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Year : 2020  |  Volume : 9  |  Issue : 1  |  Page : 80-83

Peridens – Case series of nonsyndromic patients with varied clinical presentations

1 Department of Oral Medicine and Radiology, Ragas Dental College and Hospital, Chennai, Tamil Nadu, India
2 Department of Oral and Maxillofacial Pathology, Balaji Dental College and Hospital, Chennai, Tamil Nadu, India

Date of Submission01-Aug-2019
Date of Decision26-Sep-2019
Date of Acceptance08-Nov-2019
Date of Web Publication13-Jan-2020

Correspondence Address:
Dr. Narmatha Namachivayam
Ragas Dental College and Hospital, Chennai, Tamil Nadu
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijhas.IJHAS_57_19

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Supernumerary tooth may be encountered by the general dental practitioner as an incidental finding on a radiographic examination or as the cause of an impacted tooth. However, in certain cases, it may be misinterpreted as a bony growth (mandibular torus) when it makes its appearance in the lingual aspect of mandibular arch. We present two cases of peridens, a form of supplemental tooth, the former case with the clinical feature of bony swelling and ending in a dilemmatic differential diagnosis and another case of impacted supernumerary tooth, accidentally found on radiograph, thereby stressing the role of radiographs in arriving at final diagnosis apart from clinical counterpart.

Keywords: Mandibular tori, peridens, supernumerary tooth, supplemental tooth

How to cite this article:
Aparna P V, Namachivayam N, Leena S, Soundarya B. Peridens – Case series of nonsyndromic patients with varied clinical presentations. Int J Health Allied Sci 2020;9:80-3

How to cite this URL:
Aparna P V, Namachivayam N, Leena S, Soundarya B. Peridens – Case series of nonsyndromic patients with varied clinical presentations. Int J Health Allied Sci [serial online] 2020 [cited 2020 Jul 15];9:80-3. Available from: http://www.ijhas.in/text.asp?2020/9/1/80/275648

  Introduction Top

Supernumerary teeth are those that develop in addition to the normal complement and may be morphologically normal or abnormal. Synonyms for supernumerary teeth are hyperdontia, distodens, mesiodens, peridens, para teeth, para molars, and supplemental teeth. Teeth having normal morphological features are called supplemental teeth. Teeth that occur between maxillary central incisors are called mesiodens and that occur in the premolar area are peridens and those that occur in the molar area are called as distodens.[1] Numerous genes that regulate tooth development such as bone morphogenetic protein, fibroblast growth factor, Hedgehog, and Wnt have been identified, whereas of note, ectodysplasin (Eda), an NFkB family signal, plays key roles in the development of teeth and other ectodermal appendages. Hence, overactivation of the Eda receptor is responsible for extra teeth.[2] Any disturbances in the stage of initiation of tooth development result in either missing or excess teeth.[3] The etiopathogenesis of supernumerary tooth formation is due to the hyperactivity of dental lamina, dichotomy, atavism, and DNA mutations along with environmental factor.[4] Syndromes associated with multiple supernumerary tooth are Gardner's syndrome, cleft lip and palate, Fabry–Anderson syndrome, cleidocranial dysostosis, pycnodysostosis,[5] Rothmund–Thomson syndrome, and Nance–Horan syndrome.[6]

Para premolar is a form of supernumerary tooth which is commonly seen in the mandibular premolar region with the frequency of 74% and commonly referred as peridens. We present two cases of peridens along with management.

  Case Reports Top

Case report 1

A 27-year-old male patient presented to the department of oral medicine and radiology with the chief complaint of painless swelling in the lingual aspect of left side of the mandible from his childhood. A history of presenting illness revealed that the swelling was painless and does not increase in size since childhood. Medical and dental history was noncontributory. On general examination, the patient revealed no abnormalities pertaining to syndromes. On intraoral examination, on inspection, swelling was seen on the left side of the mandibular arch in relation to the lingual aspect of 34, 35 [Figure 1]a. The swelling was normal mucosal color and shows lobulation [Figure 1]b and no secondary changes over the surface and adjacent structures. On palpation, the swelling was bony hard in consistency and fixed to the underlying tissue. It was nontender, immobile, and does not show any pedunculation, compressibility, and fluctuation. Associated teeth 34, 35 were vital and periodontally healthy. Functional disturbance was present due to the swelling. Based upon history, site and the clinical presentation, provisional diagnosis of mandibular tori was given. The following radiographic investigations were carried out; periapical radiograph revealed two supplemental premolar teeth with normal morphology in relation to the lingual aspect of 34, 35 [Figure 2]. No resorption, widening of PDL space is seen. Mandibular lateral occlusal radiograph revealed radiopaque structure resembling the occlusal cap of premolars lingual to 34, 35 region [Figure 3]. Final radiographic diagnosis of peridens, a supplemental or supernumerary tooth was given. The patient was managed by open extraction of the supplemental teeth [Figure 4], and the specimen was sent for ground section. Sutures were placed and the patient was put on antibiotics for 3 days. Ground section of the extracted teeth shows normal-appearing enamel, dentin, cementum, and pulp space. On review, the extraction site was completely healed and no evidence of recurrence was seen.
Figure 1: (a) Intraoral examination. (b) Swelling in relation to lingual aspect of 34, 35 showing lobulation

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Figure 2: Periapical radiograph revealed two supplemental premolar teeth with normal morphology in relation to 34, 35

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Figure 3: Mandibular lateral occlusal radiograph revealed radiopaque structure resembling the occlusal cap of premolars lingual to 34, 35 region

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Figure 4: Extracted supplemental teeth

