See

discussions, stats, and author profiles for this publication at: https://www.researchgate.net/publication/283079320

Multiple Impacted Permanent and

Supernumerary Teeth in the Anterior Mandible
of Nonsyndromic Case: A...

Article October 2015

DOI: 10.4103/2277-4696.167571

CITATIONS READS

0 41

5 authors, including:

Pushkar Gawande Amit Dhansukhlal Hindocha

Sinhgad Technical Education Society Sinhgad Technical Education Society
6 PUBLICATIONS 13 CITATIONS 5 PUBLICATIONS 10 CITATIONS

SEE PROFILE SEE PROFILE

Rajshekhar Halli
Bharati Vidyapeeth Deemed University
37 PUBLICATIONS 159 CITATIONS

SEE PROFILE

All content following this page was uploaded by Amit Dhansukhlal Hindocha on 22 October 2015.

The user has requested enhancement of the downloaded file. All in-text references underlined in blue are added to the original document
and are linked to publications on ResearchGate, letting you access and read them immediately.
[Downloaded free from http://www.jdas.in on Thursday, October 22, 2015, IP: 117.215.20.147]

Case Report

Multiple Impacted Permanent and Supernumerary Teeth in the

Anterior Mandible of Nonsyndromic Case: A Systematic Review
and Multidisciplinary Approach to Management
Pushkar Gawande, Manjula Hebbale1, Tushar Patil2, Amit Hindocha3, Rajshekhar Halli4
Departments of Oral and Maxillofacial Surgery and 3Prosthodontics and Implantology, Sinhgad Dental College and Hospital, Departments of 1Oral Medicine and
Radiology and 4Oral and Maxillofacial Surgery, Bharati Vidyapeeth University Dental College and Hospital, 2Department of Orthodontics and Dentofacial Orthopedics,
M.A. Rangoonwala Dental College and Hospital, Pune, Maharashtra, India

Abstract
Multiple impacted permanent and supernumerary teeth have been associated with the syndromes and metabolic disorders. Approximately, 75%
of all the supernumerary teeth are impacted and are asymptomatic. Consequently, most such teeth constitute casual findings in the context of
routine X-ray studies. Lack of eruptive force and rotation of tooth buds may cause multiple impactions, and additional examinations may be
necessary to exclude systemic and metabolic conditions. We present a rare nonsyndromic case with 11 multiple impacted teeth in the anterior
mandible, with systematic literature review and multidisciplinary management.

Key words: Impacted teeth, multiple teeth, nonsyndromic case, supernumerary teeth

Introduction when 2000 school children were surveyed.[7] While there

Hyperdontia is an odontostomatologic anomaly characterized
by an excess in tooth number, both erupted and nonerupted.
It can be described as real if determined by an increased
number of teeth, otherwise it is false if caused by a delay
in shedding of deciduous teeth beyond the transition period.[1]
Multiple impacted teeth may be related to syndromes and metabolic
disorders. In some cases, however, impaction of multiple teeth is
not accompanied by a fixed complex of symptoms.[2]
Supernumerary teeth were first reported between AD 23
and 79.[3] The etiology of supernumerary teeth still remains
unclear. One theory suggests that these teeth are formed because
of local, independent, and conditioned hyperactivity of the dental
lamina.[4,5] Another theory states that the supernumerary tooth
is formed because of dichotomy of tooth bud.[4] Hereditary and
environmental factors are also considered important etiological
factors in the occurrence of supernumerary teeth. Autosomal
dominant trait has been suggested by Sedano and Gorlin.[6]
Brook found that supernumerary teeth were present in 0.8%
of primary dentitions and 2.1% of permanent dentitions
Access this article online
Quick Response Code:
Website:
www.jdas.in
DOI:
10.4103/2277-4696.167571
is no significant sex distribution in primary supernumerary
teeth, males are affected approximately twice as frequently
as females in the permanent dentition.[8]
Multiple supernumerary teeth are reported to be associated
with few syndromes such as cleidocranial dysostosis, cleft
lip and palate, Gardners syndrome, and chondroectodermal
dysplasia. Multiple supernumerary teeth not being associated
with any syndrome are very rare.[9]
The etiology is unknown, although a number of theories have
been proposed: Atavism, tooth germ dichotomy, hyperactivity
of the dental lamina, and genetic factors comprising a dominant
autosomal trait characterized by low penetrance.[10] Such teeth
Address for correspondence: Dr. Rajshekhar Halli,
Department of Oral and Maxillofacial Surgery, Bharati Vidyapeeth University
Dental College and Hospital, Pune - 411 040, Maharashtra, India.
E-mail: drrajshekharh@gmail.com
This is an open access article distributed under the terms of the Creative
Commons Attribution-NonCommercial-ShareAlike 3.0 License, which
allows others to remix, tweak, and build upon the work non-commercially,
as long as the author is credited and the new creations are licensed under
the identical terms.
For reprints contact: reprints@medknow.com
How to cite this article: Gawande P, Hebbale M, Patil T, Hindocha A,
Halli R. Multiple Impacted Permanent and Supernumerary Teeth in the
Anterior Mandible of Nonsyndromic Case: A Systematic Review and
Multidisciplinary Approach to Management. J Dent Allied Sci 2015;
4:47-51.

