International Medical Journal Vol. 27, No. 3, pp. 369 - 371 , June 2020

CASE REPORT

Twin Mesiodens with Buccally Displaced Maxillary Canine

Md. Kamal Abdullah1), Mohammad Khursheed Alam2), Ranjit Ghosh3), Mostafa Md. Anisuzzaman4)

ABSTRACTBackground: Mesiodens is the most common supernumerary in the midline, located in the premaxilla between the two cen-

tral incisors. Mesiodentes is a rare condition when mesiodens erupt in multiples. Diagnosis is usually done by clinical and radio-logical examination.

Case presentation: Here, we report a case of a boy of 13 years old, with Class I malocclusion and anterior crowding with twin mesiodens. The patient had also buccally displaced maxillary canine.

Conclusion: The patient was treated by extraction of mesiodentes (supernumerary teeth) and fixed orthodontic treatment with standard edgewise orthodontic therapy.

KEY WORDSmesiodens, mesiodentes, supernumerary teeth, developmental anomaly, maxilla, crowding

Received on June 13, 2019 and accepted on September 19, 20191) Department of Orthodontics, Islami Bank Medical College Rajshahi, Bangladesh2) Orthodontic Department, College of Dentistry, Jouf University Sakaka, Al-Jouf, Saudi Arabia3) Department of Orthodontics, Bangabandhu Sheikh Mujib Medical University Dhaka, Bangladesh4) Department of Oral and Maxillofacial Surgery, Bangladesh Dental College Dhanmondi, Dhaka, BangladeshCorrespondence to: Md. Kamal Abdullah(e-mail: shanto.dental@gmail.com)

369

INTRODUCTION

Supernumerary teeth or hyperdontia is defined as excess number of teeth as compared to the normal dental formula1). Primosch2) classified supernumerary teeth into two types according to the shape: supplemen-tal (eumorphic) and rudimentary (dysmorphic, including conical, tuber-culate and molariform type). The most common supernumerary tooth as indicated by Alberti is mesiodens. According to Mosby's Medical Dictionary, "Mesiodens is defined as a supernumerary erupted or a unerupted tooth that develops between two maxillary central incisors"3). They are usually small, with a cone shaped crown and a short root, occurring singly or paired, erupted or impacted and occasionally even inverted.

Mesiodens may occur as single, multiple, unilateral, or bilateral. Multiple mesiodens are called mesiodentes4,5). Single supernumerary teeth account for 76-86%, in pair accounts for 12 3% and less than 1% cases with three or more extra teeth6).

Etiopathogenesis of supernumerary teeth remains obscure. Many theories have been put forward which include the phylogenetic process of atavism (evolutionary throwback), the anomalous splitting of the tooth bud (dichotomy), localized hyperactivity of dental lamina, heredi-ty and some environmental factors. Among these, hyperactivity of den-tal lamina is mostly accepted7).

About 25% of mesiodens that erupt into the oral cavity, can be easi-ly diagnosed clinically, and the unerupted ones are best diagnosed by clinical and radiological evaluation8).

The presence of mesiodens may lead to various complications such as delayed eruption, malposition and impaction of permanent incisors; crowding, spacing, median diastema, rotation and root resorption of the adjacent teeth or even eruption of incisor in the nasal cavity and cyst

formation9-12).Management is done either by extraction or by retention and obser-

vation of the mesiodens, although early extraction is desirable to pre-vent future complications13).

Here, we report a case of double mesiodentes in a non-syndromic patient, which are in line with the maxillary central incisors and causing malocclusion, and unaesthetic appearance.

CASE PRESENTATION

A 13-year-old boy reported to department of orthodontics, Bangabandhu Sheikh Mujib Medical University with the chief com-plaint of irregularly arranged teeth in the upper front teeth region of the jaw, causing unaesthetic appearance. There was no relevant medical and family history, and the patient was otherwise healthy with no associated syndrome.

On clinical examination patient had an oval face form and convex profile with competent lips (Figure 1). Intra oral examination revealed normal complete permanent dentition and in addition, there were two conical mesiodentes present in line with and in between central incisors resulting in severe crowding and buccally placed both upper canine (Figure 1). No interference with the occlusion was noted, and the soft-tissue appeared normal. To investigate further, routine radiographic (Figure 1) (orthopantomograph and lateral cephalogram) examinations were carried out to evaluate the status of the mesiodens, as well as the other teeth and to exclude the presence of any other impacted supernu-merary teeth. X-ray studies revealed presence of two supernumerary teeth in the upper arch, located at the midline with completely formed roots between the central incisors and also highly placed maxillary canines (both right and left).

C 2020 Japan Health Sciences University & Japan International Cultural Exchange Foundation

Abdullah M. K. et al.370

After a detailed examination the decision was made to extract the two mesiodens (Figure 2) under local anesthesia followed by fixed orthodontic treatment (Figure 2) to establish & maintain occlusal har-mony and interdigitation (Figure 3) for improved aesthetics and proper function (Figure 2).

DISCUSSION

Both genetic and environmental factors play a role in the etiology of supernumerary teeth14). The theories put forward are as follows:

● Atavism theory, which suggests that supernumerary teeth are a result of phylogenetic reversion to extinct primates with three pairs of incisors2).

● Dichotomy theory, which suggests that the tooth bud splits into two equal or different-sized parts, which may form two teeth of equal size, or one normal and one dysmorphic tooth respectively15).

● Dental lamina hyperactivity theory, which suggests localized, independent, conditioned hyperactivity of the dental lamina. According to this theory, a supplemental form would develop from the lingual extension of an accessory tooth bud, whereas a rudi-mentary form would develop from the proliferation of epithelial remnants of the dental lamina3). This is the most accepted theory.

