Ectopic & Supernumerary Tooth

[drmithila]

Removal Warnings
It is quite common to have extra teeth (supernumerary
teeth) or teeth in the wrong position (ectopic teeth) or
both.

The prevalence of supernumerary teeth is reportedly
between 0.15 – 3.9%. Most commonly, extra teeth are
found between the upper central incisors
(mesiodentes) or in the region of the premolars
(paramolars) or very occasionally, behind the wisdom
teeth (distomolars).

Supernumerary Teeth. 80 – 90% of all supernumerary
teeth occur in the upper jaw. Half are found at the ‘front’ of
the upper jaw. Mesiodentes frequently interfere with the
eruption and alignment of the upper incisors. They can
delay or prevent eruption, displace or rotate the erupting
central incisors or less commonly, ‘bend’ (dilaceration) the
developing roots of the central incisors so that tooth
eruption is slowed / stopped, ‘eat away’ (resorption) the
surrounding teeth, develop cysts around the crowns of the
extra teeth (dentigerous cyst formation) and loss of tooth
vitality. Rarely, the mesiodens can erupt into the nasal
cavity.

Ectopic Teeth. Ectopic teeth are teeth that develop in the
wrong position. Ectopic teeth are not rare. In most cases,
ectopic tooth can be repositioned with braces.

        

[drsushant]

The following list of warnings regarding the removal of
ectopic / supernumerary teeth is neither exhaustive nor is it
predictive. The most pertinent warnings have been included
here.

Ectopic +/- Supernumerary Surgery-Specific Warnings.

Numbness of the Lip, Chin +/-Tongue. The nerves that
supplies feeling to the tongue, lower lip and the chin run risk
that when bicuspid teeth squeezed out of the line of teeth
towards the tongue are removed, these nerves can be
crushed, bruised or stretched resulting in numbness (at the
worse end of the scale) to altered sensation (at the other
end of the scale) in the region of the lower lip, chin and/or
tongue. This nerve bruising tends to be temporary (rarely
is it permanent) but ‘temporary’ can stretch from several
days to several months. It is hard to predict who will get
nerve bruising and if it will be temporary / permanent and if
temporary, how long for.

Mouth-Sinus Communications. Upper premolar & canines
are often in close proximity to the sinus. In removing these
teeth, there is a chance that a communication can be made
between the mouth & the sinus (this is sometimes not
evident at the time of operation but may develop 4 – 6
weeks afterwards). If this communication persists or is left
un-repaired, every time you drink, fluid can come out of the
nose and you may develop a marked sinusitis. This
communication, if small enough, can spontaneously close.
It can be assisted in this by ‘cover plates’ that prevent food
& fluids going into the sinus allowing the hole to close
naturally. However, communications above a certain size
need to be surgically closed.

Surrounding Teeth. The surrounding teeth may be sore
after the extraction; they may even be slightly wobbly but
the teeth should settle down with time. It is possible that
the fillings or crowns of the surrounding teeth may come
out, fracture or become loose. If this is the case you will
need to go back to your dentist to have these sorted out.
Every effort will be made to make sure this doesn’t
happen.

In very rare instances, the surrounding teeth may
actually come out as well as the intended tooth. Extra
teeth can be very hard to get at and in doing so, the blood-
supply to the surrounding teeth may be compromised. If
this happens, these teeth can die (under go ‘devitalisation’);
the teeth change colour (turn grey), become spontaneously
painful or become infected. A tooth that is dying may not
be immediately obvious and may take several weeks to
become so.

        

[drsushant]

General Surgical Warnings.

Pain. As it is a surgical procedure, there will be soreness
after the tooth removal. This can last for several days.
Painkillers such as ibuprofen, paracetamol, Solpadeine or
Nurofen Plus are very effective. Obviously, the painkiller
you use is dependent on your medical history & the ease
with which the tooth was removed.

Swelling. There will be swelling afterwards. This can last
up to a week. Use of an icepack or a bag of frozen peas
pressed against the cheek adjacent to the tooth removed
will help to decrease the swelling. Avoidance in the first
few hours post-op, of alcohol, exercise or hot foods / drinks
will decrease the degree of swelling that will develop.

Occasionally, there is bleeding into the cheek. The swelling
caused by this may take much longer to resolve; at the
same time, there may well be limitations to mouth opening.
This also improves with time.

Bruising. Some people are prone to bruise. The bruising
can look quite florid; this will eventually resolve but can take
several weeks (in the worst cases).

Stitches. The operation site will often be closed with
stitches. These dissolve and ‘fall out’ within 10 – 14 days.

Limited Mouth Opening. Often the chewing muscles and
the jaw joints are sore after the procedure so that mouth
opening can be limited for the next few days. If you are
unlucky enough to develop an infection in operation site
afterwards, this can make the limited mouth opening worse
and last for longer.

