DENTOALVEOLAR SURGERY

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Removal of Supernumerary Teeth 60
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7 Utilizing a Computer-Aided Design/ 62
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9 Computer-Aided Manufacturing 65
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11 Surgical Guide 67
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13 Q3 Chanwoo Jo, DDS, MSD,* Doohwan Bae, DDS, MSD,y Byungho Choi, DDS, PhD,z 69
14 and Jihun Kim, DDS, MSDx 70
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16 Supernumerary teeth need to be removed because they can cause various complications. Caution is needed 72
17 because their removal can cause damage to permanent teeth or tooth germs in the local vicinity. Surgical 73
18 guides have recently been used in maxillofacial surgery. Because surgical guides are designed through 74
19 preoperative analysis by computer-aided design software and fabricated using a 3-dimensional printer 75
20 applying computer-aided manufacturing technology, they increase the accuracy and predictability of sur- 76
21 gery. This report describes 2 cases of removal of a mesiodens—1 from a child and 1 from an adolescent— 77
22 Q1 using a surgical guide; these would have been difficult to remove with conventional surgical methods. 78
23 Ó 2016 American Association of Oral and Maxillofacial Surgeons 79
24 J Oral Maxillofac Surg -:1.e1-1.e9, 2016 80
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Supernumerary teeth (SNTs) can cause diastema, This report describes 2 cases of successful removal
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disturbances in tooth eruption, root resorption, den- of the mesiodens from a child and from an adolescent
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tigerous cysts, and other problems; therefore, it is using surgical guides fabricated with CAD and CAM
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important to remove SNTs in their early stage.1-3 technology.
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However, caution is needed, because removal of
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an SNT might damage nearby permanent teeth or Report of Cases
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tooth germs.4
33 CASE 1 89
The use of surgical guides in maxillofacial surgery,
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especially in implant surgery, is recent.5-7 Such A 12-year-old girl visited the Department of Pediatric
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surgical guides can be used for the removal of Dentistry, Wonju College of Medicine, Yonsei Univer-
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impacted SNTs that are difficult to remove by sity (Wonju, Korea) with a chief complaint of an SNT.
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conventional methods owing to damage to anatomic There was no relevant dental or medical history. There
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structures near the impacted SNTs. Surgical guides were no special clinical findings at oral examination.
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fabricated with computer-aided design (CAD) and Cone-beam computed tomography (CBCT) showed
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computer-aided manufacturing (CAM) technology that the root apex of the SNT was dilacerated and
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have been shown to be effective tools in maxillofacial located near the root of the left maxillary central
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surgeries.8-12 In particular, the use of a surgical guide in incisor (Fig 1).
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surgical tooth extraction has been reported.13 Howev- If the SNT were to be removed directly from the
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er, there have been no reports of SNTs being removed palatal side of the maxilla, then the root of the left
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with surgical guides fabricated with CAD and CAM maxillary central incisor could be damaged. There-
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technology. fore, the SNT was approached from the labial
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49 Received from the Wonju College of Medicine, Yonsei University, versity, 20, Ilsan-ro, Wonju-si, Gangwon-do 220-701, Republic of 105
50 Wonju, Republic of Korea. Korea; e-mail: drpedo@naver.com 106
51 *Resident, Department of Pediatric Dentistry. Received August 17 2016 107
52 yResident, Department of Pediatric Dentistry. Accepted November 3 2016 108
53 zProfessor, Department of Oral and Maxillofacial Surgery. Ó 2016 American Association of Oral and Maxillofacial Surgeons 109
54 xAssistant Professor, Department of Pediatric Dentistry. 0278-2391/16/31117-X 110
55 Address correspondence and reprint requests to Dr Kim: Depart- http://dx.doi.org/10.1016/j.joms.2016.11.002 111
56 ment of Pediatric Dentistry, Wonju College of Medicine, Yonsei Uni- 112

