|Year : 2016 | Volume
| Issue : 1 | Page : 63-65
Inverted and impacted supernumerary tooth: Case report
Subraj Shetty, Treville Pereira
Department of Oral Pathology and Microbiology, School of Dentistry, Dr. DY Patil University, Navi Mumbai, Maharashtra, India
|Date of Web Publication||21-Jan-2016|
Department of Oral Pathology and Microbiology, School of Dentistry, Dr. DY Patil University, Sector - 7, Nerul, Navi Mumbai - 400 706, Maharashtra
Source of Support: None, Conflict of Interest: None
Inverted teeth have been reported in both maxilla and mandible and mostly they are inverted and impacted third molars and premolars. However, a few cases of inverted supernumerary teeth attached to an impacted third molar have been reported. This case report would add to the academic literature and case series on inverted and impacted teeth. The present case reports an inverted and impacted supernumerary tooth attached to a third molar in a middle-aged male patient.
Keywords: Impacted teeth, inverted tooth, maxilla, supernumerary teeth, third molar
|How to cite this article:|
Shetty S, Pereira T. Inverted and impacted supernumerary tooth: Case report. Muller J Med Sci Res 2016;7:63-5
| Introduction|| |
An impacted tooth is one that is erupted, partially erupted, or unerupted and will not eventually assume a normal arch relationship with the other teeth and tissues.  Tooth impaction is a frequent phenomenon but inversion of the impacted tooth is rare. Inverted tooth is the one where the crown is pointing downwards and the root apex pointing toward the alveolar crest.  Supernumerary teeth are defined as those that grow in addition to the normal series of deciduous or permanent dentition. They may occur anywhere in the mouth. 
We report a case of an inverted and impacted supernumerary tooth in a 28-year-old male patient.
| Case Report|| |
A 28-year-old male patient reported to our clinic for the extraction of grossly decayed teeth. On clinical examination, multiple grossly decayed teeth were observed in all the four quadrants. The maxillary left third molar had partially erupted from the palatal side [Figure 1]. There was a supernumerary tooth present in close association with the maxillary left third molar. Orthopantomogram (OPG) showed generalized presence of grossly decayed teeth. The maxillary left third molar was impacted. There was the presence of two supernumerary teeth in close association with the impacted third molar [Figure 2]. Grossly decayed teeth were extracted. Since the maxillary left third molar was erupting in a palatal direction, its extraction along with the extraction of the two supernumerary teeth was performed. During extraction, it was observed that the impacted supernumerary tooth was inverted and was attached to the third molar with the help of soft tissue [Figure 3]. Postoperative period was uneventful.
|Figure 1: Intraoral photograph showing partially erupted maxillary left third molar|
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|Figure 2: Orthopantomogram showing partial eruption of maxillary left third molar along with a fully erupted supernumerary tooth and an impacted supernumerary tooth|
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|Figure 3: Maxillary left third molar along with the two supernumerary teeth with one of them attached to the third molar|
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| Discussion|| |
A supernumerary tooth is one that is additional to the normal series and can be found in almost any region of the dental arch. Supernumerary teeth may be encountered by the general dental practitioner as a chance finding on a radiograph or as the cause of an impacted permanent tooth. They may also be found intraorally following spontaneous eruption.  In the present case, discovery of the two supernumerary teeth was a chance finding. One supernumerary tooth was discovered upon clinical examination and the other one was discovered after radiographic examination. Supernumerary teeth can be classified according to the chronology, location (topography), morphology, and their orientation. Chronologically, they can be classified as predeciduous, similar to permanent teeth, and postpermanent or complementary; morphologically, they can be classified as conical, tuberculate, supplemental (eumorphic), and odontome; topographically, they can be classified as mesiodens, paramolar, distomolar, and parapremolar, and according to orientation they can be classified as vertical, inverted and transverse. Paramolar are supernumerary molars, usually rudimentary (dysmorphic), situated bucally or lingually/palatally to the molar row. Mostly, they are situated between the second and third molars, while in very rare cases they can be found in between the first and second molars. Distomolars are situated either directly distal or distolingual to the third molar and are usually of rudimentary conical shape.  The supernumerary teeth in the current case were situated distal to the third molars and hence may be classified as distomolars. They were conical in shape and one of the two supernumerary teeth was inverted.
The exact etiology of the supernumerary teeth has not yet completely understood. Several theories have been suggested for their occurrence, such as the phylogenetic theory, the dichotomy theory, occurrence due to hyperactive dental lamina, and due to a combination of genetic and environmental factors. Generally, multiple supernumerary teeth are associated with diseases or syndromes. Supernumerary teeth show strong association with developmental disorders such as cleft lip and palate, cleidocranial dysostosis, and Gardner syndrome and less commonly with Ehlers-Danlos syndrome More Details, Fabry-Anderson's syndrome, chondroectodermal dysplasia, incontinentia pigmenti, and trichorhinophalangeal syndrome. 
