Palatal Approach for Extraction of an Inverted Impacted Supernumerary Tooth in the Maxilla: A Case Report and Technical Considerations

Palatal Approach for Extraction of an Inverted Impacted Supernumerary Tooth in the Maxilla: A Case Report and Technical Considerations | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Palatal Approach for Extraction of an Inverted Impacted Supernumerary Tooth in the Maxilla: A Case Report and Technical Considerations Wusimanjiang Aierken, Chuntao Leng, Abulajiang Anayeti This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6436050/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Supernumerary teeth (ST), a developmental dental anomaly, frequently occur in the maxillary anterior region and may necessitate surgical intervention due to complications such as adjacent tooth displacement or root resorption. Case Presentation Cone-beam computed tomography (CBCT) identified an inverted supernumerary tooth within the nasopalatine canal, prompting extraction via a palatal approach. During the procedure, a deviation in positioning resulted in damage to the nasal mucosa, which was promptly managed with good recovery. Conclusion Preoperative CBCT planning and multidisciplinary coordination are critical for safe extraction, while minimally invasive techniques reduce complications in complex cases. Supernumerary teeth Impacted teeth Cone-beam computed tomography (CBCT) Nasopalatine canal Minimally invasive surgery Pediatric dentistry Figures Figure 1 Figure 2 Figure 3 Figure 4 Background Supernumerary teeth (ST), also known as hyperdontia, are teeth that exceed the normal dental count and are a common developmental anomaly. Epidemiological studies indicate an incidence rate of 1%-3% in China [ 1 ], predominantly during the mixed and permanent dentition stages [ 1 , 2 , 9 ]. The exact etiology remains unclear, though proposed theories include atavism, dichotomy of tooth buds, hyperactivity of the dental lamina, and potential influences from embryonic trauma or infection [ 3 , 4 ]. Clinically, impacted supernumerary teeth are most common in the maxillary anterior region. while some cases may be asymptomatic, they often cause complications such as dental crowding, malpositioning of adjacent teeth, root resorption, abnormal spacing, and even cyst or tumor formation [ 2 – 4 ]. these complications can significantly affect the development of the child's dentofacial system, making timely and appropriate management essential. The maxillary anterior region is anatomically complex, and precise localization of impacted supernumerary teeth can be challenging. intraoperative positioning errors may lead to excessive bone removal, resulting in serious complications such as damage to the nasopalatine neurovascular bundle (causing palatal mucosal sensory abnormalities), adjacent tooth loosening or pulp necrosis, developmental disturbances of tooth buds, or even accidental displacement of the supernumerary tooth into the nasal cavity [ 8 – 12 ]. these risks make the extraction of supernumerary teeth in children a highly challenging oral surgical procedure. This article reports a case of a 9-year-old boy with an inverted impacted supernumerary tooth in the maxillary anterior region, focusing on the prolonged surgical time and complications caused by intraoperative measurement and positioning errors. The case highlights the importance of preoperative precision and optimized surgical planning for ensuring treatment efficacy. Case presentation A 9-year-old male patient was referred to our hospital after a supernumerary tooth was detected in the maxillary anterior region during a winter break examination at another institution. the patient had no history of systemic diseases, infectious diseases, or allergies, and no contraindications for tooth extraction. general examination revealed good overall health, normal development, clear consciousness, and cooperative behavior. facial examination: symmetrical facial features, normal proportions, and no abnormalities in mouth opening or temporomandibular joint function. no enlarged lymph nodes were palpable. mixed dentition stage with Angle Class I malocclusion and mesial inclination of maxillary central incisors. deciduous teeth (53–55, 63–65, 73–75, 83–85) were present. no obvious abnormalities in the oral mucosa, and no clinically visible supernumerary tooth eruption. CBCT showed a conical supernumerary tooth between the roots of the maxillary central incisors (Fig. 1 a), with the crown on the palatal side and the root on the labial side (Fig. 1 b), covered by cortical bone. The tooth was positioned between the