Introduction
Mesiodens exceed normal dental formula despite of their morphology and location.1 Presence of extra tooth in dental arch is called hyperdontia. Mesiodens can be seen in deciduous, mixed and permanent dentition as well. It can be solitary, multiple, unilateral, bilateral. Prevalence of mesiodens is 0.3-0.8% and in permanent dentition 1.5-3.5%.2, 3 Usually mesiodens is more prevalent in men than women.4 Mesiodens is generally asymptomatic and detected during routine dental checkup but sometimes it can be associated with various complications like spacing, crowding,ectopic eruption etc. It is more frequently seen in maxilla, specifically in premaxilla region.4, 3 The etiology of mesiodens is multifactorial and genetics play a crucial role. The treatment plan depends on thorough clinical and radiographical examination.
Etiology
Etiology of mesiodens still remains unclear and it is multifactorial.3 There are two popular theories present regarding the etiology of mesiodens. According to the dichotomy theory, a single tooth germ splits into two and as a result two teeth are developed. Size of these two teeth may be equal or unequal.4, 3
Another theory suggests that mesiodens can be formed due to hyperactivity of dental lamina. Heredity is an important factor while discussing development of mesiodens. According to Nislander & Sujaku (1963), supernumerary teeth may be an autosomal dominant trait. Some theories suggests that presence of mesiodens and gene mutation are strongly associated with each other. Bruning et al stated that mesiodens can be sex linked also as it is commonly found in males.4, 3, 5 Multiple supernumerary teeth can be associated with syndromes like cleidocranial dysplasia, Gardener syndrome, Ehlers danlos syndrome etc. Non syndromic familial mesiodens is very rare. Mesiodens can be developed in heterozygous or homozygous gene mutation. APC gene [5q21- q22] mutation which is responsible for Gardener syndrome, may one of the factors causing supernumerary teeth. Sudden inactivation or forced activation of APC gene is suggestive of supernumerary tooth development.4, 3, 5, 6, 7, 8
Diagnosis
Most of the times supernumerary tooth remains unnoticed until they cause any disturbance. It can be diagnosed during routine dental check up or when patients come with some other dental problems. Clinical and Radiographical examination both are crucial to detect the number, position and morphology of mesiodens. Generally occlusal radiography, RVG or IOPAR can be done. In case of submerged or ectopic mesiodens, CBCT is required.9
Case Report
A nine year old girl and her elder brother, who was eleven years old, came to department of Pedodontics and Preventive Dentistry, with their grandfather with the chief complaint of presence of extra teeth in the mouth.
Case 1
The elder brother (11 years old boy), complained about one extra teeth present in his mouth.
Medical history: Non relevant
Family history: Patient gave history of presence of extra tooth and irregular arrangement of teeth in his mother and maternal aunt (sister of his mother).
Dental history: This was the first visit.
Pre Natal history: Non relevant. No history of viral or bacterial infection and or any trauma during pregnancy. No history of nutritional deficiency or alcohol use & smoking.
Natal history: Child was full term and delivery through c-section.
Post natal history: No history of allergy or hospitalisation.
General examination: Height 4 ft 3 inch and weight 35 kg, gait- normal. Built- mesomorphic, posture- erect
Extra oral examination:
Facial profile: Convex
Facial form: Mesoproscopic
Facial divergence: Posterior divergent
Shape of head: Mesocephalic
Intraoral examination: One conical shaped mesiodens was present behind the two maxillary central incisors. Anterior cross bite was present.
Radiographic examination: RVG was taken
Treatment planning: After orthodontic consultation, extraction of mesiodens was planned.
Treatment done: Extraction was some under local anaesthesia and bleeding was controlled. Post operative instructions were given to the grandfather. Antibiotics and analgesics were prescribed.
Recall visit: Patient was recalled after 5 days for further orthodontic treatment.
Case 2
The younger sister (9 years old), complained about presence of 2 extra teeth in her mouth
Medical history: Non relevant
Family history: Patient gave history of presence of extra tooth and irregular arrangement of teeth in his mother and maternal aunt (sister of her mother)
Dental history: This was the first time she visited a dentist.
Prenatal history: Non relevant. No history of viral or bacterial infection and or any trauma during pregnancy. No history of nutritional deficiency or alcohol use & smoking.
Natal history: Child was full term and delivery through c-section.
Post natal history: No history of allergy or hospitalisation.
General examination: Height 4 ft and weight 32 kg, gait- normal. Built- mesomorphic, posture- erect
Extra oral examination:
Facial profile: Convex
Facial form: Mesoproscopic
Facial divergence: Posterior divergent
Shape of head: Mesocephalic
Intraoral examination: Two small mesiodens was present in between maxillary central incisors. Flaring of central incisors were noticed
Radiographic examination: RVG was taken
Treatment planning: After orthodontic consultation, extraction was planned.
Treatment done: Extraction was some under local anaesthesia and bleeding was controlled. Post operative instructions were given to the grandfather. Antibiotics and analgesics were prescribed.
Recall visit: Patient was recalled after 5 days for further orthodontic corrections.
Conclusion
According to Chidgonza, mesiodens should be extracted at the age of 8 to 10 years, when the roots of permanent incisors are fully formed.4, 3, 9 The best treatment option is the extirpation of unerupted mesiodens while permanent teeth are in formative stage.9 Some suggests that mesiodens should be kept under observation so that it can’t cause any abnormality during the eruption of incisors. If presence of mesiodens cause malalignment of teeth, orthodontic treatment should be planned and mesiodens should be extracted according to the planning at right age. 10, 11
Discussion
Mesiodens is the most common supernumerary teeth found in anterior maxilla. Mesiodens can be conical, tuberculate, or molariform. Sometimes it resembles normal teeth. It can be present vertically or horizontally, sometimes it can be impacted. Radiographic examination is very crucial to determine the root morphology whether it is straight or curved, root formation is completed or not. Supernumerary tooth in anterior region should be extracted only when the roots of permanent incisors are fully formed.
Mesiodens can interfere with normal occlusion or normal eruption process. It can cause flaring of incisors, crossbite, midline diastema, malalignment of teeth. Depending on the position, type and complications, extraction is the treatment of choice. There’s no clear opinion regarding the treatment.
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