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Multiple Recurrent Supernumerary Teeth: A Case Report Mariyah Nazir Dental Update 2024 12:1, 707-709.
Authors
MariyahNazir
BDS(Hons), MFDS RCS(Eng), MPhil, MOrth RCS(Ed)
FTTA in Orthodontics, Orthodontic Department, University Dental Hospital of Manchester, Manchester, M15 6FH and University Hospital of South Manchester, Wythenshawe, M23 9LT, UK
Supernumerary teeth affect approximately 1–3% of the population, however, recurrent supernumerary teeth are extremely rare (prevalence = 0.0001%) and may be associated with undiagnosed syndromes. The syndromes associated with recurrent supernumerary teeth vary widely and a diagnosis often necessitates involvement of a spectrum of medical disciplines. This case report describes a patient with recurrent supernumerary teeth and a history of sebaceous cysts that indicated the potential presence of Gardner's syndrome. It highlights the importance of multidisciplinary communication and investigation for effective patient management.
CPD/Clinical Relevance: Supernumerary teeth can be a feature of several syndromes. Dental health professionals should be aware of this association and of the signs that indicate that further investigation may be warranted.
Article
Mohammad Owaise Sharif
Supernumerary teeth are those teeth occurring in excess of the normal series. The prevalence of such teeth has been reported to be as high as 3% in the permanent dentition.1 Most commonly, they present as single units, however, multiple supernumerary teeth account for 8–27% of all cases.2,3,4 They can present in isolation, but systemic or genetic factors may be implicated, for example:
Supernumerary teeth are classified according to location (mesiodens, paramolar, distomolar or parapremolar) or morphology (conical, tuberculate, supplemental or odontome) (Table 1 and Figures 1–4). In contrast to hypodontia, males are affected more commonly than females (ratio – 2:1).8 Other factors associated with supernumerary teeth include:
Delayed eruption;
Pathology (cysts, root resorption);
Spacing (eg a midline diastema);
Malposition of erupting teeth;
Dilaceration of developing teeth;
Crowding (in the case of erupted supernumeraries);
Over-retention of primary teeth (in the case of Cleido-Cranial Dysostosis).
Site
Morphology
MesiodensIn between Maxillary central insicors
Conical (Figure 1)Occurrence: 75% of all supernumerariesShape: conical or triangular crown with complete root formation
ParamolarBuccal or lingual to the permanent molar teeth
Tuberculate (Figure 2)Occurrence: 12% of all supernumerariesShape: barrel-shaped crown, with multiple tubercles (round nodules), with partial or no root formation
ParapremolarBuccal or lingual to premolar teeth
Supplemental (Figure 3)Occurrence: 7% of all supernumerariesShape: resemble permanent teeth, with root formation
DistomolarDistal to the third molars (upper or lower)
Odontome (Figure 4)Occurrence: 6% of all supernumerariesShape: Two types:
Complex – Single irregular mass
Compound – Multiple small tooth-like structures
Figure 1. Two conical supernumeraries, positioned as mesiodens teeth.Figure 2. Tuberculate supernumeraries, positioned palatal to the upper incisor teeth.Figure 3. Supplemental upper left lateral incisor.Figure 4. Compound supernumerary, positioned between upper left central and lateral incisor.
This case reports describes the management of a patient with recurrent multiple supernumerary teeth in the premolar region.
Case report
A 13-year-old female was referred by her General Dental Practitioner (GDP) to the Orthodontic Department at The University of Manchester. Medically, the patient was fit and well, the reason for referral being dental crowding.
