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Journal of the Chinese Medical Association xx (2016) 1e6
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Original Article

Clinical evaluation of the timing of mesiodens removal

Wen-Yu Shih a,b, Chun-Yi Hsieh a,*, Tzong-Ping Tsai a
a
Division of Pedodontics, Department of Stomatology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
b
Faculty of Dentistry, School of Dentistry, National Yang-Ming University, Taipei, Taiwan, ROC

Received June 24, 2015; accepted October 16, 2015

Abstract

Background: Mesiodens is a common clinical finding among children and has a higher prevalence in Asian populations. The timing of the
removal of mesiodens remains controversial. Clinical studies comparing early versus late removal are lacking. The aim of this retrospective
study was to evaluate the frequency of clinical complications regarding the timing of childhood mesiodens removal and to explore the factors
associated with complications following mesiodens removal.
Methods: In total, 384 Taiwanese children diagnosed with unerupted mesiodens who had attended the Pediatric Dentistry Department, Taipei
Veteran General Hospital, Taipei, Taiwan from 2005 to 2012 were identified as potential participants. Among these patients, 105 children had
received surgical odontectomy of the mesiodens under general anesthesia and had complete longitudinal clinical and radiographic follow-up
records, including computed tomography (CT) evaluations; these patients were enrolled. The influence of age, the developmental stage of
the adjacent permanent teeth, and the location of the mesiodens were explored regarding complications that were noted at the time of surgery,
injury to the adjacent permanent teeth during surgical intervention, and the need for orthodontic treatment after surgery.
Results: The 105 children enrolled had 145 mesiodens. Removal of the mesiodens before the child was 5 years of age or 1/3 root-completed was
associated with fewer complications at the time of surgery and a reduced need for orthodontic treatment after surgery. However, no significant
difference was noted between the different groups in terms of surgical injury to the adjacent permanent teeth.
Conclusion: The early removal of an unerupted mesiodens before the age of 5 years would seem to reduce complications and the need for
orthodontic treatment. With the help of general anesthesia and evaluation by CT imaging, concerns regarding the child's cooperation and the
possibility of damage to adjacent permanent teeth during early surgical intervention can be minimized.
Copyright © 2016 Elsevier Taiwan LLC and the Chinese Medical Association. This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/by-nc-nd/4.0/).

Keywords: mesiodens; supernumerary tooth; surgical odontectomy; surgical removal

1. Introduction premaxilla area.1 The most common type of supernumerary

tooth is a mesiodens, which is located in the maxillary central
A supernumerary tooth is defined as an excess in the incisor region. The prevalence of mesiodens varies between
number of teeth when compared to the normal dental set and different racial groups, and there is a higher frequency in the
can occur in almost any region of the dental arch, but with a Asian population of about 3% or even higher compared to the
particularly strong predilection of about 90% towards the Caucasian population.2,3 In addition, it appears that males are
more commonly affected than females, with a reported ratio of
5.5:1 among Japanese and from 3.1:1 to 6.5:1 among Hong
Conflicts of interest: The authors declare that they have no conflicts of interest Kong children.2e5
related to the subject matter or materials discussed in this article. The etiology of the occurrence of supernumerary teeth re-
* Corresponding author. Chun-Yi Hsieh, Division of Pedodontics, Depart- mains unclear. A combination of genetic and environmental
ment of Stomatology, Taipei Veterans General Hospital, 201, Section 2, Shih-
factors has been proposed. In addition, several systemic dis-
Pai Road, Taipei 112, Taiwan, ROC.
E-mail address: [email protected] (C.-Y. Hsieh). turbances, such as Gardner syndrome, cleidocranial dysplasia,

