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Received: 18 June 2018    Accepted: 17 September 2018

DOI: 10.1111/jicd.12377

ORIGINAL ARTICLE
Paedodontics

Radiographic characteristics of mesiodens in a non-­syndromic

pediatric population in the Black Sea region

Halenur Altan1  | Sumeyra Akkoc1 | Ahmet Altan2

1
Department of Pediatric Dentistry, Faculty
of Dentistry, Gaziosmanpasa University,
Tokat, Turkey
2
Department of Maxillofacial Surgery,
Faculty of Dentistry, Gaziosmanpasa
University, Tokat, Turkey
Correspondence
Sümeyra Akkoç, Department of Pediatric
Dentistry, Gaziosmanpasa University, Tokat,
Turkey.
Email: sumeyrakkoc@gmail.com
Abstract
Aim: A mesiodens is the most frequent type of supernumerary tooth. They can be
related to several complications, such as ectopic eruption and midline diastema. The
aim of the present study was to assess the radiographic properties of mesiodens by
analyzing the associated age, sex distribution, number of mesiodens per patient,
shape, direction of eruption, and their association with complications.
Methods: The present study was performed using panoramic radiographs of 14 400
pediatric patients (4-­14 years old) who visited the Department of Pediatric Dentistry
at Gaziosmanpasa University for a variety of dental complaints from 2015 to 2018.
Results: There were 82 mesiodens diagnosed in a total of 71 patients. Among the 82
mesiodens, 51 (62.1%) were conical in shape, which was the most commonly seen shape,
followed by 14 supplemental (17.07%), and 12 (14.6%) tuberculate. Of the 82 mesiodens,
65 (79.2%) were aligned vertically, nine (10.9%) were inverted, and eight (9.7%) were
horizontally placed. Clinical complications were observed in 76.8% of patients.
Conclusion: The management of mesiodens can be performed using three methods:
(a) spontaneous eruption; (b) early intervention; and (c) delayed intervention.
However, the management of mesiodens should be evaluated on an individual basis
to determine the best treatment method. Mesiodens-­
associated complications
should be addressed prior to the lateral incisors erupting.

KEYWORDS
mesiodens, pediatric population, prevalence, supernumerary tooth, Turkish population

1 |  I NTRO D U C TI O N
Supernumerary teeth are described as a developmental abnor-
mality in the number of excessive teeth, other than the normal
series of teeth, which can develop in nearly any area of the dental
arch.1,2 Mesiodens are the most frequent type of supernumerary
teeth. They occur unilaterally or bilaterally in the maxillary ante-
rior area. 2,3
2
The prevalence of mesiodens differs by racial group. The re-
ported prevalence of mesiodens varies between 0.3% and 0.8% in
the primary dentition and between 0.1% and 3.8% in permanent
dentition.4 The prevalence of mesiodens in males is twice as much as
that of females. The reason for the variation in reported prevalence
ranges could be due to the identification methods and differences in
the populations examined.4
It is difficult to see mesiodens in clinical examinations, and radi-
ography was the first method used to identify them. 5 For early iden-
tification, regular radiographic examinations are needed. Commonly,
radiographic data can be acquired by periapical, occlusal, and pan-
oramic radiographs. The most comprehensive image of the incisor
region can be obtained with a single occlusal or periapical film, while
horizontal tube shift techniques are typically used to define the
buccolingual position. However, cone-­beam computed tomography
(CBCT) scans can provide data concerning the 3-­D association of
the mesiodens with the relevant teeth and surrounding structures,
which is significant for making decisions on treatment alternatives.3,6

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https://doi.org/10.1111/jicd.12377
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2 of 5       ALTAN et al.