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138 FIGURE 1. Sagittal cone-beam computed tomographic view of case 1. The root apex of the SNT was dilacerated and located near the root
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139 of the left maxillary central incisor. SNT, supernumerary tooth. Q2 195
140 Jo et al. SNT Removal Using Surgical Guide. J Oral Maxillofac Surg 2016. 196
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143 side of the maxilla to cut the root apex and then apex of the SNT with a fissure bur. Next, a crevicular 199
144 from the palatal side to remove it. A surgical guide incision of the palatal gingiva was made to elevate 200
145 was used for the ostectomy without causing damage the palatal flap. The palatal ostectomy was performed 201
146 to the nearby left maxillary central incisor in the with a surgical round bur and a fissure bur, and the 202
147 vicinity of the SNT by approaching it from the labial SNT was successfully removed without damaging the 203
148 side. nearby left maxillary central incisor. After removal 204
149 Fabrication of the surgical guide was based on anal- of the SNT, suturing and postoperative dressing were 205
150 ysis of the preoperative data. CAD software (Simplant; performed. The patient showed no complications, 206
151 Materialise, Leuven, Belgium) was used to reconstruct such as pain, edema, bleeding, or damage to nearby 207
152 a 3-dimensional (3D) image based on the CBCT image permanent teeth, after surgery. 208
153 and to measure the appropriate location, direction, 209
154 width, and depth of ostectomy on the CBCT image 210
155 to design the surgical guide (Fig 2). Then, the surgical CASE 2 211
156 guide was fabricated through manual procedures A 9-year-old child visited the Department of Pediat- 212
157 based on the measurements. ric Dentistry, Wonju College of Medicine, Yonsei Uni- 213
158 Surgery was performed under general anesthesia versity with chief complaints of an unsightly tooth 214
159 after the patient and her guardian agreed to the pro- and dental caries. There was no relevant dental or 215
160 cedure. To begin the surgical procedure (Fig 3), a crev- medical history. During the clinical examination, 216
161 icular incision in the maxillary labial gingiva was made the following findings were recorded: advanced 217
162 and the labial flap was elevated to expose the bone. caries in the left maxillary central incisor and the 218
163 Next, the surgical guide was attached to the location left maxillary lateral incisor, ectopic eruption of the 219
164 determined by the software. The ostectomy was con- left maxillary canine, and prolonged retention of 220
165 ducted with a surgical drill (Megagen Surgical Kit; the left maxillary deciduous canine. The CBCT image 221
166 Megagen Implant, Kyungsan, Korea) according to the showed that access from the labial side to the SNT 222
167 data analyzed before surgery; after surgery, the surgical would be difficult because of the left maxillary cen- 223
168 guide was detached to cut out the dilacerated root tral incisor and the left maxillary canine, and that 224

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253 FIGURE 2. Preoperative cone-beam computed tomographic analysis of the positional relation between the supernumerary tooth and the 309
reference point (vertex of wedge-shaped figure). A, Sagittal view. The distance from the reference point to the supernumerary tooth is
254 14.10 mm, and the angle formed by the intersecting lines of the axis of the drill and the axis of the wedge-shaped figure is 62.54 . (Fig 2 310
255 continued on next page.) 311
256 Jo et al. SNT Removal Using Surgical Guide. J Oral Maxillofac Surg 2016. 312
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259 access from the palatal side to the SNT also would be guide by reconstructing an image of the intraoral 315
260 difficult because of the left maxillary lateral incisor. A structure of the patient. The procedure of preparing 316
261 3D CT image showed that access to the SNT would the surgical guide in case 2 is depicted in a mimetic 317
262 be difficult from the labial and the palatal sides diagram (Fig 5). 318
263 (Fig 4). Before surgery, root canal treatment and orthodon- 319
264 Therefore, orthodontic traction of the left maxillary tic traction were performed. The left maxillary cen- 320
265 canine was applied to create a labial space to access tral incisor and left maxillary lateral incisor were 321
266 the SNT for removal. During the labial ostectomy, a treated by root canal. After root canal treatment, to 322
267 surgical guide was used to prevent damage to the create space for the left maxillary canine, the pro- 323
268 nearby permanent teeth and to perform a minimally longed retained left maxillary deciduous canine 324
269 invasive ostectomy. was extracted. Then, orthodontic traction was 325
270 The surgical guide was fabricated based on anal- applied to the left maxillary canine. Approximately 326
271 ysis of the preoperative data. However, only CAD 8 months after orthodontic traction was applied, suf- 327
272 technology was used in case 1, whereas CAD and ficient labial space was created to access the SNT 328
273 CAM technology were used in case 2. The surgical for removal. 329
274 guide was fabricated using a 3D printer (ProJet Surgery was performed under general anesthesia. 330
275 3510 HDMax; 3D Systems, Rock Hill, SC) applying For the surgical procedure (Fig 6), the surgical guide 331
276 CAM technology. In case 2, the CAD software was attached before a vertical incision was made 332
277 (Implant Studio; 3Shape, Copenhagen, Denmark) on the labial gingiva. Next, the ostectomy was per- 333
278 was different from the one used in case 1. In addi- formed with a surgical drill (Dio NAVI Kit; Dio, 334
279 tion, an oral scanner (Trios; 3Shape, Copenhagen, Pusan, Korea) according to the data analyzed before 335
280 Denmark) was used in case 2 to design the surgical surgery. The SNT was successfully removed from 336

