Mesiodens

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					Mesiodens with a labial position in jaw - Case Reports
Gbujie Daniel, Lovda Michael,

ABSTRACT

The purpose of this article is to bring to the notice of dentists the position of
mesiodens(conical shape teeth) in the upper jaw found labially and also the
surgical approach used, which was a labial approach , this surgical approach was
utilized because it allowed for greater conservation of alveolar bone and improved
access during removal of the mesiodens.

Supernumerary teeth is defined as teeth that exceed the normal dental formula,
regardless of their location and morphology . They may be single, multiple,
unilateral or bilateral erupted or unerupted and in one or both jaws.
Mesiodens is the most common type of supernumerary tooth found in the maxilla
between two central incisors.

This case report describes a labially positioned maxillary mesiodens in an 13 -year-
old boy child that was partially erupted in the oral cavity, but in no way cause
causing malocclusion or displacement.

Keywords: Supernumerary tooth, mesiodens,conical shaped tooth,malocclusion



INTRODUCTION

 A Supernumerary teeth is defined as teeth that exceed the normal dental formula,
regardless of their location and morphology (1). aetiology of the development of
supernumerary teeth is not clear, 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 (2) . Heredity may also play a role in the occurrence of this anomaly,
as supernumeraries are more common in the relatives of affected children than in
the general population. However, the anomaly does not follow a simple mendelian
pattern. (20)
Supernumerary teeth are classified according to morphology and location.
In the primary dentition, morphology is usually normal or conical.
There are four morphological different types of supernumerary teeth in perment
dentition they are; conical, tuberculate, supplemental and odontome.(3)
Classification on the basis of position: Mesiodens-present in the incisor region,
Paramolar-present beside a molar and a Distomolar-present distal to the last
molar.(2)

 supernumerary teeth can give rise to a broad range of complications, such as
delayed eruption of permanent teeth, diastemas, the rotation of adjacent teeth,
periodontitis and cyst lesions or the reabsorption of teeth(4,5,19).
supernumerary teeth are usually detected as a chance finding during clinical
examination or radiographic examination.

The prevalence of hyperdontia in various populations is reportedly between 0.1-
3.8% With a male to female ratio of 2:1.(6,7) They occur more commonly in
permanent dentition (prevalence of 0.10-3.6%) (7), when compared to the primary
dentition (prevalence of 0.02-1.9%),(3).The hyperodontia may be single, multiple,
unilateral or bilateral, erupted or unerupted and in one or both dental arch.

Multiple supernumerary teeth are rare in individuals with no other associated
diseases or syndromes.(8) Multiple hyperdontia are usually associated with
conditions such as cleft lip and palate or syndromes like Cleidocranial Dysplasia
,Gardner syndrome, Fabry-Anderson syndrome, Ehler-Danlos syndrome and facial
fissures (9). Cases involving mesiodens are most commonly occur in the anterior
maxilla, followed by mandibular premolar region.(1,5)
When multiple supernumerary teeth are present the most common site is
mandibular premolars.(9)

Presented here is a case of a labially positioned maxillary mesiodens in an 13 -
year-old male child that was partially erupted in the oral cavity but in no way
caused malocclusion or displacement .



CASE REPORT

A 13 -year-old boy, presented with hyperdontia in the labial premaxilla region
during a free dental / medical treatment programme, organized by Hands and
Hearts international, {a Non-governmental organization (NGO) based in united
states of america} in Ohaji-egbema Local government area of Imo state Nigeria.

A complaint of irregular front tooth was his presenting complaint.
oral examination revealed a conical-shaped mesiodens labially position in the
premaxillary region with (Fig. 1). With all the other teeth in the upper and lower
jaw in normal alignment and occlusion.


ORAL EXAMINATION

The intraoral soft tissues were healthy ,Oral hygiene of the patient was poor with
chronic generalized gingivitis. He presented in the mixed dentition stage with a
class 1 molar relationship. There was no anterior spacing between the central
incisors and lateral incisors. The four anterior teeth were fully erupted (Fig 1).
 Carious lesions was not seen and no restorations was required.

The maxillary central incisors on the left had a chipped off incisal edge , no
mobility, and was not tender to percussion. A partially erupting Labial mesiodens
was observed on the anterior maxillary area.
Radiographic investigations were not carried out to evaluate the status of all the
teeth,because it was a poor rural community with no dental equipment, and no
equipments for radiographs but a proper clinical examination ,a medical and family
history was documented.

The approach adopted for the management of the case was extraction of conical-
shaped mesiodens,which was planned for to prevent the displacement of the
permanent central incisors. The mesiodens was asymptomatic, and partially
erupted in the labial mucosa of the maxilla. We decided to keep the patient on
regular monthly follow up.


