EUROPEAN JOURNAL OF PAEDIATRIC DENTISTRY • 1/2006

45
Supernumerar y teeth and mental
retardation: the importance of early
surgical inter vention
P. COZZA, M. MUCEDERO, F. BALLANTI, L. DE TOFFOL
ABSTRACT. Aim This paper reported a rare case of hyperdontia in a children of 10 years old who revealed a mixed
dentition and a light mental retardation. Materials and methods The therapeutic approach has been based on
interdisciplinary cooperation between the pediatric dentist, orthodontist and oral surgeon. TC-Dentascan, with a
panoramic and occlusal radiographs revealed the presence of two supernumerary teeth in the premaxillary region
and clinical examination showed an abnormality of dentoalveolar complex. Both impacted supernumerary teeth
were extracted under general anesthesia. Clinical examination revealed that they appeared two premolars in
shape with fully formed crowns and partly formed roots. Results Three months after the extraction of
supernumerary teeth there was a spontaneous eruption of permanent central incisors and left lateral incisor.
Conclusion The authors emphasized the importance of removal of supernumerary teeth to eliminate the cause of
a delayed eruption of permanent teeth.
KEYWORDS: Supernumerary teeth, Mental retardation.
*University of Rome “Tor Vergata”, School of Dentistry,
Department of Orthodontics
E-mail: paolacozza@tiscali.it
commonly are found in the maxilla [Luten, 1967;
Nazif et al., 1983; Solares, 1990; Scheiner and
Sampson, 1997]. Luten [1967] reported that 97% of
supernumerary teeth are located in the anterior area;
Nazif [1983] found that 80% of these teeth with
impeded that eruption occurred in the maxillary
anterior region.
Supernumerary teeth may appear in a variety of
shapes; they can be conical, tubercular or
supplemental. Zilberman [1992] observed that the
most common shape of supernumerary teeth is conical
(61%), followed by premolar morphology. At the same
way Liu [1995] reported on 152 supernumerary teeth,
67.7% is conical, 28.3% is tubercolate shape and 4%
is a supplemental type.
Supernumerary teeth may occur singly, or in
multiples. Zilberman [1992] in a group of 100 patients
with a total of 130 supernumeraries found that 74
children had one, 23 had two, 2 had three and in 1
child there were four teeth. Liu [1995] registred on
152 supernumerary teeth among the 112 patient
analyzed, 64.3% had one supernumerary tooth; 35.7%
had two supernumerary teeth.
This report describes the occurrence of hyperdontia
in a child with mental retardation and the authors
emphasize the importance of interdisciplinary
Introduction
Supernumerary teeth or hyperdontia means extra
teeth; they are known to occur in conjunction with cleft
lip and palate, cleidocranial dysplasia, Gardener’s
syndrome, Down syndrome etc. [Primosch, 1981;
Rubin et al.,1981; Turner and Hill, 1986; Brattstrom
and Mc William, 1989; Yamamoto et al., 1989; Jesen
and Kreiborg, 1992; Odell and Hughes, 1995; Tasar et
al., 1995; Wynne et al., 1995; Atasu et al., 1996; Atar
et al., 1997; Tane and Uzamis, 1999]. However, only a
few investigators studied the relationships between
supernumerary teeth and intellectual development,
although the possibility of a correlation has raised
questions [Wynne et al., 1995].
Reports of supernumerary teeth are quite common in
mental retardation, such teeth often being discovered
on radiographic examination of dental patients who are
totally unaware of their existence [Ranalli et al., 1988;
Wynne et al., 1995].
Many authors reported that supernumerary teeth
occur anywhere in the dental arches but most
management for early removal of supernumerary teeth
to eliminate the cause of a delayed eruption of
permanent teeth with a premaxillary deformation.
Case report
The subject, referred to the orthodontist for
examination by his dentist, was a boy of 10 years who
revealed a mixed dentition.
The mother’s chief complaint, at the time of the
examination, was the noneruption of the maxillary
permanent left lateral and central incisors after the
exfoliation of primary teeth. He had a history of slight
mental retardation with no history of facial trauma.
Clinical examination revealed a caracteristically
convesse profile and labial incompetence. The patient
was in mixed dentition comprising the first permanent
molars, maxillary permanent right lateral incisor,
maxillary permanent left first premolar and
mandibular permanent incisors (Fig. 1).