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FIGURE 2 (cont’d). B, Horizontal view. The distance (4.60 mm) from the reference point to the supernumerary tooth and the angle (23.58 )
389 between the lines were measured. C, Coronal view. The distance (0.99 mm) and the angle (1.79 ) were measured. 445
390 Jo et al. SNT Removal Using Surgical Guide. J Oral Maxillofac Surg 2016. 446
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FIGURE 3. Surgical procedure for case 1. A, Preoperative clinical photograph. B, A labial flap was elevated to expose the bones. C, The
493 surgical guide and a drill tube with a hole inside were attached. The drill tube prevents shaking of the drill and accurately sets the location
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494 and direction of the ostectomy. D, The labial ostectomy was conducted with a surgical drill. E, The surgical guide was detached to cut 550
495 out the dilacerated root apex of the supernumerary tooth. F, Because the crown of the supernumerary tooth exhibited a palatal position, the 551
supernumerary tooth was removed through palatal approach, protecting the root of the left maxillary central incisor and decreasing the amount
496 of the ostectomy.
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Jo et al. SNT Removal Using Surgical Guide. J Oral Maxillofac Surg 2016.
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500 the labial side without damage to the nearby left Discussion 556
501 maxillary central incisor, left maxillary lateral incisor, 557
502 or left maxillary canine. Suturing and postoperative A mesiodens is normally removed by elevating the 558
503 dressing were applied. The patient had no complica- labial or palatal flap and performing an ostectomy. In 559
504 tions after surgery. the 2 present cases, the mesiodens was located near 560

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598 FIGURE 4. Three-dimensional computed tomograms of case 2. A, Coronal view. Access from the labial side to the SNT was difficult because of 654
the left maxillary central incisor and the left maxillary canine. B, Horizontal view. The SNT was surrounded by the left maxillary central incisor,
599 left maxillary lateral incisor, and left maxillary canine. SNT, supernumerary tooth. 655
600 Jo et al. SNT Removal Using Surgical Guide. J Oral Maxillofac Surg 2016.
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603 permanent teeth, which could have been damaged if ated root. It would have been difficult to perform this 659
604 the mesiodens had been removed by the usual surgical technique using the additional implant drills with a 660
605 method. In these cases, to avoid damage to nearby larger diameter and a longer length. Therefore, the 661
606 permanent teeth and to conduct a minimal ostectomy, ostectomy was performed after detaching the surgi- 662
607 a surgical guide fabricated using CAD and CAM tech- cal guide and then applying the surgical round bur 663
608 nology was used. and fissure bur. It might seem inefficient to detach 664
609 In the present cases, the initial ostectomy was con- the surgical guide after the initial surgical stage and 665
610 ducted without damaging the nearby permanent then apply the conventional method. However, the 666
611 teeth by using pilot drills according to the position, value of this report is the surgical guide used for 667
612 direction, and depth analyzed before the surgery. accurate and minimal initial ostectomy and its clinical 668
613 After performing the initial ostectomy with pilot applicability to various cases. 669
614 drills, a more sophisticated ostectomy was required Although surgeries with surgical guides are more 670
615 to prepare the site for removal of the SNT, create accurate than existing surgical methods, there can 671
616 space for the luxation of the SNT, and cut the dilacer- be differences between preoperative analysis data 672

