Palatally Positioned Two Mesiodens : A Case Report

Mesiodens is a supernumerary tooth located in the anterior maxilla, placed palatally, labially or in between the maxillary central incisors. It may be single or paired, erupted or impacted and at times even inverted. This case report describes a palatally positioned two mesiodens in an 8-yearold male. The clinical and radiographic appearance and therapeutic considerations are presented. The purpose of this article is to alert the clinician to the importance of radiographic localization prior to surgical intervention, because in some instances a labial surgical approach is preferred over the traditional palatal technique. In this case a labial surgical approach was utilized which allowed for greater conservation of alveolar bone and improved access during removal of the mesiodens teeth. (Agrawal S, Chandra P, Singh D, Agrawal S. Palatally Positioned Two Mesiodens: A Case Report. www.journalofdentofacialsciences.com. 2012; 1(1): 33-36)


Introduction
The term mesiodens was coined by Bolk (1917) to denote an accessory or supernumerary tooth situated in between the maxillary central incisors. 1,2It is usually a small tooth with a cone-or -peg shaped crown and a short root.The presence of a mesiodens should be suspected if there is delayed eruption of the permanent incisors or if the central incisors are displaced, malposed or exhibit spacing.The literature reports that 80% to 90% of all supernumerary teeth occur in the maxilla. 3

Case Report
An 8-year-old male reported to our dental clinic with a chief complaint of spacing in the upper front jaw since the permanent teeth have erupted.Two mesiodens were present and visible.He was a normal healthy child with a medical and dental history which was both noncontributory.He presented in the permanent dentition stage with a 60% overbite and an end to-end molar relationship, primary canines relating as Class I. Maxillary anterior spacing was slightly excessive with a 1-2 mm midline diastema present.
Radiographs then were taken in order to localize the supernumerary tooth roots and assess the potential surgical approach.

Radiographic Examination and Treatment Plan
The periapical radiograph depicted two vertical long axis of the mesiodens.Root development appeared normal with the mesiodens primarily affecting tooth position.From the radiographic survey it was determined that the mesiodens was likely inverted with the long axis oriented vertically.A labial surgical approach was planned to execute the mesiodens followed by orthodontic space closure after healing.

Treatment
The surgical procedure was performed in the outpatient dental clinic in local anesthesia under antibiotic coverage two days prior.After anesthesia was an elliptical incision was made from the distal aspect of the maxillary right lateral incisor to the distal aspect of the maxillary left lateral incisor.A full thickness flap then was reflected with a periosteal elevator.A slight elevation in the alveolus was evident midway between the root apices of the permanent central incisors.
Care was taken to avoid excessive bone removal or damage to roots of the adjacent permanent teeth.Silk suture were placed and postoperative instruction were explained and medication prescribed.The sutures were removed 1 week postoperatively with normal healing at the surgical site.Six month follow-up found continued eruption of the maxillary permanent lateral incisors with minimal scar formation in the area.Initiation of comprehensive orthodontic treatment with a removable appliance was done with the progressive activation of the appliance was done after three weeks of interval.

Discussion
A mesiodens is a supernumerary tooth located in the maxillary central incisor region.The overall prevalence of mesiodens is between 0.15% to 1.9%.Its incidence is estimated to be between 46 & 67% of all supernumerary teeth.Supernumerary teeth may occur in isolation or as part of a syndrome such as cleidocranial dysplasia, Gardner's syndrome, cleft lip & palate etc. 4 Mesiodens can occur individually or as multiples and often do not erupt.According to Asaumi JI et al the number of supernumerary teeth was one in 146 cases (73%), two in 52 cases (26%) and three in 2 cases (1%).76.8% of the children reported by Gunduz K et al had one mesiodens & 23.1% had two mesiodens bilaterally to the midline.In our case described here 2 mesiodens were located palatally. 5esiodens can be classified on the basis of their occurance in the permanent dentition (rudimentary mesiodentes) or primary dentition (supplementary mesiodentes) and according to the morphology as conical, tuberculated or molariform.Supplementary mesiodentes resemble natural teeth in both size & shape where as rudimentary mesiodens exhibit abnormal shape and smaller size. 3,6Conical mesiodens usually occur singly.They are generally peg shaped and are usually located palatally between the maxillary central incisors, tending to displace the erupting permanent central incisors.They often have a completely formed root and can erupt into the oral cavity.However they may be inverted with the crown pointing superiorly in which case they are likely to erupt into the nasal cavity.Only occasionally do the mesiodens imitate the shape of maxillary lateral incisors (eumorphic). 7learly, there are indications both for the early surgical removal of supernumeraries as well as for their supervised observation.The case presented depicts 2 mesiodens that did not change position in a reasonable period of time.They were positioned such that a diastema was created between the central incisors.There effect also altered the eruption path of the permanent lateral incisors.In the present case one would not expect significant improvement in the mesiodens position and its surgical removal was indicated.

Conclusion
Surgery involving a palatal flap is most typical for impacted maxillary midline supernumerary teeth.In this case, a labial surgical approach was utilized which allowed increased visualization of the mesiodens and greater ease of removal.The background and rationale for this approach is presented and should be considered in selected cases, particularly for older children with inverted mesiodens.