The alveolar bone resulted more developed in the
premaxillary region. Maxillary primary central
incisors and lateral incisors had exfoliated but the
maxillary permanent had not erupted.
Panoramic radiographic evaluation demonstrated the
presence of upper permanent incisors with an irregular
crown and normal roots. Latero-lateral and status-x
radiographic inspections denoted the presence of two
supernumerary teeth in the premaxilla. They were
apparently tuberculate in shape interfering with the
normal eruption of maxillary permanent incisors (Fig.
2-3).
The use of TC-Dentascan with a panoramic
radiograph and an occlusal radiograph has been
advocated to localize unerupted maxillary anterior
supernumerary teeth. The examination was effected
with assial scansions of 1 mm in thickness followed by
panoramic reconstructions, dentalscan and
tridimensional reconstructions. TC-Dentascan
evaluation confirmed the presence of two
supernumerary teeth localised in the body of the
premaxilla behind the upper permanent incisors
unerupted. Supernumerary teeth resulted slightly
smaller than incisors and their root’s development was
not complete (Fig. 4-6).
The decision to remove supernumerary teeth was
made to facilitate the eruption of the maxillary
incisors. This treatment plan was explained to his
family and with their permission the teeth were
extracted together. Both impacted supernumerary
teeth were extracted under general anesthesia. The
patient tolerated the procedure well and the extractions
were uncomplicated (Fig. 7).
Clinical examination revealed that both
supernumeraries had fully formed crowns and partly
formed roots, and they appeared to be of the same
morphology of a normal premolar.
Three months later there was the spontaneous
eruption of the permanent central incisors and left
lateral incisor (Fig. 8).
The early treatment was achieved without
complication and the patient is now under regular
P. COZZA ET AL.
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EUROPEAN JOURNAL OF PAEDIATRIC DENTISTRY • 1/2006
FIG. 1 - Initial front view of patient.
FIG. 2, 3 - Initial radiographs including orthopanoramic, occlusal revealing the presence of two supernumeraries.
SUPERNUMERARY TEETH AND MENTAL RETARDATION
EUROPEAN JOURNAL OF PAEDIATRIC DENTISTRY • 1/2006
47
FIG. 4, 5, 6 - TC-Dentascan showing the position and the side of the supernumerary teeth.
FIG. 7 - Intraoral view during surgical removal of supernumerary teeth.
FIG. 9 - Final frontal view of patient. FIG. 8 - After 3 months extraction of supernumerary teeth.
P. COZZA ET AL.
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EUROPEAN JOURNAL OF PAEDIATRIC DENTISTRY • 1/2006
review regarding future fixed orthodontic therapy (Fig.
9).
Discussion
Failure of eruption of permanent incisors is often
caused by the presence of one or more supernumerary
teeth, localized in the pathway of eruption.
Most problems associated with supernumerary teeth
are due to their capacity to interfere with normal
eruption and alignment with the adjacent teeth
[Winserburg and Boering, 1981; Kock et al., 1986;
Liu, 1995]. Complications of the developing occlusion
may result in impaction, delayed eruption, or ectopic
eruption of the permanent incisors, or could contribute
to the development of a maxillary midline diastema
[Acton, 1987]. However a review of the available
literature revealed little or no information concerning
the relationship between supernumerary and
development of premaxilla.
In this patient the premaxillary complex is more
developed since the eruption pattern of serie’s teeth is
altered because of the presence of supernumeraries; in
fact due to the hyperdontia the basal bone growth is
increased and the alveolar bone results more developed
in the premaxillary region.
Early surgical intervention is preferred to induce
spontaneous eruption of the permanent incisors,
prevent anterior space loss, midline shift, and
extensive surgical/orthodontic treatment [Grijalva and
Kuster, 1993; Babu et al., 1998; Gallas and Garcia,
2000]. However mental retardation of the patient led to
serious difficulties in motivation due to limited
understanding at the initial phase of treatment.
Behavior modification techniques can be effectively
applied in dental treatment of this unfortunate patient
and therefore his compliance, in spite of mental
retardation problem, had affected treatment outcome
positively.
Our patient presented two supernumerary teeth in the
premaxillary region and because of their shape they
can be considered two molariform supernumeraries.
Conclusion
This paper reports an unusual case of supernumerary
teeth and mental retardation. The most important thing
in this case is to enumerate and to identify the present
teeth clinically and radiographically; only after this
you will be able to give a definitive diagnosis and to
formulate a treatment plan.