http://dx.doi.org/10.1016/j.jcma.2015.10.013
1726-4901/Copyright © 2016 Elsevier Taiwan LLC and the Chinese Medical Association. This is an open access article under the CC BY-NC-ND license (http://
creativecommons.org/licenses/by-nc-nd/4.0/).
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orofaciodigital syndrome, Rothmund-Thomson syndrome, and Department, Taipei Veteran General Hospital, Taipei, Taiwan
cleft lip/palate have been reported to be associated with the from 2005 to 2012. The diagnosis of mesiodens was based on
occurrence of supernumerary teeth.6 a radiographic examination and/or an additional computed
Most mesiodens are unerupted during early mixed dentition tomography (CT)/cone-beam CT examination. The patients
with the reported range being 79e91%.1,7,8 Furthermore, their accepted for the study from the above group met the following
presence is often detected during a routine clinical or radio- inclusion criteria: (1) receiving surgical odontectomy of their
graphic examination without there being an association with mesiodens under general anesthesia; and (2) having complete
any pathology in 7e20% of the cases surveyed.9 In such cases, records longitudinally covering both clinical and radiographic
close follow-up without intervention is considered reasonable, follow-up. Individuals with pathology-confirmed odontomas,
but parents of the child should be warned regarding compli- any medical condition or syndrome associated with the pres-
cations.10,11 The presence of a mesiodens in certain circum- ence of supernumerary teeth, a history of pathological apical
stances can interfere with normal eruption and the position of lesion, or dental trauma affecting the maxillary incisors were
the adjacent permanent dentition; such effects include pre- excluded from this study.
vention or delaying of eruption, retardation of development, Based on the clinical and radiographic examinations, the
root resorption, dilaceration, displacement associated prob- following information was collected: age; gender; present
lems like malocclusion, midline diastema/rotation, supernu- dentition; the number, morphology, and orientation of the
merary tooth-associated cystic formation, and eruption into the mesiodens; dental maturity stage of the permanent central
nasal cavity. incisors (Table 1)15; the location of the mesiodens relative to
The timing of mesiodens removal has remained contro- the adjacent permanent central incisors; any complications
versial. Some studies have supported delayed intervention associated with the presence of the mesiodens, including the
until the root development of the adjacent teeth is almost presence of midline diastema > 2 mm, delayed tooth eruption,
completed, which usually means that the patient is 8e10 years tooth rotation, loss of tooth vitality, root resorption of any
of age.6 An operation at this time is then considered in order to nearby permanent tooth; signs of surgical injury to the adja-
reduce the possibility of harm to adjacent permanent tooth cent permanent teeth, including dilaceration, arrest of root
germs. However, there are some potential disadvantages to this development, root resorption, loss of vitality of a tooth, or loss
approach, including a loss of eruption potential regarding the of the lamina dura, the need for further orthodontic treatment
central incisors, the loss of anterior arch space, a midline shift, and the need for further surgery due to exposure of an uner-
the need for more extensive orthodontic treatment, and a upted permanent incisor after initial surgery.
requirement for surgical exposure of the impacted in- The association between the age when surgical removal of
cisors.6,12,13 Other studies have proposed that mesiodens the mesiodens took place (
4 years old, 5 years old, 6 years
should be removed as soon as possible after the condition has old, 7 years old, 8 years old, and  9 years old), the stage of
been diagnosed in order to prevent the possible drawbacks dental maturity of the permanent central incisors (Stage
6,
mentioned above. This usually means before the patient has Stage 7, Stage 8, and Stage  9), the location of the mesiodens
reached the age of 6 years; however, such an approach in- relative to the permanent central incisors (crown, cervical,
volves the risk of damaging developing tooth germs that are root, or root apex) were analyzed in relation to, firstly, the rate
nearby.6 Although many theoretical approaches have been of clinical complications associated with the presence of
proposed, most studies published have been case-series, and mesiodens noted at the time of surgery, secondly, the fre-
there has been only one cohort study.14 Up to the present, there quency of injuries to the adjacent permanent teeth during
has been no research exploring the interrelationship between surgical intervention and, thirdly, the frequency of subsequent
the location of the mesiodens in relation to its nearby per- orthodontic treatment or a second surgical intervention for
manent central incisors and the harm that surgery may cause. exposing the impacted incisor.
Therefore, the main purpose of this retrospective study was
to evaluate if the timing of mesiodens removal from children
was associated with the frequency of clinical complications. Table 1
The influence of the patient's chronological age, the dental Dental maturity was evaluated according the stages proposed by
maturity stage of permanent central incisors adjacent to the Nolla.15
mesiodens, and the vertical location of the mesiodens were Stage Developmental condition
explored with respect to their effect on the frequency of Stage 0 Absence of crypt
clinical complications at the time of surgery, the effect of the Stage 1 Presence of crypt
surgical intervention on the adjacent permanent teeth, and the Stage 2 Initial calcification
need for subsequent orthodontic treatment or further surgery Stage 3 One-third of crown completed
Stage 4 Two-third of crown completed
for exposing the impacted incisor.
Stage 5 Crown almost completed
Stage 6 Crown completed
2. Methods Stage 7 One-third of root completed
Stage 8 Two-third of root completed
Initially, 384 Taiwanese children with unerupted mesiodens Stage 9 Root almost completedeopen apex
Stage 10 Apical end of root completed
were identified after they had attended the Pediatric Dentistry

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W.-Y. Shih et al. / Journal of the Chinese Medical Association xx (2016) 1e6 3

