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Management of supernumerary teeth in

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

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


have been presented in the published literature. The
phylogenetic relict theory[2] stated that man originally
had six incisors, and ST in modern man is a remnant
of his prehistoric dentition. The dichotomy theory
involves splitting of the tooth germ resulting in the
formation of an ST.[3] The majority supported the
theory of hyperactivity of the dental lamina due to
the pressures within the jaws and the mobility of
particular facial processes that resulted in splitting of
dental lamina.[4] A genetic factor in the occurrence
of ST is always considered because of the familial
occurrence of ST.[1,3] A unifying etiological model
was proposed by Brook[5] to explain the etiologic
factors and associations of anomalies in tooth size
and number. The model is essentially multifactorial,
combining polygenic and environmental influences.
Dental anomalies occur in both primary and
permanent dentitions and several investigators
have reported the prevalence of ST. NikHussein
and Abdul Majid[6] found a prevalence of 6% for ST
in the primary dentition of Malaysian children. This
relatively high percentage value in this study is due
to the small sample size. Whittington and Durward[7]
found in 1,680 children a total prevalence of
1.4% for dental anomalies in the primary dentition
and 0.18% of ST in permanent dentition. The
total prevalence of dental anomalies in Japanese
children was found to be at 9.67%,[8] where ST had
a prevalence of 0.07%. The prevalence of ST in the
permanent dentition of Southern Chinese children in
Hong Kong was found to be 2.8%.[9] Several reports
have indicated that there is a racial difference in
the incidence of ST. The literature indicates a range
from 0.1% to 7.8% in primary dentition and from
0.4% to 3.4% in permanent dentition.[10]
Figure 1: Summarized classification of supernumerary teeth
Journal of Cranio-Maxillary Diseases / Vol 4 / Issue 1 / January 2015
Mallineni and Nuvvula: Management of supernumerary teeth
EPIDEMIOLOGY
Males are generally found to have a higher
prevalence of ST than females in the permanent
dentition.[57] ST are more common in the permanent
dentition and are usually found as a single tooth.[1,6]
However, pairs and groups of three have also been
described in the literature. Multiple ST are characteristics
of some syndromes such as cleidocranial dysplasia,
cleft lip and palate, and Gardners syndrome.[11] ST
are also more commonly found in the maxillary arch
than in the mandibular arch. Maxillary ST may occur
in the premaxilla region or distal to the third molar.
The most common type of ST are the mesiodens,
which account for 9098% of all ST.[1]
ST can be classified based on their location,
morphology, orientation, and position[Figure1].
Aconical or pegshaped ST usually presents as a
mesiodens in premaxillary region. It may be found
high and inverted into the palate or in a horizontal
position. Most conical shaped ST are in a horizontal
position. Conical ST rarely cause delay in eruption
and are found to be frequently erupted.[12] They
rarely erupt, and frequently cause delayed eruption
of the incisors.[12] Tuberculate ST also commonly
occur bilaterally, and unilateral cases were of the
conical type.[13] The supplemental type of ST is a
duplication of teeth in the normal series and is found
at the end of the series;[14] most supplemental teeth
are premolars followed by incisors. The majority of
ST in the primary dentition are of the supplemental
type.[15] Howard[16] categorized odontoma as the
fourth category of ST. It may be termed complex or
compound odontoma depending on the anatomical
features and histological composition of the tissue.
63
Mallineni and Nuvvula: Management of supernumerary teeth
COMPLICATIONS
Various complications[1,6,1723][Table1] may
occur as the result of the presence of ST including
crowding, delayed eruption, spacing, impaction
of permanent incisors, abnormal root formation,