Further, it emphasizes the necessity of the
cooperation between orthodontist and oral surgeon.
References
Acton CHC. Multiple supernumerary teeth and possibly
implication. Aust Dent J 1987;32(1):48-9.
Atar G, Uzamis M, Olmez S. Ectodermal dysplasia with associated
double tooth. J Dent Child 1997;362-364.
Atasu M, Dumlu A, Ozbayrak S. Multiple supernumerary teeth in
association with cleidocranial dysplasia. J Clin Pediatr Dent
1996;21(1):87-93.
Babu V, Nagesh KS, Diwakar N.R. A rare case of hereditary
multiple impacted normal and supernumerary teeth. J Clin
Pediatr Dent 1998;23(1):59-62.
Brattstrom V, McWilliam J. The influence of bone grafting age on
dental abnormalities and alveolar bone height in patients with
unilateral cleft lip and palate. Eur J Orthod 1989;11:351-358.
Gallas MM, Garcia A. Retention of permanent incisor by
mesiodens: a family affair. Br Dent J 2000;188(2):63-64.
Grijalva JFO, Kuster CG. Supernumerary teeth removal and
orthodontic tooth repositioning: A case report. J Pediatr Clin
Dent 1993;17(2):95-98.
Jesen BL, Kreiborg S. Dental treatment strategies in cleidocranial
dysplasia. Br Dent J 1992;172:243-247.
Koch H, Schwartz O, Klausen B. Indications for surgical removal
of supernumerary teeth in the premaxilla. Int J Oral Maxillofac
Surg 1986;15:273-281.
Liu JF. Characteristics of premaxillary supernumerary teeth : a
rarte survery of 112 cases. J Dent Child 1995;62(4):262-265.
Luten JR. The prevalence of supernumerary teeth in primary and
mixed dentitins. J Dent Child 1967;34:346-353.
Nazif MM, RuffalloRC, Zullo T. Impacted supernumerary teeth: a
survey of 50 cases. JADA 1983;106:201-204.
Odell EW, Hughes FJ. The possible association between localized
juvenile periodontitis and supernumerary teeth. J Periodontol
1995;66:449-451.
Primosch RE. Anterior supernumerary teeth-assessment and
surgical intervention in children. Pedriatr Dent 1981; 3:204-215.
Ranalli DN, Buzzato JF, Braun TW, Murphy SM. Long-term
interdisciplinary management of multiple mesiodens and
delayed eruption: report of case. J Dent Child 1988;55(5):376-
380.
Rubin MM, Nevins A, Berg M, Border B. A comparison of
identical twins in relation to three dental anomalies: multiple
supernumerary teeth, juvenile periodontosis, and zero caries
incidence. Oral Surg 1981;Oct:391-394.
Scheiner MA, Sampson WJ. Supernumerary teeth: a review of
literature and four case reports. Aust Dent 1997;42(3):160-165.
Solares R. The complication of late diagnosis of anterior
supernumerary teeth : case report. J Dent Child 1990;57(3):209-
211.
Taner T, Uzamis M. Orthodontic treatment of a patient with
multiple supernumerary teeth and mental retardation. J Clin
Pediatr Dent 1999;23(3):195-200.
Tasar F, Bulut E, Tumer C, Saysel M, Muhtarogullari M. Cleido-
cranial dysplasia. Case report. Aust Dent 1995;40(6):352-356.
Turner C, Hill CJ. Supernumerary mandibular premolar: the
importance of radiographic interpretation. J Dent Child
1986;54(5):375-377.
Wirsenburg B, Boering G. Eruption of impacted permanent upper
incisors after removal of supernumerary teeth. Int J Oral Surg
1981;10:423-431.
Wynne SE, Aldred MJ, Bartold PM. Hereditary Gingival
fibromatosis associated with hearing loss and supernumerary
teeth- A new syndrome. J Periodontol 1995;66:75-79.
Yamamoto H, Sakae T, Davies JE. Cleidocranial dysplasia: A light
microscope electron microscope, and crystallographic study.
Oral Surg Oral Med Oral Pathol 1989;68:195-200.
Zilberman Y, Malron M, Shteyer A. Assessment of 100 children in
Jerusalem with supernumerary teeth in the premaxillary region.
J Dent Child 1992;Jan-Febr:44-47.