central incisors and the anterior nasal spine (Fig. 1 c), with the crown located within the nasopalatine canal and the long axis in a sagittal orientation (Fig. 1 ). Surgical Approach Analysis Labial Approach Feasibility: the inter-root distance of the central incisors was only 1.52 mm, with the supernumerary tooth root minimally 0.87 mm from the roots of teeth 11 and 21. potential complications included adjacent tooth damage and significant bone loss at the anterior nasal spine, risking altered nasolabial contour. Palatal Approach Advantages: the crown's maximum diameter (4.3 mm) was on the palatal side, with a safe distance of 1.2 mm from the nasopalatine canal. The approach allowed targeted bone removal (< 3 mm³). but visual field limitations, Surgeon positioning constraints. Final Surgical Plan was Palatal Approach. Incision design: 10 ± 0.5 mm below the palatal gingival papilla apex, with an 8 mm curvature radius (not exceeding 10 mm) and length covering teeth 12–22. nerve Protection: Identification and preservation of the neurovascular bundle. anesthesia: General anesthesia (Grade I) combined with local infiltration anesthesia (1:100,000 epinephrine). the patient and guardian were informed of the surgical plan and potential complications, and written consent was obtained. Surgical Procedure; A comprehensive pre-anesthetic evaluation was conducted to identify health conditions, assess anesthesia related risks, and optimize patient care. the assessment included: Medical History, Airway Assessment, Cardiovascular Evaluation, Respiratory System Assessment, Laboratory Investigations was prepared for surgery with standard preoperative measures. reports and findings were within normal limits. An arched incision was made 10 mm below the palatal gingival papilla apex of teeth 12 and 22(Fig. 2 ). osteotomy (3 mm depth) was initiated 18 mm apical to the gingival apex, but the supernumerary tooth crown was not located. probing (< 10 N force) revealed no contact with the tooth or surrounding space. the CBCT showed that the tooth crown was deviated to the left, so the bone removal was extended further leftward. during subsequent probing for the supernumerary tooth, the probe entered a space but did not make contact with the tooth. the space appeared unusually large, prompting immediate suspension of the procedure due to suspected incorrect orientation and potential perforation of the nasal mucosa. by this point, the surgery had already exceeded one hour, surpassing the preoperative estimated duration. the surgeon re-examined the CBCT and measured the bone removal range, confirming that the current osteotomy area was 5 mm away from the supernumerary tooth crown. the surgical incision was then modified (Fig. 3 ), followed by careful separation of the nasopalatine neurovascular bundle and targeted bone removal to successfully extract the supernumerary tooth. The total surgical duration was 100 minutes. Due to initial positioning errors, the osteotomy was extended approximately 5 mm leftward beyond the planned range (as measured from the CBCT re-evaluation), resulting in incidental perforation of the nasal mucosa (0.2 mm diameter, confirmed via postoperative nasal endoscopy). the dental follicle was curetted, copious irrigation with normal saline was done, the socket and nasal mucosa breach were treated with collagen sponge, and the palatal mucosa was repositioned and sutured. no active bleeding was observed. Postoperative Care: antibiotics for 3 days, Amoxicillin 500 mg every 8 h, routine post-extraction care. day 1: Minor nasal bleeding and mild pain (VAS score: 2), managed with NSAIDs. The surgical site showed no significant swelling or bleeding, patient reported no other discomfort. After consultation with the ENT department and nasal endoscopy examination, nasal mucosa perforation (0.2 mm) was confirmed via endoscopy and managed conservatively with topical recombinant human epidermal growth factor gel to promote natural healing (Fig. 4 ). As this minor trauma required no special intervention. day 2: no pain or bleeding. day 3: discharge with instructions for a soft diet and avoidance of hot, spicy, or hard foods. 1-week follow-up: no pain, good wound healing, sutures removed. 