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International journal of odontostomatology

On-line version ISSN 0718-381X

Int. J. Odontostomat. vol.8 no.3 Temuco Dec. 2014

http://dx.doi.org/10.4067/S0718-381X2014000300010 

Int. J. Odontostomat., 8(3):377-383, 2014.

 

Prevalence of Supernumerary Teeth on Panoramic Radiographs in a Non-Adult Peruvian Sample

 

Prevalencia de Dientes Supernumerarios en Radiografias Panoramicas de una Muestra de Peruanos no Adultos

 

Iván E. Pérez*; Allison K. Chávez** & Darío Ponce*

* Centro para la Investigación de las Desarmonías Dentofaciales (CIDDENT), Lima, Perú.

** Facultad de Estomatología. Departamento de Clínica Estomatológica, Universidad Peruana Cayetano Heredia, Lima, Perú.

Corresponcence to:


ABSTRACT: The design of the present study was transversal and descriptive, the objective was to determine the prevalence and distribution of supernumerary teeth in panoramic radiography from Peruvians in Lima - Peru. The panoramic radiography of 1754 non-syndromic patients between 3 to 20 years of age were evaluated in order to determine the presence of supernumerary teeth and associated variables like number of supernumerary teeth, affected jaw and region, type according to shape, type according to location, eruption status and complications. The prevalence of supernumerary teeth was 4.62% (81 patients, 113 supernumerary teeth), 2.22% in females (39 patients, 53 supernumerary teeth) and 2.4% and in the males (42 patients, 60 supernumerary teeth). A singly supernumerary tooth (72.8%), in the maxilla (72.8%) and the antero-superior region (55.8%) was the most frequent presentation; the conical (39%) and supplementary shape (25.6%) along with the anterior supernumerary teeth (34.5%) and parapremolar supernumerary teeth (31.9%) were the most frequent shape an location found; the intraosseous (46.9%) and impacted (24.8%) were the most frequent eruption status found; and the malposition of nearby teeth (38.1%) was the most frequent complication. The prevalence of supernumerary teeth in Peruvians was higher than that reported in the literature and the distribution of the supernumerary teeth associated variables was similar to those reported in the literature.

KEY WORDS: tooth abnormalities, tooth, supernumerary tooth, supernumerary/radiography tooth, supernumerary/diagnosis tooth, unerupted/radiography radiography, panoramic.


RESUMEN: El presente estudio es de tipo transversal y descriptivo. El objetivo fue determinar la prevalencia y distribución de dientes supernumerarios en radiografías panorámicas de pacientes peruanos. Se evaluaron las radiografías panorámicas de 1754 pacientes entre los 3 a 20 años de edad para determinar la prevalencia de dientes supernumerarios así como las variables de cantidad, maxilar afectado, región afectada, forma, ubicación, estatus de erupción y complicaciones. La prevalencia de dientes supernumerarios fue de 4,62% (81 pacientes, 113 dientes supernumerarios), 2,22% en mujeres (39 pacientes, 53 dientes supernumerarios) y 2,4% en hombres (42 pacientes, 60 dientes supernumerarios). Los dientes supernumerarios singulares (72,8%), ubicadas en el maxilar (72,8%) y en zona anterosuperior (55,8%) fue la presentación más frecuentemente encontrada; la forma cónica (39%) y suplementaria (25,6%) junto a los dientes supernumerarios anteriores (34,5%) y para premolares (31,9%); evolución intraósea (46,9%) e impactadas (24,8%); y la alteración de dientes adyacentes (38,1%) fueron las formas, locaciones, estatus de erupción y alteraciones más frecuentementes encontradas. La prevalencia de dientes supernumerarias en peruanos fue mayor que la reportada en la literatura; la distribución de las variables relacionadas a los dientes supernumerarios fue similar a lo reportado en la literatura.

PALABRAS CLAVE: anomalías dentarias, diente supernumerario, diente supernumerario/radiografía diente supernumerario/diagnóstico, diente no erupcionado/radiografía, radiografía panorámica.


