Eur Arch Paediatr Dent
DOI 10.1007/s40368-017-0269-9
CASE REPORT
Bilateral supplemental maxillary central incisors with double-
tooth like appearance
R. P. Anthonappa1 • S. Sudhakar2 • N. M. King1
Received: 10 October 2016 / Accepted: 1 February 2017
Ó European Academy of Paediatric Dentistry 2017
Abstract
Background Supplemental teeth refer to extra teeth that
resemble the normal tooth series. Bilateral supplemental
central incisors in a healthy individual are rare and bilateral
supplemental incisors with double-tooth like appearance
are exceptionally rare and has not been previously reported
in the dental literature.
Case report This clinical report describes an 8-year old
healthy Indian boy referred for the management of delayed
eruption of his permanent maxillary incisor teeth. Fol-
lowing clinical and radiographic examination the two
supplemental incisors closer to the midline were extracted
under local analgesia and both of them exhibited double-
tooth like appearance.
Conclusions The present case refutes the conventional
wisdom that ‘‘supplemental teeth are usually smaller than
the normal tooth type they resemble and occur distal to the
normal tooth series’’, illustrates that the unusual can occur
and that the clinician should be aware of such variations.
Keywords Supernumerary teeth
Supplemental
Double-
tooth
Central incisors
Maxillary
& R. P. Anthonappa
robert.anthonappa@uwa.edu.au
1
Paediatric Dentistry, School of Dentistry, The University of
Western Australia, 17 Monash Avenue, Nedlands WA 6009,
Australia
2
Private Practice, Bangalore, India
Introduction
Glassington 1893, coined the term ‘‘supplemental’’ to
describe supernumerary teeth (ST) that was of a similar
morphology to the normal tooth series. The majority of ST
occurs in the anterior region of the maxilla; where mesio-
dens is the most commonly occurring ST type. They may
be single, multiple, unilateral or bilateral in their distribu-
tion, and can occur in any region of the dental arch. They
may develop in the direction of normal eruption, appear
inverted, transverse, assume an ectopic position, or follow
an abnormal path of eruption (Anthonappa et al. 2008).
Nevertheless, supplemental ST, especially supplemental
central incisors, are of a rare occurrence.
Most individuals are unaware of the presence of super-
numerary teeth unless they develop complications, such as:
crowding of the teeth; non-eruption or delayed eruption of
the adjacent teeth; displacements; midline diastemas;
delayed exfoliation of primary teeth; pathological cyst
formation; paraesthesia and/or pain due to impingement of
a supernumerary tooth on an adjacent nerve; ectopic
eruption in the nose or maxillary sinus; and aesthetic
compromises (Proff et al. 2006), subsequently leading to
their identification. Therefore, both clinical and radio-
graphic assessments are essential for the identification of
the supernumerary teeth and for the determination of the
exact location (Anthonappa et al. 2012).
Clinical report
An 8-year old Indian boy was referred for the management
of delayed eruption of his permanent maxillary incisor
teeth. His medical and family histories were non-contrib-
utory and he was the only child in the family. Intra-oral
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examination revealed a mixed dentition, and grossly bro-

ken down tooth 74. In the 11 and 21 regions, multiple teeth
were present with only their incisal edges evident in the
oral cavity. Subsequently, a panoramic radiograph (Fig. 1)
revealed the presence of four permanent central incisors in
the 11 and 21 region. All the incisors were rotated and the
two incisors present on the either side of the midline
exhibited an unusual morphology. It was not possible to
identify if these ST were geminated, fused, or exhibited a
talon cusp etc. on both periapical and anterior occlusal
radiographs, as they were rotated approximately 90°. Fur-
thermore, all other permanent tooth germs were evident
and were developing consistent with the subject’s
chronological age. Consequently, the two incisors with
unusual morphology were extracted under local analgesia
and both of them exhibited a double-tooth like appearance Fig. 2 Buccal and palatal views of an extracted supplemental central
incisor in the 11 region which exhibits a double-tooth like appear-
with a distinct groove on both the buccal and palatal
ance. Note the groove extending from the incisal edge to the root apex
aspects extending from the incisal edge on the crown to the on both buccal and palatal surfaces
root apex (Figs. 2, 3). The remaining permanent incsors
erupted into the oral cavity and the patient is currently
under full fixed appliance therapy.

