An Ancient Mesiodens Investigated by Cone Beam CT

This article presents the complex case study of an ancient skeleton presenting a maxillary supernumerary tooth (mesiodens). The skeleton was found in an archaeological site in the western part of Romania and was dated back to the Eneolithic period, some 5500 years ago. The aim of this article is to analyze the mesiodens and the jaws in light of current knowledge regarding anomalies of dental development of past and present-time populations. The cranial remains were investigated from an orthodontic perspective through inspection and cone beam computed tomography (CBCT) scan. The occlusion was analyzed according to Angle’s classification and observations were made regarding the presence of calculus, dental wear, presence of caries, bone loss and ante-mortem tooth loss. Observations were made regarding tooth dimensions and comparisons were made with modern population. In this specific case, the mesiodens caused minimum disruption within the upper dental arch and the occlusion. Additionally, it did not have any negative impact on the adjacent teeth or cause any other complication. Judging by the analysis of the jaws, the presence of the mesiodens had little impact on the overall oral health of the person. As suggested by other findings in the scientific literature, the mesiodens is an anomaly found throughout all historical periods, from the oldest archaeological sites to present day.


Archaeological Background
The present article is focused on assessing the cranial remains, particularly the jaws, presenting a mesiodens, belonging to a skeleton dated back to the Eneolithic period, found in the archaeological site of Mosnita Veche-Obiectiv 16 "Dealul Salas", near Timisoara, in the western part of Romania. The Eneolithic period, also known as the Chalcolithic or the Copper Age, is the chronological sequence between the Neolithic and the Bronze Age, when copper was used alongside flint for manufacturing artefacts [1]. From a chronological standpoint, the Eneolithic period roughly covers the time span between 4500-2800 cal BC (calibrated years before Christ), this chronology being valid for our geographical area of interest. During the excavation, three well preserved graves have been uncovered, as well as a few heavily disturbed graves. One of the well preserved skeletons discovered, coded as "Individual 1", presented a mesiodens.
The grave goods found in the burial pit consisted of two clay pots, a flint blade and several flint scrapes. manifestations [11,24]. According to available data, 75% of the mesiodens are impacted [9,16].
Impacted supernumeraries may be detected by imaging techniques, such as panoramic, occlusal, periapical radiographs or cone beam computed tomography (CBCT), which provides more accurate assessments [12].
The aim of this complex case study is to analyze the mesiodens and the jaws of "Individual 1" from an orthodontic perspective, including CBCT scans to further assess the cranial remains. The results were analyzed in light of current knowledge regarding dental development anomalies of past and present-time populations, aiming to further create a database to compare the frequency and pattern of this pathology in ancient versus modern times.

Materials and Methods
Within the boundaries of the archaeological site known as Mosnita Veche 16-"Dealul Salas", three undisturbed graves, containing six well preserved skeletons, were found.
The skeletal remains presenting the mesiodens were found buried in the same grave pit with another skeleton. In order to properly document the grave, the two skeletons were each assigned an indicative. The skeleton on the right hand side, presenting the mesiodens, male, was named "Individual 1", while the one on the left hand side, female, was attributed the name "Individual 2" (Figure 1). The deceased were buried in a slightly oval shaped pit, both of them orientated on a NE-SW axis, with their heads pointed towards the North-East. "Individual 1" was buried in a crouched position, on his right side, with his head facing "Individual 2" and his left hand placed on top of the humerus of "Individual 2". "Individual 2" was placed on her back, slightly arched, with the legs bent towards the South-West and the head facing away from "Individual 1" and oriented towards the South-West. Her right hand was placed on the stomach, while the left arm was placed over "Individual 1". The arrangement of the bodies gives the impression that the two individuals were embracing each other, or to be precise, "Individual 1" was embracing "Individual 2", which is the reason for naming them "The Eneolithic Lovers".  The sex of the two individuals has been determined using morphological traits of the os coxae and the skull after the methodology proposed by Buikstra and Ubelaker [25]. Age of death has been determined using the auricular surface of the ilium, according to Lovejoy [26] and the dentition wear, according to White and Folkens [27]. Stature has been estimated using the Sjøvold method [28].
The jaws of "Individual 1", presenting a mesiodens, have been inspected macroscopically, from an orthodontic perspective. The mandible has been restored having the socket contour of the lower right central incisor (LR1) as guideline, as well as its internal and external basal margins.
The maxilla and the mandible have been assessed both separately and in occlusion. The presence of caries, hypoplasia, tooth wear, abscesses, calculus and periodontal disease have been analyzed for each tooth. Non-occlusal attrition and interproximal attrition have also been assessed, as well as dental crowding within the arch. The tooth wear has been coded according to Smith and the amount of calculus present on each tooth was coded according to Brothwell [25].
The occlusion has been assessed according to Angle's classification. The dental arches were placed in occlusion based on the attrition facets present, having the maximum number of interdental contacts as guideline.
The mesiodens has been analyzed from the point of view of its dimensions and position relative to the adjacent teeth and also within the dental arch and in occlusion. The measurements of teeth dimensions have been carried out using a digital caliper.
CBCT imaging has been chosen to further asses the maxilla bone and teeth, as it provides precise and accurate information on normal and pathologic conditions such as odontomas, supernumerary teeth, developmental anomalies and traumatic injuries. Among its advantages, the following are of most importance: 3D imaging of dental structures, easy data transfer, less imaging time, and lower ionizing radiation dose compared to CT [29,30].
The 3D images of the oral and maxillofacial structures acquired by CBCT, on a high resolution, using an extraoral imaging scanner, enable a better understanding of the anatomical structures, pathologic conditions, developmental anomalies, and traumatic injuries, the technique being especially useful in determining the supernumerary and impacted teeth position [26,31].