1-month follow-up: Mucosa healed well, no sensory deficits or functional impairments were observed. Discussion The surgical management of impacted supernumerary teeth places high demands on clinicians' technical skills and the precision of instruments. In this case, measurement errors and operational deviations by the surgeon led to prolonged surgical time and nasal mucosal injury, highlighting the critical importance of standardized surgical techniques, instrument adaptability, and the application of digital-assisted technologies in complex anatomical regions [ 13 , 14 ]. Surgical complications are frequently associated with the operator's experience and meticulous attention to technical details. In this case, the use of a straight measuring caliper failed to conform to the curved palatal anatomy, resulting in deviations from the target osteotomy site. additionally, when initial probing failed to locate the target tooth, the surgeon did not promptly review the CBCT data, but instead blindly expanded the osteotomy range. this process revealed the following issues: Limitations of measuring tools: straight instruments are unsuitable for curved palatal anatomy; flexible or 3D-adapted tools may mitigate measurement errors. Rationality of intraoperative decision-making: when the target tooth is not located, priority should be given to reviewing imaging data rather than expanding the osteotomy range to minimize unnecessary tissue damage [ 15 ]. standardized training for operators: clinicians need enhanced training in three-dimensional spatial orientation and the establishment of standardized intraoperative adjustment protocols, such as an "exploration-review-correction" model, to reduce subjective errors [ 16 ]. Traditional surgical instruments have certain limitations in complex anatomical regions and require optimization through modern technologies: adaptable measuring tools: development of curved-surface-compatible measuring devices, such as flexible probes or 3D scanning-assisted distance meters, to reduce errors caused by instrument mismatch [ 17 ]. real-time feedback systems: integration of pressure sensors into high-speed turbine handpieces or osteotomes to provide tactile or visual warnings when approaching critical structures (e.g., nerves or mucosa) [ 18 ]. minimally invasive visualization techniques: Introduction of micro-endoscopes or optical navigation devices to provide clear visualization in confined surgical fields and avoid blind operations [ 19 ]. Digital surgical technologies can significantly improve the precision and safety of procedures: while 3D-printed surgical guides improve precision, cost and production time limit accessibility. cloud-based modeling could streamline workflows. future improvements may involve optimizing design processes (e.g., cloud-based modeling, rapid 3D printing) to enhance clinical applicability [ 17 ]. Dynamic navigation systems: These systems track instrument positions in real time to assist surgeons in adjusting operational paths, but their complexity limits widespread adoption [ 19 ]. As shown by Wang et al. [ 19 ], real-time navigation systems could prevent spatial deviations in complex palatal approaches, such as the positional errors encountered in this case. future research could explore lightweight, low-cost navigation solutions. AI-assisted planning: deep learning algorithms can analyze CBCT data to automatically generate optimal surgical approaches and predict potential risk zones [ 13 ], providing decision-making support for surgeons. to reduce human errors and improve surgical efficiency, the following strategies can be adopted: Human-machine collaborative surgery: combining surgeon expertise with digital technologies, such as using augmented reality (AR) to overlay CBCT data for real-time guidance during surgery. Standardized training systems: Incorporating digital tools into oral surgery training programs to enhance clinicians' technical adaptability. Multidisciplinary collaboration: Engineers, radiologists, and clinicians can work together to develop more practical precision surgical systems, such as intelligent navigation instruments or automated osteotomy devices. Conclusion Preoperative CBCT assessment is indispensable for evaluating surgical complexity and determining the spatial relationship of the supernumerary tooth to adjacent structures, thereby facilitating minimally invasive extraction. Declarations Acknowledgements We would like to thank all the authors for theirs contributes to this article, the reviewers. Authors’ contributions W.A. performed the diagnosis, surgery, and manuscript drafting; A.A. supervised the surgery and follow-up; C.L. reviewed and edited the manuscript. Funding This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Data availability Data sharing is not applicable to this article as no datasets were generated or analyzed during the current stud. Ethics approval and consent to participate Ethical approval was waived as this report reflects standard care. Written informed consent