An orthodontic assessment revealed that the patient had Class I incisors on a Class I skeletal base with mild upper and lower arch crowding; this was complicated by retained lower deciduous first molars (LRD and LLD) and unerupted lower first premolar teeth (LR4 and LL4). As part of the assessment, an Orthopantomogram (OPG) was taken to inform diagnosis and treatment planning. The OPG revealed the presence of all permanent teeth, including developing third molars. In addition, four supernumerary teeth were identified, one in each of the upper right, lower right quadrants, and two in the lower left quadrant (Figure 5). The supernumerary teeth in the lower right and left quadrants were impeding the eruption of LR4 and LL4, resulting in an IOTN score of 5i on dental health grounds. After discussion with the patient and her parents, arrangements were made for the extraction of the retained LRD, LLD and surgical removal of all four supernumerary teeth. This was carried out under general anaesthesia 7 months later. Whilst performing the surgical removal of the supernumeraries in the LLQ the oral surgeon noted that the LL4 was in a transverse position. However, a decision was made to discharge the patient back to her GDP to monitor the developing dentition. She was subsequently re-referred to the Orthodontic Department 15 months later, at the age of 15. The reason for referral was ‘space in the LL4 region’. Medically, the patient was fit and well, however, she did report having suffered with sebaceous cysts since her last appointment. An orthodontic assessment a month later revealed that she had Class I incisors on a Class I skeletal base, with mild upper and lower arch crowding complicated by several heavily restored teeth (UR6, UL5, UL6), several carious teeth (LR5, LR6, LR7, LL5, LL6, LL7) and an unerupted LL4. The LL4 was palpable buccally and there was sufficient space present to accommodate it within the arch (Figures 6 and 7). As part of this assessment, an OPG was taken (Figure 8), which revealed that the LL4 was vertically impacted and also the presence of two supernumerary teeth, one in the lower right quadrant and one in the upper left quadrant. These supernumerary teeth were not evident on the OPG taken two years previously (Figure 5).
Figure 5. OPG at initial orthodontic assessment (2010), displaying 4 supernumerary teeth (one in each of the upper right, lower right quadrants, and two in the lower left quadrant).Figure 6. Mandibular occlusal view displaying sufficient space for impacted LL4.Figure 7. Left buccal view displaying buccal bulge in the region of the impacted LL4.Figure 8. OPG at orthodontic review (2012), in contrast to Figure 5, additional supernumerary teeth are present (lower right and upper left quadrants).
The findings were discussed with the patient. and her parents and, aside from the restoration of carious teeth, the following treatment options were discussed:
No treatment – with this option there would be the potential for cystic change of the supernumerary teeth, which could damage adjacent teeth. If this was opted for, then regular radiographic monitoring of the supernumerary teeth would be required.
Removal of the supernumerary teeth and no active treatment.
Removal of the supernumerary teeth and fixed appliances to align LL4. However, orthodontic treatment would only be commenced if oral health was at a level sufficient to support this.
The patient opted for option 3 and arrangements were made for the restoration of carious teeth, removal of the supernumerary teeth and exposure of the LL4.
The recurrent supernumerary teeth and history of sebaceous cysts indicated the potentiality of Gardner's syndrome; these signs prompted a referral to the colorectal department for further investigation. An indirect ophthalmoscopy was organized to investigate Congenital Hypertrophy of Retinal Pigment Epithelium (CHRPE), a common diagnostic sign of Gardner's syndrome.9 The patient is currently in a period of surveillance for a colonoscopy.
Discussion
Multiple supernumerary teeth are strongly associated with syndromes10 and therefore may require a multidisciplinary approach for holistic management. Gardner's syndrome is associated with the umbrella condition Familial Adenomatous Polyposis (FAP), with a potential major complication being colorectal cancer.11 The diagnosis of Gardner's syndrome can be difficult.12 Presentations which lead to diagnosis are:
Desmoid tumours;
Osteomas;
Cutaneous lesions (benign tumours, cysts, including sebaceous cysts);
Dental abnormalities (hyperdontia, hypodontia, fused roots); and
It should be noted that Gardner's syndrome is an autosomal dominant condition11 and therefore a positive family history should alert clinicians to its increased probability of presentation. The presence of multiple supernumeraries, in particular their recurrence, should also alert clinicians to consider screening for Gardner's syndrome and to explore the patient's history (medical and family) in more detail than would be normal practice. Early diagnosis of colorectal cancer is the key to increasing survival rates for patients.12 Therefore the diagnosis of Gardner's syndrome may allow for regular colorectal reviews and monitoring prior to the onset of cancer. This has the potential of increasing survival rates.
