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Management of supernumerary teeth in


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Article February 2015


DOI: 10.4103/2278-9588.151907

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Review Article

Management of supernumerary teeth in


children: Anarrative overview of published
literature
Sreekanth Kumar Mallineni, Sivakumar Nuvvula1
Consultant Paediatric Dentist, Vasan Dental Care, Hyderabad, 1Department of Pedodontics and Preventive Dentistry,
Narayana Dental College, AndhraPradesh, India

ABSTRACT
Supernumerary teeth (ST) are a developmental numerical dental anomaly defined as extra teeth to the normal
complement. ST occur more frequently in the permanent dentition but rarely in primary dentition and seen
commonly in males than in females. ST occur in all regions of the dental arch. Identification and localization of
ST are very important for diagnosis and management. ST may cause various complications that include delayed
or impaired eruption of adjacent teeth, displacement or rotation, crowding, abnormal diastema, premature space
closure, dilaceration or abnormal root development of permanent teeth, cyst formation, and eruption into nasal
cavity. Thus, the early identification and appropriate treatment plan is essential to prevent the possible complications.
There are many opinions given by different authors in management of ST based on some case studies and reports.
The removal of ST should be done at an early age to avoid possible complications. Furthermore, it is advisable to
avoid aggressive surgical approach for removal of ST, if not associated with complications.
Key words: Children, complications, dental abnormalities, extra teeth, hyperdontia, mesiodens,
supernumerary teeth

INTRODUCTION abnormal teeth. These teeth have been referred as


Dental anomalies in the primary and permanent hyperdontia, supplemental, extra, a third dentition,
dentitions can range from changes in tooth morphology superdentition, aberrant, conoidal, paramolars,
to variations in tooth number. Supernumerary teeth(ST) distomolars, mesiodens, and polyphodontism.
are a developmental numerical dental anomaly with Some case studies and reports document different
at least one tooth or an odontogenic structure in opinions and concepts for the management of ST.
addition to the normal complement. This can be found Furthermore, various authors have given different
in any region of the dental arch in both dentitions. hypotheses, based on their research, which made
The most common types of ST are mesiodens, which controversial views in management of ST. Hence,
are found in the maxillary midline area.[1] ST refer to the purpose of this study was to discuss the reported
a dentition that has one, or more extra normal, or etiological factors, epidemiological characteristics,
complications, and diagnostic methods of ST, and to
Access this article online conduct a comprehensive review on management of
Quick Response Code:
Website: ST in children.
www.craniomaxillary.com

DOI:
ETIOLOGY
The etiology of ST has not been completely
10.4103/2278-9588.151907
documented and various hypotheses and speculations
Correspondence to:
Dr.Sreekanth Kumar Mallineni, Department of Dentistry, Abhiram Institute of Medical Sciences, Atmakur, Nellore524322, AndhraPradesh, India.
Email:drmallineni@gmail.com