2015 Journal of Dental and Allied Sciences | Published by Wolters Kluwer - Medknow 47
[Downloaded free from http://www.jdas.in on Thursday, October 22, 2015, IP: 117.215.20.147]
Gawande, et al.: Multiple impacted teeth in nonsyndromic case
can erupt normally, remain impacted, invert, reach heterotopic
positions, or show abnormal eruptive patterns.[11] Likewise,
the development of supernumerary teeth can give rise to a
broad range of complications, such as delayed eruption of
permanent teeth, diastemas, the rotation of adjacent teeth, and
cystic lesions or the resorption of contiguous teeth. Therefore,
an early diagnosis and adequate treatment are essential.[12-15]
Although multiple supernumerary teeth appear to develop
more often in patients with some relative with at least one
supernumerary tooth, the hereditary trait does not exhibit
a simple Mendelian pattern.[16,17] A review of the literature
yielded 7 families in which at least two individuals presented
multiple supernumerary teeth with no associated complex
syndrome.[12,17-22]
Although few such cases have been published, it is important
to stress that an exhaustive and detailed family history
must be compiled when dealing with patients with multiple
hyperdontia, since the dominant autosomal hereditary trait
involved implies that all generations are affected. However,
although the literature points to a familial predisposition
to hyperdontia, in our case, there were no supernumerary
teeth in any of the direct relatives of the patients. This was
probably due to the low penetrance of dominant autosomal
transmission, which implies that some generations are not
affected by the disorder. On examining the few published
cases of multiple hyperdontia not associated to complex
syndromes, a predilection for the mandible and premolar
series is observed.[10]
We present systematically reviewed literature with search word
as multiple impacted teeth in the PubMed and related search
sites along with our case report managed with multidisciplinary
approach.
Case Report
A 25-year-old male reported to us for correction of his
malaligned teeth. The family and medical histories were
noncontributory. The general and extra oral examinations were
noncontributory to arrive at the diagnosis of any associated
syndromes.
Intra-oral examination revealed multiple over-retained
deciduous teeth. Hence, an orthopantomogram was advised and
it revealed multiple impacted permanent and supernumerary
teeth in mandible and maxilla [Figure 1a]. There were eleven
impacted teeth in the anterior mandible between 35 and 45
region and four teeth in the maxilla. Few impacted teeth were
inverted in position.
The patient was informed about the presence of additional
number of teeth and was advised surgical removal of the same
under general anesthesia before commencing orthodontic
treatment. Hence, surgical removal of the impacted mandibular
teeth and surgical exposure of the impacted maxillary teeth
were planned.
48
Patient under general anesthesia through naso-endo-tracheal
intubation, crevicular incision was placed from 35 to 45
along with two releasing oblique incisions. A trapezoidal
mucoperiosteal flap was reflected up till the lower border of
the mandible to expose all the impacted teeth [Figure1b].
Under copious saline irrigation, overlying bone was removed
with the help of micromotor and bur. Few teeth were
sectioned to prevent damage to the adjacent permanent teeth.
All the impacted teeth were removed [Figure 1c], and flap
was sutured to its normal position with the help of sutures.
The remaining anterior teeth were stabilized with stainless
steel wire reinforced composite splint [Figure2aand b].
Postoperative course was uneventful with no signs of
paresthesia.
Three months later, the patient was subjected to orthodontic
treatment for correction of malaligned teeth followed by
endodontic/prosthodontic rehabilitation of the anterior
mandibular teeth. Now, the patient is on regular follow-up
since 1 year [Figure 2c and d]. Complete dental rehabilitation
was done after the orthodontic phase [Figure 3].
Discussion
When there is a clinical absence of a number of teeth, and
the history indicates that they have not been extracted,
partial anodontia and tooth impaction can be considered.[23,24]
