Clinical consequence of mesiodens – A case series

Abstract

Mesiodens is the most common type of supernumerary tooth encountered in general dental practice. The clinical presentation may be varying depending on the position, number and relation to the adjacent tooth. Four cases of mesiodens with different patterns of presentation and clinical outcomes are presented here. Early detection by thorough clinical and radiographic evaluation allows adoption of less-complex and less-extensive treatment.

Full text

Journal of Oral and Maxillofacial Surgery, Medicine, and Pathology 28 (2016) 259–262
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Medicine, and Pathology
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Case Report
Clinical consequence of mesiodens – A case series
Abdulla Mufeeda,∗, Abdul Hafizb, K.R. Ashirc, Anis Ahmedd, V.J. Reshmaa
aDepartment of Oral Medicine & Radiology, MES Dental College, Perinthalmanna, Kerala, India
bDepartment of Pedodontics, MES Dental College, Perinthalmanna, Kerala, India
cDepartment of Oral Medicine & Radiology, KMCT Dental College, Calicut, Kerala, India
dDepartment of Oral Medicine & Radiology, Indira Gandhi College of Dental Sciences, Kothamangalam, Kerala, India
article info
Article history:
Received 27 May 2015
Received in revised form 8 August 2015
Accepted 19 October 2015
Available online 22 December 2015
Keywords:
Mesiodens
Supernumerary tooth
Impaction
abstract
Mesiodens is the most common type of supernumerary tooth encountered in general dental practice.
The clinical presentation may be varying depending on the position, number and relation to the adjacent
tooth. Four cases of mesiodens with different patterns of presentation and clinical outcomes are presented
here. Early detection by thorough clinical and radiographic evaluation allows adoption of less-complex
and less-extensive treatment.
© 2015 Asian AOMS, ASOMP, JSOP, JSOMS, JSOM, and JAMI. Published by Elsevier Ltd. All rights reserved.夽
1. Introduction
The term mesiodens refers to a supernumerary tooth present in
the maxilla between the two central incisors. They are frequently
associated with problems like disturbance in tooth eruption, mid-
line diastema, crowding, resorption of roots of adjacent permanent
tooth, rotations or inclination of permanent tooth, development of
dentigerous cyst and so on. Early diagnosis and treatment prevents
orthodontic and pathologic complications. This article presents
four cases of mesiodens with different clinical scenario.
2. Case reports
2.1. Case 1
An 8-year-old boy presented with a complaint of an unerupted
right maxillary central incisor. He had a normal eruption pat-
tern and all remaining maxillary and mandibular incisors were
erupted. His skeletal and dental developments were age appropri-
ate. The clinical examination revealed sufficient spacing between
the erupted 21 and 12 (Fig. 1A). A small palpable swelling over
夽Asian AOMS: Asian Association of Oral and Maxillofacial Surgeons; ASOMP: Asian
Society of Oral and Maxillofacial Pathology; JSOP: Japanese Society of Oral Pathol-
ogy; JSOMS: Japanese Society of Oral and Maxillofacial Surgeons; JSOM: Japanese
Society of Oral Medicine; JAMI: Japanese Academy of Maxillofacial Implants.
∗Corresponding author. Tel.: +91 9544180048.
E-mail address: abmufid@yahoo.co.in (A. Mufeed).
the region of 11 was evident which was hard in consistency. Intra-
oral periapical radiograph showed evidence of an impacted 11 with
almost 2/3rd of the root formation (Fig. 1B). The crown was over-
lapped by an impacted mesiodens. Based on these findings, the
region was surgically explored and the mesiodens was removed.
Orthodontic extrusion of 11 was subsequently planned.
2.2. Case 2
A 9-year-old boy came to the department with a fractured upper
right central incisor due to fall from bicycle 2 days before. Clini-
cally, a gross fracture of the crown with pulpal exposure was found
in relation to 11 (Fig. 2A). He had the entire complement of tooth
for his age. An intra-oral radiograph was taken to assess the frac-
ture and evaluate the restorability of 11. Surprisingly, radiographs
demonstrated presence of two impacted mesiodens inversely pos-
itioned overlapping the roots of the centrals (Fig. 2B). Considering
the poor prognosis of 11, it was advised to extract 11 along with
the mesiodens.
2.3. Case 3
A 32-year-old female patient reported a complaint about a dis-
colored artificial crown in the upper front tooth that was placed
7 years before. She had no other relevant complaints or findings
except for mild tenderness on 21. The bridge which was span-
ning from 21 to 13, had partly worn out. Radiographic examination
revealed presence of an impacted mesiodens invertedly positioned
apical to 11 and 21. A well-defined radiolucency attached to the
http://dx.doi.org/10.1016/j.ajoms.2015.10.006
2212-5558/© 2015 Asian AOMS, ASOMP, JSOP, JSOMS, JSOM, and JAMI. Published by Elsevier Ltd. All rights reserved.夽

