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Problems of supernumerary and congenitally missing teeth
M O S M A N N . . . VO LU M E 66, J A N U A R Y 1963 • 83/69
plasias and opacities and dental fluorosis should be understood by the dental pro fession so that a clear clinical differentia tion can be made (Table 3 ) . In any event, an unesthetic develop mental defect which occurs in such a large percentage of individuals should certainly be considered a problem in pub lic health and adequate measurement of such an entity becomes important. A method of both quantitative and quali tative appraisal of its occurrence in groups of the population should become part of the armamentarium of the public health dentist.
Presented at the American Public Health Association, Southern Branch, Louisville, Ky., A p ril 12, 1961. *Director, Dental Health Center, San Francisco, C alif. fRegional dental consultant, Region V, Public Health Service, U.S. Department o f H ealth, Education and W elfare, Chicago, III. ffD ire c to r of the dental health section, Oregon State Board of Health, Portland, Ore. 1. ZImmermann, ' E. R. Fluoride and nonfluoride en amel opacities. Public Health Rep. 69:1115 Nov. 1954. 2. Ast, D. B., and others. Newburgh-Kingston caries fluorine study. XIV. Combined clinical and roentgenographic dental findings after ten years of fluoride ex perience. 3. Hurme, V. O. Developmental opacities o f teeth in a New England community. Am. J. Dis. C hild. 77:61 Jan. 1949. 4. Sarnat, B. G., and Schour, Isaac. Enamel hypo plasia in relation to systemic disease. J.A .D .A . 28:1989 Dec. 1941 and 29:67 Jan. 1942. 5. Forrest, Jean R. Caries incidence and enamel de fects in areas with different levels of fluoride in the drinking water. Brit. D. J. 100:195 A p ril 17, 1956.
Problems of supernumerary and congenitally missing teeth
Walter H . M osm ann, D .D .S., Hackensack, N .].
Supernumerary teeth should be removed
SUPERN U M ERARY T E E TH
if removal will not harm the patient or his permanent teeth. Congenitally missing teeth present few problems if orthodontic service is available. T h e dentist need only maintain the space. I f not too many teeth are missing, a satisfactory occlusion can be obtained.
M any theories are advanced concerning the causes of supernumerary and con genitally missing teeth. Heredity must play a part because the same condition often exists in one parent. Extra or miss ing teeth are frequently associated with congenital deformities, such as a cleft palate.
Supernumerary teeth can occur in any re gion of the bone close to the teeth. They occur most commonly in the maxillary midline region between the central in cisors. They can be conical, flat, shaped like a root or the adjacent teeth. Some times only the crown of the supernumer ary tooth is formed. These teeth can be formed from before birth to 12 years of age. In later life, the extraction of a tooth may allow a blocked permanent tooth to erupt. However, this is not a supernumerary tooth or a third tooth erupting. A supernumerary tooth may grow in many positions, even upside down or horizontal to the other teeth. Roent genograms should always be taken at vari
8 4 /7 0 • T H E J O U R N A L O F THE A M E R IC A N DENTAL A S S O C IA T IO N
ous angles to be sure of the exact position of the tooth. I f surgical removal will have no harm ful effects on the patient or his permanent teeth, a supernumerary tooth should be removed. However, if the patient is young and the permanent teeth are forming, it may be advisable to wait until the child is a better surgical risk. I f the supernu merary tooth lies against a permanent tooth, there may be a risk of damage to the permanent tooth, and it may be advis able to allow the supernumerary tooth to remain in position until the surgical risk is less. For example, if a supernu merary tooth lies close to the crown of a central incisor which has not formed its root, the surgical attempt to remove the extra tooth may damage the permanent tooth. A few months or even a year later, the root of the permanent tooth will not be involved. An oral surgeon or an ortho dontist can help decide on the proper time for the removal of a supernumerary tooth. W hen the extra tooth is the twin o f the adjacent tooth and is in good occlusion, the dentist should consult an orthodontist before removing it. Some times because of the width of the teeth, the orthodontist may advise keeping a supernumerary incisor in place. Roentgenograms should be taken peri odically by the general practitioner. The dentist may not see a supernumerary tooth if he does not carefully view a well angled and properly developed dry nega tive. I f the dentist is in doubt he should seek consultation. H e should always ex plain to the parents what he has found, when he is going to remove the super numerary tooth, and what the reason is for his decision. C O N G E N IT A L L Y M IS S IN G T E E T H
Teeth are congenitally missing more often than supernumerary teeth are present. They present a greater variance in opera tive procedure. The teeth which are most likely to be missing are maxillary lateral
