A Case of Hyperdontia in a Non Syndromic Patient: A Case Report

INTRODUCTION

Hyperdontia, also called supernumerary teeth is a ‘number' dependent developmental dental anomaly, referring to any excess dental or odontological structure that is not a part of the normal dentition.¹ Multiple impacted supernumerary teeth are rare in occurrence. Furthermore, most of these cases are associated with syndromes such as cleidocranial dysostosis, Gardner’s syndrome and cleft lip and palate.^6,7,8 The prevalence of five or more supernumerary teeth was found to be 0.06%.⁹ It is often found as an incidental finding but can be seldom symptomatic. Apart from the symptomatic nature, impacted supernumerary teeth can also cause serious problems like formation of dentigerous cyst, complication due to its proximity with nasal floor and maxillary sinus, esthetic and functional complications such as crowding, midline diastema, root resorption, ectopic eruption, cystic lesions, displacement of the crowns of the neighboring teeth, intraoral infections, and delayed or failed eruption. In this report, we highlight about a case scenario of multiple impacted supernumerary teeth in the maxillary and mandibular arch managed under GA.

CASE REPORT

A 17 year old female patient was referred from Department of Orthodontics on the basis of incidental finding of multiple impacted supernumerary teeth in routine radiographic examination (OPG).

Her medical history is unremarkable and she has no relevant family history. On blood investigation her Hb was found to be slightly lower (10.4g/dl) and platelet count on a higher end 6.6 lakh/mm.³

No gross asymmetry was noted on extraoral examination. Intraoral examination revealed a mild prominence in the palatal aspect of deciduous right maxillary canine as well as missing mandibular left first molar, right second molar & permanent maxillary canines bilaterally. Also presence of retained deciduous maxillary canine bilaterally and retained deciduous maxillary left first molar was noted.

Preoperative panoramic radiograph revealed supernumerary teeth in association with retained deciduous maxillary canine bilaterally, retained deciduous maxillary left first molar, mandibular permanent right & left second premolar. It also showed impacted maxillary left first premolar and maxillary permanent canines bilaterally.

CBCT was taken to assess the nerve pathway and tooth morphology which reports the presence of an impacted supernumerary tooth with the crown resembling premolar located palatal & in contact with 53. Tooth is almost vertically impacted with the crown facing antero-inferiorly & root postero-superiorly.

Another impacted supernumerary tooth with the crown resembling premolar is located palatal & in contact with 14. Tooth is almost vertically impacted with the crown antero-inferiorly & root postero-superiorly. Root with open apex is also noticed.

Permanent right maxillary canine is impacted & located in such a way that; it is almost vertically impacted, in the antero- posterior plane. The crown of 13 is directed antero- medially and root is directed postero-laterally with no space in between adjacent tooth.

The crown of 13 is located palatal & superior to 11, in close approximation with the lateral wall of nasal cavity.

Middle part of root of 13 is seen palatal & superior to 12, in close approximation with the lateral wall of nasal cavity. Apical 3rd of root of 13 is located palatal & superior to 53, in close approximation with the lateral wall of nasal cavity.

Permanent maxillary left canine (23) is located palatal & in contact with 22 in close apposition with the lateral wall of nasal cavity. it is almost vertically impacted, in the anterior posterior plane. The crown of 13 is directed antero- medially and root is directed postero-laterally.

Another impacted supernumerary tooth with the crown resembling premolar is located palatal & in contact with 63. Tooth is almost vertically impacted with the crown antero-inferiorly & root postero-superiorly.

In addition, an impacted premolar 24 is located superior to 64. Tooth is vertically impacted. in close approximation with the floor of maxillary sinus.

And also impacted supernumerary teeth is located in the 35 and 45 region.

Findings were discussed and the patient was given an explanation of the indication to extract all impacted molars and all supernumerary teeth except 23 which was planned for orthodontic extrusion due to its favourable position.

SURGICAL TECHNIQUE

Patient was planned for surgical removal of impacted and supernumerary teeth under general anesthesia after getting fitness for the same. 1 g Cefixime intravenously was given preoperatively. Patient was aseptically painted and draped. 2% lignocaine with 1: 2,00,000 adrenaline infiltration given along the proposed site. In the mandibular arch, crevicular incision placed in the lingual aspect from 32 to 37 region & full thickness mucoperiosteal flap raised. A round bur was used to expose the crown region and bone guttering done with a straight fissure bur to expose the root of supernumerary tooth in relation to mandibular left second premolar tooth. Likewise, crevicular incision was placed from 42 to 46 region & full thickness mucoperiosteal flap raised. Bone guttering was done & supernumerary tooth in relation to mandibular right second premolar was exposed & removed.