Bleeding into Cheeks. Swelling that does not resolve
within a few days may be due to bleeding into the cheek.
The cheek swelling will feel quite firm. Coupled with this,
there may be limitation to mouth opening and bruising. Both
the swelling, bruising and mouth opening will resolve with
time.

Post-op Infection. You may develop an infection in the
socket after the operation. This tends to occur 2 – 4 days
later and is characterised by a deep-seated throbbing pain,
bad breath and an unpleasant taste in the mouth. This
infection is more likely to occur if you are a smoker, or are
on the contraceptive pill, or on drugs such as steroids and if
bone has to be removed to facilitate tooth extraction.

Surgical Removal. To facilitate the removal of teeth, it is
sometimes necessary to cut the gum and / or remove bone
from around the tooth. If this is the case, you can expect
the extraction site to be sorer afterwards, the swelling to
be greater and more prone to infection. Hence, stronger
painkillers are needed; use of icepacks mandatory and
antibiotics will probably be prescribed. The bone grows
back to a greater extent.

Bony Flakes. If a number of teeth are removed at one go,
the resulting gums may feel a bit rough. Occasionally, bony
flakes (sequestra) from the lining of the tooth sockets can
work their way loose out through the gums. These can be
quite sore. They often work their way loose without any
problems but may need to be teased out or even smoothed.

        

[drmithila]

Classification of Supernumerary Teeth

Supernumerary teeth can be classified according to the location and the morphology. The supernumerary teeth present in the front teeth are called Mesiodens. The deciduous teeth are normally conical and straight but the permanent teeth can be differentiated into different shapes. They can be classified into four types according to the morphology. These are:
Conical Supernumerary Teeth
Tuberculate Supernumerary Teeth
Supplemental Supernumerary Teeth
Odontoma, This can be complex composite odontoma and compound composite Odontoma

Conical Supernumerary Teeth

They are normally peg shaped and are present between the front teeth and are known as the Mesiodens. They develop ahead or with the formation of root but some times they are impacted and lie inverted in the palate. Rarely do they cause hindrance in the eruption of the permanent teeth but they can cause the rotation or the displacement of the permanent teeth.

Tuberculate Supernumerary Teeth

As the name implies they have more than one cusp or tubercle and are mostly present palatally to the central upper incisors. Their root formation is delayed and they are usually paired. It is very rare that they erupt and they can cause the delayed eruption of the incisors.

Supplemental Supernumerary Teeth is the duplication of teeth in normal series. Mostly it is found in lateral incisor, molar and premolar region. Most of the deciduous teeth are supplemental and are never impacted.

        

[drmithila]

Causes for Supernumerary Teeth

There is no specific cause of the supernumerary teeth. Many theories are given to explain their presence. Some says that these are there because of the abnormal division of the tooth bud but another theory says that it is because of the hyperactivity of the dental lamina. Dental lamina is the dental tissue which forms the tooth buds to form the teeth. If the dental lamina shows hyperactivity then extra teeth are formed which are known as the supernumerary teeth. Hereditary is also considered to be one of the main cause of supernumerary teeth.

What is the incidence of Supernumerary Teeth

The incidence of supernumerary teeth is more common in adult permanent teeth as compared to deciduous teeth. It is 0.8% in deciduous teeth and 2.1% in permanent teeth. These can be unilaterally present or bilaterally. It can be single or multiple. Normally it is single but multiple supernumerary teeth are present in cases of cleft lip and palate, cleidocranial dysplasia or Gardner’s syndrome. The incidence of supernumerary teeth in cleft lip and palate cases is around 22%. While in cleidocranial dysplasia cases it is 22.2% in maxillary region and 5 % in molar region. The supernumerary teeth can be present in one jaw or both the jaws. In deciduous teeth the incidence of supernumerary teeth is equal in males and females but in case of permanent teeth the incidence of supernumerary teeth is twice in males as compared to the females.

        

[drsushant]

Abnormal division of tooth bud may occur due to trauma..I have heard teeth can even erupt at places other than the oral cavity..Is that true?

        

[drmithila]

Intranasal ectopic teeth are rare and ectopic eruption of teeth can occur in a variety of locations. Commonly seen in the palate and maxillary sinus, they have also been reported in the mandibular condyle, coronoid process, orbital and nasal cavities, and through the skin. With the advent of sinonasal endoscopy in the mid 1980s, and subsequent advances in surgical techniques, endoscopic management of intranasal lesions has become possible. In the current case study, we report a successful endoscopic removal of intranasal ectopic teeth located in the nasal cavity. The endoscopic surgical approach used in this case caused less morbidity than do the more common methods of removing an intranasal ectopic tooth

In cases of incomplete descent of the thyroid gland, ectopic teeth are seen embedded in the thyroid too.

