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Nonsyndromic Bilateral Posterior Maxillary Supernumerary Teeth: A Report of Two Cases and Review.

1. Introduction

Supernumerary tooth (ST) is defined as a tooth or a structure resembling tooth which forms from dental lamina in addition to the normal dental formula [1, 2]. It can occur both in the maxillae and/or mandible, unilaterally or bilaterally, solitary or in multiples, and erupted or unerupted. It can be seen in both syndromic and nonsyndromic patients. Previous researches had documented the prevalence rate of ST to be 0.2%-0.8% and 0.5%-5.3% in deciduous and permanent dentition, respectively. The male-to-female ratio for the incidence of ST was reported to range in between 1.18: 1 and 1.5:1. Supernumerary teeth are also associated with larger than average teeth which reflect their multifactorial etiology. Various hypothesis were postulated by different authors to explain the phenomena of ST development, but the exact etiology is still unknown [3]. However, Brook [4] had hypothesized an interaction of environmental and genetic factors.

ST can be classified on the basis of the morphology (conical, tuberculate, supplemental, and odontomes), location (mesiodens, paramolar, distomolar, and parapremolar), position (buccal, palatal, and transverse), and orientation (vertical or normal, inverted, transverse, or horizontal). Mesiodens is the most prevalent supernumerary teeth which is seen in premaxilla. ST in the molar region is comparatively very rare [3]. Also, a very few cases have been reported about the bilateral presence of ST in the molar region [5].

Hence, we are reporting two cases of bilateral ST in the molar region. Our first case is of bilateral maxillary paramolars, whereas the other case is a combination of unilateral maxillary paramolar and distomolar. In addition, we have reviewed the existing literature to focus on incidence, prevalence, proposed hypothesis for etiology, and management of supernumerary teeth.

2. Case Report 1

A 17-year-old male patient visited to the department of orthodontics and dentofacial orthopedics with a chief complaint of malalignment of teeth. His medical and family histories were not significant. On intraoral examination, buccally placed bilateral paramolars were present in between first and second maxillary molars (Figure 1). No clinical complications were present secondary to paramolars. Radiological investigations (intraoral periapical radiographs and panoramic radiograph) were advised to determine the root orientation (Figure 2). Both the paramolars were vertically oriented. Extractions were advised for both the paramolars to prevent any interruption in the orthodontic treatment. Extracted paramolars showed supplemental shape and form with well-defined transverse and marginal ridges resembling maxillary premolars (Figure 3). It was followed by initiation of the orthodontic treatment.

3. Case Report 2

A 23-year-old female patient visited to the department of orthodontics and dentofacial orthopedics with a chief complaint of forwardly placed upper front teeth. No significant medical and family histories were reported. On intraoral examination, fourteen teeth were present in maxillary arch (Figure 4). Clinically, maxillary third molars were missing bilaterally. She was advised for routine radiological investigations required for the orthodontic treatment. Panoramic radiograph revealed presence of a distomolar on the right side and a paramolar between left second and third molars (Figure 5). Computed tomographic scan was advised to know the accurate orientation of these impacted supernumerary teeth to formulate the treatment plan. It revealed the vertical orientation ofboth the impacted supernumerary teeth. Extraction of supernumerary teeth followed by the orthodontic treatment was advised to the patient.

4. Discussion

ST or hyperdontia as defined earlier are those teeth which are present in excess of the usual distribution of twenty deciduous and thirty-two permanent teeth [6]. Singh et al. had reported the prevalence of ST in Nepalese population to be 1.6%, which was in accordance with Hungarian (1.53%), Swedish (1.6%), and Brazilian (1.7%) population. The same study had showed the male predilection for ST with male: female ratio of 1.3:1 which was similar to Hungarian (1.4:1), British (1.4:1), and Brazilian (1.45:1) population [7-11]. Similarly, this study had also documented the prevalence of the single ST to be the most commonest (82.60%) followed by paired (15.21%) and triple ones (2.17%). Maxillary arch (98.8%) with the anterior medial region (mesiodens) and conical form was found to be the most common location and form of the supernumerary teeth in this study [7].

