Atlas of Procedures in Neonatology, 4th Edition

Miscellaneous Procedures


Management of Natal and Neonatal Teeth

Priyanshi Ritwik

Robert J. Musselman

The occurrence of teeth in the oral cavity at birth or within the first 30 days of life is uncommon. Such teeth have been called natal and neonatal teeth, respectively. This distinction, however, is temporal and artificial. Relevant clinical inferences can be made by further describing these teeth as mature or immature based on the quality of dental tissue and degree of dental development (1). Hebling et al. classified natal teeth into four clinical categories (2) (Table 52.1).

The reported incidence of natal and neonatal teeth varies; a range of 1in 2,000 to 3,500 is widely accepted (3). However, in a study of 18,155 infants, the reported incidence of natal and neonatal teeth was 1:716 (4). About 85% of natal and neonatal teeth are mandibular incisors (5,6). However, there are case reports of natal teeth in the posterior regions of the alveolar process (3,7,8), thereby necessitating an examination of the posterior region of the alveolar processes at birth for the presence of teeth. Further, 95% of natal and neonatal teeth are a member of the normal complement of the deciduous dentition (9); this implies that supernumerary natal and neonatal teeth are rare. Hence natal and neonatal teeth should usually be retained.

  1. Etiology
  2. Superficial positioning of the primary tooth germ (10)
  3. Infection and malnutrition (10)
  4. Febrile illness (10)
  5. Maternal exposure to toxins (polychlorinated biphenols, polychlorinated dibenzofuran, polychlorinated dibenzo-p-dioxin) (11)
  6. Syndrome/medical condition (Table 52.2) (10)
  7. Clinical Presentation (Figs. 52.1,52.2,52.3 and 52.4)

There is variability in the presentation of natal and neonatal teeth. Although some have normal crown shape and color, and are held firmly in the alveolar process, others present as discolored microdonts with hypermobility. The latter are the immature type of teeth. The management of the patient depends on the clinical presentation.

  1. Clinical Assessment

Clinical assessment should include an assessment of the tooth, oral soft tissues, and the systemic disposition of the patient.

  1. Dental assessment
  2. Mobility: Tooth mobility >1 mm is usually an indication for the extraction of the natal/neonatal tooth.
  3. Color and shape of tooth: Discoloration and abnormal morphology indicate an immature natal/neonatal tooth, which usually will require removal.
  4. Root formation: This can be assessed with a dental radiograph. However, a loose tooth is likely to be lacking in root structure, and is likely to exfoliate spontaneously and early, with the risk of aspiration.
  5. Soft tissue assessment
  6. Ventral surface of the tongue: Riga-Fede disease, although not a disease, is the term given to an ulcerative granuloma formed on the ventral surface of the tongue. It results from irritation of the tongue by the sharp margins of the mandibular incisor.
  7. Gingival tissue: Gingival tissue adjacent to the natal/neonatal tooth should be examined for presence of inflammation or granulomatous lesion, caused by irritation by the sharp cervical margins of an immature tooth.
  8. General assessment:

Table 52.2 lists the systemic conditions associated with higher incidence of natal/neonatal teeth. They should each be ruled out to ensure that a pre-existing medical condition is not overlooked.

  1. Precautions
  2. Keep in mind that the initial question in management of natal teeth is whether extraction is indicated. Indiscriminate extraction of natal/neonatal teeth is discouraged (12).


TABLE 52.1 Hebling Classification of Natal Teeth

1. Shell-shaped crown poorly fixed to the alveolus by gingival tissue with absence of a root

2. Solid crown poorly fixed to the alveolus by gingival tissue with little or no root

3. Eruption of the incisal margin of the crown through the gingival tissue

4. Edema of gingival tissue with an unerupted but palpable tooth

  1. Natal and neonatal teeth should be differentiated from cystic lesions such as Bohn nodules and Epstein pearls, by palpation and location in the infant's mouth. Bohn nodules and Epstein pearls are firm and have a smooth, rounded surface. There will usually be several nodules/pearls, and they may be located on the posterior palate or mandibular ridge.

FIG. 52.1. Patient 1: Normal (edentulous) alveolar ridge in neonate.

  1. Prior to extraction, it must be confirmed that the patient has received the appropriate dose of vitamin K at birth (10). There has been one report of difficulty in achieving hemostasis by local pressure after the extraction of natal tooth. This patient received microfibrillar collagen hemostat over the extraction site (3). Current literature supports the extraction of the natal tooth at 10 days or later after birth, unless there is significant risk of aspiration (10).
  2. A detailed family history should be obtained, to rule out inherited coagulopathy.
  3. Following the extraction, the socket should be curetted to remove odontogenic tissue (see F, Complications).
  4. Long-term care: Whether the patient receives conservative restorative treatment or extraction, the parents should be encouraged to maintain regular dental appointments with a pediatric dentist. This enables monitoring of the extraction site, and parental guidance in oral hygiene practices for their infant.

