ORIGINAL

ARTICLES

Retention of permanent
incisors by mesiodens
A Case Report
AUTHORS:

ORA. TERE SA M. r l N I IO

DR.. lostr M. USTRELL T O RREN T

DR. JOAO G. R CORllElRA PlNTO

Ar;STRiKT

T he term mesiodens refers to a supernumerary tooth that is present in the

median area of the maxilla between the two central incisors. Its presence
can lead to localized disturbances near the medial maxillary line, as well
as to a displacement of central incisors with diastema or rotations or even to its
impaction, to the development of dentigerous cysts and adjacent root
resorption
This is the clinical case of a lO-year-old male patient who, at the beginning of
treatment presented retention of a permanent central maxillary incisor on the
buccal side, without enough space between the adjacent tooth roots due the
presence of mesiodens on the palatine side.
In order to resolve this dental problem , procedures , such as an orthodontic
treatment with the traction of the central incisors after the extraction of the
mesiodens were adopted. This procedure made possible the termination of
the case with improved dental and facial aesthetics.

I N T RO DUCT IO N

Th e term su pe rn u me rary refers to the presen ce of
an access ory tooth o r toothbud on the midline of
the maxilla betw een the two ce ntral incisor s with a
co nical sha pe, or a tuber cular shape (rud ime ntary
tooth) 1.2J
Most research ers are agreed on supe r nume rary as a
Although the ae tiology of hyperdo ntia rem ains
un clear, several pot entiall y causative mechanism s
have been sugges ted , nam ely tissue h yperactivity
located on th e epithelial dental lamina \ 6.7. For so me
authors, the explanatio n is based on gene tic and
enviro nme ntal factors but for others it is entire ly th e

co nge nital ph en om en on , but there is no clear-cut result of a development abno rmality \ .6.7.

answe r to its hereditar y natu re ,j .

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The reported freq uen cy of supe rnumerary teeth
varies amo ng d iffere nt studies and dep ending on the
populatio n stud ie d U .H.Y lO.11 Percentage s var y
betwee n 0.1 and 3.5% for the pe rmanen t dentition
and bet ween 0.05% and 1.9 % for the tempo rar y
dentition 1.3.12 .1 ". In general, su pe rn umerary teeth are
report ed mor e freq uently in males than in femal es,
in a 2:1 ratio, although significant differen ces can be
observed acco rd ing to th e pop ulation studied i.s io u
Asupe rnu merary tooth in the median line is called
mesiod en s. Supern umerary teeth may have vertical,
transverse o r inverted position s (2 "1)
rrc . 1: I' H O T O G IZ A PH S RFFORF TREATMf:NT ( 10 YEARS OLD ).
There are several clinical co mp lications and dental
cha nges ass ociated with th e presen ce of
su pern umera ry teeth . Co nce rn ing th e most
frequent, th e mesiod en s, its presen ce can lead to
localized disturbances near the maxillary midline , as
well as the disp laceme nt of cent ral incisor s with
diastem a o r rotation s o r even to its im pac tion, to the
developm ent of dentige rous cysts and ad jacent root
resorption ' '<. 9 10.
W VI W G N A T H 0) ~'E T I I' A G f 23
T H E CLI N ICAl CASE

A.F.S , a lO-year-old male, sought consultation for the

absen ce of permanent upper cent ral incisors du e to
the presen ce of a mesioden s (Fig . 1, 2 and 3). The
so ma tic and dental development was normal for his
age , and his medical history revealed no relevant
data.

F1Ci.2: PA N O RA MI C X-RAY AN D H EA D FI LM IN Ll\ rER AI. I N C I D EN CE !)F f O RE TREAHvlEN I""

FIG . 3: CAST HEFOR[ TIUATM E.NT.

WW W G NAT J-I O , N CT I P AGE 2~
 FIG. 4: D ETA IL O F T HF H EA D FI LM IN LATE RA L I N C I D EN C E
5EFOR I TREATI\HN T A D V ISUA LI ZAT ION O F TH F TH FRA PEU T I C
O LI! ECT I \IF.S (\ITO) .