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691 FIGURE 5. Flow diagram of surgical guide fabrication for case 2. 3D, 3-dimensional; CAD, computer-aided design; CAM, computer-aided
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692 manufacturing; CBCT, cone-beam computed tomography. 748
693 Jo et al. SNT Removal Using Surgical Guide. J Oral Maxillofac Surg 2016. 749
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696 and the actual surgery. Such errors can occur during appropriate location.15,16 If a surgical guide is used, 752
697 presurgical procedures or during the surgery. Presur- then an implant can be positioned accurately based 753
698 gical errors can occur during the procedure of surgi- on the location analyzed before the surgery, even on 754
699 cal guide fabrication, such as when taking manual or shallow bone, such as the type found in the area of 755
700 digital impressions, fabricating the cast, or overlap- the maxillary anterior teeth.17 756
701 ping the CBCT and 3D images.14 Errors can occur Because of these advantages, surgical guides can 757
702 during surgery if the guide is tilted, which can occur be used in various surgeries. The authors’ hospital 758
703 if it is not placed accurately or it receives sideway uses surgical guides in oral surgeries in which accu- 759
704 forces during the ostectomy. Errors also can occur racy and predictability are required; these proced- 760
705 if the drill is tilted, which can occur if there is a small ures include implant surgery, removal of impacted 761
706 but specific space between the guide hole and SNTs, apicoectomy, and autotransplantation. Surgical 762
707 the drill.14 guides are used in other oral and maxillofacial sur- 763
708 The use of surgical guides has disadvantages. Expen- geries. Hamza13 reported a methodology of surgical 764
709 sive equipment, such as a CT scanners, oral scanners, tooth extraction using a surgical guide, and Kang 765
710 and 3D printers, are required. In addition, the fabrica- and Kim10 reported on a case in which a surgical 766
711 tion of surgical guides is time consuming and labor guide was used to conduct dento-osseus ostectomy 767
712 intensive. For such reasons, most local clinics cannot without damaging nearby permanent teeth. Lim 768
713 fabricate surgical guides on their own. Although et al11 reported on a case in which genioplasty was 769
714 case-specific surgical guides can be fabricated by conducted using a surgical guide, and Darwood 770
715 external manufacturers, the cost can be prohibi- et al8 reported on a case in which a surgical guide 771
716 tively expensive. was used to successfully remove the tumor of a pa- 772
717 Despite the drawbacks, the use of a surgical guide tient with fibrous dysplasia. Seruya et al9 showed 773
718 greatly increases the effectiveness of a procedure. Sur- the value of surgical guides in neurosurgery when 774
719 gical guides enhance the accuracy and predictability of they reported on a case in which a surgical guide 775
720 the surgery, decrease technologic sensitivity, and was used to perform a craniectomy. 776
721 decrease the time required for surgery. They are espe- It is expected that this research will lead to the 777
722 cially outstanding for accuracy and predictability of increased usage of surgical guides for the surgical 778
723 the surgery. When an implant surgery is conducted removal of SNTs in many children and adolescents. 779
724 using a surgical guide, the implant is positioned in an To minimize the errors that can occur in surgeries 780
725 appropriate location.15,16 However, if the implant using surgical guides, CAD and CAM technology 781
726 surgery is conducted using the current method, then must be enhanced further. There is a need to 782
727 the location of the implant can deviate from the lower the costs of surgical guides according to 783
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830 FIGURE 6. Surgical procedure for case 2. A, Preoperative clinical photograph. B, A vertical incision was made on the labial gingiva. C, The 886
831 surgical guide and a drill tube were attached, and the ostectomy was performed according to the data analyzed before surgery. D, After 887
performing the ostectomy, the supernumerary tooth was exposed. E, An additional ostectomy was performed, and the supernumerary tooth
832 was luxated. F, The supernumerary tooth was successfully removed from the labial side.
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Jo et al. SNT Removal Using Surgical Guide. J Oral Maxillofac Surg 2016.
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836 enhancements of CAD and CAM technology. These are especially useful in children and adolescents 892
837 will allow the additional use of surgical guides. who are vulnerable to having permanent teeth and 893
838 In summary, surgical guides fabricated using tooth germs damaged during surgical removal of 894
839 CAD and CAM technology were used to successfully SNTs. Therefore, surgical guides that are fabricated 895
840 remove the mesiodens in 2 cases. Surgical guides through CAD and CAM technology are expected to 896

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