction, extraction followed by orthodontic treatment, or simply monitoring or control of the supernumerary teeth, with a view to minimizing the risk of complications secondary to the presence of these teeth. 
Surgical management in turn ranges from removal of the supernumerary teeth to removal of the latter followed by orthodontic treatment aiming to ensure correct occlusion. In the more complex cases, the possible existence of multiple impactions of supernumerary teeth gives rise to destructuring of the dental arch, with numerous malpositioned teeth. These situations require close cooperation among professionals to define combined surgical-orthodontic management. In such cases, the orthodontist defines the general management lines, specifying which teeth must be removed or preserved in order to optimize occlusion through orthodontic treatment. ,,
Since there is always a risk of damaging some adjacent anatomical structure during extraction, the risk-benefit ratio of tooth removal must be evaluated in all cases. , As has been described by most authors, the current tendency is not to extract asymptomatic supernumerary teeth, with a view to avoid possible postoperative complications. In this sense, Hopcraft  suggested that particularly in the case of supernumerary lower premolars, the latter must be monitored - since extraction entails a high risk of loss of vitality or root damage of the adjacent teeth.
In our case, as determined by the location and position of the impacted teeth, none of them were in favorable position for surgically assisted orthodontic alignment. Hence, all the impacted teeth were surgically removed.
Multiple hyperdontia is rarely not associated to complex syndromes. The condition is infrequent and is normally asymptomatic. The diagnosis is usually established as a result of a casual finding when performing routine panoramic X-ray studies. Prophylactic surgical removal of the supernumerary teeth, coupled with orthodontic treatment of favorably placed teeth, , with resolution of their complications, is generally the treatment of choice with an aim of complete oral rehabilitation. Emphasis should be placed on the need to perform periodic radiographic follow-up, due to the possible late appearance of new supernumerary teeth.
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[Figure 1], [Figure 2], [Figure 3]