Skeleton Class
convexity of point A 6.0
distance A-B 8.7
Inferior maxillar
facial axis 84.4"
facial depth 86.0"
mandibular plane angle 30 .~
inferior facial height 48.1 c
mandibular arch 28.4"
Superior maxillar
maxillar depth 91.9'"
Teeth
distance inferior incisor /A­ 1.8
Po
distance inferior incisor
/occ1usal plane
inferior incisor
angle/mandibularplane
overjet 3.4
overbite 5.6
Esthetic
exposition of superior incisor 8.3
inferior lip/plane E .3.1
nasolabial angle 109.4°

ric; 5: I N I r i A L ANA LYS1S AND Cf I' H A LO M ETR IC I\\EAS U I~F.MEN TS flY fU C K ETT S.

FIC;. 6 : SURG IC/\ L I' H A SF Of- T H l' M ESJ U DENS EXT RACT ION FOR I'A LAT I N F SI D E AND C O LLAG E OF

T i l E [\ U TT O N I'OR BU CC A L A SPECT.

WWW .G NATHOS NeT I PA G l 25

D IAGNOSIS
From th e aes the tic po int o f view , th e pati ent
pr esented a st raight facial p rofile (Fig .I) with
sym me trical and proportional facial thi rd s, lip
regularity and a normal smile line . In relation to th e
mid -line of the face , the mid-line of th e dental
maxilla was shown to have deviated to the right
about 2mm du e to the abse nce in the arcad e o f the
right upper ce ntral incisor (Fig.1). No apparent
skeletal asym me try was detected.
From the dental point of view, th e pati ent presented
impacted upper right ce ntral maxillary incisor due
the impaction of mesiod ens without enoug h bon y
space and in the arcade for its erup tion (Fig.2) .
From the dental point of view, the pati ent pre sented:
right ce nt ral upp er inciso r includ ed in a high
b uccalize d po siti on du e to th e presence of a
me siodens in the palatin e po sition : d ecreased inter­
radi cu lar and inter-coronal space am ong th e
adj acent te eth; th e Class T mol ar a nd ca nine
relation ship o f right and left side with a slight vertical
ove rbite of 5.6 mm (Fig.l and 3) .
FIG . 7: P H AS eS OF O RT HODON llC CO rUUCT ION .
WWW GN i\T l-lOS NeT / PA GE 2 6
Th e hygiene was fault y with so me ves tiges of
bacte rial plate , but with good periodontal co nd itio n.
Th e telerradiograph shows the ce n tral incisor
meetin g in a highl y buccalized positio n and the
mesiodens in a palatin e position (Fig.2 and 4).
The ce phalome tric analysis (Fig. 4) re vealed a mild
class II skele tal (co nvexity of po int A = 6 mm ) with
Class IT alveolar (distance A-B = 8 .7 mm ) , smoo th
doli cofacial pattern with - 0.8 grade of severity, light
prom a:.xillia (91.9°) and orthornandibulia (86°). The
u ppe r and lower incisors showed normal inclination
and position relative to A-Po line (Fig. 5) .
Th e obj ectives of treatment co nsisted of rne siod en s
extrac tion to crea te space betw een the root s and the
crow ns of the right u pp er lateral incisor (too th 12)
an d left upper ce n tral incisor (too th 21) for
po sterior traction right upper cent ral incisor (too th
11) that met in a very high bu ccalizcd position to
maint ain the relation ship o f molar and ca nine Class
1. The co rrec tion of th e ove rbite was done and was
also part o f the objectives (Fig. 4) .
j [G8 . r ,\ Nl 1t 1\ ,M l l_ A j-tA'c ' l 1l I Il.I N t::i f RE A I .... l t.f'.J I \0\1 1111 fI r I c nH. ~ l l ' 1 1 1~ l r l >N Cr> I N T i l E
II C/\D E

11<; " ru. TO Cd ,,.,, 1' Sl 'l) \ 1HR TI l EJ\.',[1 '/\ L (H I H L r rx D A I 1' ll AN e l l lJ .\ { ~ I