TREATMENT

The extraction was performed in our make shift dental chair. Initially the patient
was mildly apprehensive, but after been told what the outcome of the surgery
would look like he became relaxed and very cooperative.
Local anesthetic, 1.8ml of 2% lidocaine with 1/ 100,000 epinephrine, was
administered slowly via labial and palatal infiltration .
After anesthesia was achieved , with a size #15 blade, an incision was made on the
labial mucosa from the distal aspect of the maxillary right central incisor to the
mucoginigival sulcus,then another incision was made on distal aspect of the
maxillary left lateral incisor to the mucogingival sulcus.

Then,a full flap was reflected with a periosteal elevator,with the aid of a bone file
excess bone deposition on buccal plate of the upper jaw was removed allowing the
tooth to be slightly mobile and properly visible .
 Care was taken to avoid excessive bone removal or damage to roots of the
adjacent permanent teeth, with the aid of an elevator the tooth was luxated and
eventually removed. The mesiodens measured 10 mm in length.
The extraction site was gently curetted, and irrigated with saline, the wound closed
with 8 interrupted 4-0 silk sutures, patient tolerated the procedure comfortably.

Postoperative pain was controlled with ibuprofen. Swelling was prevented via use
of medication such as chymoral and immediate application of an ice pack .

The patient's recovery was uneventful with no unusual signs or symptoms reported.
The sutures were removed 5 days after, with satisfactory healing at the extraction
site. Six month follow-up continued with no impediment to the four permanent
incisors in anterior maxilla.




DISCUSSION

 A Supernumerary teeth is defined as teeth that exceed the normal dental formula,
regardless of their location and morphology (1). aetiology of the development of
supernumerary teeth is not clear, 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 (2) . Heredity may also play a role in the occurrence of this anomaly, as
supernumeraries are more common in the relatives of affected children than in the
general population. However, the anomaly does not follow a simple mendelian
pattern. (20)
It has been stated that only 25% of maxillary anterior supernumeraries erupt (Tay
et al. 1984). Nazif et al. (1983) reported that only 6% of the impacted mesiodens
are found to be in a labial position.
The vast majority (80%) are reported to be positioned palatally with the remaining
14% located between the roots of the permanent central incisors (Nazif et al.
1983).

The small percentage that are labially positioned are due, in large part, to growth
changes of the premaxilla that influence the position of the mesiodens.
Enlow (1982) described apposition-resorption patterns of the nasal floor, palate,
premaxilla, and alveolus which help explain the mesiodens relative labiolingual
positional change over time. His growth theories are confirmed by a study that
found that mesiodens become more labial and nearer the nasal floor with
developement (Stermer Beyer-Olsen et al. 1985).

This is particularly true for inverted supernumerary teeth. From this, a labial
surgical approach would seem to have practical applications and should be
considered when removing midline supernumeraries in young children.
The conventional radiography was not use. Thus, it was felt that clinical
observation was the only way to resolve this pre-operative diagnostic discrepancy.

Authors till today remains divided as to the optimal time for the surgical removal
of an unerupted mesiodens (Tay et al. 1984; Kaler 1988). Many advocate early
intervention, preschool-age removal of a mesiodens in order to prevent future
orthodontic problems and the need for more difficult surgical procedures
(Primosch 1981; Nazif et al. 1983; Rotberg and Kopel 1984).

It is reported that early surgical removal of mesiodens can be performed without
the loss of vitality of the permanent incisors and without causing any negative
psychological effect on the young child (Rotberg and Kopel 1984; Hogstrom and
Andersson 1987). Whereas, others felt it was best to monitor the development of
supernumeraries tooth until 8-10 years of age (Stermer Beyer-Olsen et al. 1985;
McDonald and Avery 1987). The basis for this to allow for complete root
development of the permanent incisors in order to decrease the chance of root
damage, as well as to reduce the chance of devitalization.

In this case report one would not expect significant improvement in the mesiodens
position and its surgical removal was indicated.
CONCLUSION

Surgery involving a labial flap is was used to extract the partially erupting
mesiodens . In this case, a labial surgical approach was utilized which allowed
increased visualization of the mesiodens and greater ease upon removal.



Figure 1: The initial appearance of the mesiodens with the picture upside down




Figure 2: The appearance in a blurred picture
THE AUTHORS

Gbujie Daniel
A registrar, Department of Oral and maxillofacial surgery, University of portharcourt teaching
hospital, choba, Rivers state ,Nigeria

Lovda Michael,
A dentist, Michael A Lovda DDS Ltd, General practitioner in private practice,1644 W
Algonquin Rd, Hoffman Estates, a past president of the Schaumburg Dental Study

Reprint requests should be sent to:
Dr. Gbujie Daniel,University of portharcourt teaching hospital, Faculty of
Dentistry, Dept. of Oral and maxillofacial surgery,gbujie2dan@yahoo.com



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DOCUMENT INFO
Description: mesioden with a given population in west africa , Nigeria