Radiographic examination, however, may reveal multiple
impacted teeth, and partial anodontia can be rejected.[25-27]
Panoramic radiographs may show multiple impacted teeth or
in some instances radiopacities scattered throughout the jaws.
A detailed description of the positional relationship between
each impacted tooth and the neighboring tooth may also be
given using three-dimensional computed tomographic images,
if surgical or orthodontic treatment is planned.[28]
Multiple impacted teeth may be related to syndromes and
metabolic disorders. Multiple impacted teeth were reported as
a feature of cleidocranial dysostosis, Gardner syndrome, and
Yunis-Varon syndrome.[27,29,30] This condition has also been
reported in mucopolysaccharidoses.[31,32] After encountering
multiple impacted teeth other than third molars or canines, the
clinician should then be prompted to look for other features of
the syndromes and metabolic disorders that may be present.[25]
In some cases, lack of space or crowding of dental arches, the
premature loss of the primary teeth with subsequent partial
closure of the area, and rotation of tooth buds are some of the
most common causes contributing to impaction.[33]
The supernumerary teeth are more likely to be present in
patients whose relatives possessed supernumeraries, although
the inheritance of these teeth does not follow a simple
Mendelian pattern.[34] It also seems that Asian populations are
more affected with supernumeraries than others.[35-37]
Different studies have reported a prevalence of supernumerary
teeth in the permanent dentition of between 0.15% and 3.8%.
Journal of Dental and Allied Sciences Jan-Jun 2015 Volume 4 Issue 1
[Downloaded free from http://www.jdas.in on Thursday, October 22, 2015, IP: 117.215.20.147]
Gawande, et al.: Multiple impacted teeth in nonsyndromic case
Figure 1: (a) preoperative orthopantomogram, (b) intra-operative intra-
oral picture, (c) specimen
Figure 2: (a) Immediate postoperative intra-oral picture with splint in place,
(b) orthopantomogram-immediate postoperative, (c) intra-oral 1-year
postoperative, (d) orthopantomogram 1-year postoperative
Figure 3: (a) Or thopantomogram during or thodontic phase, (b)
orthopantomogram after completion of orthodontic phase, (c) intra-oral
picture after complete dental rehabilitation
Journal of Dental and Allied Sciences Jan-Jun 2015 Volume 4 Issue 1
Supernumerary teeth are single teeth in 76-86% of
[15,16]
cases, while two supernumerary teeth are found in 12-23% of
cases, and three or more such teeth in the same individual are
only found in 2-8% of cases. However, according to Rajab
and Hamdan,[13] this percentage is <1% when hyperdontia
comprises 5 or more supernumerary disease, while Aikgz
et al. report a 0.06% prevalence of multiple supernumerary
teeth.[15] In our case, 11 teeth were impacted in the anterior
mandible and 4 teeth in the anterior maxilla.
A review of the literature yielded several studies in which large
series of supernumerary teeth were analyzed.[13,15] In the case
of simple hyperdontia, the supernumerary teeth were most
often located in the maxilla the mesiodens being the most
common supernumerary tooth, followed by supernumerary
premolars and supernumerary fourth molars.[13-16] In contrast,
on examining the few published cases of multiple hyperdontia
not associated to complex syndromes, a predilection for the
mandible and premolar series was observed.[23]
Supernumerary teeth may erupt or remain impacted within the
maxilla. Approximately, 75% of all the supernumerary teeth are
impacted and are asymptomatic. Consequently, most such teeth
constitute casual findings in the context of routine X-ray studies.[13,15]
It has been reported that supernumerary teeth may be
associated to other dental anomalies such as hypodontia,
taurodontism, germination, or macrodontia.[38,39] However,
no such anomalies were observed in our case, in coincidence
with the findings of Baccetti,[40] who recorded no relationship
between supernumerary teeth and other dental anomalies.
In contrast to the general opinion that cysts are only rarely
formed from a supernumerary tooth, Hopcraft[41] found such
lesions in 9% of all cases. In our case, however, there were no
cysts or enlarged dental follicles.