Discussion

Supplemental supernumerary teeth are of a rare occurrence

and a literature search for bilateral occurrence of supple-
mental incisors identified 21 reports, with a predilection to
males, and more commonly affecting the permanent den-
tition compared to the primary dentition (Table 1). There
were no reports of bilateral supplemental central incisors
exhibiting a double-tooth like appearance, hence makes
this report novel. Nevertheless, one could term these teeth

Fig. 3 Buccal and palatal views of an extracted supplemental central

incisor in the 21 region which exhibits a double-tooth like appear-
ance. Note the groove extending from the incisal edge to the root apex
on both buccal and palatal surfaces

as macrodonts either due to gemination or fusion of

Fig. 1 Panoramic radiograph illustrates the presence of two supple-
mental incisors in the 11 and 21 region. All other permanent tooth
germs were evident and were developing consistent with the patients
chronological age
supernumerary tooth germs. The phenomenon of gemina-
tion arises when two teeth develop from a single tooth bud
and, consequently, the patient has a larger tooth. In gemi-
nated teeth, division is usually incomplete and results in a
large tooth crown that has a single root and a single canal.
Conversely, fused teeth arise through the union of two
normally separated tooth buds. Depending on the stage of
tooth development at the time of the union, it may be either
complete or incomplete and, on certain occasions, two
independent pulp chambers and root canals are evident.
However, the present case exhibited large tooth crowns
with a distinct groove on both the buccal and palatal
aspects extending from the incisal edge on the crown to the

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Table 1 List of published reports on bilateral supplemental incisors in non-syndromic patients

References Age Country Gender Teeth*

Brown (1954) 7y8m England Female 52 s, 62 s, 12 s

Munro (1954) 2 y11 m Scotland Male 52 s, 62 s, 12 s
Poutlon and Pruzansky (1958) 11 y UK Male 11 s, 21 s
Robertson (1962) 7y – Female 72 s, 82 s, 32 s, 42 s
Rock (1991) 9y6m – Male 11 s, 21 s
Steelman (1991) 10 y USA Male 11 s, 21 s
Dowling (1997) 10 y 2 m Ireland Male 12 s, 22 s
Tomizawa et al. (2002) 8y6m Japan Male 51 s, 61 s
Camilleri (2003) 13 y – Male 11 s, 21 s
Cho (2005) 8y – Female 31 s, 41 s
Roberts et al. (2005) 22 m UK Male 53 s, 51 s, 63 s
Schulz-Weidner et al. (2007) 4y Germany Male maxillary central incisors- triplication
Sivapathasundharam and Einstein (2007) 20 y India Male 11 s, 22 s
Lo et al. (2008) 10 y – Male 12 s, 22 s
Hans et al. (2011) 18 y India Male 11 s, 21 s
Nuvvula et al. (2011) 14 y India Male 11 s, 21 s
Yildirim and Bayrak (2011) 8y – Male 11 s, 21 s, 51 s, 61 s
Marwah et al. (2013) – India – 12 s, 22 s
Nagpal et al. (2013) 21 y India Female 12 s, 22 s
Bhullar et al. (2014) 14 y India Female 12 s, 22 s
Babaji (2015) 13 y India Male 12 s, 21 s, 22 s
* FDI tooth numbering system; y years; m months

root apex. Furthermore, as the patient and his parents
wished to take the extracted teeth we were unable to sub-
ject the extracted teeth to further investigation e.g. micro-
CT analysis and/or tooth sectioning to confirm if teeth
exhibited gemination or fusion. Therefore, it would be
logical to term both these ST as exhibiting a double-tooth
like appearance.
Multiple supplemental teeth with unusual morphology
can occur in the anterior region of the maxilla and this is
the first report of bilateral supplemental central incisors
exhibiting a double-tooth like appearance. Furthermore,
conventional wisdom would suggest that supplemental
teeth are usually smaller than the normal tooth type they
resemble and occur distal to the normal tooth series. The
present case rejects this conventional wisdom and illus-
trates that the unusual can occur and that the clinician
should be aware of such variations. Furthermore, one
should employ both clinical and appropriate radiographic
examinations to formulate the best treatment plan tailored
to suit the requirements of the particular individual.
Compliance with ethical standards
Conflict of interest The authors declare that they have no conflict of
interest.
Research involving human participants and/or animals This
article does not contain any studies with human participants per-
formed by any of the authors.
Informed consent Informed consent was obtained from the indi-
vidual participant included in this report.
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