Retrospective analysis of factors influencing

the eruption of delayed permanent incisors

after supernumerary tooth removal
R.A.E. BRYAN*, B.O.I. COLE**, R.R. WELBURY*

ABSTRACT. Aim This was to assess the predictability of eruption of delayed permanent incisors after
supernumerary removal and creation of adequate space, in relation to: root maturity, degree of vertical impaction,
and degree of angulation of impaction. Methods The dental records of children with supernumerary teeth
delaying the eruption of permanent incisors were analysed. The type of a supernumerary tooth, its location and
position were recorded, along with the stage of root maturation, angulation and vertical distance of impaction of
the permanent incisor. At the initial surgery, the unerupted supernumerary tooth and any retained primary incisors
were removed. The unerupted permanent incisor was not exposed. If necessary, the maxillary primary canines
were removed to create sufficient space for eruption of the delayed permanent tooth. A secondary surgical
procedure was planned after 18 months if there was no significant progress of the permanent tooth towards
eruption. Statistics All data were entered onto a Microsoft Excel spread sheet and analysed using Fisher’s Exact
Tests throughout due to the small numbers. Results Sixty-six supernumerary teeth were removed, 22 from boys and
44 from girls with ages ranging from 6 to 10 years 6 months at the time of surgery. Primary canines were extracted
in 59.1% of cases. Spontaneous eruption occurred in 89.4% of delayed permanent teeth. The mean time to eruption
was 9.2 months (median = 7 months). There was no statistically significant association between tooth eruption and
root maturity or the degree of vertical impaction. There was an association between eruption and the degree of the
angle of impaction of the permanent incisor (p<0.05). Conclusion The majority of delayed permanent teeth erupt
spontaneously if sufficient space is available or created at the time of removal of the unerupted supernumerary. The
angulation of impaction of the permanent incisor is associated with a delay in eruption.

KEYWORDS: Supernumerary teeth, Delayed incisor eruption.

Introduction Prevalence. There is a wide range of reported

Supernumerary teeth are those that are additional to
the normal complement. They occur in both the
primary and permanent dentitions, and in any region of
either dental arch. The aetiology is not clearly
understood, and their classification is usually based on
their morphology and location within the arch.
Several hypotheses have been suggested for the
development of supernumerary teeth. Both
environmental factors and a genetic component are
thought to be associated, with siblings and twins more
often affected [Liu, 1995; Di Biase, 1969].
*Department of Child Dental Care,
Glasgow Dental Hospital and School, Glasgow, Scotland
**Department of Child Dental Health,
Newcastle Dental Hospital and School, Newcastle, England
E-mail: r.bryan@leeds.ac.uk
prevalence depending on the method of detection, the
population assessed and their age. In those studies
where radiographs have not been used, the prevalence
is greatly underestimated. Brook [1974] surveyed
approximately 2,000 predominately Caucasian
schoolchildren, and reported a prevalence of 2.1% in
the permanent dentition and 0.8% in the primary
dentition. The occurrence of supernumeraries shows a
predilection for males (2:1) [Brook, 1984].
Supernumeraries are more often found in the
maxilla, with a ratio of maxilla to mandible of 9:1, and
are especially frequent in the maxillary incisor region
[Luten, 1967; Mitchell and Bennett, 1992]. They occur
singly in approximately 76-80% of cases, doubly in
12-23% and as multiples in less than 1% [Luten,
1967]. Multiple supernumeraries are associated with
several syndromes, most common of these being cleft
lip and palate, cleidocranial dysostosis and Gardners