was obtained from the patient’s guardian for publication. Consent for publication Written informed consent was obtained from the patient’s guardian to publish this case report. Clinical trial number not applicable. Consent for publication Not applicable. Competing interests The authors declare that they have no competing interests References Gao H, Chen YM, Ting LY, et al. A CBCT study on the effect of impacted mesiodenson the root development of upper central incisors. Chin J Conserv Dent. 2017;27(06):330–3. Rallan M, Rallan NS, Goswami M et al. Surgical manage ment of multiple supernumerary teeth and an impacted maxil lary permanent central incisor. BMJ Case Rep, 2013: bcr2013009995. Ata-Ali F, Ata-Ali J, Peñarrocha-Oltra D, et al. Prevalence, etiology, diagnosis, treatment and complications of supernumerary teeth. J Clin Exp Dent. 2014;6(4):e414–8. Gurler G, Delilbasi C, Delilbasi E. Investigation of impacted supernumerary teeth: a cone beam computed tomography(cbct)study. J Istanb Univ Fac Dent. 2017;51(3):1824. 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Supernumerary nasal tooth removed with a modified maxillary vestibular approach: case report and literature review. Oral Maxillofacial Surg. 2019;23(2):247–52. Tuna EB, Kurklu E, Gencay K, et al. Clinical and radiologi cal evaluation of inverse impaction of supernumerary teeth. Med Oral Patol Oral Cir Bucal. 2013;18(4):e613e618. Mallineni SK, Jayaraman J, Wong HM, et al. Dental devel opment in children with supernumerary teeth in the anterior region of maxilla. Clin Oral Investig. 2019;23(7):2987–94. Wang W, Somar M, Lv K. Safer alternative for extraction of impacted supernumerary teeth of a patient in the mixed denti tion stage with the aid of an image-guided operating system. Br J Oral Maxillofac Surg. 2017;55(5):551–3. Additional Declarations No competing interests reported. Supplementary Files cbct.zip Panoramicview.jpg Combinedsagittalandpanoramicview.jpg Sagittalview.jpg Coronalview.jpg 3Dreconstruction.jpg Initialpalatalincisiondesign.png ModifiedincisionafterintraoperativeCBCTreassessment.png Postoperativenasalendoscopy.jpg Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. 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Considerations","fulltext":[{"header":"Background","content":"\u003cp\u003eSupernumerary teeth (ST), also known as hyperdontia, are teeth that exceed the normal dental count and are a common developmental anomaly. Epidemiological studies indicate an incidence rate of 1%-3% in China [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e], predominantly during the mixed and permanent dentition stages [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. The exact etiology remains unclear, though proposed theories include atavism, dichotomy of tooth buds, hyperactivity of the dental lamina, and potential influences from embryonic trauma or infection [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eClinically, impacted supernumerary teeth are most common in the maxillary anterior region. while some cases may be asymptomatic, they often cause complications such as dental crowding, malpositioning of adjacent teeth, root resorption, abnormal spacing, and even cyst or tumor formation [\u003cspan additionalcitationids=\"CR3\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. these complications can significantly affect the development of the child's dentofacial system, making timely and appropriate management essential.\u003c/p\u003e \u003cp\u003eThe maxillary anterior region is anatomically complex, and precise localization of impacted supernumerary teeth can be challenging. intraoperative positioning errors may lead to excessive bone removal, resulting in serious complications such as damage to the nasopalatine neurovascular bundle (causing palatal mucosal sensory abnormalities), adjacent tooth loosening or pulp necrosis, developmental disturbances of tooth buds, or even accidental displacement of the supernumerary tooth into the nasal cavity [\u003cspan additionalcitationids=\"CR9 CR10 CR11\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. these risks make the extraction of supernumerary teeth in children a highly challenging oral surgical procedure.\u003c/p\u003e \u003cp\u003eThis article reports a case of a 9-year-old boy with an inverted impacted supernumerary tooth in the maxillary anterior region, focusing on the prolonged surgical time and complications caused by intraoperative measurement and positioning errors. The case highlights the importance of preoperative precision and optimized surgical planning for ensuring treatment efficacy.