The literature describes different management options for
patients with multiple hyperdontia not associated to complex
syndromes. Treatment is partly dependent upon the position
and clinical manifestations of the supernumerary tooth.
Thus, an early diagnosis is very important to decide among
extraction, extraction followed by orthodontic treatment, or
simply monitoring or control of the supernumerary teeth, with
a view to minimizing the risk of complications secondary to
the presence of these teeth.[10]
Surgical management in turn ranges from removal of the
supernumerary teeth to removal of the latter followed by
orthodontic treatment aiming to ensure correct occlusion. In
the more complex cases, the possible existence of multiple
impactions of supernumerary teeth gives rise to destructuring
of the dental arch, with numerous malpositioned teeth. These
situations require close cooperation among professionals to
define combined surgical-orthodontic management. In such
cases, the orthodontist defines the general management lines,
specifying which teeth must be removed or preserved in order
to optimize occlusion through orthodontic treatment.[21,42,43]
49
[Downloaded free from http://www.jdas.in on Thursday, October 22, 2015, IP: 117.215.20.147]
Gawande, et al.: Multiple impacted teeth in nonsyndromic case
Since there is always a risk of damaging some adjacent
anatomical structure during extraction, the risk-benefit ratio of
tooth removal must be evaluated in all cases.[41,43] As has been
described by most authors, the current tendency is not to extract
asymptomatic supernumerary teeth, with a view to avoid
possible postoperative complications. In this sense, Hopcraft[41]
suggested that particularly in the case of supernumerary lower
premolars, the latter must be monitored since extraction
entails a high risk of loss of vitality or root damage of the
adjacent teeth.
In our case, as determined by the location and position of
the impacted teeth, none of them were in favorable position
for surgically assisted orthodontic alignment. Hence, all the
impacted teeth were surgically removed.
Multiple hyperdontia is rarely not associated to complex
syndromes. The condition is infrequent and is normally
asymptomatic. The diagnosis is usually established as a result
of a casual finding when performing routine panoramic X-ray
studies. Prophylactic surgical removal of the supernumerary
teeth, coupled with orthodontic treatment of favorably
placed teeth,[44,45] with resolution of their complications, is
generally the treatment of choice with an aim of complete
oral rehabilitation. Emphasis should be placed on the need to
perform periodic radiographic follow-up, due to the possible
late appearance of new supernumerary teeth.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
References
1. Inchingolo F, Tatullo M, Abenavoli FM, Marrelli M, InchingoloAD,
Gentile M, et al. Non-syndromic multiple supernumerary teeth in
a family unit with a normal karyotype: Case report. Int J Med Sci
2010;7:378-84.
2. Nayak UA, Mathian VM, Veerakumar. Non-syndrome associated
multiple supernumerary teeth: A report of two cases. J Indian Soc Pedod
Prev Dent 2006;24 Suppl 1:S11-4.
3. Weinberger BW. An Introduction to the History of Dentistry. St. Louis,
MO: CV Mosby Co.; 1948.
4. Liu JF. Characteristics of premaxillary supernumerary teeth: A survey of
112 cases. ASDC J Dent Child 1995;62:262-5.
5. Levine N. The clinical management of supernumerary teeth. J Can Dent
Assoc 1961;28:297-303.
6. Sedano HO, Gorlin RJ. Familial occurrence of mesiodens. Oral Surg
Oral Med Oral Pathol 1969;27:360-1.
7. Brook AH. Dental anomalies of number, form and size: Their prevalence
in British school children. J Int Assoc Dent Child 1974;5:37-53.
8. Kinirons MJ. Unerupted premaxillary supernumerary teeth. A study of
their occurrence in males and females. Br Dent J 1982;153:110.
9. Scheiner MA, Sampson WJ. Supernumerary teeth: A review of the
literature and four case reports. Aust Dent J 1997;42:160-5.
10. Yage-Garca J, Berini-Ayts L, Gay-Escoda C. Multiple supernumerary
teeth not associated with complex syndromes: A retrospective study.
Med Oral Patol Oral Cir Bucal 2009;14:E331-6.
11. Ramsaran AS, Barclay S, Scipio E, Ogunsalu C. Non-syndromal