        

[Drsumitra]

The usual cause behind tooth dilaceration is trauma to the tooth while it is still forming. This causes a distortion in position of the forming tooth, resulting in the remaining part to form at an angle. The extent and point of dilaceration, whether it affects the crown or the root, is determined by the trauma induced. Example of such disturbances include blow to the face or falling over. Other more rare incidents include replantation of a knocked out or avulsed primary tooth, more commonly referred to as baby tooth. Another possible contributing factor includes orthodontics braces on a tooth with incomplete root formation. Other developmental problems or syndromes can also contribute to tooth dilacerations. A common disorder associated with dilacerated tooth is Turner’s hypoplasia. Occurrence of cyst or tumour which may cause an infection can also displace the developing tooth, causing dilacerated crown or root.

How to avoid tooth dilaceration

Head guard with attached mouth guard to minimise injury
Accidents are unpredictable hence making it hard to avoid tooth dilaceration. There are some general guides which can help minimize the occurrence especially if your child is playing contact sports. It is highly recommended that they wear a mouth guard not just to prevent tooth dilaceration, but any trauma to the oral region in general. In case of trauma, the child should be assessed by a dentist as soon as possible to evaluate the condition and if any steps can be done early on to prevent future complications. It is also important to note that if a baby tooth is knocked out that in no circumstances should the avulsed tooth be replanted back to its socket. This is because the replanted baby tooth may impinge or graze the developing tooth during replantation, causing unnecessary trauma to the permanent tooth leading to shape malformations. Another risk associated with avulsed tooth includes bacteria infestation on the surface of replanted baby tooth, leading to infection that can compromise the development of the permanent tooth underneath it.

 

        

[drsushant]

Complications associated with dilacerated tooth

Dentigerous cyst formation from an impacted tooth
The site and extent of tooth dilaceration significantly affects the outcome. In a case of dilacerated crown, the tooth may appear unaesthetic due to its altered shape and hence requiring cosmetic dental treatment such as dental crowns or porcelain veneers. Where the root is dilacerated, the tooth may be impacted or fail to erupt due to the sharp curve and get lodged in the jaw. This may cause a problem in the future as the impacted tooth may turn cystic. Dilacerated tooth can sometimes erupt in an awkward position causing crowding or displacement of other teeth. Other associated risks with tooth dilaceration are pulpal death or inflammation as the angled portion of the tooth consist of slightly abnormal structure, acting as a passageway for bacteria to access the pulp.

Intervention and treatment options

In some cases of tooth dilaceration, it may be possible to realign the tooth by surgically exposing the tooth. This can be done with or without the help of orthodontic braces. Due to the angulation of the tooth, realignment by relying solely on orthodontic measures is usually not feasible. Dilacerated areas which are exposed to the mouth, i.e. in crown dilacerations, restorative work such as fillings or dental crowns should be carried out to prevent bacterial ingression which can lead to pulpal problems as mentioned above.

Dilacerated tooth when presented as a problem, is usually difficult to treat especially when it involves the root. Root canal treatment on dilacerated tooth is very challenging and normally requires an endodontist to complete. Extraction or removal of dilacerated tooth is complicated due to the sharp bends that acts as a hook, lodging it firmly into the jaw. It frequently breaks and requires surgical extraction to section it into fragments to ensure complete removal. When nothing is done, careful monitoring of dilacerated tooth is recommended to detect any early signs of changes.

 

        

[Drsumitra]

The size of our jaws decreases with age. This is shown in a unique study from the Faculty of Dentistry at Malmö University that followed a cohort of dentists throughout their adult lives.
The unique study started in 1949. Plaster molds were made of the jaws of dental students, who were then in their twenties. Ten years later the procedure was repeated, and in 1989, forty years after the first molds, a final round was performed. On that occasion the researchers were in touch with 18 of the original 30 participants.
"We found that over these forty years there was less and less room for teeth in the jaw," says Lars Bondemark, professor of orthodontics, who analyzed the material together with his colleague Maria Nilner, professor of clinical bite physiology at the College of Dentistry, Malmö University .
This crowdedness comes from shrinkage of the jaw, primarily the lower jaw, both in length and width. While this is only a matter of a few millimeters, but it is enough to crowd the front teeth.
"We can also eliminate wisdom teeth as the cause, because even people who have no wisdom teeth have crowded front teeth."
How much the jaw shrinks is individual, but for some patients the changes are sufficiently great for them to perceive that something is happening to their bite.
"In that case it’s good to know that this is normal," says Lars Bondemark, who maintains that dentists need to take into consideration the continuous shrinking of the jaws when they plan to perform major bite constructions on their patients.
"We’re working against nature, and it’s hard to construct something that is completely stable."
Why the jaws change throughout life is not known, but the magnitude of the change is probably determined by both hereditary and anatomical factors, including what the patient’s bite looks like.

 

        

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