260 A. Mufeed et al. / Journal of Oral and Maxillofacial Surgery, Medicine, and Pathology 28 (2016) 259–262
Fig. 1. (A) Maxillary anterior region showing unerupted 11. (B) Radiograph revealing the presence of a mesiodens obstructing eruption of 11.
crown of the mesiodens that was circular in shape, with a scle-
rotic border was also evident (Fig. 3). These findings concluded the
diagnosis of dentigerous cyst arising from the impacted mesiodens.
The impacted tooth along with the cystic lesion was removed under
local anesthesia. The patient was placed on regular observation and
assessment of pulp vitality of 21.
2.4. Case 4
A 20-year-old boy was referred by his physician for opinion of
his discolored upper front tooth. Mild yellowish discoloration of
left central incisor was noticed with grade 1 mobility. Radiograph
showed presence of two impacted mesiodens each corresponding
to the roots of the permanent tooth (Fig. 4). The root of 21 was
considerably resorbed and root canal was sclerosed. The second
mesiodens located in relation to 11 was not very clearly evident
probably due to overlapping of anatomic structure (anterior nasal
spine). The patient was instructed to extract 21 with the impacted
tooth, but the patient was lost to follow-up.
3. Discussion
The most common type of supernumerary tooth is mesiodens
which may occur as single, multiple, unilateral or bilateral [1]. The
presence of multiple supernumerary teeth is called ‘mesiodentes’.
According to the shape and size, two subclasses are considered in
the classification of mesiodens, namely, eumorphic and dysmor-
phic [2]. The eumorphic subclass is usually similar to a normal-sized
central incisor, whereas the dysmorphic teeth have different shapes
and sizes and are categorized into conical, tuberculate, supplemen-
tal and odontomes.
The clinical complications of mesiodens reported in the studies
include delayed eruption of permanent incisors, midline diastema,
axial rotation or inclination of permanent incisors, resorption of
adjacent tooth, root anomaly, cyst formation, intra-oral infections
and mesiodens pulpitis [3].
The presence of a supernumerary tooth is the most common
cause for failure of eruption of maxillary incisors. It has been stated
that the tuberculate type of mesiodens more likely causes delay in
eruption due to its position, which is mostly located palatal to the
Fig. 2. (A) Fractured right maxillary central incisor. (B) Radiograph demonstrating presence of two impacted and inverted mesiodens.

A. Mufeed et al. / Journal of Oral and Maxillofacial Surgery, Medicine, and Pathology 28 (2016) 259–262 261
Fig. 3. Radiograph showing an impacted, inverted and dilacerated mesodense with
a cystic lesion.
maxillary incisors [4]. Gündüz et al. in a study among patients aged
4–14 years found that the delayed eruption of permanent incisors
was the most common complication encountered [3] and no inci-
dence of cystic lesion was found, whereas studies by Asaumi et al.
[5] reported more than 30% of mesiodens presenting cystic lesions
where the examined group was of higher age. This clearly indi-
cates that dentigerous cyst formation takes place in long-standing
Fig. 4. Radiograph demonstrating impacted mesiodens causing resorption of the
roots of maxillary centrals.
impacted mesiodens. Among the cases presented here, it was the
32-year-old patient who had the cystic lesion.
In contrast to unerupted mesiodens, eruption of mesiodens into
the oral cavity leads to crowding of anterior tooth. Root resorption
and non-vitality of permanent tooth as we documented in case 4
have been reported rarely and no statistical data are available [6].
Ectopic eruption of mesiodens into the nasal cavity and midline of
palate have also been reported earlier in isolated cases.
Conventional radiographs like intra-oral periapical radiographs
(IOPA) and occlusal radiographs are routinely used for evalua-
tion of mesiodens. However, recent studies have reported that
advanced imaging modalities like the Cone beam Computed
Tomography (CBCT) is an excellent diagnostic tool for providing
three-dimensional information and accurate localizing of mesio-
dens [7].
3.1. Management
Management of supernumerary teeth depends on the type and
position of the tooth. Immediate removal of mesiodens is usu-
ally indicated in the following situations: inhibition or delay of
eruption, displacement of the adjacent tooth, interference with
orthodontic appliances, presence of pathologic condition, or spon-
taneous eruption of the supernumerary tooth. The earlier the
mesiodens is removed, the better the prognosis [8]. In order to
promote eruption and proper alignment of adjacent teeth, it is
recommended to extract mesiodens in the early mixed dentition,
which may reduce the need for orthodontic treatment. It might take
6 months to 3 years for an unerupted tooth to erupt after removal
of the mesiodens.
Periodic review and monitoring of mesiodens may be advised
in the following situations: satisfactory eruption of the succee-
ding teeth, absence of any associated pathologic lesions and risk
of damage to the vitality of the related teeth. It has also been rec-
ommended to keep unerupted symptomless mesiodens, which do
not affect the dentition. These teeth, which are usually found by
chance, are better left in place under observation. However, a recent
study of Yagüe-García et al. [9] emphasized that the early removal
of the supernumerary teeth in order to prevent complications is the
treatment of choice.
4. Conclusion
A mesiodens should be suspected when there is asymmetry in
the eruption pattern of the maxillary incisors; the maxillary pri-
mary incisors are overretained, especially if the over-retention is
asymmetric, or if there is significant ectopic eruption of one or both
permanent maxillary incisors. Given that only 25% of supernumer-
ary teeth erupt, it is important to have a high index of suspicion in
these situations. It is important to radiographically evaluate for the
presence of any supernumerary tooth prior to treatment of rotated
incisor or diastema. The clinical presentation and complications
vary considerably depending on the number, size, and position of
mesiodens and dental age of the patient.
Ethical approval
Not applicable.
Conflicts of interest
None declared.

262 A. Mufeed et al. / Journal of Oral and Maxillofacial Surgery, Medicine, and Pathology 28 (2016) 259–262
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