incisors, and maxillary and mandibular second bicuspids. Patients who have miss ing teeth frequently have supernumerary or odd-shaped and odd-sized teeth. The missing teeth often are bilateral. Super numerary teeth usually occur unilaterally. Roentgenograms inform the dentist of such situations at an early date and en able him to plan a procedure for the patient. Congenitally missing teeth seldom oc cur in deciduous dentitions, but if they do, usually nothing is done about them. Where permanent teeth are missing, the roots of the deciduous predecessors may not be resorbed. Care must be taken when these deciduous teeth are removed be cause they frequently are firmly em bedded. The dentist should consult an orthodontist to determine whether to re move or maintain a deciduous tooth which has no successor. Sometimes the congenitally missing central incisor in the mandibular arch is not noted because of the large deciduous central incisors which are in place. T h e dentist should always count teeth and know the anatomy of deciduous and permanent teeth. I f deciduous teeth are lost in the an terior region of the arch, it usually is not necessary to maintain the space. I f the deciduous molars are lost, the space should be maintained so that the perma nent molars will not drift forward. I f a bicuspid is missing and the deciduous tooth is lost, the space must be main tained to enable the orthodontist to de termine whether the posterior teeth should be allowed to drift forward or the space held. T h e space over a congenitally missing tooth often must be maintained to enable the orthodontist to correct a malocclusion. In orthodontic tooth movement it may be advisable to consider comfort and lack of future dental problems before es thetics. I f the maxillary lateral incisors are congenitally missing, the permanent cuspids can be orthodontically moved for ward into the space so that the mesial
M O S M A N N . . .V O L U M E 66, JA N U A R Y 1963 • 85/71
surface of the cuspid contacts the distal surface of the central incisor. Then bridgework is not needed to replace the missing lateral incisor, and the dentist only needs to disk the tip of the cuspid slightly to make it resemble the lateral incisor. This procedure is not as accept able esthetically as if the lateral incisor were in place, but the problems of an terior bridgework are omitted. Usually, the orthodontist removes two mandibular bicuspids to obtain proper occlusion. Congenitally missing bicuspids do not present a problem when orthodontic consultation and future treatment are planned. By maintaining the deciduous molars, or if lost, maintaining the space, the orthodontist can use the space to cor rect the occlusion. After tooth movement, all spaces are closed, and the patient does not need bridgework. Congenitally missing cuspids are rare but impacted cuspids are not. A roent genogram shows which situation is pres ent. Missing cuspids may be corrected orthodontically by substituting the first bicuspid for the cuspid. This procedure is good and esthetically passable. I f second and third permanent molars are missing, which rarely occurs, it some times is advisable to extract the opposing second molars, leaving the patient no masticating surface distal to the first
molars. This can be a better procedure than attempting a restoration for the sec ond molars. Congenitally missing third molars present no problem. Since many third molars are impacted, the dentist should be relieved to see that these teeth are missing. Teeth may be lost as the result of acci dents or pathological problems. In these instances the dentist takes an alginate impression and constructs an acrylic ap pliance to maintain the space, thereby preventing drifting and subsequent mal occlusion. SUM M ARY
Supernumerary teeth should be removed if the removal will not affect the physical well-being of the patient or damage the permanent teeth. Congenitally missing teeth present little problem if orthodon tic services are available. T h e dentist only needs to maintain the spaces. If not too many teeth are missing, an occlusion can be obtained in a satisfactory manner. Roentgenograms are of utmost impor tance, and to practice without them may be considered negligence. W hen super numerary teeth are seen in roentgeno grams, it is best to take roentgenograms of different angles o f the teeth to locate them accurately. 70 Andersen Street
Pattern of Illness • The pattern of illness today has changed from the acute and specifically
caused disease to the more chronic, ill-defined trouble based upon a host of interrelated causes not always purely in the domain of medicine. Increasingly we must bring new batteries to bear on the target. Increasingly this involves the behavioral sciences, political groups, voluntary agencies and the whole society. Frank Stanton, Stanford University M ed ic a l C enter Dedication Cerem ony, Septem ber 18, 1959.
plasias and opacities and dental fluorosis should be understood by the dental pro fession so that a clear clinical differentia tion can be made (Table 3 ) . In any event, an unesthetic develop mental defect which occurs in such a large percentage of individuals should certainly be considered a problem in pub lic health and adequate measurement of such an entity becomes important. A method of both quantitative and quali tative appraisal of its occurrence in groups of the population should become part of the armamentarium of the public health dentist.