Morphologically, mesiodens can have heterogeneous forms. 3 | R E S U LT S

Generally, mesiodens in the primary dentition have a normal or coni-
cal morphology. Alternatively, mesiodens in the permanent dentition 3.1 | Sex distribution
generally have three types or morphology: conical or peg shaped, tu-
Between 2015 and 2018, 71 patients were diagnosed with mesi-
berculate, and supplemental. Among these, the conical type is the
odens from 14 400 samples of the pediatric group (4-­14 years of
most frequent. The tuberculate shape and supplemental type might
age); 82 mesiodens were diagnosed in 71 patients. Furthermore,
exist to reproduce a natural tooth that is commonly composed of an
there were 49 (69.0%) male patients and 22 (30.9%) female patients,
arched and globular type. Mesiodens generally emerge unilaterally;
with a sex ratio of 2.2:1.
however, bilateral forms are also observed. However, it is rare to ob-
serve three or more supernumerary teeth in the median region of the 3.2 | Number of mesiodens
palate.4,7,8
Of the 82 diagnosed mesiodens in the 71 patients, 60 (84.5%) pa-
It has been established that mesiodens do not lead to any clinical
tients had one mesiodens and 11 (15.4%) had two bilateral mesi-
indicators in most cases, but they sometimes lead to clinical com-
odens. Approximately 21 (35%) female patients and 39 (65%) male
plications, which include complications to the adjacent teeth and
patients had one mesiodens. Ten (90.9%) male patients and one (9%)
tissue. 8,9 These complications include delayed eruption (failure of
female patient had two bilateral mesiodens. None of the participants
eruption) in children with mixed dentition or permanent dentition,
had three or more mesiodens.
midline diastema, displacement or rotation of adjacent permanent
incisors, crowding, malocclusion, loss of vitality of adjacent teeth, 3.3 | Shapes of the mesiodens
cyst formation or cystic changes, resorption or dilaceration of adja-
cent tooth roots, and nasal cavity eruption.6,7,9 To avoid such com- Among the mesiodens, 51 (62.1%) were conical in shape, which was
plications, it is important to diagnose and treat the patient early. the most commonly observed shape, followed by supplemental
The aim of the present study was to assess the radiographic (N = 14, 17.07%) and tuberculate (N = 12, 14.6%) (Table 1).
properties of mesiodens by analyzing the associated age, sex distri-
bution, number of mesiodens per patient, shape, direction of erup- 3.4 | Directions of the mesiodens
tion, and their association with complications.
In the present study, 65 (79.2%) of the mesiodens were aligned verti-
cally, nine (10.9%) were inverted, and eight (9.7%) were aligned hori-
zontally (Table 1).
2 | M ATE R I A L S A N D M E TH O DS

The present study was approved by the institutional ethics board. 3.5 | Positions of the mesiodens
Informed consent was not required, as this was a retrospective study.
According to Yuhyun et al’s classification, mesiodens are analyzed in the
The study was performed using panoramic radiographs of
frontal plane when determining their location.3 The mesiodens were
14 400 pediatric patients who were 3-­14 years old and had visited
mostly in the middle position (N = 58, 70.7%), followed by 11 (13.4%) that
the Department of Pediatric Dentistry at Gaziosmanpasa University
were central incisor left, eight (9.7%) were left of the central incisor, four
(Tokat, Turkey) for a variety of dental complaints during 2015-­2018.
(4.8%) were lateral incisor left, and one (1.2%) was lateral incisor right.
Radiographic examinations of the premaxilla region were based
on panoramic, occlusal, and periapical radiographs by one pediat-
ric dental researcher with over 7 years of clinical experience. The 3.6 | Maturation of the mesiodens
second researcher controlled the radiographs. Standard equipment
Of the 82 mesiodens, 58 (70.7%) were mature and 19 (23.1%) were
(Veraviewepocs 2D; J. Morita, Kyoto, Japan) and a charge-­coupled
immature (Table 1). The maturation type of five horizontal mesi-
device sensor were used.
odens was not identified.
Patients who had systemic disturbances, such as cleidocranial
dysplasia, orofaciodigital syndrome, Gardner syndrome, Rothmund-­
Thomson syndrome, and cleft lip/palate, were not included in the 3.7 | Eruption of the mesiodens
present study. In addition, radiographs that were not clearly visible
Of the 82 mesiodens, 38 (46.3%) had erupted, while 44 (53.6%) had
were excluded from the study.
not erupted (Table 1).