Statistical analysis was carried out using SPSS version 19.0 Table 3
(SPSS Inc., Chicago, IL, USA). In addition to the stages of The association between total cases with clinical complications noted at the
time of mesiodens removal and the various ages of the patients.
dental maturity, for which inter- and intraexaminer reliability
were determined, all radiographic diagnoses were made by Age (y)
4 5 6 7 8 9
two examiners who were postgraduate dentists, and a
4 d 0.490 <0.001* <0.001* <0.001* <0.001*
consensus was reached if there were differences in opinion. 5 d <0.001* <0.001* <0.001* <0.001*
6 d 0.450 0.719 >0.99
Interexaminer reliability was tested using Cohen's Kappa; 7 d 0.294 0.398
specifically, 25 mesiodens were randomly chosen by com- 8 d 0.702
puter, and the stages of dental development were separately 9 d
determined by the two examiners. The Kappa value was 0.76, *p < 0.05, Fisher's exact test.
indicating a substantial interexaminer consistency. Fisher's
exact test was carried out to test the association between the
Table 4
variables during the various comparisons and p < 0.05 was The association between total cases with clinical complications noted at the
considered to be statistically significant. time of mesiodens removal and the development stage of the associated per-
manent tooth using Nolla's15 method.
3. Results Stage
6 7 8 9

6 d 0.242 <0.001* <0.001*
In total, 105 patients were enrolled in our analysis [82 7 d <0.001* <0.001*
(78.1%) males and 23 (21.9%) females]. These individuals had 8 d 0.826
a mean age at the time of surgical removal of the mesiodens of 9 d
6.35 ± 1.85 years, with a range of 3e12 years (Table 2). *p < 0.05, Fisher's exact test.
Overall, 38 (36.2%) of the patients had a mesiodens in their
primary dentition, 62 (59.0%) had one present in the early
1.5%). On statistical analysis, a significant difference was
mixed dentition, four (3.8%) had one present in the late mixed
found regarding the complications noted at the time of
dentition, and one (1.0%) had one present in the permanent
mesiodens removal between patients who were aged younger
dentition. There were 65 patients (61.9%) with a single
than 5 years old and those who were aged 5 years or older
mesiodens and 40 patients (38.1%) with two mesiodens
( p ¼< 0.001; Table 3). Similarly, a statistically significant
bilaterally. When these 145 mesiodens were examined, there
difference was noted for complications when patients who had
were 130 (89.7%) of conical shape, 11 (7.6%) of tuberculate
a dental development stage that was lower than Stage 7 were
shape, and four (2.8%) of a supplemental type. In addition,
compared to patients who were Stage 7 or above ( p < 0.0001;
125 mesiodens (86.2%) were inverted, 17 (11.7%) were
Table 4).
normal, one (0.7%) was transverse (M-D) and two (1.4%)
Five cases had signs of injuries to one or more adjacent
sagittal (A-P).
permanent teeth as a result of the surgical intervention based
Among the 145 mesiodens examined in the study, 54
on the follow-up radiography (retarded root development, 3;
mesiodens (37.2%) were identified as the cause of an associ-
root resorption with loss of tooth vitality of a permanent
ated complication (midline diastema, 52.2%; delayed eruption,
incisor, 1; and loss of the lamina dura, 1). Most complications
25.4%; rotation of an adjacent tooth, 16.4%; single tooth
were noted when the patients were aged 9 years or more
crossbite, 3.0%; root resorption of an adjacent tooth, 1.5%;
(15.8%; Fig. 1), when the stage of dental development was
loss of vitality of an adjacent tooth, 1.5%; and cyst formation,
about 9 (8.33%; Fig. 2), when the location of the supernu-
merary was cervical (6.25%), and when the location of the
Table 2 supernumerary was in the root area (7.89%) of an associated
Distribution of age and dental maturity stage of the permanent central incisor incisor (Fig. 3). However, no significant difference was noted
of 105 patients enrolled.
No. of patients (%)
Total 105 (100) 20%
Age (y) Mean (range) 6.35 ± 1.85 (3e12) 15.80%

4 17 (16.2) 15%
5 17 (16.2)
6 24 (22.9) 10%
7 24 (22.9)
8 9 (8.6) 5% 4% 3.13%
9 14 (13.2)
0 0 0
Dental stagea Mean (range) 7.70 ± 1.26 (5e10) 0%

6 19 (17.7) ≤4 5 6 7 8 ≥ 9 (age)
7 21 (19.6)
Complica on rates (%)
8 37 (34.6)
9 30 (28.1)
Fig. 1. Complication rates of cases with injury to an adjacent permanent tooth
a
Nolla's15 method. as a result of surgical intervention relative to the age of the patients.

