The first stage of management is the localisation and identification of complications associated with supernumeraries. Teeth can be localised using the vertical or horizontal parallax technique (Figure 32.1B). A periapical radiograph taken using the paralleling technique gives the most detailed assessment compared with other radiographic views.

If teeth are causing no complications and are not likely to interfere with orthodontic tooth movement they can be monitored with yearly radiographic review. The patient should be warned of complications such as cystic change and migration with damage to nearby roots. If the patient does not wish to risk such complications, it is acceptable to remove supernumerary teeth. If they are associated with the roots of permanent teeth it is often sensible to await full root development before surgical extraction to prevent damage to Hertwig’s epithelial root sheath. Root development of the maxillary incisors should be complete by the age of 10 years.

If supernumerary teeth are associated with complications, it is usual to extract such teeth which usually involves a surgical procedure. Early extraction of supernumeraries causing incisor impaction may have the benefit of minimising loss of eruptive potential, space loss and centreline displacement. One disadvantage of early removal is the risk of root damage to adjacent teeth. After removal, an impacted incisor may take an average of 20 months to erupt (range 7-36 months) and in 50% of cases the tooth may not erupt. It is therefore recommended that unerupted incisors are also exposed and bonded at the time of supernumerary tooth removal and that a space maintainer is fitted whilst awaiting spontaneous eruption.

If supernumerary teeth are likely to interfere with orthodontic tooth movement, they should be removed prior to the commencement of treatment.

If a supplemental tooth is present and erupted, it may be difficult to determine which is the supplemental and which is the tooth of the normal dental series. In these circumstances, assuming both teeth are healthy, it is logical to extract the tooth most displaced from the line of the arch for the relief of crowding.

Finally, the presence of a supernumerary tooth should alert the clinician to the possibility of the development of late forming supernumerary teeth especially in the lower premolar region. It has been reported that up to 20% of patients with an anterior maxillary supernumerary tooth may later develop supplemental premolars (Figure 34.1E).

Treatment techniques

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