 

INTRODUCTION

The supernumerary teeth (SNT) or hyperodontia is a developmental alteration expressed as teeth formed in excess of the normal dental formula (Ashkenazi et al., 2007) that may occur singly or multiple, uni or bilaterally and in one or both jaws (Kara et al., 2012), with shape and size usually consistent with the dentition in the region of the jaw in which they are localized or with little or no resemblance (Fleming et al., 2010) and it may be encountered as a chance finding during routine radiographic evaluation or as the cause of an impacted teeth (Garvey et al., 1999).

The SNT can be classified (Fleming et al.) according to their: (a) shape as rudimental or supplemental teeth; (b) chronology as pre-deciduous, similar-to-permanent teeth and post-permanent or complementary; (c) topography as mesiodens, paramolar, distomolar and parapremolar; and (d) orientation as vertical, inverted and transverse (Parolia et al., 2011). A SNT can remain impacted for many years without complications or be the cause of complications related with tooth eruption and development of the dentition (Schmucki et al., 2010) that includes: comprised space closure (Orhan et al., 2006); closure of the eruption path leading to delayed or non-eruption (Khandelwal et al., 2011); crowding (Kara et al.); diastema (Mali et al., 2012); resorption or malformation of adjacent roots due pressure with lose of vitality of adjacent teeth (Parolia et al.); cystic formation (Acikgöz et al., 2006); and interference with orthodontic mechanics (Orhan et al.) or alveolar bone grafting or implant placement (Parolia et al.). The objective of the present study was to determine the prevalence of supernumerary teeth in the panoramic radiography of Peruvian patients between 3 to 20 years of age, determine if there are significant differences between genres and compare our findings with similar studies in the scientific literature.

MATERIAL AND METHOD

The present study is descriptive and transversal, and was performed utilizing the digitalized images of panoramic radiographs of 1754 non-syndromic patients between 3 to 20 years who attended a private radiological center from January 2011 to December 2012. The exclusion criteria were: (a) patient age older than 20 years, (b) poor quality image, (c) cleft palate, (d) any syndrome, and (e) odontogenic tumors (including odontoma).

When a SNT was found, the information about the number (one, two or multiple), the afflicted jaw (maxilla, mandible or both), the region (anterior or posterior), the shape type (conical, supplementary or tuberculated), the topography type (anterior, mesiodens, parapremolar, paramolar or distomolar), the eruption status (intraosseous, impacted or extraosseous-erupted), the dental development status (crypt, incomplete crown, complete crown-incomplete root), the inclination-position (vertical-inclined, horizontal, transversal, inverted), and the alterations on nearby teeth (blockage of eruption, impaction, malposition of nearby teeth and no effect) were recorded. The term undetermined was used when we could not determine any of the SNT characteristic described before.

Database was grouped in Microsoft Office Excel and the statistical analysis of the data was performed by the use of the SPSS 21.0 statistical package (SPSS Inc., Chicago, IL). The determination of the significant differences between genres was determined by the chi-squared test with a confidence level of 95%.

In order to assess the strength of agreement, 271 radiographic images were randomly selected and reevaluated to determine the Kappa statistic value which was 0.87 that means an excellent strength of agreement.

Fig. 1. Images of anterior SNT: (A) Erupted mesiodens with blockage of the eruption of 11.
(B) Impacted microtooth with blockage of the eruption of 13.
(C) Erupted supplemental tooth superimposed to 11.

Fig. 2. Images of posterior SNT: (A,B) Supplementary parapremolar in intraosseous evolution.
(C) Distomolar in intraosseous evolution. (D) Paramolar in intraosseous evolution with blockage of the eruption of 47.

RESULTS

Of the 1754 patients, 977 (55.7%) were female and 777 (44.3%) were male; the mean age was 12.15 ± 3.55 years. The prevalence of SNT was 4.62% (81 patients, 113 SNT), 2.22% in female (39 patients, 53 SNT) and 2.4% in male (42 patients, 60 SNT), the male to female ratio was 1.1:1. There were no significant differences in the frequency of the SNT between genres according to the chi-squared test (p>0.05).

