a 38-year - old male patient reported to the department of oral medicine and radiology with complaint of pus discharge from the right lower third of face of 2 - 3 months duration .
extra oral examination revealed a draining sinus surrounded by indurated granulation tissue on the right lower border of the mandible 4 cm away from the midline in the molar region [ figure 1 ] .
extra oral view showing the extra oral sinus and indurated granulation tissue intraoral examination revealed caries broken right mandibular molar along with pus discharge from the same [ figure 2 ] .
an orthopantomograph view was taken that revealed presence of completely developed bilateral supernumerary premolars below the first molars .
right supernumerary premolar was placed near the lower border of mandible and was surrounded by intense pericoronal radiolucency of about 5 - 6 mm without sclerotic borders .
the right first molar was caries broken and showed periapical radiolucency with both root apices , and track of radiolucency was running down from the apex of mesial root to involve the pericoronal radiolucency of the right supernumerary premolar . on the left side , supernumerary premolar was placed near the apex of the first molar with its follicle almost in close approximation with the root apices of the first molar .
considering the clinical and radiographic findings , a provisional diagnosis of supernumerary premolar associated secondarily infected dentigerous cyst with extra oral draining sinus on the right side and supernumerary premolar occurring in close vicinity of the left first molar on the left side and taurodontism of all molars was made .
intra oral view showing the carious broken first molar panoramic view showing the bilateral supernumerary premolars and taurodontism with molars the right supernumerary premolar associated with the cystic lining around its crown along with the extra oral chronic indurated tissue was surgically removed extra orally under local anesthesia .
showing the surgically removed supernumerary premolars postoperative intra oral view after six weeks postoperative extra oral view after six weeks
supernumerary teeth are classified according to the morphology as conical , tuberculate , supplemental , and odontoma , topographically as mesiodens , paramolar , distomolar , parapremolar , chronologically as pre deciduous , similar to permanent teeth and post permanent , or complementary and according to orientation as vertical , inverted , and transverse .
the term supplemental tooth refers to extra tooth resembling the tooth of normal series in dentition .
supernumerary premolars are usually of normal form and 75% are impacted and generally unerupted . in the present cases , both supernumerary premolars were unerupted and of supplemental type .
cases of bilateral supplemental premolar teeth developing later than their counter parts have been reported in literature .
various theories exist for different types of supernumerary . the phylogenetic theory of atavism , dichotomy theory , heredity , hyperactivity of dental lamina , aberrations during embryologic formation , progress zone , and unified etiological explanation are various theories for the developmental of supernumerary teeth .
there may be no effect with the supernumerary tooth or teeth discovered either as a chance radiographic finding or following their eruption .
various complications associated with the presence of supernumerary tooth are failure of permanent teeth eruption , crowding , ectopic eruption displacement , root resorption , dilaceration , loss of vitality of adjacent teeth , dental caries , periodontal abscess , gingival inflammation , sub acute pericoronitis , incomplete space closure during orthodontic treatment , and pathological problems such as dentigerous cyst formation , ameloblastomas , odontomas , and fistulae .
they may also interfere in alveolar bone grafting and implant placement . because large percentage of supernumerary premolar remain impacted , unerupted , and are usually asymptomatic and because most cases are diagnosed by chance during inspection of radiograph prior to the commencement of orthodontic treatment .
dentigerous cyst and root resorption have been cited in literature as frequent complication associated with supernumerary premolar .
kasat , et al . , reported a case of supernumerary premolars associated with odontogenic keratocyst .
bhardwaj , et al . , reported a case of bilateral supernumerary premolars present in close vicinity of permanent teeth . in the present case , left supernumerary premolar was present in close vicinity of molar that may cause its root resorption and , on the right side , periapical infection from first molar was moving down to infect the dentigerous cyst associated with supernumerary premolar and giving rise to extra oral draining sinus .
although both taurodontism and occurrence of supernumerary premolars are different entity , such association has not been documented earlier . in planning the treatment alternatives for impacted
supernumerary premolars , the potential risk of leaving them in situ and hazards of surgical removal of these teeth especially around the lower premolar region , where the teeth are close proximity to inferior dental and mental nerves and blood vessels should be assessed judiciously .
the timing of surgical removal of supernumerary premolar is as much debated among clinicians as are treatment methods .
whenever these teeth are associated with any pathological formation or when hinder eruption of or give rise to malpositioning of permanent teeth , they should be removed as soon as possible . if left in situ , periodic examination is recommended for their clinical behavior . in the present cases , both the supernumerary premolar
were surgically removed because right supernumerary premolar was associated with clinical complication and left supernumerary premolar might cause root resorption as it was in close approximation with the first molar roots .
extractions of supernumerary premolars should be performed carefully to prevent the damage to the adjacent permanent teeth .
clinician should also be alert during surgical removal of supernumerary premolars to avoid complications of damaging mental nerve and blood vessels .
recurrence of supernumerary premolars after being surgically removed has been reported in 8% of cases reviewed .
. impacted supernumerary premolars exhibiting the pathological changes seen in the present case should be removed at the earliest .
clinician should also be alert during surgical removal of supernumerary premolars to avoid complications of damaging mental nerve and blood vessels .
appropriate follow - up with panoramic radiographs are extremely important as the recurrence of supernumerary premolars after being surgically removed has also been reported .
 supernumerary teeth are extra teeth in comparison to the normal dentition . 
 their prevalence varies between 0.1% and 3.8% . 
 supernumeraries are more common in permanent dentition and its incidence is higher in maxillary incisor region , followed by maxillary third molar and mandibular molar , premolar , canine , and lateral incisor . 
 the prevalence of supernumerary premolars is between 0.075 - 0.26% , and they may occur in single or multiple numbers bilateral occurrence is uncommon and large percentage of supernumerary premolars remains impacted , unerupted , and usually asymptomatic ; radiograph plays an important role in diagnosis of these . 
 the present paper reports a case of bilaterally impacted completely developed supernumerary premolars associated with common clinical complication in unusual manner along with taurodontism of the upper and lower molars . 
Case Report
Discussion
Conclusion