Presented at the American Public Health Association, Southern Branch, Louisville, Ky., A p ril 12, 1961. *Director, Dental Health Center, San Francisco, C alif. fRegional dental consultant, Region V, Public Health Service, U.S. Department o f H ealth, Education and W elfare, Chicago, III. ffD ire c to r of the dental health section, Oregon State Board of Health, Portland, Ore. 1. ZImmermann, ' E. R. Fluoride and nonfluoride en amel opacities. Public Health Rep. 69:1115 Nov. 1954. 2. Ast, D. B., and others. Newburgh-Kingston caries fluorine study. XIV. Combined clinical and roentgenographic dental findings after ten years of fluoride ex perience. 3. Hurme, V. O. Developmental opacities o f teeth in a New England community. Am. J. Dis. C hild. 77:61 Jan. 1949. 4. Sarnat, B. G., and Schour, Isaac. Enamel hypo plasia in relation to systemic disease. J.A .D .A . 28:1989 Dec. 1941 and 29:67 Jan. 1942. 5. Forrest, Jean R. Caries incidence and enamel de fects in areas with different levels of fluoride in the drinking water. Brit. D. J. 100:195 A p ril 17, 1956.
Problems of supernumerary and congenitally missing teeth
Walter H . M osm ann, D .D .S., Hackensack, N .].
Supernumerary teeth should be removed
SUPERN U M ERARY T E E TH
if removal will not harm the patient or his permanent teeth. Congenitally missing teeth present few problems if orthodontic service is available. T h e dentist need only maintain the space. I f not too many teeth are missing, a satisfactory occlusion can be obtained.
M any theories are advanced concerning the causes of supernumerary and con genitally missing teeth. Heredity must play a part because the same condition often exists in one parent. Extra or miss ing teeth are frequently associated with congenital deformities, such as a cleft palate.
Supernumerary teeth can occur in any re gion of the bone close to the teeth. They occur most commonly in the maxillary midline region between the central in cisors. They can be conical, flat, shaped like a root or the adjacent teeth. Some times only the crown of the supernumer ary tooth is formed. These teeth can be formed from before birth to 12 years of age. In later life, the extraction of a tooth may allow a blocked permanent tooth to erupt. However, this is not a supernumerary tooth or a third tooth erupting. A supernumerary tooth may grow in many positions, even upside down or horizontal to the other teeth. Roent genograms should always be taken at vari
8 4 /7 0 • T H E J O U R N A L O F THE A M E R IC A N DENTAL A S S O C IA T IO N
ous angles to be sure of the exact position of the tooth. I f surgical removal will have no harm ful effects on the patient or his permanent teeth, a supernumerary tooth should be removed. However, if the patient is young and the permanent teeth are forming, it may be advisable to wait until the child is a better surgical risk. I f the supernu merary tooth lies against a permanent tooth, there may be a risk of damage to the permanent tooth, and it may be advis able to allow the supernumerary tooth to remain in position until the surgical risk is less. For example, if a supernu merary tooth lies close to the crown of a central incisor which has not formed its root, the surgical attempt to remove the extra tooth may damage the permanent tooth. A few months or even a year later, the root of the permanent tooth will not be involved. An oral surgeon or an ortho dontist can help decide on the proper time for the removal of a supernumerary tooth. W hen the extra tooth is the twin o f the adjacent tooth and is in good occlusion, the dentist should consult an orthodontist before removing it. Some times because of the width of the teeth, the orthodontist may advise keeping a supernumerary incisor in place. Roentgenograms should be taken peri odically by the general practitioner. The dentist may not see a supernumerary tooth if he does not carefully view a well angled and properly developed dry nega tive. I f the dentist is in doubt he should seek consultation. H e should always ex plain to the parents what he has found, when he is going to remove the super numerary tooth, and what the reason is for his decision. C O N G E N IT A L L Y M IS S IN G T E E T H
Teeth are congenitally missing more often than supernumerary teeth are present. They present a greater variance in opera tive procedure. The teeth which are most likely to be missing are maxillary lateral
