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| CASE REPORT |
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| Year : 2015 | Volume
: 5
| Issue : 2 | Page : 129-132 |
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Mystery behind discoloration of central incisor: An inverted, labially impacted mesiodens
Pulkit Khandelwal1, Neha Hajira2
1 Department of Oral and Maxillofacial Surgery, Pacific Dental College and Hospital, Udaipur, Rajasthan, India
2 Department of Prosthodontics, Darshan Dental College, Udaipur, Rajasthan, India
| Date of Web Publication | 10-Mar-2016 |
Correspondence Address:
Dr. Pulkit Khandelwal
1/102, Vidhyadhar Nagar, Jaipur, Rajasthan
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/2231-6027.178500
Supernumerary teeth are defined as the dental structures present besides the normal series of deciduous or permanent teeth. Mesiodens are the most common supernumerary teeth, occurring in 0.15–1.9% of the population. The precise etiology of mesiodens is yet uncertain and is not fully understood, although proliferation of the dental lamina and genetic factors has been implicated. Often mesiodens produces complications while in certain instances, mesiodens are accidental radiographic findings. Early diagnosis often reduces the chances of occurrence of any future complications. Treatment is the surgical extraction of the mesiodens, however the decision to extract this supernumerary tooth should be based on a risk/benefit analysis. This paper presents a case of inverted, labially impacted mesiodens which had led to nonvitality of the central incisor. Keywords: Complications, dentition, incisor, mesiodens, supernumerary tooth
How to cite this article:
Khandelwal P, Hajira N. Mystery behind discoloration of central incisor: An inverted, labially impacted mesiodens. Int J Oral Health Sci 2015;5:129-32 |
| Introduction | |  |
The dentition plays very important role not only in mastication and speech but also the esthetics of an individual. The normal maximum number of permanent teeth is 32 and that of deciduous teeth is 20. During evolution, the number of teeth in humans has decreased; however, variation in tooth development may result in increase in the number of teeth.[1],[2] These teeth which are present in excess of the normal series are known as “supernumerary teeth.” Supernumerary teeth are most often seen in maxilla, specifically in incisor and molar regions. The supernumerary teeth that occur in between central incisors or just posterior to the central incisors are known as “mesiodens;” those supernumeraries erupting in the molar region are known as “paramolars;” and those that develop distal to the third molar are called as “distomolars.” These extra teeth may erupt in both deciduous as well as permanent dentition, but they are more commonly seen in the permanent dentition. These teeth are often rudimentary in shape and smaller in size. They may erupt or may be impacted. Impacted ones are accidentally diagnosed on radiographs.[1]
The first report of supernumerary tooth appeared around 23–79 AD. The most common type of supernumerary tooth is mesiodens. The term “mesiodens” was coined by Balk in 1917 to indicate a supernumerary tooth present mesial to both central incisors and appeared as peg shaped with normal or inverted position. There are two subtypes of mesiodens, depending on their shape and size. The first type is eumorphic teeth having normal morphology and resembling the central incisor. The second type is dysmorphic teeth with different shapes and sizes and further categorized into conical, tuberculate, supplemental, and odontomas.[3]
It is important for dentist to know the prevalence and early diagnosis of the mesiodens in terms of preventing any complications. In this article, we report a case of impacted mesiodens causing discoloration of central incisor, which is diagnosed accidentally on the radiograph.
| Case Report | | |
A 25-year-old male reported to our clinic with a chief complaint of discolored upper front teeth. There was also history of chipping off of crown portion around 6 months. He neither had history of any trauma to upper tooth region nor there were any sign or symptom related to trauma from occlusion. Following clinical examination, the periapical radiograph was taken, which revealed root resorption of the left central incisor, radiolucency present apical to both incisors on the left side and the presence of impacted mesiodens between roots of central incisors [Figure 1]. Endodontic treatment of central incisor was started. Under local anesthesia, mesiodens was extracted [Figure 2]. The mesiodens had almost normal morphology with curved root; crown and root were significantly developed but smaller in size [Figure 3]. | Figure 1: Intraoral periapical radiograph showing inverted and conical mesiodens and resorption of the root of the left maxillary central incisor
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 | Figure 2: Intraoperative view showing discolored upper left permanent central incisor and mesiodens
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| Discussion | | |
Supernumerary tooth is basically any teeth or tooth substance in excess of the usual configuration and series of the normal number of deciduous or permanent dentition. The most common supernumerary teeth, in order of occurrence, are the mesiodens, maxillary distomolars, maxillary paramolars, mandibular parapremolars, mandibular para and disto molars, and maxillary parapremolars.[1],[2] A mesiodens is a conical supernumerary tooth which erupts between the maxillary central incisors and is usually located palatal to the permanent incisors. Only a few of them lie within the arch or labially. Eighty percent of impacted mesiodens are palatally positioned while only 6% of the impacted mesiodens are found labially. Remaining 14% are located between the roots of the permanent central incisors. The mesiodens is usually smaller in size, with a triangular or conical crown.