\u003c/p\u003e"},{"header":"Case presentation","content":"\u003cp\u003eA 9-year-old male patient was referred to our hospital after a supernumerary tooth was detected in the maxillary anterior region during a winter break examination at another institution. the patient had no history of systemic diseases, infectious diseases, or allergies, and no contraindications for tooth extraction. general examination revealed good overall health, normal development, clear consciousness, and cooperative behavior. facial examination: symmetrical facial features, normal proportions, and no abnormalities in mouth opening or temporomandibular joint function. no enlarged lymph nodes were palpable. mixed dentition stage with Angle Class I malocclusion and mesial inclination of maxillary central incisors. deciduous teeth (53\u0026ndash;55, 63\u0026ndash;65, 73\u0026ndash;75, 83\u0026ndash;85) were present. no obvious abnormalities in the oral mucosa, and no clinically visible supernumerary tooth eruption. CBCT showed a conical supernumerary tooth between the roots of the maxillary central incisors (Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e1\u003c/span\u003ea), with the crown on the palatal side and the root on the labial side (Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e1\u003c/span\u003eb), covered by cortical bone. The tooth was positioned between the central incisors and the anterior nasal spine (Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e1\u003c/span\u003ec), with the crown located within the nasopalatine canal and the long axis in a sagittal orientation (Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eSurgical Approach Analysis Labial Approach Feasibility: the inter-root distance of the central incisors was only 1.52 mm, with the supernumerary tooth root minimally 0.87 mm from the roots of teeth 11 and 21. potential complications included adjacent tooth damage and significant bone loss at the anterior nasal spine, risking altered nasolabial contour. Palatal Approach Advantages: the crown's maximum diameter (4.3 mm) was on the palatal side, with a safe distance of 1.2 mm from the nasopalatine canal. The approach allowed targeted bone removal (\u0026lt;\u0026thinsp;3 mm\u0026sup3;). but visual field limitations, Surgeon positioning constraints. Final Surgical Plan was Palatal Approach. Incision design: 10\u0026thinsp;\u0026plusmn;\u0026thinsp;0.5 mm below the palatal gingival papilla apex, with an 8 mm curvature radius (not exceeding 10 mm) and length covering teeth 12\u0026ndash;22. nerve Protection: Identification and preservation of the neurovascular bundle.\u003c/p\u003e \u003cp\u003eanesthesia: General anesthesia (Grade I) combined with local infiltration anesthesia (1:100,000 epinephrine). the patient and guardian were informed of the surgical plan and potential complications, and written consent was obtained.\u003c/p\u003e \u003cp\u003eSurgical Procedure; A comprehensive pre-anesthetic evaluation was conducted to identify health conditions, assess anesthesia related risks, and optimize patient care. the assessment included: Medical History, Airway Assessment, Cardiovascular Evaluation, Respiratory System Assessment, Laboratory Investigations was prepared for surgery with standard preoperative measures. reports and findings were within normal limits.\u003c/p\u003e \u003cp\u003eAn arched incision was made 10 mm below the palatal gingival papilla apex of teeth 12 and 22(Fig.\u0026nbsp;\u003cspan refid=\"Fig6\" class=\"InternalRef\"\u003e2\u003c/span\u003e). osteotomy (3 mm depth) was initiated 18 mm apical to the gingival apex, but the supernumerary tooth crown was not located. probing (\u0026lt;\u0026thinsp;10 N force) revealed no contact with the tooth or surrounding space. the CBCT showed that the tooth crown was deviated to the left, so the bone removal was extended further leftward. during subsequent probing for the supernumerary tooth, the probe entered a space but did not make contact with the tooth. the space appeared unusually large, prompting immediate suspension of the procedure due to suspected incorrect orientation and potential perforation of the nasal mucosa. by this point, the surgery had already exceeded one hour, surpassing the preoperative estimated duration. the surgeon re-examined the CBCT and measured the bone removal range, confirming that the current osteotomy area was 5 mm away from the supernumerary tooth crown. the surgical incision was then modified (Fig.