Accidental Finding of Supernumerary Teeth in Relation to Impacted Canine - A Case Report

INTRODUCTION

Occlusal and aesthetic issues will arise from the impacted tooth's failure to erupt in its proper position.^[1] The canine is the tooth that gets impacted after the third molar, and it occurs more frequently in the maxilla (0.8% to 2.8%) than in the mandible (0.2%).^[2] The canines are the last teeth to erupt in the arch and are impacted by several factors, including deflection (facially or palatally) of the lateral incisor, over-retention of deciduous teeth, and loss of space.^[3] To prevent the problems linked to the impacted canines, several treatment approaches have been suggested. These issues include loss of arch length, infection linked to partial eruption, internal or external resorption, and the resorption of the lateral incisor roots.^[4] The crucial stage in surgically exposing a tooth is determining the precise location of the tooth. Numerous techniques can be used, including occlusal radiographs, periapical radiographs, and palpation of the teeth's labial surface.^[5] Cone-beam computed tomography (CBCT) can precisely determine the impacted tooth's position in relation to the neighboring teeth.^[4]

Several surgical methods were suggested to expose the impacted canine. Kokich states that the cuspule position of the labially impacted maxillary canine determines the three crucial surgical techniques for exposing it: gingivectomy, apically positioned flap, and closed-eruption technique.^[6]

An extra tooth located anywhere within the dental arch is known as a supernumerary tooth.^[7]The eruption of teeth will be delayed by these extra teeth. The type and position of the teeth will determine the treatment options. Radiographic examinations are crucial for pinpointing the tooth's precise location. Upon buccal placement, the tooth is located using periapical and occlusal radiographs. When supernumerary teeth are located in the deep palate, CBCT and lateral radiographs are utilized to help the practitioner determine whether to approach the teeth from the buccal or palatal aspect.^[8]

CASE REPORT

An 18-year-old healthy male patient was referred from the Department of Orthodontics to the Departments of Periodontology and Implantology at Vivekanandha Dental College, Tiruchendur, Namakkal, with the chief complaint of an upper right impacted canine. The patient presented a history of spacing in his upper and lower front tooth region initially, and it gradually increased. There was a delayed exfoliation of deciduous teeth in his upper canine region. And palpating the surface, a cup of canine was exposed, and there was no impending bone; only the soft tissue covered the impacted tooth, and the amount of Keratinized tissue was adequate. The procedure was planned with the surgical exposure of the impacted canine, followed by orthodontic treatment with traction force. On CBCT and periapical radiographic examination, [Figures 1 and 2] the position of the impacted tooth was confirmed, which was placed both labially and palatally. There was an inadvertent discovery of a supernumerary tooth present in relation to 13. The diagnosis of the case is generalized chronic gingivitis with an impacted canine in relation to 13. And treatment plan for unerupted teeth was planned as an open technique through gingivectomy with the consent of both the patient and their guardian. The crown was exposed by gingivectomy under Local anesthesia using a No. 15C blade. An incision was made, and the tissue was removed in 13 steps until the canine was exposed. Palatally, an external bevel incision was made from the mesial aspect of 12 to the distal aspect of 15 [Figure 3].

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Figure 1: The preoperative view and intraoral periapical covering 12 to 15 region.

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Figure 2: Radiograph intraoral periapical showing 12 to 15 region.

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Figure 3: Exposure of supernumerary teeth

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Extraction of supernumerary teeth

Under LA (nasopalatine nerve block) in the right side of the maxillary arch and using a No. 15 blade, the palatal incision is given from the 12 distal to the 14 mesial aspects, and a full-thickness flap is elevated, and the tooth is exposed by the palatal guttering technique with the help of a 701 bur, and the tooth was Toto in the region of 13. In order to approximate the flap, 3.0 suture material (simple interrupted suture technique) was used, and 13 regions underwent hemostasis, and postoperative care was given to the patient. The patient was asked to report to the department for re-evaluation of the surgical site after 3 weeks. Figure 4 shows the extracted supernumerary tooth.

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Figure 4: Removal of supernumerary tooth

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DISCUSSION

The way the impacted canine is treated has a significant impact on the patient's functionality and appearance. For a correct diagnosis, prognosis, course of treatment, and outcome, this case required a multidisciplinary departmental approach. Selecting the appropriate orthodontic force and surgical technique is one of the most important treatment decisions. The correct position of the impacted tooth with respect to the surrounding teeth is precisely determined by cone-beam computed tomography (CBCT). Because it aids in diagnosis and treatment planning, CBCT offers a comprehensive image of teeth, nerve pathways, soft tissue, and bone.^[9] Reducing radiation exposure, enhancing diagnosis capabilities, enhancing patient comfort, and increasing the accuracy of treatment plans are some advantages of the CBCT. By removing the extra teeth, the tooth eruption delay will be eliminated. The development of follicular cysts, overcrowding, spacing irregularities, or the ectopic eruption of an adjacent tooth are complications linked to the extra teeth.^[10] In a 1997 study, Seddon et al. found that more than 26–52% of cases of extra teeth resulted in the delayed eruption of the neighboring permanent tooth, and more than 28–63% of cases caused the neighboring teeth to shift and rotate.^[11] In the current study, Kokich's gingivectomy was used to surgically expose the impacted canine.^[8] In a case study on impacted canines, Radha Katiya et al. (2013) found that, at the age of 16, none of the four permanent canines had erupted to their typical position. He decided to surgically expose all four impacted canines; fixed orthodontic mechanotherapy was used to position the attached bonded traction, which was administered using a K-9 spring.^[12] A case report on the clinical management of extra teeth was completed by Meenu Mittal et al. in 2010.^[13]Similarly, in our case report, we have exposed the impacted canine by using the gingivectomy technique and fixed orthodontic brackets and wires are placed.

CONCLUSION

This case report discussed the unintentional discovery of the extra teeth using CBCT and the traditional method of gingivectomy of the impacted canine. In this instance, the appropriate follow-up resulted in a smile that is aesthetically pleasing and a periodontium condition free of surgical complications. The proper course of treatment and the interdisciplinary approach taken by the department of orthodontists, periodontists, and oral and maxillofacial surgeons also had a significant impact on the case's outcome.