They may occur as a single isolated dental anomaly or in associa-tion with other developmental anomalies or syndromes such as cleft lip and palate, cleidocranial dysostosis, Down's syndrome and Gardener's syndrome16).

The conical shaped supernumerary teeth have certain specific char-acteristics17):

● They are usually located between the permanent maxillary central incisors but rarely erupt labially.

● They usually have complete root formation ahead of the adjacent teeth.

● They rarely cause delay in the eruption of central incisors, but may cause alteration of the path of eruption of these teeth.

In the present case, the associated mesiodens were conical, non-in-verted, erupted, and caused distalization of permanent central and lateral incisors and buccally.

There is no precise indication concerning the ideal time for surgical removal of mesiodens. According to Canoglu et al, mesiodens can be best removed when the permanent central incisors begin to erupt18), but this may not be always possible. On the contrary, Primosch2), discourag-es early extraction of mesiodens due to the risk of iatrogenic damage to the developing adjacent permanent teeth. In this particular case, consid-ering the age of the patient as well as the problems associated with the mesiodens, removal of the mesiodens was carried out (Figure 2) under local anesthesia, since both the maxillary central incisors had totally

Figure 1. Pretreatment extraoral, intraoral photograph and Pretreatment Orthopantomograph.

Figure 2. Extracted mesiodentes, post-extraction - palatal view and different stages of orthodontic treatment

Figure 3. Post-treatment extraoral photograph, intraoral photo-graph and Orthopantomograph

Mesiodens 371

erupted showing complete root formation and advanced apical closure. Then extensive orthodontic treatment carried out to close the space and alignment of maxillary canines (Figure 2). No treatment carried out in lower jaw as the jaw was well aligned. After active treatment fixed retention was given from upper left 1st premolar to right 1st premolar (Figure 3).

CONCLUSION

In this paper, we have reported a rare case of twin mesiodens in the maxillary arch, causing malocclusion and aesthetic problem in the patient. It also puts forward a decision support system, which helps in overcoming the controversies regarding the timing of removal of the supernumerary tooth. Detailed examination of the patient is important to rule out any other unknown problems that may be associated with mesiodens. In this case the treatment plan consisted of the extraction of mesiodentes followed by orthodontic treatment for closing of space and alignment of the teeth.

REFERENCES

1) V. Verma, A. Goel, and M. Sabir, "Supernumerary eumorphic mandibular incisor in assoc ia t ion wi th aggress ive per iodont i t i s , " Journa l of Indian Socie ty of Periodontology, vol. 14, no. 3, pp. 136-138, 2010.

2) Primosch RE. Anterior supernumerary teeth assessment and surgical intervention in children. Pediatr Dent. 1981 Jun; 3(2): 204-15.

3) Mosby, Inc. Mosby's Medical Dictionary. 8th ed. St. Louis: Mosby Elsevier; 2009. 4) V. Khandelwal, A. V. Nayak, R. B. Navan, N. Ninawe, P. A. Nayak, and S. V.

Saiprasad, "Prevalence of mesiodens among six to seventeen year old school going

children of Indore," Journal of Indian Society of Pedodontics and Preventive Dentistry, vol. 29, no. 4, pp. 288-293, 2011.

5) G. Meighani and A. Pakdaman, "Diagnosis and management of supernumerary (mesiodens). A review of the literature," Journal of Dentistry Tehran University of Medical Sciences, vol.7, pp. 41-49, 2010.

6) S. A. Sharma, "Mandibular midline supernumerary tooth: a case report," Journal of the Indian Society of Pedodontics and Preventive Dentistry, vol. 19, no. 4, pp. 143-144, 2001.

7) Khanduri N, Gupta B, Kaul R, Sasan NS. Surgical removal of mesiodens in a 8 year old male. IJCCI 2015; 6: 125-30.

8) Wood GD, Mackenzie I. A dentonasal deformity. Oral Surg Oral Med Oral Pathol 1987; 63: 656-7.

9) Lustmann J, Bodner L. Dentigerous cysts associated with supernumerary teeth. Int J Oral Maxillofac Surg 1988; 17: 100-2.

10) Asaumi JI, Shibata Y, Hisatomi M, Matsuzaki H, Konouchi H, Kishi K, et al. Radiogrsaphic examination of mesiodens and their associated complications. Dentomaxillofac Radiol 2004; 33: 125-7.

11) Solares R. The complications of late diagnosis of anterior supernumerary teeth: Case report. ASDC J Dent Child 1990; 57: 209-11.

12) Munns D. Unerupted incisors. Br J Orthod 1981; 8: 39-42. 13) Khatri MP, Samuel AV. Overview of mesiodens: A review. Int J Pharm Bio Sci 2014; 5:

526-39. 14) Shah A, Gill DS, Tredwin C, Naini FB. Diagnosis and management of supernumerary

teeth. Dent Update 2008; 35: 510-520, 514-6, 519-20. 15) Rajab LD, Hamdan MA. Supernumerary teeth: Review of the literature and a survey of

152 cases. Int J Paediatr Dent 2002; 12: 244-54 16) Liu JF. Characteristics of premaxillary supernumerary teeth: a survey of 112 cases.

ASDC J Dent Child. 1995 Jul-Aug; 62(4): 262-5. 17) Ray D, Bhattacharya B, Sarkar S, Das G. Erupted maxillary conical mesiodens in

deciduous dentition in a Bengali girl - A case report. J Indian Soc Pedod Prev Dent. 2005 Sep; 23(3): 153-5

18) Canoglu E, Er N, Cehreli ZC. Double inverted mesiodentes: report of an unusual case. Eur J Dent. 2009 Jul; 3(3): 219-23.