84 EUROPEAN JOURNAL OF PAEDIATRIC DENTISTRY • 2/2005


syndrome, with reported frequencies of up to 22%
[Garvey et al., 1999].
Classification. Supernumeraries are classified
according to their morphology and location. In the
primary dentition, they are usually of normal
morphology (supplemental) or conical, and generally
erupt. In the permanent dentition, the morphology is
more varied. They are classified as conical,
tuberculate, supplemental or odontome. Conical
supernumeraries are the most common form [Liu,
1995; Rajab and Hamdan, 2002], accounting for
approximately 75%, followed by tuberculate (12%),
supplemental (7%) and odontomes (6%). True midline
conical supernumeraries are often referred to as
mesiodens.
Their orientation is described as vertical (i.e.
normal), inverted (upside-down) or transverse
(horizontal). Several studies have shown inverted
supernumeraries to be the most common [Tay et al.,
1984; Liu, 1995] although Rajab and Hamdan [2002]
showed 83% to have a normal vertical orientation.
Diagnosis. The presence of supernumerary teeth
may be diagnosed as the result of a clinical problem, or
may be an incidental finding on a radiograph. Clinical
problems may be associated with both erupted and
unerupted supernumeraries, and include the following:
- failure of eruption of a permanent tooth; this occurs
most frequently in the maxillary incisor region.
Tuberculate supernumeraries are more likely to
impede eruption, especially if they are palatally
placed [Mason et al., 2000],
- displacement or rotation of a permanent tooth
[Howard, 1967],
- crowding, especially in the maxillary lateral incisor
region with the eruption of a supplemental incisor,.
- abnormal diastema, associated with an erupted or
unerupted mesiodens,
- dilaceration, delayed or abnormal root development;
occasionally, the presence of a supernumerary may
lead to resorption of the roots of adjacent permanent
teeth,
- cyst formation,
- eruption into the nasal cavity of an inverted
supernumerary.
Treatment. The options for dealing with
supernumerary teeth depend on their position and
orientation, the age of the patient and any associated
clinical problems. Early surgical intervention carries
the risks of psychological disturbances to the child,
and damage to the adjacent unerupted developing
teeth. Late intervention may be associated with loss of
the eruptive potential of the unerupted permanent
teeth, loss of anterior arch space and curvature, and a
EUROPEAN JOURNAL OF PAEDIATRIC DENTISTRY • 2/2005
DELAYED INCISOR ERUPTION WITH SUPERNUMERARY TEETH
midline shift, with a subsequent need for orthodontic
treatment.
The aim of this study was, therefore, to assess the
predictability of eruption of delayed permanent
incisors, after supernumerary removal and creation of
adequate space, in relation to: root maturity, degree of
vertical impaction, and degree of angulation of
impaction of the permanent tooth, and the type,
location and orientation of the supernumerary tooth
removed.
Materials and methods
Children were assessed in the Department of Child
Dental Health at Newcastle Dental Hospital following
referral for the management of unerupted
supernumerary teeth, either as a chance finding or as
the result of the delayed eruption of a permanent
incisor. The data for children attending between May
1994 and December 2000 were identified from the
Paediatric Dentistry National Audit Package [Royal
College of Surgeons of England, 2000]. The children
were included in the present study if they fulfilled the
following criteria:
- medically fit and well,
- delayed eruption of a permanent incisor associated
with one or more unerupted supernumerary teeth. In
this context, delayed eruption is defined as a tooth
delayed more than 6 months beyond the eruption of
its altemere, or beyond the eruption of the next tooth
in the series.
Fifty-five patient records were available for analysis.
All children had been assessed and treatment
planned by a paediatric dentist. Details of their
hospital number, gender, date of birth, date of first
assessment, and reason for referral were identified
from the dental hospital records, and entered onto
specially prepared data collection sheets.
Radiographic assessment and localisation of the
supernumerary and unerupted permanent teeth were
completed by two observers using panoramic and
maxillary standard occlusal views. Some children also
had parallax periapical views taken.
From the radiographs the following assessments
were made:
- the permanent tooth (or teeth) delayed (FDI
notation),
- the type of supernumerary (conical/tuberculate/
odontome/supplemental),
- the location of the supernumerary (maxillary
central/maxillary lateral/mandibular central/
mandibular lateral),
- the orientation of the supernumerary (inverted/
85
R.A.E. BRYAN, B.O.I. COLE, R.R. WELBURY