multiple buried supernumerary teeth: Report of two cases from the
English-speaking Caribbean and a review of the literature. West Indian
Med J 2005;54:334-6.
50 Journal of Dental and Allied Sciences Jan-Jun 2015 Volume 4 Issue 1
12. Desai RS, Shah NP. Multiple supernumerary teeth in two brothers: A
case report. J Oral Pathol Med 1998;27:411-3.
13. Rajab LD, Hamdan MA. Supernumerary teeth: Review of the literature
and a survey of 152 cases. Int J Paediatr Dent 2002;12:244-54.
14. Mason C, Rule DC, Hopper C. Multiple supernumeraries: The
importance of clinical and radiographic follow-up. Dentomaxillofac
Radiol 1996;25:109-13.
15. Aikgz A, Aikgz G, Tunga U, Otan F. Characteristics and prevalence
of non-syndrome multiple supernumerary teeth: A retrospective study.
Dentomaxillofac Radiol 2006;35:185-90.
16. Salcido-Garca JF, Ledesma-Montes C, Hernndez-Flores F, Prez
D, Garcs-Ortz M. Frequency of supernumerary teeth in Mexican
population. Med Oral Patol Oral Cir Bucal 2004;9:407-9.
17. Batra P, Duggal R, Parkash H. Non-syndromic multiple supernumerary
teeth transmitted as an autosomal dominant trait. J Oral Pathol Med
2005;34:621-5.
18. Umweni AA, Osunbor GE. Non-syndrome multiple supernumerary
teeth in Nigerians. Odontostomatol Trop 2002;25:43-8.
19. Marya CM, Kumar BR. Familial occurrence of mesiodens with unusual
findings: Case reports. Quintessence Int 1998;29:49-51.
20. Mercuri LG, ONeill R. Multiple impacted and supernumerary teeth in
sisters. Oral Surg Oral Med Oral Pathol 1980;50:293.
21. Becker A, Bimstein E, Shteyer A. Interdisciplinary treatment of
multiple unerupted supernumerary teeth. Report of a case. Am J Orthod
1982;81:417-22.
22. Wang XX, Zhang J, Wei FC. Autosomal dominant inherence of multiple
supernumerary teeth. Int J Oral Maxillofac Surg 2007;36:756-8.
23. Yusof WZ. Non-syndrome multiple supernumerary teeth: Literature
review. J Can Dent Assoc 1990;56:147-9.
24. Yildirim D, Yilmaz HH, Aydin U. Multiple impacted permanent and
deciduous teeth. Dentomaxillofac Radiol 2004;33:133-5.
25. Wood NK, Goaz PW. Differential Diagnosis of Oral and Maxillofacial
Lesions. St. Louis, MO: Mosby; 1997,
26. Yalcin S, Gurbuzer B. Multiple impacted teeth in the maxilla. Oral Surg
Oral Med Oral Pathol 1993;76:130.
27. Kirson LE, Scheiber RE, Tomaro AJ. Multiple impacted teeth in
cleidocranial dysostosis. Oral Surg Oral Med Oral Pathol 1982;54:604.
28. Kitai N, Fujii Y, Murakami S, Takada K. Three-dimensional evaluation
of a rare case with multiple impacted teeth using CT. J Clin Pediatr Dent
2003;27:117-21.
29. Lapeer GL, Fransman SL. Hypodontia, impacted permanent teeth,
spinal defects, and cardiomegaly in a previously diagnosed case
of the Yunis-Varon syndrome. Oral Surg Oral Med Oral Pathol
1992;73:456-60.
30. Bradley JF, Orlowski WA. Multiple osteomas, impacted teeth and
odontomas A case report of Gardners syndrome. J N J Dent Assoc
1977;48:32-3.
31. Nakamura T, Miwa K, Kanda S, Nonaka K, Anan H, Higash S, et al.
Rosette formation of impacted molar teeth in mucopolysaccharidoses
and related disorders. Dentomaxillofac Radiol 1992;21:45-9.
32. Schmidt H, Ullrich K, von Lengerke HJ, Kleine M, Brmswig J.
Radiological findings in patients with mucopolysaccharidosis I H/S
(Hurler-Scheie syndrome). Pediatr Radiol 1987;17:409-14.
33. Babu V, Nagesh KS, Diwakar NR. A rare case of hereditary multiple
impacted normal and supernumerary teeth. J Clin Pediatr Dent
1998;23:59-61.
34. Orhan AI, Ozer L, Orhan K. Familial occurrence of nonsyndromal
multiple supernumerary teeth. A rare condition. Angle Orthod
2006;76:891-7.
35. Zhu JF, Marcushamer M, King DL, Henry RJ. Supernumerary and
congenitally absent teeth: A literature review. J Clin Pediatr Dent
1996;20:87-95.
36. So LL. Unusual supernumerary teeth. Angle Orthod 1990;60:289-92.
37. Moore SR, Wilson DF, Kibble J. Sequential development of multiple
supernumerary teeth in the mandibular premolar region A
radiographic case report. Int J Paediatr Dent 2002;12:143-5.
38. Sharma A. A rare non-syndrome case of concomitant multiple
supernumerary teeth and partial anodontia. J Clin Pediatr Dent
2001;25:167-9.
39. Manrique Mor MC, Bolaos Carmona MV, Briones Lujn MT.
[Downloaded free from http://www.jdas.in on Thursday, October 22, 2015, IP: 117.215.20.147]