To the best of our knowledge, no studies from Nepal have reported the incidence of bilateral maxillary paramolars or the combination of unilateral maxillary paramolar and distomolar till date. The documented incidences similar to our cases reported in other population are briefed in Tables 1 and 2 [12, 13]. Hou et al. [14], Dhull et al. [15], Shetty [16], and Sulabha and Sameer [17] had reported the presence of bilateral maxillary paramolars similar to our first case report. Nirmala and Tirupathi [12] had documented the combination of unilateral maxillary paramolar and distomolar similar to our second case report.

The exact etiology of occurrence of ST is not known. Numerous theories have been postulated to understand their existence along with the normal dentition. Atavism theory stated the occurrence of supernumerary teeth as the phylogenetic reversion to the extinct ancestral human dentition [33]. Dichotomy theory suggested that a developing tooth bud can divide into two teeth, giving rise to ST and a normal tooth [34]. Dental lamina hyperactivity theory, the most accepted one, suggests the localized and independent hyperactivity of the dental lamina to be the cause for the development of ST [7, 35]. Niswander and Sujaku [36] also proposed the presence of an autosomal recessive gene which explains the familial tendency to ST. It have been reported in patients with syndromes like cleft lip and palate, cleidocranial dysplasia, Ehlers-Danlos syndrome type III, Fabry-Anderson's syndrome, Ellis-van Creveld syndrome, Gardner's syndrome, Goldenhar syndrome, HallermannStreiff syndrome, orofaciodigital syndrome type I, incontinentia pigmenti, Marfan syndrome, Nance-Horan syndrome, and trichorhinophalangeal syndrome 1 [12].

ST may be associated with different clinical complications. These can result into clinical problems like midline diastema; crowding; malocclusion due to insufficient space; dilaceration, delayed, or failure of eruption of permanent teeth; root resorption of adjacent teeth; cyst formation; cheek bite; periodontal problems; dental caries, and other difficulties related to ectopic position. These complications occur rarely, but earlier diagnosis can help to prevent these complications [4, 13].

Radiographic screening plays a significant role in identification and localization of ST, especially when they are impacted or need surgical intervention. Two-dimensional imaging modalities (periapical radiographs, occlusal radiographs, and orthopantomographs) do provide sufficient information to the clinicians, but accurate position of buccally or lingually placed ST is difficult to determine due to the superimposition by the surrounding structures [4, 13, 37]. Clark and Richards had suggested horizontal and vertical tube shift technique, respectively, to determine exact location of ST using conventional radiography. Both of these are widely accepted due to their simplicity [4, 38, 39]. Recently, Toureno et al. proposed a guideline to use three-dimensional imaging modalities (cone beam computerized tomography) along with two-dimensional imaging modalities for better assessment of ST, planning surgical intervention with minimal treatment errors [40].

There are two different school of thoughts about the management of ST. Some authors recommended the removal of ST as soon as detected, whereas others emphasized the periodic monitoring and removal only in the case of any associated pathology or hindrance to any dental treatment especially the orthodontic treatment [41-43]. Hogstrom and Andersson also suggested two different options for ST removal. According to them, ST either should be removed as early as it is identified or after completion of the adjacent tooth's root formation. However, former option could result into creation of dental phobia in young children and can disturb the growth of adjacent teeth [44]. Recently, Omer et al. suggested the optimal time for the removal of ST during 6 to 7 years, based upon their retrospective analysis. According to them, during this age interval, ST removal can be done with minimal disturbances to the adjacent teeth [1].

5. Conclusion

Supernumerary teeth are uncommon and generally present without causing any complications like our cases. Our cases required surgical intervention for future orthodontic treatment and planning. Although complications are rare, clinicians should be aware of early identification, proper management, and associated complications with the same.

Conflicts of Interest

The authors declare that there are no conflicts of interest regarding the publication of this article.