The SNT were most frequent in the maxilla in both genres (72.8%), with a singly presentation (72.8%) and in the antero-superior region (55.8%). The conical shape was the most frequent (39%, 45.5% of them were mesiodens), followed by the supplementary shape (25.6%, 65.6% of them were parapremolars and the rest were anterior teeth) and then by the tuberculated shape (8% mostly SN-molars); the undetermined shape was 27.5% because the dental development were in the early stages and the final SNT shape could not be determined. The distributions of the distinct variables of the SNT in both sexes are described in Table I.

Table I. Prevalence, distribution and related
variables of the supernumerary teeth in Peruvians.

DISCUSSION

The reported prevalence of the SNT in distinct countries varies between 0.3­0.85% for Arabia (Osuji & Hardie, 2002; Afify & Zawawi, 2012); 1.4­3.7% for Brazil (Küchler et al., 2011; De Oliveira Gomes et al., 2008); 2.7­3.4% for China and Japan (Kumar et al., 2012); 0.72­0.74% for Iran (Amini et al., 2013; Vahid-Dastjerdi et al., 2010); 0.85% for Lithuan (Trakiene et al., 2013); 3.2% for Mexico (Salcido-Garcia et al., 2004); 2.8% for Portugal (Coelho et al., 2011); 0.4­3.2% for Spain (Leco Berrocal et al., 2007; Ferrés-Padró et al., 2009; Fernández Montenegro et al., 2006); 1.5% for Sweden (Schmucki et al.); and 0.4­1.9% for Turkey (Kapdan et al., 2012). The studied sample was Peruvian and the prevalence of SNT was higher than those in other countries including México.

The distribution of SNT appears to be different regarding sex with males affected approximately twice than females in the permanent SNT (Parolia et al.). The male-to-female ratio reported in the literature were 1.45:1 to 2.1:1 in Brazilian (Küchler et al.; De Oliveira Gomes et al.); 3:1 to 6.5:1 in Chinese (Esenlik et al., 2009; Anthonappa et al., 2008); 2.9:1 in Indian (Sharma & Singh, 2012; Mukhopadhyay, 2011; Khandelwal et al.); 5:1 in Iranian (Meighani & Pakdaman, 2010); 2.8:1 in Japanese (Asaumi et al., 2004); 2.2:1 in Jordanian (Esenlik et al.); 1.18:1 in Mexican (Salcido-García et al.); 1.4:1 to 2.3:1 in Spanish (Leco Berrocal et al.; Ferrés-Padró et al.); and 1.13:1 to 1.4:1 in the Turks (Esenlik et al.; Öztas et al., 2011). The male-to-female ratio found in the present study (1.1:1) is lower than those reported for most countries with an exception for Turks (Esenlik et al.; Öztas et al.) and Mexicans (Salcido-García et al.), this suggests that the prevalence of SNT could not be related to sex in the studied sample.

The SNT are singly in 76-86% of the cases, while double SNT occurs in 12-23% and multiple SNT occurs in less than 1% of the cases (Khandelwal et al.; Kumar et al.). Cases involving one or two SNT most commonly affect the anterior maxilla, followed by the premolar region; and cases involving multiple (more than five) SNT tend to involve the mandibular premolar region (Shah et al., 2008). The distribution of single-double-multiple SNT per case in distinct countries is 64.1%­25.6%­0.095% for American Blacks and Whites (Harris & Clark, 2008); 92.5%­30.8%­6.2% for Brazilian (Küchler et al.; De Oliveira Gomes et al.); 61.5%-29.8% for Chinese (Anthonappa et al.); 79%­20%­1% for Indian (Sharma & Singh); 100%­14.3% for Iranian (Amini et al.; Vahid-Dastjerdi et al.); 90%­7.5%­2.5% for Portuguese (Coelho), 77.5%-27.85%-2.8% in Spanish (Ferrés-Padró et al.; Fernández Montenegro et al.); 78.2%­24%­24.3% in Turks (Esenlik et al.; Öztas et al.; Peker et al., 2009). The distribution of single-double-multiple SNT found in the present study was 72.8%­21%­6.2%, which is similar to the results found in the literature with an exception for Turks.