62 Journal of Cranio-Maxillary Diseases / Vol 4 / Issue 1 / January 2015


Mallineni and Nuvvula: Management of supernumerary teeth

have been presented in the published literature. The EPIDEMIOLOGY


phylogenetic relict theory[2] stated that man originally Males are generally found to have a higher
had six incisors, and ST in modern man is a remnant prevalence of ST than females in the permanent
of his prehistoric dentition. The dichotomy theory dentition.[57] ST are more common in the permanent
involves splitting of the tooth germ resulting in the dentition and are usually found as a single tooth.[1,6]
formation of an ST.[3] The majority supported the However, pairs and groups of three have also been
theory of hyperactivity of the dental lamina due to described in the literature. Multiple ST are characteristics
the pressures within the jaws and the mobility of of some syndromes such as cleidocranial dysplasia,
particular facial processes that resulted in splitting of cleft lip and palate, and Gardners syndrome.[11] ST
dental lamina.[4] A genetic factor in the occurrence
are also more commonly found in the maxillary arch
of ST is always considered because of the familial
than in the mandibular arch. Maxillary ST may occur
occurrence of ST.[1,3] A unifying etiological model
in the premaxilla region or distal to the third molar.
was proposed by Brook[5] to explain the etiologic
The most common type of ST are the mesiodens,
factors and associations of anomalies in tooth size
which account for 9098% of all ST.[1]
and number. The model is essentially multifactorial,
combining polygenic and environmental influences.
ST can be classified based on their location,
morphology, orientation, and position[Figure1].
Dental anomalies occur in both primary and
permanent dentitions and several investigators Aconical or pegshaped ST usually presents as a
have reported the prevalence of ST. NikHussein mesiodens in premaxillary region. It may be found
and Abdul Majid[6] found a prevalence of 6% for ST high and inverted into the palate or in a horizontal
in the primary dentition of Malaysian children. This position. Most conical shaped ST are in a horizontal
relatively high percentage value in this study is due position. Conical ST rarely cause delay in eruption
to the small sample size. Whittington and Durward[7] and are found to be frequently erupted.[12] They
found in 1,680 children a total prevalence of rarely erupt, and frequently cause delayed eruption
1.4% for dental anomalies in the primary dentition of the incisors.[12] Tuberculate ST also commonly
and 0.18% of ST in permanent dentition. The occur bilaterally, and unilateral cases were of the
total prevalence of dental anomalies in Japanese conical type.[13] The supplemental type of ST is a
children was found to be at 9.67%,[8] where ST had duplication of teeth in the normal series and is found
a prevalence of 0.07%. The prevalence of ST in the at the end of the series;[14] most supplemental teeth
permanent dentition of Southern Chinese children in are premolars followed by incisors. The majority of
Hong Kong was found to be 2.8%.[9] Several reports ST in the primary dentition are of the supplemental
have indicated that there is a racial difference in type.[15] Howard[16] categorized odontoma as the
the incidence of ST. The literature indicates a range fourth category of ST. It may be termed complex or
from 0.1% to 7.8% in primary dentition and from compound odontoma depending on the anatomical
0.4% to 3.4% in permanent dentition.[10] features and histological composition of the tissue.

Figure 1: Summarized classification of supernumerary teeth

Journal of Cranio-Maxillary Diseases / Vol 4 / Issue 1 / January 2015 63


Mallineni and Nuvvula: Management of supernumerary teeth

COMPLICATIONS supplement especially if the tooth is dilacerated to


Various complications[1,6,1723][Table1] may allow for a threedimensional assessment of the
occur as the result of the presence of ST including impacted tooth.
crowding, delayed eruption, spacing, impaction
of permanent incisors, abnormal root formation,
alteration in the path of eruption of permanent MANAGEMENT
incisors, median diastema, cystic lesions, intraoral There is no sufficient evidence in the published
infection, rotation, root resorption of the adjacent literature that indicates the exact age of removal
teeth or even eruption of incisors in the nasal cavity, of ST. Conflicting ideas on the type and timing of
and retained deciduous teeth.[15,18,24] Management treatment still persist[Table2].[15,23,24,2740] Those
of ST always depends on the type of ST and its who advocate the immediate removal of the ST
position, relation to adjacent teeth, and its effects argue that it would prevent space loss by inducing
on surrounding structures. The removal of ST is not natural eruption of the unerupted tooth and
the treatment of choice in all clinical scenarios. also prevent a midline shift, therefore, avoiding
Impacted ST that are symptomless and not affecting extensive orthodontic and surgical treatment.[1,17,41]
the dentition in any manner and those found by However, waiting for the root development of the
chance are sometimes best left as they are and kept adjacent teeth may help prevent loss of vitality or
under regular observation. malformation of the adjacent teeth.[21,29,41] Hogstrom
and Andersson[19] demonstrated that the prognosis
DIAGNOSIS of the adjacent teeth was not affected by whether
the ST was surgically removed upon diagnosis
Diagnosis of an ST may be through clinical or or surgery was postponed after complete root
radiographic examination. Impacted ST may be
development of the adjacent teeth. On the other
diagnosed during a routine radiographic examination.
hand, Nuvvula etal.[23] postulated that the early
Some patients present at the surgery complaining
removal of causative ST in cases of severely rotated
of an impacted anterior tooth or persistent midline
unerupted incisors may result in selfcorrection and
diastema. As a rule, radiographic examination
proper alignment. The authors had a concern with
should be performed for teeth that have not erupted
early removal of ST that it may disturb the formation
within 6months after the contralateral teeth have
of adjacent roots if the ST are in close proximity
erupted. The identification and localization of ST
to the developing roots of permanent teeth, and in
plays a vital role in management.[25,26] Combinations
those cases, delayed removal has been suggested.
of different radiographs are useful in locating ST.
Another argument was that the surgical removal
Radiographs to be taken include a panoramic view
of impacted ST may not be necessary unless
to show the evidence of whole dentition. Anterior
developing complications are suspected and if the
occlusal or pariapical radiographs should be taken
to evaluate the incisor region completely. The tube tooth is associated with a pathological condition.[42]
shift technique can be employed to determine Adequate clinical and radiographic diagnosis and
whether the ST is located labially or palatally. a sound surgical intervention with proper behavior
Alateral skull radiograph may be taken as a management must be considered if early extraction
is essential.[42,43]
Table1: Complications associated with supernumerary
teeth After surgical removal of the ST, there is
Failure of eruption[6] also the question of whether or not to allow the
Midline diastema[17,18] impacted tooth to erupt spontaneously or to
Displacement[18] facilitate its eruption. Some authors support the
Crowding[15] concept of removing the supernumerary tooth and
Cystic degeneration[1,19] providing adequate space for the impacted tooth
Resorption[1,21] to spontaneously erupt.[44] It has been found that
Ectopic eruption[18,22] 75% of impacted teeth may erupt within 18months
Impaction[18,23]
of removal of the ST.[13] Mitchell and Bennett[45]

