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Multiple impacted unerupted supernumerary teeth
Exodontia MULTIPLE
IMPACTED
UNERUPTED Report
SUPERNUMERARY
TEETH
of a Case
ROBERT A. ATTERBURY,
B.S., D.D.S., F.I.A.A.,” AND SUNDER J. VAZIRANI, D.D.S., F.I.A.A.,** CHICAGO, ILL.
MPACTED supernumerary teeth present the same problems as other types of impactions. These abnormalities are found in any region of the jaws. They are most frequently seen in the maxillary incisor region, at or near the median line. Most of them arc impacted, although at times they erupt in or near the arch.
I
Etiology.-The etiology of supernumerary teeth is obscure. Various theories are prevalent concerning the cause of supernumerary teeth. The disorder has been described in the literature as hyperplasia of dentition, hereditary, a phylogenetic reversion (atavism). Local causes which may have an influence are inflammation, scarring, abnormal pressure, and disturbed relation in odontogenesis. Common Site.-Supernumerary teeth arc more common in the maxilla than in the mandible, and are most often found in the anterior region. Clinical Manifestations.-Certain clinical manifestations of supernumerary teeth are present to a greater or lesser degree, depending on the number of teeth, location, and surrounding pathology. The effect that the supernumerary teeth have on the normal occlusion is the important factor. Supernumerary teeth may interfere with growth, causing delayed eruption, noneruption, malposition, separation of permanent teeth (diastema), eruption into the nares causing chronic irritation, development of dentigerous or follicular cysts, headaches, and paresthesias. The most objectionable complaint is usually a disfigured appearance. From
the
Division
of
Oral
Surgery.
University
of
Illinois
Research
and
Educational
Hospitals. *Clinical
Assistant
Professor
of
Oral
Surgery
and
Director
of
Hospital
Oral
Surgery
Clinic. **Chief
Resident
in
Oral
Surgery
and
at
Medicine.
141
present
Instructor
in
Anatomy,
College
of
1-42
ATTERRURY
AND
0 s., 0. M., & 0. P. Frbruary. 19CP
\‘ARTRANI
The technique for their rcmoyal is tlctermined by their size anil location and is the same as for the surgical removal of any impacted tooth in that area, except, possibly for the size and location of the mucopcriosteal flap. An examl)lc+ of this is given in the following case of multiple impact,ecl supernumerary 1 cvth.
Case Report History.--On July 6, 1955, a lo-year-old white boy was referred to the Oral Surgery Service of the Research and Educational Hospitals by the Department of Pediatrics with the history of persistent swelling of the soft tissues in the palate region. The swelling had been present. for six months, and there were no subjective symptoms of pain or discomfort. The patient had been given antibiotic treatment for several months by his local physician, but the swelling did not respond to antibiotic therapy. The patient was then referred to this hospital for evaluation and treatment. Six months before admission, the patient had noted a slight swelling of the soft tissue in the roof of the mouth, which he and his parents attributed to “hot coffee drink.” The swelling did not subside in two weeks.
J?W.
l.-Intraoral cisal
photograph edge behind
showing the right
palatal central
soft-tissue permanent
bulging incisor
and (see
exposure arrow).
of
an
in-
The local physician whom the patient consulted diagnosed this as gumboil and prescribed oral antibiotics for three months. In the ensuing three months until admission, the patient and his family physician noted the enlargement of the swelling, which was of a benign nat,ure. Finally, the patient was referred for diagnosis and treatment. Past history included childhood diseases. Family history revealed that his father had arrested tuberculosis and one brother had died of diabetes at the age of 18 years. Physical well-nourished, the palate.