2.1 | Statistical analysis 3.8 | Dentition of the mesiodens

Qualitative data were presented as frequency and percentage. Among the 82 mesiodens, 46 (56%) were in mixed dentition, 18
The data were statistically analyzed with SPSS version 21.0 (SPSS, (21.9%) were in permanent dentition, and seven (8.5%) were in pri-
Chicago, IL). mary dentition (Table 1).
ALTAN et al. |
      3 of 5

the male-­to-­female ratio was 2.2:1. Mesiodens can be classified by

3.9 | Complications caused by mesiodens
There were clinical complications in 76.8% of patients. These com-
plications are described in relation to the number of mesiodens.
3.9.1 | Complications caused by
unilateral mesiodens
Among the 60 unilateral mesiodens, ectopic eruption of a permanent
incisor was seen in 28 patients. A midline diastema was observed in
25 patients, while a delayed eruption was observed in 19 patients.
Axial rotation was observed in 12 patients and cyst formation oc-
curred in one patient (Figure 1).
3.9.2 | Complications caused by bilateral mesiodens
Among the 11 bilateral mesiodens, a midline diastema was seen in six
patients. An ectopic eruption was observed in five patients. Axial ro-
tation and a delayed eruption were observed in four patients, while
a cyst formation was not observed (Figure 1).
4 | D I S CU S S I O N
Mesiodens are regarded among the most important dental anoma-
10
lies that have an impact on both primary and early mixed dentition.
In the present study, we aimed to investigate the radiographic char-
acteristics in patients in the Black Sea region in a non-­syndromic
Turkish pediatric population. Studies on the prevalence of mesiodens
have shown that the rate varies between 0.15% and 2.2%. In stud-
ies conducted in Turkey, Gündüz et al., Bereket et al, Kazancı et al,
and Colak et al reported the prevalence of mesiodens to be 0.3% in
23 000, 0.3% in 111 293, 0.3% in 6154, and 0.13% in 11 256 pediat-
4,10–12
ric patients, respectively. Kara et al found a mesiodens preva-
lence of 0.27% in a multicenter study involving 35 108 patients.13 In
the present study, the mesiodens prevalence of Turkish children in
the Black Sea region was 0.49% in 14 450 patients.
Previous studies have reported that the prevalence of mesiodens
in males is twice as much as that of females.14,15 In the present study,
their number, morphology, eruption pattern, and position.6,9 They
can be categorized as single (one mesiodens) or multiple (2, 3, or 4
mesiodens).3,9 Gündüz et al, Kazancı et al, and Kocatas Ersin et al
found one mesiodens in 76.8% of patients, and two mesiodens in
23.1%, one in 80%, and two in 20%, and one in 41.72% and two in
58.82% of patients, respectively.7,10,11 In the present study, one me-
siodens in 84.5% (N = 60) of patients and two mesiodens in 15.4%
(N = 11) of patients were found, and more than two mesiodens were
not found in any of the patients.
Based on the morphology, mesiodens can be categorized as con-
ical, tuberculate, and supplemental.6,9 The most frequently observed
form is conical, and it generally emerges as a single mesiodens in
the palatal area between the two maxillary central incisors.16 Conical
mesiodens generally exist in a single form. Moreover, tuberculate-­
shaped mesiodens are observed frequently in permanent dentition
and, in general, they disrupt eruption.17 Conical-­shaped teeth do
not have total root formation, while tuberculate-­shaped teeth have
an incomplete or a total lack of root formation. Supplemental me-
siodens are observed more frequently in primary dentition.17 These
tend to look like the normal series of teeth and barely encounter
eruption. When examined in terms of morphology, the present study
showed that the prevalence of conical-­shaped mesiodens was simi-
lar to the findings in the literature. Mesiodens were of conical shape
in 62.1% of patients; supplemental mesiodens were of conical shape
in 17.5% of patients and tubular shape in 14.6% of patients. In the
present study, and contrary to the literature, the supplemental tooth
rate was much higher in permanent dentition than the primary den-
tition, and much of it had erupted. The reason for this is that the
supplemental teeth in the form of natural teeth are often confused
with permanent teeth, and the patient’s family might think that the
central teeth have erupted.11
The majority (76.8%) of the mesiodens in the current study were
in the vertical position, consistent with previous studies. Of the 82
mesiodens, 65 were vertical (76.8%), nine were inverted (12.1%), and
eight were horizontal (10.9%). In general, conical mesiodens have a
total root formation and can erupt into the oral cavity. Unlike coni-
cal mesiodens, tuberculate mesiodens frequently erupt themselves.
In the present study, the teeth with the highest eruption rate were