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Ravi Kumar Mahto (iD), (1) Shantanu Dixit, (2) Dashrath Kafle, (1) Aradhana Agarwal, (1) Michael Bornstein, (3) and Sanad Dulal (4)

(1) Department of Orthodontics, Dhulikhel Hospital, Kathmandu University School of Medical Sciences, Dhulikhel, Nepal

(2) Department of Oral Medicine and Radiology, Dhulikhel Hospital, Kathmandu University School of Medical Sciences, Dhulikhel, Nepal

(3) Oral and Maxillofacial Radiology, Applied Oral Sciences, Faculty of Dentistry, University of Hong Kong, Pokfulam, Hong Kong

(4) Department of Oral and Maxillofacial Surgery, Dhulikhel Hospital, Kathmandu University School of MedicalSciences, Dhulikhel, Nepal

Correspondence should be addressed to Ravi Kumar Mahto;

Received 25 January 2018; Accepted 18 March 2018; Published 11 April 2018

Academic Editor: Gavriel Chaushu

Caption: Figure 1: Intraoral images of Case 1 depicting bilateral maxillary paramolars (shown by arrows).

Caption: Figure 2: Panoramic and intraoral radiographs showing bilateral maxillary paramolars (encircled).

Caption: Figure 3: Extracted paramolars resembling maxillary premolars.

Caption: Figure 4: Intraoral images of Case 2.

Caption: Figure 5: Panoramic radiograph showing maxillary the right distomolar and left paramolar (encircled).
Table 1: Reported cases of paramolars.


Arch/side      Author      Year    Population          Location

Maxillae    Puri et al.    2013      Indian         Bucally placed
                [18]                              between second and
                                                     third molars

            Nayak et al.   2012      Indian        Palatally placed
                [19]                              between left first
                                                   and second molars

            Nagaveni et    2010      Indian         Buccally placed
              al. [13]                            between right first
                                                   and second molars

             Ghogre and    2014      Indian      Fused with the second
             Gurav [20]                                  molar

            Venugopal et   2013      Indian      Fused with the right
              al. [21]                               second molar

             Rudagi et     2012      Indian       Fused with the left
              al. [23]                               second molar

            Salem et al.   2010       Iran        Fused with the left
                [24]                                 second molar

Mandible    Rosa et al.    2010      Brazil      Fused with the right
                [25]                                  first molar

             Ballal et     2007      Indian      Fused with the second
              al. [26]                                   molar

            Ghoddusi et    2006       Iran        Fused with the left
              al. [27]                               second molar

            Dubuk et al.   1996     Japanese      Mesial to the right
                [28]                                 second molar

            Kumasaka et    1988     Japanese         Two impacted
              al. [29]                             paramolar on the
                                                      right side


Arch/side      Author      Year    Population          Location

Maxillae    Sulabha and    2015      Indian         Buccally placed
             Sameer et                             between first and
              al. [17]                               second molars

            Dhull et al.   2012      Indian        Between first and
                [15]                                 second molars

            Shetty et al.  2012      Indian        Palatally placed
                [16]                               between first and
                                                     second molars

             Hou et al.    1995     Taiwanese       Buccally placed
                [14]                               between first and
                                                     second molars

            Dhull et al.   2014      Indian      Mesial and lingual to
                [15]                               the second molar

            Nunes et al.   2002      Brazil      Fused with the second
                [22]                                     molar

Table 2: Reported cases of combination of paramolar and distomolar/
bilateral paramolars.

Arch           Author      Year    Population          Location

Maxillae    Present case   2017     Nepalese        Buccally placed
                                                 bilateral paramolars
                                                 in between first and
                                                    second molars;
                                                   combination of a
                                                   distomolar on the
                                                   right side and a
                                                   paramolar between
                                                 left second and third

            Nirmala and    2015      Indian         Combination of
             Tirupathi                           developing unerupted
                [12]                               paramolar on the
                                                    right side and
                                                   distomolar on the
                                                       left side

            Omal et al.    2011      Indian       Bilateral paramolar
                [30]                              between second and
                                                     third molars;
                                                 bilaterally impacted

            Mayfield and   1990     Hispanic     Bilateral paramolars
            Casamassimo                             and distomolars

Mandible    Reddy et al.   2013      Indian       Bilateral paramolar
                [32]                               between first and
                                                    second molars;
                                                 bilateral distomolar
                                                 with impacted second
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Title Annotation:Case Report
Author:Mahto, Ravi Kumar; Dixit, Shantanu; Kafle, Dashrath; Agarwal, Aradhana; Bornstein, Michael; Dulal, S
Publication:Case Reports in Dentistry
Article Type:Report
Date:Jan 1, 2018
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