WWW GNAI H O S NET I PAGC 27

TREATME NT Afte r the eru ption of the su ppo rt zone per manent
teeth the bands of the first maxillary molars were
Trea tment began by cementing the band s of the first ceme nted and were glued on the brackets of the
maxillary molar s and straigh t wire bracket s, Roth rem aining teeth. The alignme nt and the coronary
versio n with a slot of 0.018 x 0.022" were glued on levelling of the maxillary was achieved with 0.014"
maxillary incisor s. Placem ent of a ut ility arch 0.016 x arches and po ste riorly by 0.016" o ne s o f nickel­
0.022" of steel with a spring in T for alignme nt titanium , later substituted by arc he s in 0.016" steel.
between 21 and 22, and a spring in nickel titanium After exfoliation of the lower sup po rt zo ne , the
between 12 and 21, for th e opening space . It was band s of the first mandibular molars were cemente d
allowed to rem ain this way for th ree mor e months and were glue d o n th e brackets of the rem ainin g
be fore th e surgical access for th e extract ion of th e teeth.
mesioden s and collage of the butto n with a th read of
0.0 10" stee l, in the bu ccal asp ect of th e 11 for
pos te rior traction (Fig 6) .
Before beginning 11 traction , it was necessary to
achieve th e righ t posi tion of the bracke t of th e 12
and th e su bstitution of th e utilitarian arch for o ne
with a spring in T near the 12 mesial as pec t (Fig. 7) .
It was in th is way that the possible d istalization of 12
root was clone to recove r th e bony space between
the adjacent tooth roo ts, facilitating the 11 trac tion
inside th e alveolar bon e . This traction was applied
with elastics tha t we re change d eve ry thr ee wee ks.
Thirteen mon ths after th e treatment began , whe n
the right ce ntral upp er incisor appeared in the
arcade , th e button was replaced by a bracke t.
Super position of an arch of 0.014 nickel-titanium
indi re ctly link ecl to the brac ke t was lat er o n
s ubs titu ted fo r a 0.016 arch." The connectio n of th e
11 to th e arch was macl e in a progressively way to a
utilit y'0.016'· x 0.022" arc h (Fig. 7) .

FIG . 10: !'ANORAM IC X- RAY AN D TE l EX N RAY. LATER A L VI EW. AFTER T HE T IU J\T MF N T.

WW W .G N AT HO~. NE T / PA G E 28
 fi G . II : (''\5T AFTE R T H E T R EAT M EN T.

Skeleton Class
convexity of point A 3.3
distance A-B 6.6
Inferior maxillar
facial axis 83 .80
facial depth 86.6°
mandibular plane angle 30.0°
inferior facialheight 49.4°
mandibular arch 28.8°
Supeliot' maxillar
maxillar depth 89.4°
Teeth
distance inferiorincisor 3.6
lA-Po
distance inferiorincisor 2.3
locclusal plane
inferior incisor 88.3°
angle/mandibular plane
overjet 4.1
ove~~e 3.4

FI G . 12: ANMYS IS AND ( [\l H A LO M ET RI C M EASUIU M EN TS. ACCO I~ I) ING T O R. ICKErT:' , I N T Il [

fI N A L T RI:AT J'v\ EN T.

Taki ng int o acco unt that the Bolton analysis showed
a seco nd lower pre m olar disc repancy, th e
inte rp roximal surfaces in thei r mesial and distal
aspec ts were filed after using a rubber se pa rato r fo r
two d ays.
The align ment and the coro nary levelling of the
ma nd ibular teeth were achieve d with 0.014" arches
and pos terio rly by means o f 0.016" nickel-titaniu m
arches, late r subs titu ted fo r 0.016" steel arches .
The alignment an d levelling ph ase of th e ro ots o f
both arcades was achieved with a braided 0.016" X
0.022·'a rch, s ubs titu ted pos te rio rly for nickel-

wWW G N ,\ T 1-] 0 S . NIl / I' A G [ 2 »