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4 W.-Y. Shih et al. / Journal of the Chinese Medical Association xx (2016) 1e6

0.1 Stage 7 or more. Finally, a similar result was also obtained

8.33%
0.08 when patients at Stage 9 were compared to patients at a lower
stage (Table 6).
0.06

0.04 3.33% 4. Discussion

1.85%
0.02
0 More male patients than female patients were enrolled in
0
Stage ≤ 6 Stage 7 Stage 8 Stage ≥ 9
this study, with the ratio being 3.6:1. This ratio is in agreement
with other studies of Asian populations2,4,5 and is higher than
Complica on rates (%)
results reported for Caucasian populations, which are
Fig. 2. Complication rates of cases with injury to an adjacent permanent tooth approximately 2:1.6 A gender bias in the predilection to the
as a result of surgical intervention relative to the development stage of the occurrence of mesiodens strongly favors males in Asian
associated permanent tooth using Nolla's15 method. populations.
In agreement with other published reports, conical mesio-
0.1 dens were found to be the most common type in our study; this
7.89% was followed by tuberculate mesiodens and supplemental-type
0.08
6.25% mesiodens. In addition, the proportion of patients with only
0.06 one mesiodens present in the mouth was 61.9%, which is
0.04 similar to the findings in Liu's24 study (64.3%) and in
Anthonappa et al's4 study (61.5%). None of our patients had
0.02
0 0 more than two mesiodens, but unlike some other studies,
0 odontoma was not counted as a supernumerary tooth. When
Crown Cervical Root Apex
the orientation of mesiodens was investigated, the majority
Complica on rates (%) were of the inverted type, which accounted for 86.2%; this is
Fig. 3. Complication rates of cases with injury to their adjacent permanent
higher than the frequency presented in the study of Roy-
tooth as a result of surgical intervention relative to its position in relation to the choudhary et al,16 who reported that 62.7% of impacted
permanent central incisors. mesiodens were inverted. This difference might due to the fact
that in our study, the normally aligned mesiodens might have
already erupted or have been extracted at a local dental clinic
with respect to age, dental maturity stage or the location of the before the more difficult ones were referred to our department
mesiodens ( p > 0.05). for further management.
Of the 105 patients who underwent odontectomy, 30 In the present study, 62.8% of the 145 cases (mean age,
received orthodontic treatment or a second surgery. Of these 6.35 ± 1.85 years) were clinically normal after treatment and
interventions, 17 (9%) were due to persisting rotation of the did not have any complications that could be associated with
affected permanent incisor, six (4.1%) were due to a midline the removal of a mesiodens. This percentage is greater than the
shift > 2 mm, three (2.1%) were due to the presence of a large 53.1%17 of mesiodens reported to be clinically normal for
diastema > 2 mm, three (2.1%) were due to there being an patients with a mean age of 11 years and much greater than
anterior crossbite, and one (0.7%) was because there had been another reported (19.1% of 204 mesiodens) when patients had
a second surgery due to surgical exposure. A statistically ages between 6 years and 9.5 years.5 These differences might
significant difference was noted when the proportion of total be associated with the fact that we enrolled younger patients
patients with subsequent treatment were compared between than did these two studies, with the result that many central
those aged younger than 5 years and those aged  5 years incisors remained unerupted. Therefore, it is not surprising
(Table 5). Furthermore, a similar result was obtained when the that the results of the study show significantly fewer compli-
patients with stages of dental development lower than Stage 6 cations when patients were aged < 6 years old and were before
were compared to patients whose stage of development was Stage 8 of Nolla's15 classification of dental development. In the
present study, the complications resulting from mesiodens

Table 5
The association between total cases with orthodontic treatment or second Table 6
surgery and the various ages of the patients. The association between total cases with orthodontic treatment or second
Age (y)
4 5 6 7 8 9 surgery and the development stage of the associated permanent tooth using
Nolla's15 method.

4 d 0.490 0.030* 0.015* 0.006* <0.001*
Stage
6 7 8 9
5 d 0.276 0.167 0.051 <0.001*
6 d >0.99 0.248 0.006*
6 d 0.117 0.014* <0.001*
7 d 0.430 0.015* 7 d 0.557 0.015*
8 d 0.450 8 d 0.035*
9 d 9 d
*p < 0.05, Fisher's exact test. *p < 0.05, Fisher's exact test.