horizontal/normal), orthodontic bracket and gold chain attachment. Some

- the total number of supernumeraries (one/two/three
or more),
- the stage of maturation of the root of the delayed
permanent tooth (divergent/parallel/convergent/
closed),
- the vertical distance from the nasal spine to the
lowest point of the incisal edge of the unerupted
permanent tooth,
- the angle of the long axis of the unerupted
permanent tooth to the mid-sagittal plane.
The initial surgery was carried out under general
anaesthetic. At the time of surgery, the unerupted
supernumerary tooth, and any retained primary
incisors, was removed. The unerupted permanent tooth
was not exposed. If necessary, the primary canines
were also removed to create sufficient space to allow
spontaneous eruption of the delayed permanent tooth.
Following surgery, orthodontic treatments included
space maintenance or the creation of space in the
region of the delayed permanent incisor with either a
removable or fixed orthodontic appliance.
All cases were reviewed 3-6 monthly. The date of
eruption of the permanent tooth was recorded as the
date of the recall appointment at which the tooth was
first noted as being present in the mouth.
A second surgical procedure was planned if 18
months after the initial surgery there appeared to be no
significant progress of the permanent tooth towards
eruption. This consisted of either soft tissue removal to
expose the permanent tooth, or exposure via a
mucoperiostial flap, with or without bonding of an
cases had additional space created by removal of the
primary canines at this stage, and some required
removable or fixed orthodontic appliances to maintain
or create further space. The time from the second
surgery to eruption was recorded. No case required a
third intervention.
Statistics. All data were entered onto a Microsoft
Excel spread sheet and analysed using Fisher’s Exact
Tests throughout due to the small numbers.
Results
Sixty-six supernumeraries were identified in the 55
children. The children’s ages ranged from 4 years 7
months to 10 years 6 months at the time of their initial
assessment, with 22 supernumeraries in males and 44 in
females (male:female = 1:2). Of the 55 children, 44 had
1 supernumerary, 10 had 2, and 1 had 3 or more. Table
1 shows the distribution of type, location and orientation
of the supernumeraries. The vertical distance of the
incisal edge of the delayed permanent incisor from the
anterior nasal spine was grouped into 5 mm bands for
ease of analysis. Table 2 shows the distribution of the
vertical distances, angulation and apical development of
the delayed permanent incisor. None was at more than
60° to the vertical as measured on the panoramic
radiograph. Maxillary central incisors were the most
frequently delayed permanent teeth, 62/66 (94%). Only
4 maxillary lateral incisors were affected, and no
mandibular incisors. The ages ranged from 6 years to 10
years 6 months at the time of the surgery.

Supernumerary type Number % Vertical distance (mm) Number %

0-5 0 0
Conical 38 57.6
6-10 10 15.2
Tuberculate 17 25.8
11-15 23 34.8
Odontome 3 4.5
16-20 19 28.8
Supplemental 8 12.1
21-25 14 21.2
Supernumerary location Angulation of long axis
Maxillary central 62 93.9 <30 degrees 57 86.4
Maxillary lateral 4 6.1 30-60 degrees 9 13.6

Supernumerary orientation Apical development

Inverted 18 27.3 Divergent 21 31.8
Horizontal 6 9.1 Parallel 29 43.9
Normal 42 63.6 Convergent 16 24.2
TABLE 1 - Distribution of type, location and orientation of TABLE 2 - Vertical distance, angulation and apical
a series of supernumerary teeth in an English child development of the delayed permanent incisors in relation
population. to supernumerary teeth.