alteration in the path of eruption of permanent
incisors, median diastema, cystic lesions, intraoral
infection, rotation, root resorption of the adjacent
teeth or even eruption of incisors in the nasal cavity,
and retained deciduous teeth.[15,18,24] Management
of ST always depends on the type of ST and its
position, relation to adjacent teeth, and its effects
on surrounding structures. The removal of ST is not
the treatment of choice in all clinical scenarios.
Impacted ST that are symptomless and not affecting
the dentition in any manner and those found by
chance are sometimes best left as they are and kept
under regular observation.
DIAGNOSIS
Diagnosis of an ST may be through clinical or
radiographic examination. Impacted ST may be
diagnosed during a routine radiographic examination.
Some patients present at the surgery complaining
of an impacted anterior tooth or persistent midline
diastema. As a rule, radiographic examination
should be performed for teeth that have not erupted
within 6months after the contralateral teeth have
erupted. The identification and localization of ST
plays a vital role in management.[25,26] Combinations
of different radiographs are useful in locating ST.
Radiographs to be taken include a panoramic view
to show the evidence of whole dentition. Anterior
occlusal or pariapical radiographs should be taken
to evaluate the incisor region completely. The tube
shift technique can be employed to determine
whether the ST is located labially or palatally.
Alateral skull radiograph may be taken as a
Table1: Complications associated with supernumerary
teeth
Failure of eruption[6]
Midline diastema[17,18]
Displacement[18]
Crowding[15]
Cystic degeneration[1,19]
Resorption[1,21]
Ectopic eruption[18,22]
Impaction[18,23]
64 Journal of Cranio-Maxillary Diseases / Vol 4 / Issue 1 / January 2015
supplement especially if the tooth is dilacerated to
allow for a threedimensional assessment of the
impacted tooth.
MANAGEMENT
There is no sufficient evidence in the published
literature that indicates the exact age of removal
of ST. Conflicting ideas on the type and timing of
treatment still persist[Table2].[15,23,24,2740] Those
who advocate the immediate removal of the ST
argue that it would prevent space loss by inducing
natural eruption of the unerupted tooth and
also prevent a midline shift, therefore, avoiding
extensive orthodontic and surgical treatment.[1,17,41]
However, waiting for the root development of the
adjacent teeth may help prevent loss of vitality or
malformation of the adjacent teeth.[21,29,41] Hogstrom
and Andersson[19] demonstrated that the prognosis
of the adjacent teeth was not affected by whether
the ST was surgically removed upon diagnosis
or surgery was postponed after complete root
development of the adjacent teeth. On the other
hand, Nuvvula etal.[23] postulated that the early
removal of causative ST in cases of severely rotated
unerupted incisors may result in selfcorrection and
proper alignment. The authors had a concern with
early removal of ST that it may disturb the formation
of adjacent roots if the ST are in close proximity
to the developing roots of permanent teeth, and in
those cases, delayed removal has been suggested.
Another argument was that the surgical removal
of impacted ST may not be necessary unless
developing complications are suspected and if the
tooth is associated with a pathological condition.[42]
Adequate clinical and radiographic diagnosis and
a sound surgical intervention with proper behavior
management must be considered if early extraction
is essential.[42,43]
After surgical removal of the ST, there is
also the question of whether or not to allow the
impacted tooth to erupt spontaneously or to
facilitate its eruption. Some authors support the
concept of removing the supernumerary tooth and
providing adequate space for the impacted tooth
to spontaneously erupt.[44] It has been found that
75% of impacted teeth may erupt within 18months
of removal of the ST.[13] Mitchell and Bennett[45]
 Mallineni and Nuvvula: Management of supernumerary teeth