incisors, and maxillary and mandibular second bicuspids. Patients who have miss ing teeth frequently have supernumerary or odd-shaped and odd-sized teeth. The missing teeth often are bilateral. Super numerary teeth usually occur unilaterally. Roentgenograms inform the dentist of such situations at an early date and en able him to plan a procedure for the patient. Congenitally missing teeth seldom oc cur in deciduous dentitions, but if they do, usually nothing is done about them. Where permanent teeth are missing, the roots of the deciduous predecessors may not be resorbed. Care must be taken when these deciduous teeth are removed be cause they frequently are firmly em bedded. The dentist should consult an orthodontist to determine whether to re move or maintain a deciduous tooth which has no successor. Sometimes the congenitally missing central incisor in the mandibular arch is not noted because of the large deciduous central incisors which are in place. T h e dentist should always count teeth and know the anatomy of deciduous and permanent teeth. I f deciduous teeth are lost in the an terior region of the arch, it usually is not necessary to maintain the space. I f the deciduous molars are lost, the space should be maintained so that the perma nent molars will not drift forward. I f a bicuspid is missing and the deciduous tooth is lost, the space must be main tained to enable the orthodontist to de termine whether the posterior teeth should be allowed to drift forward or the space held. T h e space over a congenitally missing tooth often must be maintained to enable the orthodontist to correct a malocclusion. In orthodontic tooth movement it may be advisable to consider comfort and lack of future dental problems before es thetics. I f the maxillary lateral incisors are congenitally missing, the permanent cuspids can be orthodontically moved for ward into the space so that the mesial
M O S M A N N . . .V O L U M E 66, JA N U A R Y 1963 • 85/71
surface of the cuspid contacts the distal surface of the central incisor. Then bridgework is not needed to replace the missing lateral incisor, and the dentist only needs to disk the tip of the cuspid slightly to make it resemble the lateral incisor. This procedure is not as accept able esthetically as if the lateral incisor were in place, but the problems of an terior bridgework are omitted. Usually, the orthodontist removes two mandibular bicuspids to obtain proper occlusion. Congenitally missing bicuspids do not present a problem when orthodontic consultation and future treatment are planned. By maintaining the deciduous molars, or if lost, maintaining the space, the orthodontist can use the space to cor rect the occlusion. After tooth movement, all spaces are closed, and the patient does not need bridgework. Congenitally missing cuspids are rare but impacted cuspids are not. A roent genogram shows which situation is pres ent. Missing cuspids may be corrected orthodontically by substituting the first bicuspid for the cuspid. This procedure is good and esthetically passable. I f second and third permanent molars are missing, which rarely occurs, it some times is advisable to extract the opposing second molars, leaving the patient no masticating surface distal to the first
molars. This can be a better procedure than attempting a restoration for the sec ond molars. Congenitally missing third molars present no problem. Since many third molars are impacted, the dentist should be relieved to see that these teeth are missing. Teeth may be lost as the result of acci dents or pathological problems. In these instances the dentist takes an alginate impression and constructs an acrylic ap pliance to maintain the space, thereby preventing drifting and subsequent mal occlusion. SUM M ARY
Supernumerary teeth should be removed if the removal will not affect the physical well-being of the patient or damage the permanent teeth. Congenitally missing teeth present little problem if orthodon tic services are available. T h e dentist only needs to maintain the spaces. If not too many teeth are missing, an occlusion can be obtained in a satisfactory manner. Roentgenograms are of utmost impor tance, and to practice without them may be considered negligence. W hen super numerary teeth are seen in roentgeno grams, it is best to take roentgenograms of different angles o f the teeth to locate them accurately. 70 Andersen Street
Pattern of Illness • The pattern of illness today has changed from the acute and specifically
caused disease to the more chronic, ill-defined trouble based upon a host of interrelated causes not always purely in the domain of medicine. Increasingly we must bring new batteries to bear on the target. Increasingly this involves the behavioral sciences, political groups, voluntary agencies and the whole society. Frank Stanton, Stanford University M ed ic a l C enter Dedication Cerem ony, Septem ber 18, 1959.