Surgical Management of Dual Mesiodens Followed by Orthodontic Correction of Malaligned Incisors in a 12-year-old Patient: A Case Report

INTRODUCTION

Detection of variations in shape, size, and number of teeth usually comes into play only when diagnosing some other problems.¹ Balk in 1917 coined the term mesiodens and mentioned them as supernumerary teeth located mesial to both central incisors that appeared as peg-shaped crowns.² The mesiodens is the most frequently found supernumerary tooth, which may occur as bilateral, unilateral, multiple, or single. The presence of multiple supernumerary teeth is called “mesiodentes.” The exact etiology is unknown. There are many theories that suggest potential etiological factors, such as (a) the dichotomy of tooth germs; (b) genetics; (c) hyperactivity of the dental lamina; and (d) environment. The male-to-female ratio is 2:1. Mesiodens appear most frequently, and the incidence is 0.3–0.8% for deciduous teeth and 0.15–3% for permanent teeth in the Caucasian population. Vertical (55.2%) mesiodens are more common, followed by inverted (37.6%) and horizontal (7%).³ Multiple supernumerary teeth are found in cleft lip and palate, cleidocranial dysplasia, or Gardner’s syndrome.⁴ According to reports, 82% of cases occur in the maxillary region, specifically the premaxillary region.

We present a case with both clinically erupted mesiodens and palatal-impacted asymptomatic mesiodens without patient awareness, which were detected on routine radiographic examination.

CASE DESCRIPTION

The department of pediatric and preventive dentistry got a 12-year-old male patient who complained about irregularly placed teeth in the upper front teeth region. The medical history was non-contributory, and he presented with good general health. Intraoral examination revealed the patient has clinically erupted mesiodens between the upper two central incisors. The left upper central incisor was placed too superolabially as compared with the right upper central incisor because of mesiodens (Fig. 1). We planned for surgical extraction of mesiodens, followed by 2 × 4 for incisor alignment. To confirm the upper permanent canine position, whether it has crossed the upper permanent lateral incisor or not for 2 × 4 treatment, the patient was advised to undergo an orthopantomogram (OPG), which revealed abnormal radio-opacity apical to 11 (Fig. 2). Occlusal radiograph and radiovisiography revealed that the patient has another mesiodens, which was impacted palatally apical to 11 (Fig. 2). It was found that the erupted mesiodens occupied 21 positions and led to their displacement superolabially.

TREATMENT PLAN

Treatment was planned in two phases:

• First phase: Surgical extraction of both erupted and impacted mesiodens.

• The second phase: Orthodontic alignment of malaligned upper permanent central incisors.

DISCUSSION

The mesiodens are most commonly positioned palatally and they emerge between the maxillary central incisors. Very few are present within the arch or labially. Approximately 80% of impacted mesiodens are found palatally, 6% are located labially, and 14% are positioned between the roots of the permanent central incisors. Cystic alteration occurs in 4–9% of cases, with 90% of them affecting the anterior maxilla.⁵ Mesiodens removal is indicated to prevent (a) delayed eruption, (b) displacement of the adjacent tooth, and (c) midline diastema. According to Munns, removing the mesiodens early improves the prognosis.⁶ In the present case, the conical crown of the impacted mesiodens was small in size and the root was fully developed. The position of the impacted mesiodens crown is postero-superiorly and the root is antero-inferiorly. Thus, immediate extraction of the supernumerary tooth was considered as there was a hindrance to the eruption of the incisors. The problems arising from the extraction of mesiodens were categorized by Barham et al. based on the contact between mesiodens and adjacent teeth.⁷ The timing for the extraction of mesiodens is either before the root formation of the permanent incisors or after the root formation of the permanent incisors. Some authors recommend early removal of most supernumerary teeth, especially those that are inverted and/or unlikely to erupt. This could eventually prevent the need for orthodontic treatment or additional surgical and periodontal procedures. Henry and Post recommended a delay in extracting the mesiodens at the age of 10, when the apex of the central incisor is almost forming.⁸ The final decision is made by the clinician depending on the patient’s condition. According to Yagüe-García et al., the best way to prevent complications is to remove supernumerary teeth early.⁹ In our case, both maxillary central incisors had totally erupted and had complete root formation. In this case, the palate was approached by raising a full-thickness mucoperiosteal flap to create a window for the removal of impacted mesiodens. The amount of bone amputation and the potential damage to existing incisors should determine the approach to removal.⁵ According to the literature review, the palatal approach was used to remove inverted mesiodens placed palatally, while those near the frontal region were removed by the transnasal approach.¹⁰ Inverted supernumerary teeth needs careful removal due to their proximity to developing permanent teeth.¹¹ In this case, a micromotor with a straight handpiece-assisted tungsten carbide bur (45 mm long, head diameter size 3.5 mm) was used for drilling the bone. Working with a straight handpiece in the maxillary anterior was found to be difficult in terms of accessibility and visibility in the present case. Other options, like piezotomes and lasers, can be considered as alternatives to rotary bone-cutting burs. Piezotomes are suggested to be promising due to their precise osteotomy design, good depth control, and soft tissue protection.¹² The post-surgical medications like Tab. Augmentin (625 mg), Tab. Ibuclin Junior (ibu 100 mg + para 125 mg), and Tab. Serratio peptidase 10 mg had been prescribed twice daily for 5 days, along with Hexidine mouthwash. Mesiodens are usually detected during routine radiographic examinations or when the patient has a complaint of delayed tooth eruption.⁷ In the present case, the patient had clinically erupted and palatally impacted mesiodens, which were identified using different radiographs like occlusal radiographs, OPGs, and RVGs. All these techniques will show a 3D object as 2D, which can lead to difficulty in the exact localization of the impacted tooth position. Cone beam computed tomography (CBCT) provides 3D imaging of the location of mesiodens and their contact with adjacent teeth and other neighboring anatomic structures. Hence, it is useful in minimizing trauma to the adjacent hard and soft tissues.¹³ The CBCT was not made in the present case due to economic reasons; instead, localization of impacted mesiodens was done using the Gutta percha point. Approximately 6% taper 30 number gutta percha was cut to 1 cm and placed over the apical portion of 11, and RVG was made to determine the exact location of impacted mesiodens for bone cutting. Frequently, the mesiodens are totally impacted (88.7%), which may cause a delay or even prevent the central incisors from erupting.¹ In the present case, erupted mesiodens had displaced 21 to the superolabial position. The postoperative management to follow the tooth position as it moves toward the occlusal line is important. Just the removal of the supernumerary tooth itself is not enough; also, the permanent tooth should be set in its right position. In this case, malpositioned upper central incisors were corrected using 2 × 4 fixed mechanotherapy to address patients concerns about occlusal interference and unpleasing looks.

CONCLUSION

Supernumerary teeth cause a lot of anxiety for patients, parents, and dentists due to their potential problems and complications. Proper imaging of erupted supernumerary teeth is important to detect supernumerary teeth early. Preventive extraction of these supernumerary teeth is suggested to prevent problems and decrease complications. Orthodontical management of malaligned incisors is as important as surgical removal of impacted teeth.

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