Examination.-On clinical admission, white male child who was not acutely His blood pressure, pulse, respiration,
examination revealed a well-developed, ill, but was concerned about a swelling temperature, and medical examination
of
$;;ir
;I
MULTIPLE
IMPACTED
UNERUPTED
SUPERNUMERARY
143
TEETH
were essentially normal. The intraoral examination showed normal dentition, and ocelusion was according to his chronological age. Examination of the palate revealed exposure of an in&al edge behind the permanent right central incisor. There was soft tissue bulging in the right anterior palatine region opposite the primary deciduous molars. On manThe swollen ual examination, a soft, rubbery swelling was felt, with no pain or tenderness. mucosa was much softer than the surrounding muoosa. Examination of the maxillary teeth revealed a bilateral carious lesion of the deciduous canine with no periapical pathology. A few amalgam fillings were noted in the molar region. The examination of the soft tissue, nose, and neck was essentially normal (Fig. 1). Laboratory Studies..-Routine blood, urine, and serology studies were within normal limits. X-ray films of the periapical region were essentially normal. The occlusal view demonstrated multiple impacted supernumerary (accessory) teeth in the anterior palatine region. There was a malposed rudimentary tooth located in the right side of the maxilla lateral to the median suture of the maxillary bones opposite the deciduous molars. An area of rarefaction was visible over the crown portion and resembled a cystic cavity. A peg-shaped, conical tooth was noted in the medial aspect of the permanent right central incisor root portion. A third tooth with a broad incisal edge was located in the lateral position, palatal to the permanent incisor teeth. No root resorption was noted in the roentgen film (Fig. 2).
Fig.
2.-Occlusal
Clinical
view
revealing
Impression.-Multiple
multiple impacted
impacted
supernumerary
supernumerary
teeth
teeth with
in the cystic
Palate.
lesion.
After a halfOperation.-& July 13, 1955, the patient was given 50 mg. of Seconal. hour the patient was prepared and draped in the usual manner. A bilateral greater palatine block was achieved with local anesthesia. The incision was made with a #ll Parker blade, freeing the attached gingiva from the palatal aspect of the teeth. Then, with a periosteal elevator, the palatal mucoperiosteum was elevated and retracted to the first permanent molar region. A gauze pack was placed in the mouth to prevent blood aspiration. The palatal bone was visualized and the three impacted teeth were exposed. The anterior right supernumerary tooth was elevated and delivered with a Potts elevator. The overlying bluish thin bone was removed with a sharp osteotome to expose the left lateraltooth, which was then delivered. The third posterior tooth was embedded under thick cortical bone which
ATTERRURY ut :tn-vay with a sharp mth was visualize(l. ate<1 eu tot0 with the The nasal elevator. saline solution The rtal spaces the palatal
Fig.
s material. a hen oatoma and black silk through suturl
0. s.. 0. M.. & 0. P.
VAZIRANI
February,
1958
~liaruoncl-cutting burr. After the overlying bone was rc :m0vea, Tissue resembling a c,vstic sac euveloped the crown a ntl was blunt curl of a curette. This tooth was also tleliveretl with a Inme was thin on examination. The wound was irrigate ed with palatal mucoperiosteum was approximatell and through the inmucosa was suturetl to the labial mucosa, using 00001 D nylon
3.-Supernumerary
Fig.
AND
4.--Occlusal
A petrolatum postoperative the interdental
teeth
view
removed
showing
from
bony
gauze pack was palatine swelling. spaces.
anterior
healing
area
after
of
six
the
palate.
months.
placed as a pressure dressing to prevent The pack was retained, using 0 braided
~ul;~;r;l
MULTIPLE
The two days, prescribed, home with postoperative The pack tion and tenth day. postoperative asymptomatic
patient was given the following postoperative instructions: (1) (2) sedation for pain, (3) ice bag over the face, (4) bed rest, (6) oral rinses with alkaline mouthwash. The patient was his parents. The specimen was sent for histologic examination recovery was uneventful, except for slight discomfort from was removed on the third day; the wound was irrigated with showed normal healing. The remaining gingival sutures were Complete healing took place in twenty days. The six-month radiographs showed normal findings and healing and (Fig. 4).
tion
IMPACTED
Histelogic Diagnosis.-The of the teeth was compatible
UNERUPTED
SUPERNUMERARY
specimen was reported as dentigerous with a diagnosis of supernumerary
TEETH
145
clear liquids for (5) no antibiotic discharged to go (Fig. 3). The the palatal pack. warm saline soluremoved on the follow’-up and the patient was
cyst teeth.
and
examina-
Summary The etiology, clinical features, treatment, and surgical technique of supernumerary teeth have been described. A case of impacted supernumerary teeth is presented, emphasizing the fact that their removal presents the same problems as other types of impactions. 840 s. WOOD
ST.
