Académique Documents
Professionnel Documents
Culture Documents
ABSTRACT. Aim This was to assess the predictability of eruption of delayed permanent incisors after
supernumerary removal and creation of adequate space, in relation to: root maturity, degree of vertical impaction,
and degree of angulation of impaction. Methods The dental records of children with supernumerary teeth
delaying the eruption of permanent incisors were analysed. The type of a supernumerary tooth, its location and
position were recorded, along with the stage of root maturation, angulation and vertical distance of impaction of
the permanent incisor. At the initial surgery, the unerupted supernumerary tooth and any retained primary incisors
were removed. The unerupted permanent incisor was not exposed. If necessary, the maxillary primary canines
were removed to create sufficient space for eruption of the delayed permanent tooth. A secondary surgical
procedure was planned after 18 months if there was no significant progress of the permanent tooth towards
eruption. Statistics All data were entered onto a Microsoft Excel spread sheet and analysed using Fisher’s Exact
Tests throughout due to the small numbers. Results Sixty-six supernumerary teeth were removed, 22 from boys and
44 from girls with ages ranging from 6 to 10 years 6 months at the time of surgery. Primary canines were extracted
in 59.1% of cases. Spontaneous eruption occurred in 89.4% of delayed permanent teeth. The mean time to eruption
was 9.2 months (median = 7 months). There was no statistically significant association between tooth eruption and
root maturity or the degree of vertical impaction. There was an association between eruption and the degree of the
angle of impaction of the permanent incisor (p<0.05). Conclusion The majority of delayed permanent teeth erupt
spontaneously if sufficient space is available or created at the time of removal of the unerupted supernumerary. The
angulation of impaction of the permanent incisor is associated with a delay in eruption.
syndrome, with reported frequencies of up to 22% midline shift, with a subsequent need for orthodontic
[Garvey et al., 1999]. treatment.
Classification. Supernumeraries are classified The aim of this study was, therefore, to assess the
according to their morphology and location. In the predictability of eruption of delayed permanent
primary dentition, they are usually of normal incisors, after supernumerary removal and creation of
morphology (supplemental) or conical, and generally adequate space, in relation to: root maturity, degree of
erupt. In the permanent dentition, the morphology is vertical impaction, and degree of angulation of
more varied. They are classified as conical, impaction of the permanent tooth, and the type,
tuberculate, supplemental or odontome. Conical location and orientation of the supernumerary tooth
supernumeraries are the most common form [Liu, removed.
1995; Rajab and Hamdan, 2002], accounting for
approximately 75%, followed by tuberculate (12%),
supplemental (7%) and odontomes (6%). True midline Materials and methods
conical supernumeraries are often referred to as Children were assessed in the Department of Child
mesiodens. Dental Health at Newcastle Dental Hospital following
Their orientation is described as vertical (i.e. referral for the management of unerupted
normal), inverted (upside-down) or transverse supernumerary teeth, either as a chance finding or as
(horizontal). Several studies have shown inverted the result of the delayed eruption of a permanent
supernumeraries to be the most common [Tay et al., incisor. The data for children attending between May
1984; Liu, 1995] although Rajab and Hamdan [2002] 1994 and December 2000 were identified from the
showed 83% to have a normal vertical orientation. Paediatric Dentistry National Audit Package [Royal
Diagnosis. The presence of supernumerary teeth College of Surgeons of England, 2000]. The children
may be diagnosed as the result of a clinical problem, or were included in the present study if they fulfilled the
may be an incidental finding on a radiograph. Clinical following criteria:
problems may be associated with both erupted and - medically fit and well,
unerupted supernumeraries, and include the following: - delayed eruption of a permanent incisor associated
- failure of eruption of a permanent tooth; this occurs with one or more unerupted supernumerary teeth. In
most frequently in the maxillary incisor region. this context, delayed eruption is defined as a tooth
Tuberculate supernumeraries are more likely to delayed more than 6 months beyond the eruption of
impede eruption, especially if they are palatally its altemere, or beyond the eruption of the next tooth
placed [Mason et al., 2000], in the series.
- displacement or rotation of a permanent tooth Fifty-five patient records were available for analysis.