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removal were consistent with those seen in previous of the current study seem to be in contrast to earlier studies
studies.5,17,18 Midline diastema was the most commonly noted that mention early surgical removal of mesiodens and indicate
complication, constituting 50% of all cases with complica- an increased risk of harm to the tooth germs of adjacent per-
tions; this was followed by delayed eruption and rotation of an manent teeth or result in a retardation of tooth development.
adjacent tooth. Root resorption, loss of vitality of an adjacent They suggest that there should be a delay in treatment until
tooth, and cyst formation occurred less often. Thus, maloc- there has been almost complete root development of the
clusion was the major complication associated with the pres- adjacent permanent incisors, which usually occurs at the age
ence of a mesiodens in the premaxillary regions. Clinically, if of 8e10 years.6,21 The present results seem to support recent
patients have a complaint regarding malocclusion of the upper research by Omer et al,14 who found early removal of uner-
anterior region, the presence of a mesiodens needs to be ruled upted mesiodens seemed to be advantageous and that more
out early. complications are to be expected after a cutoff point of 6 years
Among the patients enrolled in the present study, 30 cases old or 7 years old, which is when the permanent teeth are
received orthodontic intervention after the surgical removal of about to complete crown formation. In our study, the numbers
a mesiodens. The most common reason for orthodontic treat- of cases with injuries to the adjacent permanent teeth post-
ment of these patients was rotation of the affected permanent operatively were too few to reach statistical significance when
incisors, which accounted for 17 cases in the study; by way of a comparison between the groups with different ages and
contrast, only three cases were related to persistent diastema. different stages of dental development was carried out. With
This is in contrast to the findings of several previous reports the help of CT or cone-beam CT, which are able to provide
that investigated the recovery and proper alignment of the accurate three dimensional information about the orientation
rotated permanent incisors; those studies suggested that the of the mesiodens, sagittal positioning, local problems, and
early removal of mesiodens before the age of 9 years resulted neighboring anatomic structures, the operator is able to lower
in a proper alignment.14,19 In our study, there was no evidence the risk of harming adjacent teeth during the operation. All of
to suggest that there was an improvement in permanent in- these factors are of great significance when carrying out a
cisors rotation after odontectomy. However, it would seem that pretreatment evaluation and creating a treatment plan.22e24
most problems associated with midline diastema are able to However, if the mesiodens is closed to the adjacent perma-
self-correct following the eruption of the lateral incisors and nent incisors, a delay in the surgical removal is recommended
canines. In the present study, only 0.7% (1 case) who was aged because early surgical intervention may injure Hertwig's
9 years old had a second surgery to correct for the surgical epithelial root sheath and cause disruption or cessation of
exposure of unerupted central incisors after odontectomy; this future development of the affected roots.25
incidence is much lower than the findings presented by Finally, there are a number of limitations that affect this
Foley,26 in which 27% of cases with a mean age about 9.9 study and need to be considered. First, since there was no
years had a need for such surgery. This is puzzling because the absolute definition of an early or a delayed intervention, the
chronological ages of the cases in the present study and the groupings used for comparison are difficult to choose. Second,
cases in Foley's study are similar. However, the study of the presence of complications related to the associated tooth
Leyland et al20 pointed out that space availability was an were in some cases diagnosed only from the occlusal film of a
important factor when there was spontaneous eruption of an radiograph, which is a two dimensional rather than a three
unerupted tooth after extraction of a mesiodens. The results of dimensional image; this may have caused an underestimation
this study indicate that the need for the subsequent orthodontic of the incidence of such cases. Third, excluding cases that
therapy and/or further surgical intervention is significantly were lost during postsurgical follow-up might have led to bias
reduced when patients undergo odontectomy of a mesiodens at and affected the results.
an age that is younger than 6 years and when it is before Based on the findings of the present study, it seems likely
Nolla's15 Stage 7. These findings suggest that the early surgical that the early removal of unerupted mesiodens before the age
removal of mesiodens before the patient is 6 years old or of 5 years may significantly reduce future complications and
before the associated central incisor has 1/3 root formation is limit the need for orthodontic treatment. With the help of
likely to result in better options for patients. general anesthesia and a CT image evaluation, concerns
In the present study, the mean age of the patients at the time regarding child cooperation and possible damage to adjacent
of the surgical removal of the mesiodens was permanent teeth during such early surgical interventions can
6.35 ± 1.85 years, and only two cases were found to have be overcome successfully.
retarded root development after surgery; one was 4 years old,
while the other was 7 years old. These two patients accounted
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Please cite this article in press as: Shih W-Y, et al., Clinical evaluation of the timing of mesiodens removal, Journal of the Chinese Medical Association (2016),
http://dx.doi.org/10.1016/j.jcma.2015.10.013