The shape classification of the SNT is one of the most important variables in their investigation, Küchler et al. and De Oliveira Gomes et al. (Brazil) reported a frequency of 55.5%­54.3% of conical SNT, 25.9%­38.6% of tuberculated SNT and 18.5%­16.7% of supplemental SNT respectively. Anthonappa et al. (China) reported 71.5% of conical SNT, 11.6% of supplemental SNT and 10.9% of tuberculated SNT. Sharma & Singh (India) reported 59.7% of conical SNT, 18.2% of supplemental SNT, 14.3% tuberculated SNT and 7.8% molariform SNT. Vahid-Dastjerdi et al. (Iran) reported 42.8% of conical SNT, 21.4% of supplemental SNT and 14.2% of tuberculated SNT. Fernández-Montenegro et al. and Ferrés-Padró et al. (Spain) reported 56.5%­69.62% of conical SNT, 19.3%­17.72% of supplemental SNT and 11.39% of tuberculated SNT. Esenlik et al. and Öztas et al. (Turkey) reported 50%­29.3% of conical SNT, 47.6%­42.2% of supplemental SNT, 2.3%­28.4% of tuberculated SNT respectively. Our results confirms the conical-supplemental-tuberculated order when compared to similar studies, the difference in the frequency of tuberculated SNT may be due to differences in the age range and the higher frequency of undetermined shape because the incomplete crown formation.

The topographical-classification of SNT has been extensively reported; Harris (USA) reported 43.75% of distomolars, 32.8% of premolars, 15.6% mesiodens and 7.8% of anterior teeth. Osuji & Hardie (Arabia) reported 55% of mesiodens, 45% of anterior teeth. Küchler et al. and De Oliveira Gomes et al. (Brazil) reported 33.33%­28.4% of mesiodens and 14.8% of premolars respectively. Anthonappa (China) reported 81.4% of mesiodens and 14.4% of anterior teeth. Amini et al. (Iran) reported 58.3% of mesiodens, 25% of anterior teeth and 16.7% of paramolars. Trakiene et al. (Lithuan) reported 0.73% of mesiodens. Coelho et al. (Portugal) reported 60% of mesiodens, 26.7% of anterior teeth and 13.3% of premolars. Leco-Berrocal et al., Fernández-Montenegro et al. and Ferrés-Padró et al. (Spain) reported 42.8%­18% and 6.33% for distomolar, 28.6%-46.9% and 53.16% for mesiodens, 4.8%­25.32% for anterior teeth, 24.4%-24.1% and 12.67% for premolars, 5.6%­2.5% for paramolars and 18.99% for anterior teeth. Esenlik et al., Peker et al. and Öztas et al. (Turkey) reported 51.2%­19.2% and 19.8% for mesiodens, 28.6%-8.2% and 3.5% for anterior teeth, 20.3%-35.7 and 43.1% for premolars, 26.5%­31% for distomolars, and 5.5%­2.6% for paramolars. Salcido-García et al. (Mexico) reported 40.5% for mesiodens, 36.3% for premolars, 1.7% for anterior teeth, 4.9% for distomolar and 4.8% for paramolar. Our results demonstrate that anterior SNT were the most frequently found (34.51%), followed by premolars (31.85%), mesiodens (23.92%) and paramolar­distomolar teeth (9.72%); such differences with respect to previous studies may represent a characteristic distribution of SNT in the studied sample of Hispano-American Peruvians.