[Howard, 1967], All children had been assessed and treatment
- crowding, especially in the maxillary lateral incisor planned by a paediatric dentist. Details of their
region with the eruption of a supplemental incisor,. hospital number, gender, date of birth, date of first
- abnormal diastema, associated with an erupted or assessment, and reason for referral were identified
unerupted mesiodens, from the dental hospital records, and entered onto
- dilaceration, delayed or abnormal root development; specially prepared data collection sheets.
occasionally, the presence of a supernumerary may Radiographic assessment and localisation of the
lead to resorption of the roots of adjacent permanent supernumerary and unerupted permanent teeth were
teeth, completed by two observers using panoramic and
- cyst formation, maxillary standard occlusal views. Some children also
- eruption into the nasal cavity of an inverted had parallax periapical views taken.
supernumerary. From the radiographs the following assessments
Treatment. The options for dealing with were made:
supernumerary teeth depend on their position and - the permanent tooth (or teeth) delayed (FDI
orientation, the age of the patient and any associated notation),
clinical problems. Early surgical intervention carries - the type of supernumerary (conical/tuberculate/
the risks of psychological disturbances to the child, odontome/supplemental),
and damage to the adjacent unerupted developing - the location of the supernumerary (maxillary
teeth. Late intervention may be associated with loss of central/maxillary lateral/mandibular central/
the eruptive potential of the unerupted permanent mandibular lateral),
teeth, loss of anterior arch space and curvature, and a - the orientation of the supernumerary (inverted/
Additional space was created at the time of the first For the whole group, there was no statistically
surgery by extraction of the primary canines in 33/55 significant association between tooth eruption and
(60%) cases. A space maintainer was fitted in 10 vertical distance or apical development (Table 3).
cases (15.2%), and additional space created with a However, there was a statistically significant
fixed or removable appliance in 21 cases. association between eruption and the angle of the
Spontaneous eruption occurred in 59 of the 66 long axis of the permanent incisor (p=0.048). In
delayed permanent teeth (89.4%), without the need those teeth that did not erupt, four had an angle of
for further intervention. Eruption occurred in less <30°, compared with three at 30°–60°. In contrast, in
than 12 months in 42 teeth (66%), 11 (18.6%) in 12- those teeth that did erupt, 53 (90%) had an angle of
23 months, and 6 (10.2%) in 24-35 months. The <30°, compared with only 6 (10.2%) with an angle of
mean time from first instance of surgery to eruption 30°–60°.
was 9.2 months (median = 7 months, range 1-27 Of the teeth that erupted spontaneously (Table 4),
months). there was a statistically significant difference
In the seven cases where further treatment was between time to eruption and vertical distance
needed, this was carried out between 18 and 34 (p=0.022). There were 42/59 teeth that erupted
months after the initial surgery. In three children, within the first 12 months from initial surgery
only soft tissue removal was required. In the (71%), and 25 of these (60%) were 16 mm or more
remaining four cases, a mucoperiostial flap was from the nasal spine (i.e. closer to the alveolar
raised and either apically repositioned or an ridge). Neither the angle of the long axis nor the
attachment bonded to the unerupted incisor prior to apical development were statistically significantly
replacement of the flap. Five of the secondary associated with the time to eruption in those teeth
surgical procedures were carried out under general which erupted spontaneously.
anaesthesia, and the remaining two under local The effect on the subsequent eruption of the
analgesia. Only one child required the creation of permanent teeth of the type, location and orientation of
additional space by the extraction of primary canines. the supernumerary teeth prior to their removal could
Following the secondary surgical procedure, space not be assessed because of the small numbers
was controlled with a maxillary fixed orthodontic involved. The type of supernumerary associated with
appliance in four instances. The time from secondary the teeth that did not spontaneously erupt after surgery
surgery to eruption ranged from 1 to 25 months, with was 4 conical, 2 tuberculate and 1 odontome. One
four teeth erupting within 3 months. The mean time supernumerary was inverted; 4 were single and 3 were
to eruption was 8.1 months (median 3 months). double.
TABLE 3 - Association between tooth eruption and vertical distance, angulation and apical development
of the permanent incisors in relation to supernumerary teeth.
Angulation
<30 degrees 92.9 [39] 81.8 [9] 83.3 [5]
30-60 degrees 7.1 [3] 18.2 [2] 16.7 [1] 0.262
Apical development
Divergent 26.2 [11] 35.4 [4] 66.7 [4]
Parallel 42.9 [18] 45.5 [5] 33.3 [2]
Convergent 31.0 [13] 18.2 [2] 0 0.324
TABLE 4 - Association between time to eruption and vertical distance, angulation and apical development
in the permanent incisors that erupted spontaneously following supernumerary removal [N=59].