 FIG . 13: CE PH ALOME TR IC SU PErUOS lT lON (RI C K H T S M ET H O D ).
titanium and later for s tee l of the sa me calipe r
(Fig.7) . Panoramic radi ographs we re take n to
co nfi rm the position of the roots (Fig.S)
Two months before the end of treatment, the upp er
arch was changed for 0,015" coax ial and
int ermaxillary e lastics of Class I of 4.8mm diamet er
to imp rove the interarcad e intercuspidation (Fig. 7) .
CONTENT ION
Thirty-seven months afte r the beginning of the
trea tment, the bands and bracket s we re rem oved
and th e es tablish me nt of the oc clusion was
acco m plished .
Impressions for th e retainer were taken. Th e
maxillary ret ainer was preformed in a vacuum . On
the mandibl e. a lingual arch was attache d by gluing
it to incisors and canines on their lingu al asp ects.
The stabilization of the occlusio n was in this way
achi eved . Phot o graphs, pan oramic radiographs,
telerradiographs and dental casts we re taken (Fig. 9,
10 and 11). A cephalome tric evaluation was mad e
(Fig. 12 and 13)
Two yea rs afte r th e beginning of treatm ent,
photographs were taken to evaluate the stability of
th e results (Fig. 14) .
WV-1W G N A T J-lO S N ET / PA G E 3 0
DiSCUSSION
Supe rnume rary teeth are co nside red to be o ne of
the mo st significan t dental an omalies affe ct ing
mixed dentition J,
<f Anterior maxillar y
supe rn umeraries in young patients are of great
co nce rn to both den tist and parents because of the
del ayed eruption, occlusal and aestheti c probl ems
they can create.
Since mo st supe rn ume rary teeth are impacted . the
radiograph s are an esse ntial diagn ostic tool, no t only
to identify and characte rize these teeth , but also to
det ect the rep ercussion s o n ad jacent teeth and
nearby tissues, and the distan ce of the unerupted
permanent tee th from the occlusal plane. Early
diagnosis of supe rn ume raries is crucial, if these
co m plications are to be avoid ed or minimized .
Clinically, th e presen ce of supe rn ume raries sho uld
be suspe cted , if ther e is a sign ifican t delay in the
er up tion of the permanent maxillary ce n tral incisors.
as in this case 4.
A supe rn ume ra ry tooth is ind icated for rem oval if
any co m plications are identified . The timing of the
surgical rem oval of supe rn ume rary teeth has two
schoo ls of thou ght, immediate vs. delayed . The
imm ediate ap p roac h calls for rem oval of th e
supe rn ume rary tooth or tee th soon after the initial
diagnosis o f the co nd itio n. The delayed approach
recommends rem oval at the time adjacent root
 FI G . 14 : PHO TOGRAP HS T W O YEARS AFTER THE ORT HO DON T IC T REAT M EN T.
form ation is co mplete, usu ally at ages eigh t to te n
years 6.
Perma nent incisor re tentio n is an anoma ly that is
infreq uent in the po p ulation 2. Curre nt ly, however,
increasing d e mands o f o ur patie nts rega rding the
aes thet ics o f the front sector have led clinicians to
focus o n the probl em . As shown in this case ,
treatme nt of impac ted teeth is the typical example of
interd isciplina ry cooperatio n and the solution is
usually th e shared aim of odon thoped iatrician ,
orthodontist and d ental surgeo n .
Generally, ea rly surgical int e rve ntion is pre ferre d .
This app roac h takes advantage of the spontaneo us
erup tive pot enti al of the per man ent incisors and
may pre vent d iastema for matio n a nd exte nsive
surgical/o rtho don tic treatment 4,6.
In this case , taking int o acco u nt that the un erupted
tooth is located too high and the ne ighbo uring teeth
close the space by bodily movem ent; it is impo rtan t
to e nsure sufficient space to accommoda te the
e rupting pe rma ne nt tooth bu t, in this case, using
o rt hodontic forces . The opening of th e s pace
be twe e n the adjacent tee th, no t o nly intercoronal
but inter rad ic ula r as we ll, sho uld p recede the
surgical ph ase . This is followed by traction of the
included eleme nt accordi ng to the right axis. In this
case the distalization o f root of the too th 12 was
requi red. In this W<Jy the space is recove red for the
correct traction positioning of 11, to allow the
alignmen t of the upper medi al line and to res tore
the sym me try of the upper arcade .
The cep halo me tric analysis at the en d of treatm ent
WWW G N AT H O S N ET I P AG E 31
(Fig. 12) cle arl y shows th e form su pe rim pose d o n
th e alt erati ons ob tained with trea tm ent an d th ose
a ttrib u te d to growth . The ini tial aug me n ted bony
co nvexity must be to th e prornaxilia, probabl y owi ng
to th e high buccalization of th e cen tra l right upper
in cisor justi fying in thi s way th e re duced co nvex ity
verified in th e final treatment afte r trac tio n (Fig 4
and 11) .
Th e bone altera tio ns also have an impact a t th e
alve ol ar tooth level by redu cin g Class II at th is level
fro m 8 .7 mm to 6 .6 mm ; in turn , a sm all o pe n ing o f
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Dr. Patricio Soto PaY1Ja
• Assistant Professor 0/ Orthodontics, Instituto
Supe rior de Ciencias da Saude-Norte, Porto,
Portugal.
• Gna tbos Foundation Graduate.
E-rnail. terpin bo@netcabo.pt
Dr. ]osep M. Ustrell Torrent
• Professor. Uniuersitat de Barcelona, Spain.
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Dr. ]oao G. R. Correia Pinto
• Prof essor of Orthodontics, In stitute Supe rior de
Ciencias da Saude -Norte, Port, Portugal.