Hidden Extra Teeth: How 3D Imaging Is Changing Surgery for Childhood Mesiodens

Deep in the anterior maxilla, between the two front teeth, a small developmental accident can unfold silently for years. Dentists call it a mesiodens: a supernumerary tooth that forms in excess of the normal dentition, right in the midline of the upper jaw. It is the most common type of extra tooth in humans, accounting for roughly 80 percent of all supernumerary teeth, yet most people never know they have one. Only about a quarter of mesiodens ever erupt into the oral cavity; the rest remain impacted within the bone, asymptomatic and invisible, often discovered by chance on a routine radiograph taken for an entirely unrelated reason. A newly published three-case series in Clinical Case Reports offers a vivid, clinically detailed look at how these anomalies present in children, how cone-beam computed tomography has transformed their evaluation, and how timely surgery can steer a developing dentition back onto a normal path.

The numbers behind hyperdontia are striking. Supernumerary teeth occur in an estimated 0.3 to 3.5 percent of the population, with a pronounced male predominance on the order of five males for every female. Morphologically, mesiodens come in three flavors: conical, or peg-shaped, which is the most common; tuberculate, with barrel-shaped crowns and multiple tubercles; and supplemental, which duplicates the appearance of a normal adjacent tooth. Why they form at all remains an open question. The leading hypotheses include hyperactivity of the dental lamina, the embryonic band of tissue that seeds tooth development; dichotomy, or splitting, of the tooth bud; and genetic predisposition. Mesiodens can also appear as a feature of syndromes such as cleidocranial dysostosis and Gardner’s syndrome, though many occur in otherwise healthy children, as in all three patients described in the new series.

What makes an impacted mesiodens clinically dangerous is not its presence but its position. Because it occupies space in the premaxillary region, it can delay or deflect the eruption of the permanent central incisors, prolong the retention of primary teeth, create a midline diastema, cause malocclusion, and trigger root resorption of neighboring teeth. Cyst formation, occlusal disturbance, and aesthetic concerns round out the list of potential complications. One cited study reported that certain positions of an impacted tooth may raise the risk of root resorption by as much as 50 percent, and delayed eruption of permanent incisors has been documented in up to 60 percent of affected patients. In rare instances, mesiodens have even been reported to migrate toward the nasal cavity, producing nasal obstruction, epistaxis, infection, or oronasal fistula. These are the stakes that make early detection and intervention more than a cosmetic matter.

The first case in the series illustrates the erupted form of the anomaly. A seven-year-old child arrived with an extra tooth visible in the anterior maxilla, positioned palatally near the incisive papilla and irritating the tongue. The tooth was conical, with incomplete root formation, and the child’s primary maxillary central incisors were still retained. A panoramic radiograph then revealed something the clinical examination could not: a second, impacted mesiodens hiding in the premaxillary bone. Cone-beam computed tomography, acquired on a NewTom 5G XL system with a 5 by 5 centimeter field of view and a fine 0.15-millimeter voxel size, confirmed that the second tooth was inverted, sat palatal to the right central incisor, and lay in close proximity to the incisive canal and the palatal cortical plate. Critically, the scan showed no root resorption, no cystic change, and no cortical bone involvement, information that allowed the surgical team to proceed with confidence.

Both teeth were removed under local anesthesia in a single session: the erupted conical tooth extracted first, followed by elevation of a palatal flap to access and remove the impacted, inverted one. Healing was uneventful, but the follow-up story proved instructive. At six months, the maxillary left central incisor had erupted, yet it arrived rotated and in a partial anterior crossbite, evidence that the extra teeth had subtly altered its eruption pathway. The clinicians initiated tongue-blade therapy, a simple interceptive orthodontic technique, to guide the tooth into position. By twelve months, the rotation and crossbite had fully resolved, the contralateral central incisor had erupted in an appropriate position, and the smile looked, in the published photographs, entirely conventional. The case demonstrates that removing an obstruction often permits spontaneous correction, but that some eruption disturbances still need a gentle mechanical nudge.