IMPACTED
UNERUPTED Report
SUPERNUMERARY
TEETH
of a Case
ROBERT A. ATTERBURY,
B.S., D.D.S., F.I.A.A.,” AND SUNDER J. VAZIRANI, D.D.S., F.I.A.A.,** CHICAGO, ILL.
MPACTED supernumerary teeth present the same problems as other types of impactions. These abnormalities are found in any region of the jaws. They are most frequently seen in the maxillary incisor region, at or near the median line. Most of them arc impacted, although at times they erupt in or near the arch.
I
Etiology.-The etiology of supernumerary teeth is obscure. Various theories are prevalent concerning the cause of supernumerary teeth. The disorder has been described in the literature as hyperplasia of dentition, hereditary, a phylogenetic reversion (atavism). Local causes which may have an influence are inflammation, scarring, abnormal pressure, and disturbed relation in odontogenesis. Common Site.-Supernumerary teeth arc more common in the maxilla than in the mandible, and are most often found in the anterior region. Clinical Manifestations.-Certain clinical manifestations of supernumerary teeth are present to a greater or lesser degree, depending on the number of teeth, location, and surrounding pathology. The effect that the supernumerary teeth have on the normal occlusion is the important factor. Supernumerary teeth may interfere with growth, causing delayed eruption, noneruption, malposition, separation of permanent teeth (diastema), eruption into the nares causing chronic irritation, development of dentigerous or follicular cysts, headaches, and paresthesias. The most objectionable complaint is usually a disfigured appearance. From
the
Division
of
Oral
Surgery.
University
of
Illinois
Research
and
Educational
Hospitals. *Clinical
Assistant
Professor
of
Oral
Surgery
and
Director
of
Hospital
Oral
Surgery
Clinic. **Chief
Resident
in
Oral
Surgery
and
at
Medicine.
141
present
Instructor
in
Anatomy,
College
of
1-42
ATTERRURY
AND
0 s., 0. M., & 0. P. Frbruary. 19CP
\‘ARTRANI
The technique for their rcmoyal is tlctermined by their size anil location and is the same as for the surgical removal of any impacted tooth in that area, except, possibly for the size and location of the mucopcriosteal flap. An examl)lc+ of this is given in the following case of multiple impact,ecl supernumerary 1 cvth.
Case Report History.--On July 6, 1955, a lo-year-old white boy was referred to the Oral Surgery Service of the Research and Educational Hospitals by the Department of Pediatrics with the history of persistent swelling of the soft tissues in the palate region. The swelling had been present. for six months, and there were no subjective symptoms of pain or discomfort. The patient had been given antibiotic treatment for several months by his local physician, but the swelling did not respond to antibiotic therapy. The patient was then referred to this hospital for evaluation and treatment. Six months before admission, the patient had noted a slight swelling of the soft tissue in the roof of the mouth, which he and his parents attributed to “hot coffee drink.” The swelling did not subside in two weeks.
J?W.
l.-Intraoral cisal
photograph edge behind
showing the right
palatal central
soft-tissue permanent
bulging incisor
and (see
exposure arrow).
of
an
in-
The local physician whom the patient consulted diagnosed this as gumboil and prescribed oral antibiotics for three months. In the ensuing three months until admission, the patient and his family physician noted the enlargement of the swelling, which was of a benign nat,ure. Finally, the patient was referred for diagnosis and treatment. Past history included childhood diseases. Family history revealed that his father had arrested tuberculosis and one brother had died of diabetes at the age of 18 years. Physical well-nourished, the palate.
