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Authors : Dr. M.K. Jindal, Dr. R.K.Tewari, Dr. Mohammad Abbas Khan

Mesiodens is a peg shaped supernumerary tooth located in the maxillary midline either in normal or inverted position. These supernumerary teeth occur frequently in permanent dentition but they are rare in deciduous dentitions. This article reports three different cases of inverted mesiodens of deciduous and mixed dentition.

An excess of teeth when compared to the normal dental formula is called as “hyperdontia or hyperdonua.” Several theories for the explanation of development of supernumerary teeth have been put forth which include split in tooth bud (dichotomy theory), locally conditioned hyperactivity of dental lamina (Dental lamina theory), phylogenetic reversion (Atavistic theory) and a combination of genetic and environmental factors (unified etiologic explanation) 1,2,3. However most of the cases have genetic background but environmental disturbances during initiation and proliferation phases of dental development at 6-8 months of Intrauterinal life may be responsible. The first case of supernumerary teeth was reported between 23 and 79 AD .4
Mesiodens may be found either singly or paired, erupt normally or stay impacted, follow an abnormal path of eruption or erupt at ectopic positions or may be even inverted .5, 6
Primosch classified supernumerary teeth in to two types based on shape-supplemental and rudimentary (dysmorphic including conical, tuberculate and molariform.)7
Mesiodens is defined as most common supernumerary tooth located mesial to both centrals, appearing like peg-laterals in a normal or inverted position.8 It is more commonly found in maxilla than mandible (8:1) with preponderance for premaxilla.7 The incidence of mesiodens in permanent dentitions ranges from 0.15% to 3.8%. In about 50% cases supernumerary teeth in primary dentition are followed by supernumerary teeth in permanent dentition.3

Case Report 1:-
A ten year old girl reported to the department of pedodontics  Dental College,  with the history of trauma in relation to upper front teeth. On examination Ellis Class III fracture was seen in relation to maxillary central incisors. The patient was advised intraoral periapical radiograph (fig.2) as well as orthopantomograph (fig.1)
Figure: 1- CASE I: Preoperative OPG showing inverted mesiodens Figure: 2 – Post obturation IOPA Radiogarph of Maxillary Central Incisors.
Both revealed completely formed inverted conical mesiodens. The patient was advised root canal treatment in the traumatized teeth followed by extraction of mesodens. The extraction of mesiodens was carried out using labial approach. After administration of Local Anesthesia, angulated flap incision was given in the gingival crevice of both central incisors with vertical incision extending into mucobuccal fold. After raising the muco-periosteal flap the overlying bone was removed using a chisel and mallet till the tooth was exposed. Deep cut was made on the side of root to elevate the tooth with straight elevators. The tooth was then extracted with the help of root forceps (fig.3). After proper cleaning of the area, the flap was repositioned and sutured
Figure: 3 – Surgical Procedure and Extracted teeth.
Case Report II:
- A nine year old boy reported to the department of pedodontics, with the complaint of pain in upper front teeth region with fractured front teeth. On examination, Ellis class IV fracture on maxillary left central incisor and Ellis class III fracture on maxillary right central incisor was found. The patient was advised intraoral periapical radiograph (fig.4). It was revealed by examining radiograph that paired impacted mesiodens were present just in relation to both the maxillary centrals. The mesiodens in relation to left central incisor was in normal position while the mesiodens  in relation to right central incisor was inverted. Root Canal Treatment was carried out in both the fractured central incisors and both impacted mesiodens teeth were extracted.
Figure: 4- CASE II: Showing normal and inverted mesiodens.
Case Report III:
Another patient, a five year old girl reported to the department of Pedodontics, with the complaint of pain in relation to upper front teeth .Patient was advised Intraoral Periapical Radiograph,  on radiographic examination it was revealed that mesiodens was present between the deciduous maxillary central incisors (fig.5). On radiograph, permanent maxillary central incisor was also seen in which root formation was incomplete, hence it was decided to keep patient on regular periodic observation until permanent central incisor erupts as extraction process may disturbed the erupting permanent centrals as well as it may result in loss of deciduous central leading to aesthetic loss of the patient which may further lead to psychological trauma to the child.
Figure: 5- CASE III: Showing inverted mesiodens in deciduous dentition.
The mesiodens in primary dentition is rare further inverted unerupted are
rarest of the case. A variety of complications are caused  due  to mesiodens , which include crowding , delayed  eruption , diastema , rotation , cystic lesion , resorption  of  adjacent teeth , etc . Supernumerary teeth may either occur as single dental anomaly or in  association with other development disturbances like cleft lip and cleft palate  (28%) , Cleido-cranial dysostosis ,Gardner’s syndrome, Down’s syndrome . 9
Detection of mesiodens or supernumerary teeth is best achieved by clinical examination and radiographs i.e. IOPA, Occlusal views, orthopantomograph etc. The management depends upon the type and position of such teeth and their effects on adjacent teeth. Before surgical removal accurate localization and relation to the roots of primary teeth and erupted and unerupted permanent teeth, the floor of the nose, maxillary sinuses and other structure must be assessed. 10
If the tooth is not interfering with the development and eruption of adjacent teeth and there is no evidence of cyst formation, the correct decision may be observation of the tooth till the child is old enough to tolerate the surgical procedure.

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