Sex, Stature and Age
At the inspection it has been noted that the two skeletons were well preserved. Their crania were broken but most of the pieces were present, while the cranium of "Individual 2" has been dislodged and rotated to 180 degrees, probably due to ground pressure, as all other bones seem to be found in more or less the same position as they would have been at the time of their deposition ( Figure 1).
"Individual 1" (on the right hand side) has been estimated at 159.2 ± 4.32 cm and was determined to be male, around 30-35 years old.
"Individual 2" (on the left hand side) has been estimated at 164.6 ± 4.52 cm and was determined to be female, around 40-45 years of age ( Figure 1).

Inspection of the Jaws
Only "Individual 1" (Figure 1) (male according to the anthropological report) presented a mesiodens. The further presented data refer to the jaws belonging to "Individual 1". His maxilla and mandible have been coded as 1 for completeness of a bone, according to Buikstra and Ubelaker [25].

The Maxilla
As shown in Figure 2, the maxilla presented with the following teeth: the upper right premolars (UR5, UR4), the upper right canine (UR3), the mesiodens, the upper left central incisor (UL1), the upper left canine (UL3), both upper left premolars (UL5, UL4) and the upper left first molar (UL6). The alveoli of the upper right lateral incisor (UR2), that of the upper right central incisor (UR1) and of the upper left lateral incisor (UL2) have been well preserved and had undergone no bone remodeling showing that the teeth had clearly been lost postmortem. Both right and left tuberosities were broken and the molars missing, except for the upper left first molar (UL6). The teeth are well aligned, except for the mesiodens, which had a 90-degree rotation, with its buccal side towards the upper left central incisor (UL1). The position of the mesiodens coincides with the maxillary midline suture, adjacent to the UL1 on the left and to the UR1 on the right, the latter being lost post-mortem. It caused no asymmetry in the upper arch. The lower midline also coincides with the mandibular symphysis as well as with the mesiodens.
The UL1 and the UR1 roots presented with an approximately 20 degree inclination towards the distal side because of the presence of the mesiodens. The inclination of the UR1 has been confirmed radiologically by the inclination of its socket.
General minor to moderate alveolar bone recession is present, but it has also to be considered that some interdental alveolar margins could have been damaged during the excavation of the cranium, especially the buccal alveolar bone covering the root of the upper left central incisor (UL1).

The Mandible
The mandible has been broken along the symphysis region, with the fracture line going through the socket of the lower right central incisor (LR1) (Figure 3). The teeth are well aligned, except for the mesiodens, which had a 90-degree rotation, with its buccal side towards the upper left central incisor (UL1). The position of the mesiodens coincides with the maxillary midline suture, adjacent to the UL1 on the left and to the UR1 on the right, the latter being lost post-mortem. It caused no asymmetry in the upper arch. The lower midline also coincides with the mandibular symphysis as well as with the mesiodens.
The UL1 and the UR1 roots presented with an approximately 20 degree inclination towards the distal side because of the presence of the mesiodens. The inclination of the UR1 has been confirmed radiologically by the inclination of its socket.
General minor to moderate alveolar bone recession is present, but it has also to be considered that some interdental alveolar margins could have been damaged during the excavation of the cranium, especially the buccal alveolar bone covering the root of the upper left central incisor (UL1).