\u0026nbsp;\u003cspan refid=\"Fig7\" class=\"InternalRef\"\u003e3\u003c/span\u003e), followed by careful separation of the nasopalatine neurovascular bundle and targeted bone removal to successfully extract the supernumerary tooth. The total surgical duration was 100 minutes. Due to initial positioning errors, the osteotomy was extended approximately 5 mm leftward beyond the planned range (as measured from the CBCT re-evaluation), resulting in incidental perforation of the nasal mucosa (0.2 mm diameter, confirmed via postoperative nasal endoscopy). the dental follicle was curetted, copious irrigation with normal saline was done, the socket and nasal mucosa breach were treated with collagen sponge, and the palatal mucosa was repositioned and sutured. no active bleeding was observed.\u003c/p\u003e \u003cp\u003ePostoperative Care: antibiotics for 3 days, Amoxicillin 500 mg every 8 h, routine post-extraction care. day 1: Minor nasal bleeding and mild pain (VAS score: 2), managed with NSAIDs. The surgical site showed no significant swelling or bleeding, patient reported no other discomfort. After consultation with the ENT department and nasal endoscopy examination, nasal mucosa perforation (0.2 mm) was confirmed via endoscopy and managed conservatively with topical recombinant human epidermal growth factor gel to promote natural healing (Fig.\u0026nbsp;\u003cspan refid=\"Fig8\" class=\"InternalRef\"\u003e4\u003c/span\u003e). As this minor trauma required no special intervention. day 2: no pain or bleeding. day 3: discharge with instructions for a soft diet and avoidance of hot, spicy, or hard foods. 1-week follow-up: no pain, good wound healing, sutures removed. 1-month follow-up: Mucosa healed well, no sensory deficits or functional impairments were observed.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe surgical management of impacted supernumerary teeth places high demands on clinicians' technical skills and the precision of instruments. In this case, measurement errors and operational deviations by the surgeon led to prolonged surgical time and nasal mucosal injury, highlighting the critical importance of standardized surgical techniques, instrument adaptability, and the application of digital-assisted technologies in complex anatomical regions [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eSurgical complications are frequently associated with the operator's experience and meticulous attention to technical details. In this case, the use of a straight measuring caliper failed to conform to the curved palatal anatomy, resulting in deviations from the target osteotomy site. additionally, when initial probing failed to locate the target tooth, the surgeon did not promptly review the CBCT data, but instead blindly expanded the osteotomy range. this process revealed the following issues: Limitations of measuring tools: straight instruments are unsuitable for curved palatal anatomy; flexible or 3D-adapted tools may mitigate measurement errors. Rationality of intraoperative decision-making: when the target tooth is not located, priority should be given to reviewing imaging data rather than expanding the osteotomy range to minimize unnecessary tissue damage [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. standardized training for operators: clinicians need enhanced training in three-dimensional spatial orientation and the establishment of standardized intraoperative adjustment protocols, such as an \"exploration-review-correction\" model, to reduce subjective errors [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eTraditional surgical instruments have certain limitations in complex anatomical regions and require optimization through modern technologies: adaptable measuring tools: development of curved-surface-compatible measuring devices, such as flexible probes or 3D scanning-assisted distance meters, to reduce errors caused by instrument mismatch [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. real-time feedback systems: integration of pressure sensors into high-speed turbine handpieces or osteotomes to provide tactile or visual warnings when approaching critical structures (e.g., nerves or mucosa) [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. minimally invasive visualization techniques: Introduction of micro-endoscopes or optical navigation devices to provide clear visualization in confined surgical fields and avoid blind operations [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eDigital surgical technologies can significantly improve the precision and safety of procedures: while 3D-printed surgical guides improve precision, cost and production time limit accessibility. cloud-based modeling could streamline workflows. future improvements may involve optimizing design processes (e.g., cloud-based