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Case report 2

A 30-year-old female patient reported with the chief complaint of continuous, vague pain in relation to the left lower back tooth region for about 1 week. Medical and dental history was noncontributory. On general examination, the patient revealed no abnormalities pertaining to syndromes. Intraoral examination revealed Class 1 carries in relation to 36 along with tenderness on percussion. There were no vestibular changes in relation to 35, 36 [Figure 5]a and [Figure 5]b. Orthopantomogram was taken and it revealed a bilateral impacted supernumerary tooth in relation to distal root of 35, 45 and mesial root of 36, 46 [Figure 6]. The supplemental tooth in relation to 35, 36 region is lying over the root of 36 and shows dilaceration toward distal side.
Figure 5: (a) Intraoral examination of case 2. (b) Intraoral examination of 44, 45 region

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Figure 6: Orthopantomogram shows bilateral impacted supernumerary teeth in relation to 35, 36 and 45, 46

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The pain may be due to the impacted supplemental tooth in relation to 36. The patient was advised for restoration of the caries to exclude the overlying pathology and later advised for open extraction of the impacted tooth in case of pain persistence.

  Discussion Top

Supernumerary tooth otherwise termed as hyperdontia is more common in maxilla, followed by mandibular region.[7] It has higher predilection for males (3:1),[8] indicating a sex-linked inheritance as in our case 1, but occasionally female predominance is mentioned (male-to-female ratio of 1:2.3) as in case 2.[9]

A supernumerary tooth may be single or multiple, unilateral or bilateral, and erupted or impacted. In both the cases, it was impacted. Case 1 was unilateral, whereas the second case showed bilateral presentation. Supernumerary teeth were classified as accessory and supplemental according to morphology. Teeth that do not resemble the normal form and having varying morphology are called accessory teeth. Teeth having shape and size of normal teeth are called supplemental teeth.[10] In our case, the teeth was of normal morphology of permanent tooth and considered as supplemental teeth.

Considering the clinical differential diagnosis, according to site, the possible diagnosis could be exostoses, cementifying fibroma, and cementoblastoma. Exostosis could be the closest diagnosis based on bony hard consistency comparing to cementifying fibroma and cementoblastoma which is soft/hard to firm in consistency. In case 1, the swelling was bony hard in consistency and showed lobulation and the common site for mandibular torus, and thus, we arrived at provisional diagnosis of mandibular torus.

Radiologic examination was of utmost importance in determining the exact position and morphology of supernumerary tooth. The tooth was smaller than normal tooth and had the normal morphology of fully formed crown and root, making us to arrive at the radiographic final diagnosis of supplemental teeth – peridens/para premolar in both the cases.

Para premolars are most commonly seen in lingual aspect. Para premolars are found beneath the roots of permanent premolars and molars.[4] It holds the same in case 1.

Complications and management of supernumerary teeth may be delayed eruption, displacement of permanent teeth, crowding, spacing, abnormal root formation, and root resorption. In our case, the supernumerary tooth was extracted to prevent the complications in spite of controversies regarding the timing of the removal of the supernumerary tooth.

  Conclusion Top

In this case report, we would like to stress that, supernumerary tooth though common in syndromic cases, is rather a rare finding in normal cases. Thus diagnosis can be narrowed down based on the site, consistency, gender predilection and final diagnosis should be made only after radiographic presentation apart from relying on clinical picture alone, to avoid misdiagnosis.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Lam EW. Dental anomalies. In: White SC, Pharaoh MJ, editors. Oral Radiology: Principles and Interpretation. 6th ed., Ch. 19. China: Elsevier Inc.; 2009. p. 295-8.  Back to cited text no. 1
Nanci A. Development of the tooth and its supporting tissues. Ten Cate's Oral Histology. Development, Structure, and Function. 1st South Asian edition, Ch.5, Elsevier Inc; p. 68-9.  Back to cited text no. 2
Hattab FN, Yassin OM, Rawashdeh MA. Supernumerary teeth: Report of three cases and review of the literature. ASDC J Dent Child 1994;61:382-93.  Back to cited text no. 3
Priya E, Kurunji Kumaran N, Rajasigamani K, Bhaskar V, Thiruneelakandan. An Overview of Supernumerary Teeth with Special Emphasis About Parapremolars -An Orthodontic Perspective. IOSR J Dent Med Sci 2017;16:78-81.  Back to cited text no. 4
Thumati P, David CM, Tiwari R. Non-syndromic multiple supernumerary teeth: A case report and review of literature. IJSS Case Rep Rev 2014;1:1-4.  Back to cited text no. 5
Tyrologou S, Koch G, Kurol J. Location, complications and treatment of mesiodens: A retrospective study in children. Swed Dent J 2005;29:1-9.  Back to cited text no. 6
Shah A, Gill DS, Tredwin C, Naini FB. Diagnosis and management of supernumerary teeth. Dent Update 2008;35:510-20, 514-6, 519-20.  Back to cited text no. 7
Rokaya D, Humagain M, Tamrakar M, Upadhayaya C. Bilateral supernumerary premolars: A rare case report. Inter J Dent Clin 2014;6:21-2.  Back to cited text no. 8
Kaya GS, Yapici G, Omezli MM, Dayi E. Non-syndromic supernumerary premolars. Med Oral Patol Oral Cir Bucal 2011;16:e522-5.  Back to cited text no. 9
Kalra N, Chaudhary S, Sanghi S. Non-syndrome multiple supplemental supernumerary teeth. J Indian Soc Pedod Prev Dent 2005;23:46-8.  Back to cited text no. 10
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