The Mandible
The mandible has been broken along the symphysis region, with the fracture line going through the socket of the lower right central incisor (LR1) (Figure 3). Appl. Sci. 2021, 11, x FOR PEER REVIEW 6 of 18 Both the base of the mandible and the ramus display no abnormalities. The mandibular symphysis, the mentoneal protuberance, as well as the left side coronoid process and condyle (the right side coronoid process and condyle are unobservable as they were damaged and could not be assessed) are all within normal appearance.
The lower left central incisor (LL1), as well as the lower right central (LR1) and lateral incisors (LR2) were missing, as was the lower right wisdom tooth (LR8), all of them being lost post-mortem.
The present lower teeth are well aligned and the sockets of the missing lower teeth show a normal root position; hence, the missing teeth were most-likely well aligned as well.

The Teeth
The total number of observable teeth is 21 (Table 1), with six anterior teeth being lost post-mortem, while the rest belong to parts of the jaws that were damaged and could not be retrieved.

Tooth Presence Development Wear Caries Abscess Calculus Hypoplasia
Missing, lost post-mortem - Both the base of the mandible and the ramus display no abnormalities. The mandibular symphysis, the mentoneal protuberance, as well as the left side coronoid process and condyle (the right side coronoid process and condyle are unobservable as they were damaged and could not be assessed) are all within normal appearance.
The lower left central incisor (LL1), as well as the lower right central (LR1) and lateral incisors (LR2) were missing, as was the lower right wisdom tooth (LR8), all of them being lost post-mortem.
The present lower teeth are well aligned and the sockets of the missing lower teeth show a normal root position; hence, the missing teeth were most-likely well aligned as well.

The Teeth
The total number of observable teeth is 21 (Table 1), with six anterior teeth being lost post-mortem, while the rest belong to parts of the jaws that were damaged and could not be retrieved.
Both the upper and lower teeth lack any sign of caries or any type of enamel defects, such as hypoplasia or decalcification (Table 1). They display evidence of moderate attrition of the occlusal and incisal surfaces with patches of dentine being exposed around the cusps and the incisal margins, but the enamel rim is not destroyed in any of the teeth. The interproximal attrition facets are also moderate throughout the dental arches ( Figure 2).
All teeth have moderate calculus deposits in the cervical region, moreso on the labial surface than on the lingual, with no major differences between the right side and the left side, suggesting a balanced, normal mastication pattern of the individual (Table 1).
On inspection, as well as radiographically, there is no apical pathology noted and there is no sign of abscesses.
The crowns and roots of all teeth present with normal morphology. The mesio-distal dimensions of the present frontal teeth crowns are given in Table 2. There is no barrel shape appearance of the UL1, contrary to Brook's findings [21]. Attrition (according to Smith): Code 1 stands for unworn (no dentin exposure); Code 2 stands for point or hairline of dentine exposure/moderate cusp removal; Code 3 stands for dentine line of distinct thickness/moderate dentine patches; Code 4 stands for moderate dentine exposure no longer resembling a line/at least one large dentine exposure on one cusp; Code 5 stands for large dentin area with enamel rim complete/two large dentin areas; Code 6 stands for large dentin area with enamel rim lost on one side or very thin enamel only/dentinal areas coalesced; Code 7 stands for enamel rim lost on two sides/full dentin exposure, loss of rim at least one side; Code 8 stands for complete loss of crown/severe loss of crown height [25].
Calculus (according to Brothwell): Code 1 stands for small amount of calculus present; Code 2 stands for moderate amount of calculus present; Code 3 stands for large amount of calculus present [25].

The Occlusion
The occlusion has been assessed according to the Angle classification, hence the individual presented with a normal occlusion, i.e., both right and left side class I canine relationship and class I molar relationship on his left side (his upper right first molar was missing, so that the lateral occlusion on his right side could not be assessed under the same criteria). Judging by the teeth present, it can be presumed that the posterior teeth presented with normal occlusion (Figures 4 and 5).

The Occlusion
The occlusion has been assessed according to the Angle classification, hence the individual presented with a normal occlusion, i.e., both right and left side class I canine relationship and class I molar relationship on his left side (his upper right first molar was missing, so that the lateral occlusion on his right side could not be assessed under the same criteria). Judging by the teeth present, it can be presumed that the posterior teeth presented with normal occlusion (Figures 4 and 5).