Examination.-On clinical admission, white male child who was not acutely His blood pressure, pulse, respiration,
examination revealed a well-developed, ill, but was concerned about a swelling temperature, and medical examination
of
$;;ir
;I
MULTIPLE
IMPACTED
UNERUPTED
SUPERNUMERARY
143
TEETH
were essentially normal. The intraoral examination showed normal dentition, and ocelusion was according to his chronological age. Examination of the palate revealed exposure of an in&al edge behind the permanent right central incisor. There was soft tissue bulging in the right anterior palatine region opposite the primary deciduous molars. On manThe swollen ual examination, a soft, rubbery swelling was felt, with no pain or tenderness. mucosa was much softer than the surrounding muoosa. Examination of the maxillary teeth revealed a bilateral carious lesion of the deciduous canine with no periapical pathology. A few amalgam fillings were noted in the molar region. The examination of the soft tissue, nose, and neck was essentially normal (Fig. 1). Laboratory Studies..-Routine blood, urine, and serology studies were within normal limits. X-ray films of the periapical region were essentially normal. The occlusal view demonstrated multiple impacted supernumerary (accessory) teeth in the anterior palatine region. There was a malposed rudimentary tooth located in the right side of the maxilla lateral to the median suture of the maxillary bones opposite the deciduous molars. An area of rarefaction was visible over the crown portion and resembled a cystic cavity. A peg-shaped, conical tooth was noted in the medial aspect of the permanent right central incisor root portion. A third tooth with a broad incisal edge was located in the lateral position, palatal to the permanent incisor teeth. No root resorption was noted in the roentgen film (Fig. 2).
Fig.
2.-Occlusal
Clinical
view
revealing
Impression.-Multiple
multiple impacted
impacted
supernumerary
supernumerary
teeth
teeth with
in the cystic
Palate.
lesion.
After a halfOperation.-& July 13, 1955, the patient was given 50 mg. of Seconal. hour the patient was prepared and draped in the usual manner. A bilateral greater palatine block was achieved with local anesthesia. The incision was made with a #ll Parker blade, freeing the attached gingiva from the palatal aspect of the teeth. Then, with a periosteal elevator, the palatal mucoperiosteum was elevated and retracted to the first permanent molar region. A gauze pack was placed in the mouth to prevent blood aspiration. The palatal bone was visualized and the three impacted teeth were exposed. The anterior right supernumerary tooth was elevated and delivered with a Potts elevator. The overlying bluish thin bone was removed with a sharp osteotome to expose the left lateraltooth, which was then delivered. The third posterior tooth was embedded under thick cortical bone which
ATTERRURY ut :tn-vay with a sharp mth was visualize(l. ate<1 eu tot0 with the The nasal elevator. saline solution The rtal spaces the palatal
Fig.
s material. a hen oatoma and black silk through suturl
0. s.. 0. M.. & 0. P.
VAZIRANI
February,
1958
~liaruoncl-cutting burr. After the overlying bone was rc :m0vea, Tissue resembling a c,vstic sac euveloped the crown a ntl was blunt curl of a curette. This tooth was also tleliveretl with a Inme was thin on examination. The wound was irrigate ed with palatal mucoperiosteum was approximatell and through the inmucosa was suturetl to the labial mucosa, using 00001 D nylon
3.-Supernumerary
Fig.
AND
4.--Occlusal
A petrolatum postoperative the interdental
teeth
view
removed
showing
from
bony
gauze pack was palatine swelling. spaces.
anterior
healing
area
after
of
six
the
palate.
months.
placed as a pressure dressing to prevent The pack was retained, using 0 braided
~ul;~;r;l
MULTIPLE
The two days, prescribed, home with postoperative The pack tion and tenth day. postoperative asymptomatic
patient was given the following postoperative instructions: (1) (2) sedation for pain, (3) ice bag over the face, (4) bed rest, (6) oral rinses with alkaline mouthwash. The patient was his parents. The specimen was sent for histologic examination recovery was uneventful, except for slight discomfort from was removed on the third day; the wound was irrigated with showed normal healing. The remaining gingival sutures were Complete healing took place in twenty days. The six-month radiographs showed normal findings and healing and (Fig. 4).
tion
IMPACTED
Histelogic Diagnosis.-The of the teeth was compatible
UNERUPTED
SUPERNUMERARY
specimen was reported as dentigerous with a diagnosis of supernumerary
TEETH
145
clear liquids for (5) no antibiotic discharged to go (Fig. 3). The the palatal pack. warm saline soluremoved on the follow’-up and the patient was
cyst teeth.
and
examina-
Summary The etiology, clinical features, treatment, and surgical technique of supernumerary teeth have been described. A case of impacted supernumerary teeth is presented, emphasizing the fact that their removal presents the same problems as other types of impactions. 840 s. WOOD
ST.