Gawande, et al.: Multiple impacted teeth in nonsyndromic case

Molarization and development of multiple supernumerary teeth in the
premolar region. J Dent Child (Chic) 2004;71:171-4.
40. Baccetti T. A controlled study of associated dental anomalies. Angle
Orthod 1998;68:267-74.
41. Hopcraft M. Multiple supernumerary teeth. Case report. Aust Dent J
1998;43:17-9.
42. Arathi R, Ashwini R. Supernumerary teeth: A case report. J Indian Soc
Pedod Prev Dent 2005;23:103-5.
43. Cochrane SM, Clark JR, Hunt NP. Late developing supernumerary teeth
in the mandible. Br J Orthod 1997;24:293-6.
44. Yeluri R, Hegde M, Baliga S, Munshi AK. Multiple supernumerary
teeth associated with an impacted maxillary central incisor:
Surgicaland orthodontic management. Contemp Clin Dent
2012;3:219-22.
45. Agrawal JM, Agrawal MS, Nanjannawar LG, Adaki RV. Non-syndromic
multiple supernumerary teeth: A rare entity. BMJ Case Rep 2013;2013.
pii: bcr2012007796.

Author Institution Mapping (AIM)

Please note that not all the institutions may get mapped due to non-availability of the requisite information in the Google Map. For AIM of other
issues, please check the Archives/Back Issues page on the journals website.

Journal of Dental and Allied Sciences Jan-Jun 2015 Volume 4 Issue 1 51

View publication stats