The SNT with normal orientation will usually erupt; however, only 13­34% of all SNT are erupted (Shah et al.). Sharma & Singh (India) found 65% of unerupted (intraosseous or impacted) and 35% partially or fully erupted; Leco-Berrocal et al. (Spain) found 95.8% impacted and 4.2% erupted; Esenlik et al. (Turkey) found that 73.8% impacted and 26.2% erupted; Peker et al. (Turkey) found 69.9% impacted; and Salcido-García et al. (Mexico) found 97.2% impacted and 2.8% erupted. Our results (46.9% unerupted-intraosseous, 24.77% unerupted-impacted, 21.23% erupted-extraosseous) are similar to those reported by Sharma. Our results show a low frequency of impacted SNT and we must note that the age range of the studies of Leco-Berrocal et al. and Peker et al. were broader than ours (7­34 and 13­70 respectively, against 3­20) and that would suggests a possible positive association between the increase in age and the percentage of impacted teeth caused by the presence of SNT. The frequency of unerupted-intraosseous SNT found in the present study may be a temporary stage, which will change into an unerupted-impacted or erupted status if untreated.

The dental displacement and the failure in the eruption represent the most frequently complications reported in the literature (Leco-Berrocal et al.), the delayed eruption of the associated teeth has been reported to occur in 28-60% in Caucasians (Shah et al.). The complications caused by SNT have been reported in different studies, De Oliveira Gomes et al. (Brazil) found that 55.7% of the SNT caused permanent teeth displacement and 50.8% caused the failure of eruption. Anthonappa et al. (China) found that 53.8% of the SNT cause crowding and 6.8% cause an abnormal diastema. Leco-Berrocal et al. (Spain) found that 39% of the SNT cause the displacement of the adjacent teeth, the 12.5% cause radicular reabsorption and the 4.1% of the SNT cause the prevention of eruption. Our results are similar to those found in the literature, the malposition of nearby teeth (dental displacement) and the blockage-of-eruption/impaction represents the 38.05% and the 33.64% of all SNT respectively.

The overall patterns of presentation and incidence of SNT support the various theories proposed to explain how the condition arises and, from a developmental and molecular viewpoint, each one is plausible and can explain the origin of different types of SNT (D´Souza & Klein, 2007). The hyperactivity theory is the most accepted and hypothesizes that the dental lamina does not follow the programmed cell degeneration-death following the completion of the permanent tooth crown and continues his proliferation to form accessory tooth organs (Kara et al.; D´Souza & Klein; Wang & Fan, 2011; De Oliveira Gomes et al.). The germ dichotomy theory proposes that during early tooth development, the dental lamina splits into two parts of equal or different size, thus giving rise to two teeth with similar size, or one normal tooth and one dysmorphic tooth (Kara et al.; Wang & Fan). The atavism of phylogenetic theory (evolutionary throwback) suggests that the occurrence of SNT is a regression to the extinct ancestral tissues or anthropoids when our ancestor mammals have more teeth in each quadrant (Wang & Fan). The germ dichotomy and the atavism theories are actually discounted (Shah et al.).

At present, the most current knowledge is based upon mouse embryogenesis although the mice are not a perfect model because they only develop a single, highly-reduced (lacks of both premolars and canines) and primary dentition during their lifetime; however, the tight regulation of tooth initiation that occurs in these regions of the mouse jaw has provided useful insight into how tooth number is controlled at the molecular level (Fleming et al.). Moreover, the recent advances in cellular and molecular biology have led to the development of a variety of gene-targeting strategies and the analysis of the resultant mutant models have clarified specific functions of genes and their encoded proteins in embryogenesis and organogenesis, including tooth development (Nakamura & Fukumoto, 2013).

In conclusion, the prevalence of SNT in a sample of Hispano-American Peruvian was 4.62% and the most common presentation of a SNT were singly (72.8%), in the maxilla and the antero-superior region (72.8%­55.7%), with conical shape (38.9%) and anterior-type (34.5%), intraosseous or impacted (71.7%), vertical or inclined (48.7%) and causing the malposition of nearby teeth (38.1%) and there were no significant differences between genres in the frequency of the SNT.

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Corresponcence to:

Iván Pérez

Centro para la Investigación
de las Desarmonías Dentofaciales (CIDDENT)
Lima
PERÚ

Email: iepl76@yahoo.com

Received: 18-07-2014
Accepted: 13-11-2014

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