Acton CHC. Multiple supernumerary teeth and possibly
implication. Aust Dent J 1987;32(1):48-9.
Atar G, Uzamis M, Olmez S. Ectodermal dysplasia with associated
double tooth. J Dent Child 1997;sept-oct:362-364.
Atasu M, Dumlu A, Ozbayrak S. Multiple supernumerary teeth in
association with cleidocranial dysplasia. J Clin Pediatr Dent
1996;21(1):87-93.
Babu V, Nagesh KS, Diwakar NR. A rare case of hereditary
multiple impacted normal and supernumerary teeth. J Clin
Pediatr Dent 1998;23(1):59-62.
Brattstrom V, McWilliam J. The influence of bone grafting age on
dental abnormalities and alveolar bone height in patients with
unilateral cleft lip and palate. Eur J Orthod 1989;11:351-358.
Gallas MM, Garcia A. Retention of permanent incisor by
mesiodens : a family affair. Br Dent J 2000;188(2):63-64.
Grijalva JFO, Kuster CG. Supernumerary teeth removal and
orthodontic tooth repositioning: A case report. J Pediatr Clin
Dent 1993;17(2):95-98.
Jesen BL, Kreiborg S. Dental treatment strategies in cleidocranial
dysplasia. Br Dent J 1992;172:243-247.
Koch H, Schwartz O, Klausen B. Indications for surgical removal
of supernumerary teeth in the premaxilla. Int J Oral Maxillofac
Surg 1986;15:273-281.
Liu JF. Characteristics of premaxillary supernumerary teeth: a rarte
survery of 112 cases. J Dent Child 1995;62(4):262-265.
Luten JR. The prevalence of supernumerary teeth in primary and
mixed dentitins. J Dent Child 1967;34:346-353.
Nazif M.M, Ruffallo RC, Zullo T. Impacted supernumerary teeth:
a survey of 50 cases. JADA 1983;106:201-204.
Odell EW, Hughes FJ. The possible association between localized
juvenile periodontitis and supernumerary teeth. J Periodontol
1995;66:449-451.
Primosch RE. Anterior supernumerary teeth-assessment and
surgical intervention in children. Pedriatr Dent 198;3:204-
215.
Ranalli DN, Buzzato JF, Braun TW, Murphy SM. Long-term
interdisciplinary management of multiple mesiodens and
delayed eruption: report of case. J Dent Child 1988;55(5):376-
380.
Rubin MM, Nevins A, Berg M, Border B. A comparison of
identical twins in relation to three dental anomalies: multiple
supernumerary teeth, juvenile periodontosis, and zero caries
incidence. Oral Surg 1981;Oct:391-394.
Scheiner MA, Sampson WJ. Supernumerary teeth: a review of
literature and four case reports. Aust Dent 1997;42(3):160-165.
Solares R. The complication of late diagnosis of anterior
supernumerary teeth : case report. J Dent Child 1990;57(3):209-
211.
Taner T, Uzamis M. Orthodontic treatment of a patient with
multiple supernumerary teeth and mental retardation. J Clin
Pediatr Dent 1999;23(3):195-200.
Tasar F, Bulut E, Tumer C, Saysel M, Muhtarogullari M.
Cleidocranial dysplasia. Case report. Aust Dent 1995;40(6):352-
356.
Turner C, Hill CJ. Supernumerary mandibular premolar: the
importance of radiographic interpretation. J Dent Child,
54(5):375-377, 1986.
Wirsenburg B.; Boering G. : Eruption of impacted permanent
upper incisors after removal of supernumerary teeth. Int J Oral
Surg 1981;10:423-431.
Wynne SE, Aldred MJ, Bartold PM. Hereditary Gingival
fibromatosis associated with hearing loss and supernumerary
teeth- A new syndrome. J Periodontol 1995;66:75-79.
Yamamoto H, Sakae T, Davies JE. Cleidocranial dysplasia: A light
microscope electron microscope, and crystallographic study.
Oral Surg Oral Med Oral Pathol 1989;68:195-200.
Zilberman Y, Malron M, Shteyer A. Assessment of 100 children in
Jerusalem with supernumerary teeth in the premaxillary region.
J Dent Child 1992;Jan-Febr:44-47.
SUPERNUMERARY TEETH AND MENTAL RETARDATION
EUROPEAN JOURNAL OF PAEDIATRIC DENTISTRY • 1/2006
49