Table2: Summary of timing of removal of supernumerary teeth

Author
Munns[27]
Rotberg and Kopel[28]
Koch and Schwartz[29]
Hogstrum and Andersson[19]
Scanlan and Hodges[30]
Scheiner and Sampson[31]
Garvey etal.[14]
Shah etal.[32]
De Oliveira Gomes etal.[33]
Meighani and Pakdaman[34]
Omer etal.[24]
Nuvvula etal.[23]
Parolia etal.[35]
Bahadure etal.[36]
MnguezMartinezl etal.[37]
Tuna etal.[38]
Ramesh etal.[39]
Mohan etal.[40]
Amarlal and Muthu[41]
Summary
Earlier removal of supernumerary tooth allows for better prognosis
Removal of supernumerary before 5years of age is suggested, since
root formation of permanent incisors is indicated
Immediate removal of supernumerary teeth is not necessary if there is no underlying pathology
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
Early removal of supernumerary teeth is suggested in the presence of complications,
if not, supernumerary teeth are reviewed with appropriate followup intervals
Removal of the supernumerary only in cases where adequate space
is available for the adjacent permanent tooth to erupt
Supernumerary teeth may be monitored if there are no associated complications
Annual radiographic evaluation is advisable if the supernumerary teeth cause no
complications and are not likely to interfere with orthodontic tooth movement
Supernumerary teeth should be removed based on their development, regardless of the morphology type
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
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
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
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
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
Surgical removal by orthodontic treatment is essential if supernumerary
teeth are causing impact on adjacent teeth
Early diagnosis and timely management are key factors to prevent or minimize the complications
Mesiodens should be extracted in children and adolescents in order to avoid
possible adverse effects on adjacent teeth or cyst formation
Pathologyfree and asymptomatic cases can be treated in a conservative
manner and removal is essential if associated with pathology
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,
there are authors who believe that the delay in
eruption of the permanent teeth due to the presence
of an ST may result in a lack of space for the
permanent teeth and closure of the apices requiring
orthodontic extrusion of the impacted teeth.[37,44]
Surgical removal of the ST may also be followed
by surgical repositioning of the impacted tooth.[46]
The authors argue that orthodontic extrusion may
cause devitalization of the impacted teeth due to
large extrusive forces. From the available evidence,
it seems that one should be cautious and initiate
removal of the ST only in cases where adequate
space is available for the adjacent permanent tooth
to erupt. The available space should be monitored
for 18months to allow spontaneous eruption.
If the eruption of tooth gets delayed, orthodontic
treatment is necessary. Nevertheless, management
of ST causing problems like impaction, rotation,
delayed eruption, and displacement of permanent
teeth requires a multidisciplinary approach.
The surgical removal of ST should be performed
very carefully to avoid damage to the adjacent
permanent teeth, which might lead to ankylosis,
displacement, rotation, and ectopic position. It
also has been stated that the clinician should be
cautious to prevent possible complications like
blood vessels and the damaging of nerves during
the manipulation of the tooth, fracture of the
maxillary tuberosity, perforation of the maxillary
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
to the possibility of ST being fused with the adjacent
tooth structure at the crown or root level, which
may make the extraction difficult. ST can also be
kept under observation without extraction when
satisfactory eruption of related teeth has occurred
with no associated pathology.
Regardless of the timing of treatment and the
treatment of choice for an ST, early diagnosis is
essential to permit for a more complete longterm
treatment planning for better prognosis and minimal
intervention.[8] Most of the researchers[15,32,39,43]
opined that the extraction of erupted ST in almost
all cases except in those patients who had missing
teeth. There was concern among some researchers
that natal teeth are ST, however, in most cases,
natal teeth represent the true primary teeth and are
not ST.[47-49] A study from Hong Kong on 44 subjects
of natal and neonatal teeth reported that they were
part of the primary dentition.[47] The extraction of
these natal teeth may be questionable, if they are
mobile and are associated with any complications
they should be extracted. Various protocols have
been established for the management of ST
based on both reported studies and speculations
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
of some authors. Acomprehensive review of all
these proposals has summarized that the surgical
removal of ST is essential if it is associated with
pathology[Figure2]. The ultimate goal of this
flowchart is to help the clinician for the management
of ST. This flow chart was designed based on the
orientation of ST in consideration of ST eruption.
Erupted ST should always be extracted, unless the
adjacent teeth are missing, in which case ST should
be retained. The impacted ST, not associated
with complications, can be kept under regular
monitoring.[15,49] If the impacted ST is found to be
associated with any complications, then it should be
removed surgically. Surgical removal can be delayed
in cases if the ST is placed close to the apices of
the developing permanent teeth,[23,50-52] and it also
reported that if the ST is removed during the initial
stage there may be a chance of recurrence.[51-53]
Omer etal.[24] suggested that 67years of age is
an appropriate age range for removal of ST, if the
ST left after that age it may create complications.
Most recently, it has been reported that the removal
of ST would be justifiable based on whether the
associated complications leading to pathology or
not. Nonpathological and asymptomatic cases are
to be treated with a conservative approach.[40]

CONCLUSIONS
Controversy exists regarding the optimal
treatment time and treatment modality for impacted
ST. Inverted and transverse ST would be suggested
for surgical removal on first diagnosis and normally
oriented ST would be monitored for eruption, in
which case simple extraction should be performed.
In situations like orthodontic treatment planned for
bone graft and implantation site, ST is advised to be
removed without a second thought. However, early
removal of ST may avoid potential complications to
permanent teeth.
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How to cite this article: Mallineni SK, Nuvvula S. Management of
supernumerary teeth in children: A narrative overview of published literature.
J Cranio Max Dis 2015;4:62-8.
Source of Support: Nil. Conflict of Interest: None declared.
Submission: Aug 15, 2014, Acceptance: Oct 18, 2014