The second case shows how a mesiodens can cause trouble without ever blocking a tooth. A seven-year-old boy presented with mild spacing between his already-erupted permanent central incisors, a classic midline diastema. CBCT imaging, this time on a NewTom QR-DVT 9000 with a 10 by 10 centimeter field of view and a 0.3-millimeter voxel size, revealed an impacted, inverted conical mesiodens lodged palatally between the central incisors, adjacent to the palatal cortical plate and the incisive canal, but without pathology or interference with the adjacent teeth. Surgeons removed it through a palatal approach under local anesthesia. One year later, the diastema had measurably narrowed and both central incisors continued to erupt favorably. The authors anticipate further closure as the lateral incisors and canines come in, a reminder that the developing dentition possesses considerable self-correcting capacity once the mechanical obstacle is gone.

The third case is where the technology earns its keep. A nine-year-old boy presented with a maxillary right central incisor that had failed to erupt despite adequate space, and a panoramic radiograph showed an impacted central incisor with what appeared to be a single supernumerary tooth in the region. CBCT, acquired on a Genoray Papaya 3D system and reconstructed with TRIANA software, told a different story: there were two impacted mesiodens, both with irregular, two-cusped crown morphology, both vertically oriented, and both in intimate contact with critical structures. The left one, inclined palatally, sat with its cusp tip at the level of the cementoenamel junction of the left central incisor, its crown touching the coronal third of the root without resorption or fusion. The right one lay just below the palatal cortical plate, its crown in contact with the cingulum of the unerupted incisor. Both touched the incisive canal, yet its bony cortication remained intact. Only the three-dimensional dataset could have mapped this anatomy before a scalpel was lifted.

Both supernumerary teeth were surgically removed under local anesthesia, and at nine months the boy’s central incisors had erupted and aligned normally, with no complications. The authors highlight this case as the clearest demonstration of CBCT’s added value: the panoramic radiograph identified one mesiodens, while the tomographic scan revealed a second that would otherwise have been left behind, potentially compromising the outcome. Conventional radiographs remain useful for initial detection, but their two-dimensional projection superimposes anatomical structures and cannot reliably resolve morphology, orientation, or proximity to the incisive canal and cortical plates. CBCT delivers precise three-dimensional localization, clarifies surgical complexity, and, as the series argues, minimizes the risk of iatrogenic damage to adjacent permanent teeth during removal.

Management decisions are not always surgical. Depending on patient age, tooth position, and associated complications, clinicians may opt for periodic observation instead of extraction. Early intervention is generally recommended, however, when eruption disturbances, symptoms, or foreseeable risks are present, and in this series all three children met that threshold, whether for functional, developmental, or preventive reasons. The series also notes the demographic pattern: all three patients were male, consistent with the reported two-to-one male predominance in non-syndromic cases, and two of the three had double mesiodens, a finding the authors describe as considerably less frequent than a single extra tooth in otherwise healthy individuals.

The authors are candid about the limits of their work. A three-case series with relatively short follow-up cannot establish generalizable treatment protocols, and they call for prospective controlled studies with longer observation periods to confirm the findings. Still, the clinical message is clear and actionable. Mesiodens can silently derail the eruption of the permanent incisors, and the consequences, from midline gaps to crossbites to root resorption, are far easier to prevent than to reverse. For parents and clinicians alike, the takeaway is that an unexplained delay in a front tooth’s arrival, a persistent gap between the front teeth, or a retained baby incisor deserves prompt radiographic investigation, and when the answer matters, three-dimensional imaging can mean the difference between finding one extra tooth and finding two.

Subject of Research: Clinical variability, CBCT-based evaluation, and surgical management of mesiodens in pediatric patients

Article Title: Mesiodens: Clinical Variability, CBCT Evaluation, and Surgical Management, A Three‐Case Series

Article References: Nasr, N., Eshghi, A., Golabbakhsh, A., & SadighBatha, S. (2026). Mesiodens: Clinical Variability, CBCT Evaluation, and Surgical Management, A Three‐Case Series. Clinical Case Reports, 14(10), Article e73693. https://doi.org/10.1002/ccr3.73693

Image Credits: AI Generated

DOI: 10.1002/ccr3.73693

Keywords: mesiodens, supernumerary teeth, hyperdontia, CBCT, pediatric dentistry, impacted teeth, midline diastema, oral surgery, dental eruption, incisive canal, case series, cone-beam computed tomography