TA B L E   1   Correlations between characteristics of mesiodens and shape

Direction Maturation Eruption

Horizontal Immature Mature Unerupted

Vertical (N = 65) (N = 8) Inverted (N = 9) (N = 19) b (N = 58) b Erupted (N = 38) (N = 44)

Conical (N = 51) 39 3 9 14 37 24 27
Supplemental 14 -­ -­ 3 11 12 2
(N = 14)
Tuberculate (N = 12) 12 -­ -­ 2 10 2 10
a
Total 65 3 9 19 58 38 39c
a
Shape of five horizontal mesiodens were not identified.
b
Maturation of five horizontal mesiodens were not identified.
c
Five horizontal mesiodens were unerupted; shape and maturation could not be identified.
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4 of 5       ALTAN et al.
conical-­shaped mesiodens. Tuberculate mesiodens erupted at a very
low rate. In the children aged 4-­14 years, root development of me-
siodens was completed at a rate of 81.69%. However, there is no
direct relationship between root development and tooth eruption.
In the literature, Foster and Taylor found that different forms of me-
siodens were linked with different impacts on the dentition.17 The
tuberculate shape is more frequent in patients with delayed erup-
tion, while the conical shape is linked with displacement.
Mesiodens can result in various clinical complications, namely
involvement with the eruption and location of the adjacent
teeth, delayed or non-­e ruption of maxillary incisors, midline di-
astema, axial rotation or inclination of erupted permanent teeth,
dentigerous cyst formation, intraoral infection, and mesiodens
9,12,18
pulpitis. In the literature, the most commonly reported com-
plications were diastema, delayed eruption, rotation, root resorp-
12,19
tion, and dentigerous cyst formation. In the present study,
mesiodens in Turkish children were located mostly in the middle
(N = 58), central incisor (N = 19), and lateral incisor zones (N = 5).
Associated complications were ectopic eruption (N = 28), dias-
tema (N = 25), delayed eruption (N = 19), axial rotation (N = 12),
and cyst formation (N = 1). In Korean children, mesiodens have
been reported to be mostly located in the central incisor (N = 316),
18
middle (N = 60), and lateral incisor regions (N = 7). Yuhyun et al
found delayed eruptions (N = 79) to be the most common compli-
cation, followed by diastema (N = 35), adjacent tooth bud malposi-
tion, and adjacent tooth rotation (N = 7). 3 There was a relationship
between the location of mesiodens and the type of complication
associated with an eruption.
Mesiodens are treated based on the developmental phase of
the dentition, the type and location of the mesiodens, the form of
eruption, the distance of displacement of an unerupted permanent
tooth, and the presence of adequate space within the arch for the
unerupted tooth.16,20 The management of mesiodens can be per-
20,21
formed using three methods: (a) spontaneous eruption; (b) early
intervention; and (c) delayed intervention. For a spontaneous erup-
tion, three factors are the priorities for the waiting period: the type
of mesiodens, the distance from the back of an unerupted perma-
nent tooth, and whether there is enough space for the permanent
18,20
tooth to erupt.
There are different opinions concerning the extraction of me-
siodens. Munns reported that the offending supernumerary tooth
should be removed earlier for a better prognosis.21 Rotberg and Kopel
F I G U R E   1   Complications caused by
mesiodens ( ) cyst formation; ( )
axial rotation; ( ) delayed eruption; ( )
diastema; ( ) ecoptic eruption
and Omer et al suggested that permanent cuts should be extracted at
approximately 5 years of age without completing their roots for min-
imal complications.22,23 Scanlan and Hodges, and Garvey and Barry
recommend that if the supernumerary teeth cause no complications
and are not likely to interfere with orthodontic tooth treatment, they
can be monitored with an annual radiograph.24,25 Högström and
Andersson recommended a mesiodens extraction at the time of de-
tection to prevent future orthodontic treatment and to minimize bone
loss.26 The optimal age for the extraction of a mesiodens remains con-
troversial. In general, an early extraction is defined as an extraction