64 Journal of Cranio-Maxillary Diseases / Vol 4 / Issue 1 / January 2015


Mallineni and Nuvvula: Management of supernumerary teeth

Table2: Summary of timing of removal of supernumerary teeth


Author Summary
Munns[27] Earlier removal of supernumerary tooth allows for better prognosis
Rotberg and Kopel[28] Removal of supernumerary before 5years of age is suggested, since
root formation of permanent incisors is indicated
Koch and Schwartz[29] Immediate removal of supernumerary teeth is not necessary if there is no underlying pathology
Hogstrum and Andersson[19] 1. Removal of the supernumerary is suggested, as soon as it has been diagnosed
2. The supernumerary teeth could be left until complete root development of the adjacent teeth
Scanlan and Hodges[30] Early removal of supernumerary teeth is suggested in the presence of complications,
if not, supernumerary teeth are reviewed with appropriate followup intervals
Scheiner and Sampson[31] Removal of the supernumerary only in cases where adequate space
is available for the adjacent permanent tooth to erupt
Garvey etal.[14] Supernumerary teeth may be monitored if there are no associated complications
Shah etal.[32] Annual radiographic evaluation is advisable if the supernumerary teeth cause no
complications and are not likely to interfere with orthodontic tooth movement
De Oliveira Gomes etal.[33] Supernumerary teeth should be removed based on their development, regardless of the morphology type
Meighani and Pakdaman[34] Removal of midline supernumerary teeth in the early mixed dentition facilitates spontaneous alignment
of the adjacent teeth; however, symptomless cases could be left untreated and regular check up done
Omer etal.[24] Delayed removal of the supernumerary teeth is suggested because of more complications
if done early, and approximately 67years is the ideal time for its removal
Nuvvula etal.[23] Removal of the supernumerary teeth in the early mixed dentition stage may allow spontaneous eruption
and alignment of permanent teeth that minimizes the intervention, midline shift and space loss
Parolia etal.[35] Removal of supernumerary teeth should be performed cautiously to prevent damage to
adjacent permanent teeth, which may cause ankylosis and ectopic eruption of these teeth
Bahadure etal.[36] Management of supernumerary teeth depends on the age of the patient, cooperation on the
dental chair, and the position of supernumerary tooth and their effects. It is also based on the
length and size of supernumerary teeth and physiological resorption of adjacent teeth
MnguezMartinezl etal.[37] Surgical removal by orthodontic treatment is essential if supernumerary
teeth are causing impact on adjacent teeth
Tuna etal.[38] Early diagnosis and timely management are key factors to prevent or minimize the complications
Ramesh etal.[39] Mesiodens should be extracted in children and adolescents in order to avoid
possible adverse effects on adjacent teeth or cyst formation
Mohan etal.[40] Pathologyfree and asymptomatic cases can be treated in a conservative
manner and removal is essential if associated with pathology
Amarlal and Muthu[41] The clinician should be aware of the presence and associated complications of the supernumerary teeth
in order to make a correct decision regarding management