As such, supernumerary teeth do not cause any complication. However, these may lead to delay or failure of eruption of permanent teeth, displacement, crowding, root resorption, dilacerations, loss of vitality of adjacent teeth, subacute pericoronitis, gingival inflammation, periodontal abscesses, dental caries due to plaque retention in inaccessible areas, incomplete space closure during orthodontic treatment, and pathological problems such as dentigerous cyst formation, ameloblastomas, odontomas, and fistulae. They may also interfere in alveolar bone grafting and implant placement.  The two supernumerary teeth in the present case may have altered the path of eruption of the maxillary left third molar.
They may appear as a single tooth or multiple teeth, unilaterally or bilaterally, erupted or impacted, and in mandible/maxilla or both the jaws. The prevalence of supernumerary teeth varies between 0.1% and 3.8% and is more common in the permanent dentition.  In a survey of 2,000 school children, Brook found that supernumerary teeth were present in 0.8% of primary dentitions and in 2.1% of permanent dentitions. 
The low prevalence of supernumerary teeth in primary dentition because they are generally overlooked by the parents, are often of normal shape (supplemental type), erupt normally, and appear to be in proper alignment.  The incidence is considerably higher in the maxillary incisor region followed by the maxillary third molar and mandibular molar, premolar, canine, and lateral incisors. Though there is no significant sex distribution in primary supernumerary teeth, males are affected approximately two times more than females in the permanent dentition. 
An impacted tooth is is prevented from its normal path of eruption in the dental arch due to the lack of space in the arch or obstruction in the eruptive pathway of the tooth. Impacted teeth may therefore be nonfunctional, abnormal, or pathological. Maxillary and mandibular third molars as well as the maxillary cuspids are the most frequently impacted teeth in the permanent dentition. 
Local factors include crowding, ectopic position of the tooth germ, supernumerary teeth, and soft tissue or bony lesions contribute to tooth impaction. Most of the theories related to tooth impaction stress on the discrepancy of jaw size to the tooth. Impacted teeth may be associated with periodontal disease, dental caries, odontogenic cyst and tumors, pain of unerupted origin, jaw fracture, and resorption of root of the adjacent tooth. Many kinds of impaction include vertical, horizontal, buccal, lingual, and even inverted impaction. 
Inverted teeth have been reported in both maxilla and mandible and most of them are inverted and impacted third molars and premolars. The term "inversion" is defined as "the malposition of a tooth in which the tooth has reversed and is positioned upside down." 
Although inverted and impacted tooth may remain in position for years without clinical manifestation as seen in our case and may be detected in radiographic examinations incidentally, many complications including delayed or ectopic eruption, crowding, diastema, eruption into the nasal floor, resorption of the adjacent root, and development of a dentigerous cysts are associated with it.
Eruption of the inverted tooth is extremely rare, but it has been described for incisors and premolars. 
It is clear in literature that there are no exact treatment protocols for removing inverted teeth. The most conservative treatment is considered the safest protocol. The surgical intervention for inverted molars is more complicated than other types of impactions because the abnormal position of the crown makes it greatly inaccessible and thus it requires exhaustive bone removal, and the loss of excessive bone and nerve damage are the major disadvantages in such cases. 
Possible treatment protocol for impacted inversion is entirely dependent on the patient's needs, findings, and the surgeon's skill.
| Conclusion|| |
Supernumerary teeth can present in any region in the oral cavity. They may erupt or remain impacted and can lead to complications. Though paramolars occur rarely, a clinician should be aware of its presence and formulate a sound treatment plan, to meet the challenges. Herein, we present a rare case of an inverted and impacted supernumerary tooth fused to a maxillary third molar. This case report could further add to the present academic literature available.
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Conflicts of Interest
There are no conflicts of interest.
| References|| |
Mwaniki D, Guthua SW. Incidence of impacted mandibular third molars among dental patients in Nairobi, Kenya. Trop Dent J 1996;19:17-9.
Jacobs R, Willems G. Inverted eruption of a supplemental lower premolar: Report of an unusual case. Int J Paediatr Dent 2003;13:46-50.
Yusof WZ. Non-syndrome multiple supernumerary teeth: Literature review. J Can Dent Assoc 1990;56:147-9.
Shah A, Gill DS, Tredwin C, Naini FB. Diagnosis and management of supernumerary teeth. Dent Update 2008;35:510-2, 514-6, 519-20.
Scheiner MA, Sampson WJ. Supernumerary teeth: A review of the literature and four case reports. Aus Dent J 1997;42:160-5.
Brook AH. Dental anomalies of number, form and size: Their prevalence in British schoolchildren. J Int Assoc Dent Child 1974;5:37-53.
Garvey MT, Barry HJ, Blake M. Supernumerary teeth : An overview of classification, diagnosis and management. J Can Dent Assoc 1999;65:612-6.
Pai V, Kundabala M, Sequiera PS, Rao A. Inverted and impacted maxillary and mandibular third molars: A very rare case. J Oral Health Comm Dent 2008;2:8-9.
[Figure 1], [Figure 2], [Figure 3]