modeling, rapid 3D printing) to enhance clinical applicability [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Dynamic navigation systems: These systems track instrument positions in real time to assist surgeons in adjusting operational paths, but their complexity limits widespread adoption [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. As shown by Wang et al. [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e], real-time navigation systems could prevent spatial deviations in complex palatal approaches, such as the positional errors encountered in this case. future research could explore lightweight, low-cost navigation solutions. AI-assisted planning: deep learning algorithms can analyze CBCT data to automatically generate optimal surgical approaches and predict potential risk zones [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e], providing decision-making support for surgeons. to reduce human errors and improve surgical efficiency, the following strategies can be adopted: Human-machine collaborative surgery: combining surgeon expertise with digital technologies, such as using augmented reality (AR) to overlay CBCT data for real-time guidance during surgery. Standardized training systems: Incorporating digital tools into oral surgery training programs to enhance clinicians' technical adaptability. Multidisciplinary collaboration: Engineers, radiologists, and clinicians can work together to develop more practical precision surgical systems, such as intelligent navigation instruments or automated osteotomy devices.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003ePreoperative CBCT assessment is indispensable for evaluating surgical complexity and determining the spatial relationship of the supernumerary tooth to adjacent structures, thereby facilitating minimally invasive extraction.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe would like to thank all the authors for theirs contributes to this article, the reviewers.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors’ contributions\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eW.A. performed the diagnosis, surgery, and manuscript drafting; A.A. supervised the surgery and follow-up; C.L. reviewed and edited the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData sharing is not applicable to this article as no datasets were generated or analyzed during the current stud.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval was waived as this report reflects standard care. Written informed consent was obtained from the patient’s guardian for publication.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten informed consent was obtained from the patient’s guardian to publish this case report.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial number\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003enot applicable.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eGao H, Chen YM, Ting LY, et al. A CBCT study on the effect of impacted mesiodenson the root development of upper central incisors. Chin J Conserv Dent. 2017;27(06):330\u0026ndash;3.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRallan M, Rallan NS, Goswami M et al. Surgical manage ment of multiple supernumerary teeth and an impacted maxil lary permanent central incisor. BMJ Case Rep, 2013: bcr2013009995.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAta-Ali F, Ata-Ali J, Pe\u0026ntilde;arrocha-Oltra D, et al. Prevalence, etiology, diagnosis, treatment and complications of supernumerary teeth. J Clin Exp Dent. 2014;6(4):e414\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGurler G, Delilbasi C, Delilbasi E. Investigation of impacted supernumerary teeth: a cone beam computed tomography(cbct)study. J Istanb Univ Fac Dent. 2017;51(3):1824.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMallineni SK, Ja yaraman J, Wong HM, et al. Dental devel opment in children with supernumerary teeth in the anterior region of maxilla. Clin Oral Investig. 2019;23(7):2987\u0026ndash;94.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSoxman JA. Diagnosis and management of mesiodentes. Gen Dent. 2015;63(5):18\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWang W, Somar M, Lv K. Safer alternative for extraction of impacted supernumerary teeth of a patient in the mixed denti tion stage with the aid of an image-guided operating system. Br J Oral Maxillofac Surg. 2017;55(5):551\u0026ndash;3.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKong J, Peng Z, Zhong T et al. Clinical analysis of ap proach selection of extraction of maxillary embedded mesiodens in children. Dis Markers, 2022:6517024.