86 EUROPEAN JOURNAL OF PAEDIATRIC DENTISTRY • 2/2005


Additional space was created at the time of the first
surgery by extraction of the primary canines in 33/55
(60%) cases. A space maintainer was fitted in 10
cases (15.2%), and additional space created with a
fixed or removable appliance in 21 cases.
Spontaneous eruption occurred in 59 of the 66
delayed permanent teeth (89.4%), without the need
for further intervention. Eruption occurred in less
than 12 months in 42 teeth (66%), 11 (18.6%) in 12-
23 months, and 6 (10.2%) in 24-35 months. The
mean time from first instance of surgery to eruption
was 9.2 months (median = 7 months, range 1-27
months).
In the seven cases where further treatment was
needed, this was carried out between 18 and 34
months after the initial surgery. In three children,
only soft tissue removal was required. In the
remaining four cases, a mucoperiostial flap was
raised and either apically repositioned or an
attachment bonded to the unerupted incisor prior to
replacement of the flap. Five of the secondary
surgical procedures were carried out under general
anaesthesia, and the remaining two under local
analgesia. Only one child required the creation of
additional space by the extraction of primary canines.
Following the secondary surgical procedure, space
was controlled with a maxillary fixed orthodontic
appliance in four instances. The time from secondary
surgery to eruption ranged from 1 to 25 months, with
four teeth erupting within 3 months. The mean time
to eruption was 8.1 months (median 3 months).
Yes % [N]
Vertical distance (mm)
0-5
6-10
11-15
16-20
21-25
Angulation
<30 degrees
30-60 degrees
Apical development
Divergent
Parallel
Convergent
TABLE 3 - Association between tooth eruption and vertical distance, angulation and apical development
of the permanent incisors in relation to supernumerary teeth.
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DELAYED INCISOR ERUPTION WITH SUPERNUMERARY TEETH
For the whole group, there was no statistically
significant association between tooth eruption and
vertical distance or apical development (Table 3).
However, there was a statistically significant
association between eruption and the angle of the
long axis of the permanent incisor (p=0.048). In
those teeth that did not erupt, four had an angle of
<30°, compared with three at 30°–60°. In contrast, in
those teeth that did erupt, 53 (90%) had an angle of
<30°, compared with only 6 (10.2%) with an angle of
30°–60°.
Of the teeth that erupted spontaneously (Table 4),
there was a statistically significant difference
between time to eruption and vertical distance
(p=0.022). There were 42/59 teeth that erupted
within the first 12 months from initial surgery
(71%), and 25 of these (60%) were 16 mm or more
from the nasal spine (i.e. closer to the alveolar
ridge). Neither the angle of the long axis nor the
apical development were statistically significantly
associated with the time to eruption in those teeth
which erupted spontaneously.
The effect on the subsequent eruption of the
permanent teeth of the type, location and orientation of
the supernumerary teeth prior to their removal could
not be assessed because of the small numbers
involved. The type of supernumerary associated with
the teeth that did not spontaneously erupt after surgery
was 4 conical, 2 tuberculate and 1 odontome. One
supernumerary was inverted; 4 were single and 3 were
double.
Tooth erupts? Fisher’s
No % [N] Exact Test
0 0
15.3 [9] 14.3 [1]
35.6 [21] 28.6 [2]
25.4 [15] 57.1 [4]
23.7 [14] 0 0.304
89.8 [53] 57.1 [4]
10.2 [6] 42.9 [3] 0.048
32.2 [19] 28.6 [2]
42.4 [25] 57.1 [4]
25.4 [15] 14.3 [1] 0.882
87
R.A.E. BRYAN, B.O.I. COLE, R.R. WELBURY

Eruption times (% [N]) Fisher’s

0-11 12-23 24-35 Exact Test
months months months

Vertical distance (mm)

0-5 0 0 0
6-10 19.0 [8] 0 16.7 [1]
11-15 21.4 [9] 72.7 [8] 66.6 [4]
16-20 28.6 [12] 18.2 [2] 16.7 [1]
21-25 31.0 [13] 9.1 [1] 0 0.022

Angulation
<30 degrees 92.9 [39] 81.8 [9] 83.3 [5]
30-60 degrees 7.1 [3] 18.2 [2] 16.7 [1] 0.262

Apical development
Divergent 26.2 [11] 35.4 [4] 66.7 [4]
Parallel 42.9 [18] 45.5 [5] 33.3 [2]
Convergent 31.0 [13] 18.2 [2] 0 0.324

TABLE 4 - Association between time to eruption and vertical distance, angulation and apical development
in the permanent incisors that erupted spontaneously following supernumerary removal [N=59].

