Multiple Bilateral Supplemental Premolars in Non-Syndromic Patients- Report of Two Cases

Supernumerary teeth are superfluous teeth present in the oral cavity. They represent only a small percentage, prevalence rates being 0.1 -6.9% in permanent dentition and 0.4-0.8% in deciduous dentition. ^[1]. Supplemental teeth are a type of supernumerary teeth that has a normal, shape and size, resembling the natural tooth it is associated with.  Etiopathogenesis usually are developmental anomalies caused by either dental lamina hyperactivity or explained by dichotomy theory where the tooth germ divides into two equal or different-sized parts, resulting in the formation of two teeth of equal size or one normal and one dysmorphic tooth. Supernumeraries can lead to problems like delayed eruption of teeth, malocclusions, crowding, or cyst formation, requiring diagnosis via radiographs and potential surgical removal ^[2].

Case report 1–

A male patient aged 31 years reported to the department with the chief complaint of pain in his upper and lower right back tooth region since 1month.His medical and family history were non contributary. On intraoral examination, a carious lesion was present in #46 and the tooth was tender on palpation, root-stump in #17 and grossly decayed # 37. Maxillary arch showed palatally erupted supernumerary tooth in the interdental region of #24/#25 and mandibular arch showed lingually erupted and buccally rotated supernumerary in the region of # 34/35 (Figure 1A). A panoramic radiograph revealed 2 impacted and 2 erupted supernumerary premolars in maxillary and mandibular arches.1 impacted supernumerary teeth was present in the region of #14/#15 and 1 impacted supernumerary in the region of #44 and 1 erupted premolar in the region of # 24/#25 and 1 premolar in region of # 34/35 (Figure 1B). #46 showed periapical abscess and internal resorption in #11. Endodontic treatment was advised for #46.

Figure 1a&1b– Intraoral Image Showing Presence Of Erupted Supplemental Premolar .1b-Opg Showing Impacted And Erupted Premolars

Case report 2 –

A male patient aged 26 years reported to the department with chief complaint of irregularly placed teeth .On intraoral examination  crowding in maxillary and mandibular arch was noted with the presence of supernumerary premolars ,maxillary arch showed palatally erupted supernumerary teeth in the interdental region of #14/15, #21/22 and #24,25 respectively  and mandibular arch showed lingually erupted supernumerary in the region of # 34/35(Figure 2A) .A panoramic radiograph showed multiple impacted and erupted  supplemental premolars, in right maxillary arch 1 impacted and 1 erupted premolar in the region of #13/#14 and #14/#15 respectively. In the left maxillary premolar region, 1 impacted supernumerary was present as interradicular radiopacity in region of #22/#23 and 2 erupted supernumeraries in the region of #21/#22 and #24/#25 respectively. In the right mandibular premolar region, impacted supernumerary in the region of #43/#44 and left mandibular region 1 erupted supernumerary premolar in region of#33/#34 (Figure 2B). Patient was advised for orthodontic treatment with extraction of supernumerary teeth.

Figure 2a &2b -Intraoral Image Showing Presence Of Erupted Supplemental Premolar .2b-Opg Showing Impacted And Erupted Premolars

On general physical and extraoral examination in both the cases, there were no signs or symptoms for any syndromic manifestations. Based on clinical and radiographic findings, the cases were diagnosed as non-syndromic multiple erupted and impacted supernumerary teeth in relation to premolars. Patients were informed about supernumerary teeth and treatment was planned according to the complaint.

DISCUSSION

Supernumerary teeth do not resemble and have a morphology that swerves from the normal appearance of the teeth. However, the term supplemental is used when the teeth are extra but have the shape and size identical to normal teeth³. Extra teeth are common but supplemental teeth are rare and are usually found in syndromic patients. They can be erupted or unerupted and can be found in well-nigh any area of the dental arches and are commonly an incidental finding during radiographic evaluation. Both the primary and permanent dentitions may encompass them but more commonly seen in permanent dentition^[3]. Supernumerary teeth can be classified according to their number, location and morphology. They can be rudimentary or supplementary, single or multiple. A classification was proposed by Kalra et al in 2005 ^[4](Table1).

Presence of such supernumeraries impacted or erupted may lead to delayed eruption, impaction, crowding and may be associated with any pathological conditions like cyst formation. Hence, they need to be carefully evaluated and treated to prevent such complications. The most effective care is made possible by the timely detection of supernumerary teeth, resulting in less invasive surgery, orthodontic treatment and associated consequences. Usually supernumerary teeth are treated surgically if posing problems like delayed eruptions, malocclusions or cyst formation and in cases where they do not cause alterations in the integrity eruption or position of the permanent dentition more conservative approach is favoured. Each case must be therefore considered individually concerning its treatment ^[5]. Regular observations with radiographs is recommended. A decision tree for management of supernumeraries was formulated by Amarlal et al ^[6] (Table 2).