In the maxillary arch, crevicular incision placed in the palatal aspect from 11 to 18 & full thickness mucoperiosteal flap raised. Palatal guttering done & vertically impacted maxillary right canine with root proximity to the lateral nasal wall was cautiously exposed & removed, once the impacted tooth was removed the supernumerary tooth in relation to 53 &14 behind it was visible and it was then elevated and taken out. Retained deciduous 53 also extracted.

In order to approach the supernumerary teeth in the second quadrant, crevicular incision was placed from 21 to 25 in the buccal aspect, full thickness mucoperiosteal flap reflected. Buccal bone guttering done, supernumerary tooth in relation to 63 & 64 exposed, elevated & removed. The vertically impacted 24 which was close to the maxillary sinus was sectioned and taken out. Retained deciduous 63 & 64 also extracted. Wound closure done with 4-0 Vicryl. Patient was kept on IV antibiotics and analgesics. Postoperative follow up done for one month. Postoperative period was uneventful and healing was satisfactory.

DISCUSSION

There are limited publications of cases on numerous supernumerary teeth in healthy patients with no genetic involvement.^8,10 Hence our case is of particular interest.

Multiple impacted teeth are a rare condition and are typically associated with certain syndromes. Lack of space due to crowding or early loss of deciduous teeth, prolonged retention of deciduous teeth, abnormal position of tooth bud, excessive fibrous tissue, ankylosis and cystic formation are the common etiology of impacted teeth.^3,4

Delayed or arrested eruption is probably caused by diminished resorption of bone and of primary teeth and due to the presence of multiple supernumerary teeth.¹¹ Conditions where we find retained teeth are: hemifacial atrophy, hypopitutarism, hypothyroidism, cherubism, gingival fibromatosis, cleft palate and preceding syndromes.¹²

Preoperative radiographic evaluation is the best method to identify the position and location of impacted supernumerary teeth. Since CBCT is a new technology that has transformed maxillofacial imaging, it was utilised as one of the diagnostic methods. It offers advantages of high contrast 3D images and image reconstruction for improved treatment planning.⁵

The presence of supernumerary tooth can cause a number of issues, including pathological alterations like chance of cyst formation, root resorption, delayed tooth eruption, and failure to erupt. A multidisciplinary approach may be appropriate choice since therapy involves issues with oral health, function, and aesthetics.

Treatment depends on the type and position of the supernumerary tooth and on its effect or potential effect on adjacent teeth. The management of a supernumerary tooth should form part of a comprehensive treatment plan and should not be considered in isolation.

Extraction is not always the treatment of choice for supernumerary teeth. They may be monitored without removal where:

• Satisfactory eruption of related teeth has occurred;
• no active orthodontic treatment is envisaged;
• there is no associated pathology;
• removal would prejudice the vitality of the related teeth.

However, surgical removal was advised due to the impacted teeth's pathological potential and undesirable position. It is very important to remove supernumerary teeth at a young age if it is damaging adjacent teeth or causing any other complication. Extraction of impacted teeth, including supernumerary teeth, is a commonly performed procedure associated with several complications and potentially substantial patient morbidity.¹³ With the assistance of a prosthodontist, pedodontist, and implantologist, it is necessary to plan space maintenance until the eruption of all permanent teeth and the patient's rehabilitation with fixed dentures. The aim of the therapy would be to achieve stable outcomes and improved aesthetics, dental health, and function.

CONCLUSION

The presence of multiple impacted supernumerary teeth is usually associated with syndromes like Gardner's syndrome and cleidocranial dysplasia. The simultaneous occurrence of multiple supernumerary and impaction of permanent teeth without association with complex syndromes is infrequent and is normally asymptomatic, usually diagnosed as a casual finding during routine panoramic X–ray studies. The close proximity to the lateral nasal wall & maxillary sinus makes the case more challenging. Managing such case scenario with the help of CBCT helped in better evaluation of the vital structures, nerve proximity, depth of tooth within the bone and also the orientation of tooth. Management of such condition also requires a multidisciplinary approach involving Dept of Oral Medicine & Radiology, Dept of Oral & Maxillofacial Surgey, Dept of Orthodontics and Dept of Prosthodontics to optimize patient specific superior results.

REFERENCES