Discussion displacement. This trend was not statistically

Previously reported studies have indicated a
prevalence ratio of 2:1 male:female. In this study,
however, the complete opposite was found. The
distribution of single or multiple supernumeraries was
similar to that reported by Luten [1967] with 80%
single, 18.2% double and 1.8% multiple. The
distribution of the type of supernumerary was similar to
Liu [1995] and Rajab and Hamdan [2002], with conical
supernumeraries occurring most frequently (57.6%). In
our study normally orientated supernumeraries
occurred most frequently (63.6%), as reported by
Rajab and Hamdan [2002].
Although statistical significance was not reached for
vertical distance and apical development, there may still
be a clinically significant association. The numbers are
small in this study and subtle effects may have been
missed due to a lack of statistical power.
Munns [1981] showed that irrespective of the degree
of displacement of the unerupted incisor, the prognosis
for being able to bring it into a good arch position and
occlusal relationship was better with early diagnosis
and treatment. Howard [1967] found that the amount of
apical displacement of the unerupted incisor was related
to whether it had erupted spontaneously following the
removal of the supernumerary, or had required further
exposure. Mitchell and Bennett [1992] showed a trend
toward an increase in the time taken for an incisor to
erupt with an increase in the initial degree of its
significant, possibly due to the relatively small numbers
of teeth in this study.
In a retrospective study of unerupted maxillary
incisors associated with supernumerary teeth, Mason
et al. [2000] concluded that the maturity of the
unerupted incisor root was an important factor in the
outcome following removal of the supernumerary.
They suggested that all unerupted incisors should be
exposed (with or without bonding and orthodontic
traction). However, this may be associated with loss of
supporting bone and increased scar tissue formation.
Our study found no such relationship with apical
maturity. However, it should be noted that the numbers
in our study are small even though they were cases
collected over six years in a major referral dental
hospital. Studies of this nature are not easy to
complete because of the low prevalence recorded in
individual centres.
Patchett et al. [2001] showed a statistically significant
difference in the eruption of delayed permanent incisors
depending on the type of supernumerary removed.
Fifty-five out of eighty seven (63%) incisors erupted
spontaneously following the removal of a conical
supernumerary. In the group from whom tuberculate
supernumeraries had been removed, only 31/85 (36%)
permanent incisors erupted spontaneously. Of the teeth
requiring further treatment, 46 (54%) were surgically
exposed. In this study, there had been no assessment of

88 EUROPEAN JOURNAL OF PAEDIATRIC DENTISTRY • 2/2005


the degree of crowding present prior to supernumerary
removal, nor measurement of the initial displacement of
the permanent incisor. A similar study in Scotland
[Foley, 2004] showed 73% spontaneous eruption of
delayed permanent teeth, with a significant difference
following the removal of conical or tuberculate
supernumeraries.
In our study, a greater angle of displacement of the
permanent tooth from the midline sagittal plane
appears to lead to a greater delay in eruption
(p=0.048). This has clinical significance in treatment
planning and predicting eruption. With regard to time
taken to eruption and angular displacement, some
73% of teeth erupted spontaneously within 0-11
months in the <30° group compared with 50% in the
30°-60° group. However, there was insufficient
statistical power to detect differences between the
eruption times, and collection of larger numbers of
cases from additional centres using the same
assessment criteria is required.
Sufficient space availability, either naturally at the
time of the initial examination or its incorporation into
any treatment plan by the extraction of primary canines
at the time of the removal of the supernumerary, can
result in the eruption of most of the delayed permanent
incisors without the need for further intervention. This
concurs with the recommendation of Mitchell and
Bennett [1992]. Of the seven cases that required further
surgery in this study, only four needed a mucoperiosteal
flap to be raised. The others were treated by localised
soft tissue removal. It is possible that earlier soft tissue
removal when a tooth is approaching eruption may
result in earlier eruption. This is something to consider
in future research.
Conclusions
The majority of delayed permanent incisors erupt
spontaneously if sufficient space is created at the time of
removal of the supernumerary tooth and maintained
postoperatively. The angulation of the delayed tooth
appears to be important in trying to predict eruption.
However, more data are required from coordinated
multi-centre studies to try and elucidate the important
predictors of the prognosis for eruption.
EUROPEAN JOURNAL OF PAEDIATRIC DENTISTRY • 2/2005
DELAYED INCISOR ERUPTION WITH SUPERNUMERARY TEETH
Acknowledgements
The authors would like to thank Andrea Sherriff for the statistical
analysis.
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