report a 78% eruption within 16months. However, If the eruption of tooth gets delayed, orthodontic
there are authors who believe that the delay in treatment is necessary. Nevertheless, management
eruption of the permanent teeth due to the presence of ST causing problems like impaction, rotation,
of an ST may result in a lack of space for the delayed eruption, and displacement of permanent
permanent teeth and closure of the apices requiring teeth requires a multidisciplinary approach.
orthodontic extrusion of the impacted teeth.[37,44]
Surgical removal of the ST may also be followed The surgical removal of ST should be performed
by surgical repositioning of the impacted tooth.[46] very carefully to avoid damage to the adjacent
The authors argue that orthodontic extrusion may permanent teeth, which might lead to ankylosis,
cause devitalization of the impacted teeth due to displacement, rotation, and ectopic position. It
large extrusive forces. From the available evidence, also has been stated that the clinician should be
it seems that one should be cautious and initiate cautious to prevent possible complications like
removal of the ST only in cases where adequate blood vessels and the damaging of nerves during
space is available for the adjacent permanent tooth the manipulation of the tooth, fracture of the
to erupt. The available space should be monitored maxillary tuberosity, perforation of the maxillary
for 18months to allow spontaneous eruption. sinus, the pterygomaxillary space, and the orbit.

Journal of Cranio-Maxillary Diseases / Vol 4 / Issue 1 / January 2015 65


Mallineni and Nuvvula: Management of supernumerary teeth

Clinicians must also pay more attention sometimes of some authors. Acomprehensive review of all
to the possibility of ST being fused with the adjacent these proposals has summarized that the surgical
tooth structure at the crown or root level, which removal of ST is essential if it is associated with
may make the extraction difficult. ST can also be pathology[Figure2]. The ultimate goal of this
kept under observation without extraction when flowchart is to help the clinician for the management
satisfactory eruption of related teeth has occurred of ST. This flow chart was designed based on the
with no associated pathology. orientation of ST in consideration of ST eruption.
Erupted ST should always be extracted, unless the
Regardless of the timing of treatment and the adjacent teeth are missing, in which case ST should
treatment of choice for an ST, early diagnosis is be retained. The impacted ST, not associated
essential to permit for a more complete longterm with complications, can be kept under regular
treatment planning for better prognosis and minimal monitoring.[15,49] If the impacted ST is found to be
intervention.[8] Most of the researchers[15,32,39,43] associated with any complications, then it should be
opined that the extraction of erupted ST in almost removed surgically. Surgical removal can be delayed
all cases except in those patients who had missing in cases if the ST is placed close to the apices of
teeth. There was concern among some researchers the developing permanent teeth,[23,50-52] and it also
that natal teeth are ST, however, in most cases, reported that if the ST is removed during the initial
natal teeth represent the true primary teeth and are stage there may be a chance of recurrence.[51-53]
not ST.[47-49] A study from Hong Kong on 44 subjects Omer etal.[24] suggested that 67years of age is
of natal and neonatal teeth reported that they were an appropriate age range for removal of ST, if the
part of the primary dentition.[47] The extraction of ST left after that age it may create complications.
these natal teeth may be questionable, if they are Most recently, it has been reported that the removal
mobile and are associated with any complications of ST would be justifiable based on whether the
they should be extracted. Various protocols have associated complications leading to pathology or
been established for the management of ST not. Nonpathological and asymptomatic cases are
based on both reported studies and speculations to be treated with a conservative approach.[40]

Figure 2: Flow diagram showing management options for supernumerary teeth based on orientation

66 Journal of Cranio-Maxillary Diseases / Vol 4 / Issue 1 / January 2015


Mallineni and Nuvvula: Management of supernumerary teeth

CONCLUSIONS overview of classification, diagnosis, and management. JCan


Dent Assoc 1999;65:6126.
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15. M i t c h e l l L . S u p e r n u m e r a r y t e e t h . D e n t U p d a t e
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which case simple extraction should be performed. 17. TayF, PangA, YuenS. Unerupted maxillary anterior
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Source of Support: Nil. Conflict of Interest: None declared.
with recent updates. Conference Papers in Science, 2014,
Article ID 764050, 62014. doi: 10.1155/2014/76405 Submission: Aug 15, 2014, Acceptance: Oct 18, 2014

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