Several theories have been proposed regarding the etiology of supernumerary teeth including phylogenetic (atavism), dichotomy of tooth bud, and hyperactivity of dental lamina. However, the exact cause of development of these teeth is still unknown and not completely understood. The “phylogenetic theory” stated that these supernumerary teeth have originated and evolved as a result of atavism of the extinct ancestral tissues. The “tooth germ dichotomy theory” stated that during the development of tooth, the dental lamina may divide into two or more parts, thus leading to the development of extra teeth with similar or different sizes. According to widely accepted “hyperactivity of the dental lamina” theory, over proliferation of remnants of the undegenerated dental lamina may cause the development of supernumerary tooth/teeth. “Heredity” is also considered to be a significant factor as these teeth occur more frequently among the relatives of affected individuals when compared to the general population.[2],[3]
The mesiodens may erupt in the normal manner, get impacted, take an inverted, or horizontal position. Asymptomatic unerupted mesiodens may be diagnosed accidentally during radiographic examination of the premaxillary area. Mesiodens may be found associated with various craniofacial anomalies and syndromes such as cleft lip and palate, Gardener's syndrome, Down's syndrome, or cleidocranial dysostosis. The prevalence rate of mesiodens varies between 0.3% and 3.8% among general population with more prevalence in males than in females with ratio of 2:1.[4] It is diagnosed clinically and through radiographic examinations using periapical radiograph and orthopantomogram. In addition, maxillary occlusal radiograph can also be taken. Precise information regarding their location and relationship with adjacent tooth structures can be obtained through computerized axial tomographic scan.[1],[3]
The mesiodens may lead to the development of complications such as retention or delayed eruption of primary or permanent central incisors, rotation, unfavorable displacement, root resorption or pulpal necrosis of central incisor, midline diastema, formation of dentigerous and primordial cyst, and sometimes nasal eruption. Less common complications include dilacerations of developing tooth and loss of tooth vitality.[2],[5] Patel et al. reported a case of dentigerous cyst associated with inverted and fused mesiodens.[6] Ephraim et al. reported a labially positioned mesiodens and its repositioning as a missing central incisor.[7] Mangalekar et al. and Indira et al. found molariform mesiodens in primary dentition.[8],[9] Kalaskar and Kalaskar reported impacted central incisors due to supernumerary teeth and an associated dentigerous cyst in their findings.[10] Numerous cases have been reported in the literature describing the complications associated with the occurrence of mesiodens. Our case report is one of them.
The ultimate management of mesiodens still remains controversial – extraction or observational management. Extraction is indicated in the following situations:[11]
- Presence of an associated pathology with adjacent teeth or supernumerary tooth itself
- Delayed eruption of permanent tooth
- Increased risk of caries
- Altered eruption or displacement of adjacent tooth
- Severe rotations of adjacent tooth
- Orthodontic extraction
- Compromises alveolar bone grafting and implant placement
- Compromised esthetic and functional status.
Treatment of mesiodens depends on several factors and considering these factors will determine whether to manage surgically or to observe the condition. The first factor is the child's age. The advantage of early treatment must be important for the ever-lasting effect that any unfavorable experience may have psychological effect on a child patient. The stage of development of the surrounding teeth and proximity of the mesiodens to the incisors is another important factor. The risk of surgical trauma to the developing roots of the permanent incisors should be taken into consideration. Finally, the relative position of the mesiodens within the premaxilla should be evaluated whether mesiodens is palatally or labially present. The surgical procedure related to the amount of bone removal and potential damage to existing incisors should be considered.[5] These supernumerary teeth may be kept under observation without extraction when there are no symptoms associated with them. If extraction is indicated, it should be done carefully to prevent any damage to the adjacent permanent teeth, nerve, or blood vessels.[12] There is no precise consensus regarding the ideal timing for surgical removal of impacted mesiodens. According to Canoglu et al., mesiodens should be best extracted when the permanent central incisors start erupting.[13] However, Primosch was against the early extraction of mesiodens due to the risk of iatrogenic damage to the developing adjacent permanent teeth.[14]
In the case reported here, we found mesiodens which was associated with pathological root resorption of central incisor leading to nonvitality and subsequent discoloration of the central incisor. Mesiodens was impacted labially which is a rare incidence. Mesiodens was extracted to prevent any further damage to the central incisor or cyst formation. Endodontic treatment of central incisor was done. The patient was satisfied with the treatment.
| Conclusion | | |
The eruption of mesiodens is relatively common and can lead to a variety of complications. The clinician should recognize signs suggesting the presence of supernumerary teeth and perform the relevant investigations. On diagnosis, each case should be managed appropriately to minimize complications. Careful history taking, clinical and radiographic examinations can provide important information required for the diagnosis of such conditions. Extraction or observation is main modality of the management of such abnormality. Long-term follow-up of treated case is mandatory.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
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| 3. | Russell KA, Folwarczna MA. Mesiodens – Diagnosis and management of a common supernumerary tooth. J Can Dent Assoc 2003;69:362-6. |
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| 12. | Ghoddusi J, Zarei M, Jafarzadeh H. Endodontic treatment of a supernumerary tooth fused to a mandibular second molar: A case report. J Oral Sci 2006;48:39-41. |
| 13. | Canoglu E, Er N, Cehreli ZC. Double inverted mesiodentes: Report of an unusual case. Eur J Dent 2009;3:219-23. |
| 14. | Primosch RE. Anterior supernumerary teeth – Assessment and surgical intervention in children. Pediatr Dent 1981;3:204-15. |
[Figure 1], [Figure 2], [Figure 3]
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