TABLE 52.2 Conditions Associated with Higher Incidence of Natal/Neonatal Teeth

Ellis-Van Creveld syndrome
Hallerman-Streiff syndrome
Craniofacial synostosis
Multiple steacystoma
Congenital pachyonychia
Sotos syndrome
Cleft palate
Pierre Robin anomalad

  1. Technique

Nonextraction case

If the tooth is firm and appears of normal color and shape, extraction is not indicated.


FIG. 52.2. Patient 2: Hebling Classification #3 neonatal tooth; not indicated for extraction.




FIG. 52.3. Patient 3: Hebling classification #2 natal tooth; this tooth was extracted.

  1. Should the mother complain of discomfort while breast feeding, the use of a breast pump and bottling of milk should be encouraged.
  2. If the patient presents with Riga-Fede disease, a pediatric dentist should be consulted. The sharp margins of the tooth can be smoothed using photopolymerized dental composite restorative resin. This results in spontaneous resolution of the tongue lesion (13).
  3. Pain relief and faster healing may be accomplished by carefully applying Kenalog in Orabase (14).

Extraction Case

Extraction is indicated if there is hypermobility of the tooth, or if the tooth is of the immature type (malformed, discolored, lacking root development). These would be classified as class 1 or 2 by Hebling et al. (2).

  1. Equipment
  2. 2 x 2-in gauze piece
  3. Topical anesthetic
  4. Blunt-nosed sterile surgical scissors
  5. Technique
  6. Apply a tiny amount of topical anesthesia on the tissue attachment of the tooth.
  7. Hold the tooth with 2 x 2-in gauze square with your fingers and gently remove the tooth.

If the tooth has to be grasped with forceps, then the infant needs to be referred to a pediatric dentist for evaluation and possible extraction.

  1. Blunt-nosed scissors can be used to cut the tissue if it is too fibrous.

FIG. 52.4. Patient 3: The natal tooth—which was removed by grasping the tooth with gloved fingers—holding the tooth with a 2 x 2-in gauze square.

  1. Complications of Extraction
  2. Tissue tags comprising dental papilla and/or Hertwig's epithelial root sheath remain in the extraction socket (15). These tissues may continue to form dental hard tissues, that is, dentin and root structure (15). These aberrant dental hard tissues may interfere with the normal eruption of adjacent primary teeth (15).
  3. The development of postextraction pyogenic granuloma (16) and hamartoma (17) have been reported.


  1. Spouge JD, Feasby WH.Erupted teeth in the newborn. Oral Surg Oral Med Oral Pathol. 1966;22:198.
  2. Hebling J, Zuanon ACC, Vianna DR.Dente natal—a case of natal teeth. Odontol Clin. 1997;7:37.



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  2. Kates GA, Needleman HL, Holmes LB.Natal and neonatal teeth: a clinical study. J Am Dent Assoc. 1984;109:441.
  3. Zhu J, King D.Natal and neonatal teeth: a review of 24 cases reported in literature. J Pediatr. 1950; 36: 349.
  4. Badenhoff J, Gorlin RJ.Natal and neonatal teeth. Pediatrics. 1963;32:1087.
  5. Friend GW, Mincer HH, Carruth KR, Jones JE.Natal primary molar: case report. Pediatr Dent. 1991;13:173.
  6. Masatomi Y, Abe K, Ooshima T.Unusual multiple natal teeth: case report. Pediatr Dent. 1991;13:170.
  7. Howkins C.Congenital teeth. Br Dent Assoc. 1932;53:402.
  8. Cunha RF, Boer FA, Torriani DD, Frossard WT.Natal and neonatal teeth: review of the literature. Pediatr Dent. 2001;23:158.
  9. Alaluusua S, Kiviranta H, Leppaniemi A, et al. Natal and neonatal teeth in relation to environmental toxicants. Pediatr Res.2002;52:652.
  10. Watt J.Needless extractions. Br Dent J. 2004;197:170.
  11. Slayton R.Treatment alternatives for sublingual traumatic ulceration (Riga-Fede disease). Pediatr Dent. 2000;22:413.
  12. Seminario AL, Ivancakova R.Natal and neonatal teeth. Acta Medic (Hradec Kralove). 2004;47(4):229–233.
  13. Nedley MP, Stanley RT, Cohen DM.Extraction of natal teeth can leave odontogenic remnants. Pediatr Dent. 1995;17: 457.
  14. Muench MG, Layton S, Wright JM.Pyogenic granuloma associated with a natal tooth: case report. Pediatr Dent. 1992;14:265.
  15. Oliveira LB, Tamay TK, Wanderley MT, et al. Gingival fibrous hamartoma associated with natal teeth. J Clin Pediatr Dent.2005;29(3):249.