The Occlusion
The occlusion has been assessed according to the Angle classification, hence the individual presented with a normal occlusion, i.e., both right and left side class I canine relationship and class I molar relationship on his left side (his upper right first molar was missing, so that the lateral occlusion on his right side could not be assessed under the same criteria). Judging by the teeth present, it can be presumed that the posterior teeth presented with normal occlusion (Figures 4 and 5).   In the vertical plane, the overbite measured 3 mm and is rather normal, whereas in the sagittal plane, the overjet is increased (5 mm), because of the presence of the mesiodens.

The Mesiodens
The position of the mesiodens coincides with the maxillary midline suture, adjacent to the UL1 on the left and to the UR1 on the right, the latter being lost post-mortem. It has caused no asymmetry in the upper arch. The lower midline also coincides with the mandibular symphysis as well as with the mesiodens.
The mesiodens is fully-formed but small-scale, with the crown mimicking the incisor form, fully erupted into occlusion (Figure 6). Its mesio-distal dimension is 5.05 mm and the dimension from the cement-enamel junction (CEJ) to the incisal margin on the buccal side is 8.99 mm (Table 3). Minor damage to the alveolar margin has exposed the cement of the root at the CEJ and this also appears normally formed. It has a 90-degree rotation, with its buccal side towards the UL1 and its palatal side towards the UR1, the latter being lost post-mortem ( Figure 6). In the vertical plane, the overbite measured 3 mm and is rather normal, whereas in the sagittal plane, the overjet is increased (5 mm), because of the presence of the mesiodens.

The Mesiodens
The position of the mesiodens coincides with the maxillary midline suture, adjacent to the UL1 on the left and to the UR1 on the right, the latter being lost post-mortem. It has caused no asymmetry in the upper arch. The lower midline also coincides with the mandibular symphysis as well as with the mesiodens.
The mesiodens is fully-formed but small-scale, with the crown mimicking the incisor form, fully erupted into occlusion (Figure 6). Its mesio-distal dimension is 5.05 mm and the dimension from the cement-enamel junction (CEJ) to the incisal margin on the buccal side is 8.99 mm (Table 3). Minor damage to the alveolar margin has exposed the cement of the root at the CEJ and this also appears normally formed. It has a 90-degree rotation, with its buccal side towards the UL1 and its palatal side towards the UR1, the latter being lost post-mortem ( Figure 6).

The CBCT Scan
The CBCT scan provided the radiological confirmation of the fact that there are no other supernumerary teeth present (Figures 7 and 8).

The CBCT Scan
The CBCT scan provided the radiological confirmation of the fact that there are no other supernumerary teeth present (Figures 7 and 8).  The CBCT scan (Figures 7 and 8) shows normal bone and root contour and no apical pathology on any of the teeth present. There is evidence of minor to moderate marginal bone loss, especially around the upper left premolars (UL4, UL5) and the upper left first molar (UL6), probably due to periodontal disease.

Tooth Development and Why Tooth Anomalies of Number, Size and Structure Are Connected
Generally speaking, tooth development is an intricate mechanism that involves multiple factors, both genetic and environmental, and in order to fully comprehend the  The CBCT scan (Figures 7 and 8) shows normal bone and root contour and no apical pathology on any of the teeth present. There is evidence of minor to moderate marginal bone loss, especially around the upper left premolars (UL4, UL5) and the upper left first molar (UL6), probably due to periodontal disease.

Tooth Development and Why Tooth Anomalies of Number, Size and Structure Are Connected
Generally speaking, tooth development is an intricate mechanism that involves multiple factors, both genetic and environmental, and in order to fully comprehend the The CBCT scan (Figures 7 and 8) shows normal bone and root contour and no apical pathology on any of the teeth present. There is evidence of minor to moderate marginal bone loss, especially around the upper left premolars (UL4, UL5) and the upper left first molar (UL6), probably due to periodontal disease.