performed before the age of 6 years, whereas a late extraction is de-
fined as an extraction between 8 and 10 years, when the root devel-
opment of adjacent teeth is complete.3Early and late responses have
both advantages and disadvantages.20,27,28 The negative impacts of an
immediate response include possible injury to the adjacent teeth due
to devitalization and/or root malformation, a young child’s incapacity
to accept the surgical process in a psychological aspect, and conduct-
ing an avoidable procedure in case complications do not occur in the
future.27,29 However, if the response is delayed until the eruption of
the lateral incisors, this could aggravate the risk of a lack of eruption of
the central incisors, a loss of anterior arch space or midline shift, fur-
ther extensive surgery, and an orthodontic procedure for recovery.20
According to the literature, a subsequent delayed eruption in
permanent dentition can be managed by using conservative proce-
dures (eg follow up or removal of mesiodens only). These might in-
clude removing the supernumerary tooth with the bone covering the
unerupted tooth and replacement of the flap, if deeply located, or ex-
posure, if superficially located. This might also include removal of the
supernumerary tooth and exposure of the unerupted tooth in all cases,
with or without the placement of a bonded attachment or ligature for
orthodontic traction.20 Due to the risk of displacement of a permanent
tooth in a surgical procedure, it is generally not suggested to remove a
supernumerary tooth in the primary dentition through surgery.20
A single mesiodens positioned on the buccal, palatal, or arch that
has erupted in the mouth should be extracted when diagnosed. A
single mesiodens, especially those located in the palatal region or
in the arch, might adversely affect occlusal closure, causing space
limitation and esthetic problems. 21,22,24 The treatment of bilateral
mesiodens located in the arch is extraction. However, orthopedic
treatment should be started immediately after the extraction, as se-
vere space loss, loss of function, and esthetic loss will occur after
extraction in these patients. 23,28,29
ALTAN et al.
The tooth development stage is very important in the treatment of
axial rotation associated with mesiodens. 24,28
The main reason for the
occurrence of relapses in the rotation is transseptal fibers, which are
organized when the apical triplet of the root is developing.30 Therefore,
mesiodens should be extracted before the complete development of
the gingival fiber system to ensure that the rotation recovers rapidly,
or to ensure that relapse is minimized after orthodontic treatment.30
Complications that negatively affect the vitality of permanent teeth,
such as a dentigerous cyst, root resorption in permanent teeth, or
infection (infections present intraorally), require immediate interven-
tion.27 There are several limitations to the present study. Because the
shapes were examined in two dimensions on panoramic film, clear in-
formation could not be obtained about the shape of the teeth in the
horizontal position. CBCT scans can be used to obtain more detailed
information about the shape and position of mesiodens.
5 | CO N C LU S I O N
In non-­syndromic Turkish children in the Black Sea region, mesi-
odens were located mostly in the middle anterior region, and com-
plications associated with eruption were observed at a high rate
(39.43%). When complications are found, an early response is impor-
tant for fewer subsequent surgical and orthodontic interventions. In
addition, the management of mesiodens should be evaluated on an
individual basis to determine the best treatment method. However,
at the latest, mesiodens associated with complications should be re-
moved once the lateral incisors have erupted.
ORCID
Halenur Altan  https://orcid.org/0000-0003-3648-5989
Ahmet Altan  https://orcid.org/0000-0003-2041-6364
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How to cite this article: Altan H, Akkoc S, Altan A.
Radiographic characteristics of mesiodens in a non-­
syndromic pediatric population in the Black Sea region. J
Invest Clin Dent. 2018;e12377. https://doi.org/10.1111/
jicd.12377