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMa X, Jiang Y, Ge H, et al. Epidemiological, clinical, radio graphic characterization of non-syndromic supernumerary teeth in Chinese children and adolescents. Oral Dis. 2021;27(4):981\u0026ndash;92.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eXia TY, Punjabi A, Oh JH, et al. Updated dynamics of rhi noplasty: A review of the literature and comprehensive list of the findings. Aesthetic Plast Surg. 2020;44(3):904\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePark SY, Jang HJ, Hwang DS, et al. Complications associat ed with specific characteristics of supernumerary teeth. O ral Surg Oral Med Oral Pathol Oral Radiol. 2020;130(2):150\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSpirito FD, Scelza G, Amato A, et al. Prevalence of dental anomalies in a sample of growing subjects: a retrospective study. Epidemiol Prev. 2022;46(5\u0026ndash;6):376381.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFinkelstein T, Shapiray Y, Pavlidi AM, et al. Prevalence and characteristics of supernumerary teeth in Israeli orthodontic patients. J Clin Pediatr Dent. 2019;43(4):244\u0026ndash;51.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSingh AK, Soni S, Jaiswal D, et al. Prevalence of supernumerary teeth and its associated complications among school-going children between the ages of 6 and 15 years of Jamshedpur, Jharkhand, India. Int J Clin Pediatr Dentistry. 2022;15(5):504\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBurhan AS, Nawaya FR, Arabi ME, et al. Prevalence of supernumerary teeth in a nonsyndromic Syrian sample. J Egypt Public Health Assoc. 2015;90(4):146\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCosta SM, Dejesusao, Silbeirarl, et al. Supernumerary nasal tooth removed with a modified maxillary vestibular approach: case report and literature review. Oral Maxillofacial Surg. 2019;23(2):247\u0026ndash;52.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTuna EB, Kurklu E, Gencay K, et al. Clinical and radiologi cal evaluation of inverse impaction of supernumerary teeth. Med Oral Patol Oral Cir Bucal. 2013;18(4):e613e618.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMallineni SK, Jayaraman J, Wong HM, et al. Dental devel opment in children with supernumerary teeth in the anterior region of maxilla. Clin Oral Investig. 2019;23(7):2987\u0026ndash;94.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWang W, Somar M, Lv K. Safer alternative for extraction of impacted supernumerary teeth of a patient in the mixed denti tion stage with the aid of an image-guided operating system. Br J Oral Maxillofac Surg. 2017;55(5):551\u0026ndash;3.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Supernumerary teeth, Impacted teeth, Cone-beam computed tomography (CBCT), Nasopalatine canal, Minimally invasive surgery, Pediatric dentistry","lastPublishedDoi":"10.21203/rs.3.rs-6436050/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6436050/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003eSupernumerary teeth (ST), a developmental dental anomaly, frequently occur in the maxillary anterior region and may necessitate surgical intervention due to complications such as adjacent tooth displacement or root resorption.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCase Presentation \u003c/strong\u003eCone-beam computed tomography (CBCT) identified an inverted supernumerary tooth within the nasopalatine canal, prompting extraction via a palatal approach. During the procedure, a deviation in positioning resulted in damage to the nasal mucosa, which was promptly managed with good recovery.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion \u003c/strong\u003ePreoperative CBCT planning and multidisciplinary coordination are critical for safe extraction, while minimally invasive techniques reduce complications in complex cases.\u003c/p\u003e","manuscriptTitle":"Palatal Approach for Extraction of an Inverted Impacted Supernumerary Tooth in the Maxilla: A Case Report and Technical Considerations","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-05-05 11:39:52","doi":"10.21203/rs.3.rs-6436050/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"2bf8f86a-88cd-4371-b642-20714114a14b","owner":[],"postedDate":"May 5th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-05-05T11:47:55+00:00","versionOfRecord":[],"versionCreatedAt":"2025-05-05 11:39:52","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6436050","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6436050","identity":"rs-6436050","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}