Tooth Development and Why Tooth Anomalies of Number, Size and Structure Are Connected
Generally speaking, tooth development is an intricate mechanism that involves multiple factors, both genetic and environmental, and in order to fully comprehend the picture of developmental anomalies of teeth we must look into the mechanisms and explanations that, in time, were given for these processes.
In 1945, Dahlberg [32] modified Butler's Field Theory for the human dentition, which focused on the evolution and development of dentition and tried to explain different patterns of agenesis describing four morphological fields (incisors, canines, premolars and molars). The more mesial tooth in each field was proposed to be the more stable tooth and was rarely missing, while the teeth at the end of each field were more unstable and hence, were more frequently absent [33]. Indeed, most studies have shown that the most affected teeth by agenesis are the lower second premolars, the upper lateral incisors and the third molars, i.e., the most distal element of a field [21,26,34,35].
Sharpe puts forward the concept of an odontogenic homeobox to explain how different teeth are initiated in different parts of the oral cavity in response to molecular cues and the expression of specific groups of homeobox genes [36]. Mitsiadis proposed that the previous models could all be incorporated into a single concept to explain dental patterning [37] and Brook [21] also proposed a multifactorial model that encompasses genetic, epigenetic and environmental causes and also that there is an underlying continuous distribution of tooth and size, with thresholds determining hypodontia and supernumeraries. Hence, both hypodontia and supernumerary anomalies have to be considered, because they are interlinked [21,38]. Going forward with his explanations, Brook suggests that even if a single mutation of one gene or one major environmental insult has been identified in a patient with a dental anomaly, a careful phenotype analysis will often reveal variation between affected individuals in the same family, between dentitions in the same individual and even between different teeth in the same dentition. Thus, the same gene or environmental factor, depending on all other intricate mechanisms that happen during the dental development, will have a different phenotype expression [21]. At the same time, same or very similar clinical phenotype of whether anomalies of tooth number or structure, can arise from different aetiologies, both environmental and genetic. More than three hundred genes have been found to take part in the tooth development, while, at the same time, crucial processes need to take place between the mesenchymal and epithelial cells, and disturbances of these factors will determine the presence or absence, the size and the shape of the individual tooth [21].
Studies on mice presenting with supernumerary teeth show that these supernumeraries may develop from vestigial tooth buds that did not undergo apoptosis as they would normally have done. They also presented with an aberrant thickening of the oral epithelium [21].
As the development of number, size and structure of teeth is interconnected, so are their anomalies and therefore, they appear clinically together in the same dentition.

Is Hypodontia More Frequent in Present-Day Populations and Were Supernumeraries More Frequent in the Past?
The introduction of more processed foods over time, is believed to have had an impact on the size of human jaws and masticatory system, as less and less effort is required for mastication, leading to smaller jaws and possibly fewer teeth, as humans evolve [39].
Another theory hypothesizes that the last tooth of each class are "vestigious bodies" that became obsolete during the evolution process [33].
In present-day populations, hypodontia is reportedly the most common dentofacial malformation in humans, with prevalence rates varying between 1.6-10.1%, while Europeans and Australians are more affected than North Americans [33,40,41].
Studies looking into the etiology of hypodontia over time have come up with different answers. For instance, Mattheeuws et al. found that hypodontia had increased since 1957 [42], whereas Heuck Henriksson et al. found that there was no increase of hypodontia of the third molar from the medieval period until present [43]. Of course, it has to be considered that differences between the different type of populations are probable, so the more specimens assessed, the wider database available, in order to have a clearer picture of the phenomenon.
However, the scarcity of complete jaws and crania from archaeological records, makes it difficult to create relevant statistical records of dental pathology regarding different historical periods of time. In this view, we would like to emphasize the importance of acknowledging the presence of any supernumerary teeth in old crania, in order to create a database and compare their prevalence with present-day cases.
Regarding geminated and fusioned teeth, there is a report of a 4000 year old mummy from ancient Egypt presenting with a fusioned right maxillary incisor and a geminated left maxillary incisor [44] as well as a few more recent findings [45].
Records of supernumerary teeth from all historical periods are available, but the prevalence of supernumeraries in the past is difficult to estimate because of the practical aspects associated with the uncovering of human remains, i.e., the lack of a large study sample and also the degradation and breakage to which skeletons are subjected to, while in the ground and while being uncovered.
The oldest specimen cited in the literature is a 1.7 million year old Australopithecus robustus adult with a supernumerary tooth between the right first and second incisors [46]. Other remarkable reports of supernumerary teeth are that of a middle-aged Chalcolitic male with a supernumerary distomolar in the mandible [47] and that of a young adult woman from the Upper Paleolithic who presented with a right maxillary supernumerary molar [48]. Another study, concerning the CT scan of mummies from the Graeco-Roman Period, found two supernumerary teeth in the premaxillae region of a child [49]. Additionally, a syndromic individual from prehistoric Illinois, probably suffering from cleidocranial dysostosis, presenting with six supernumerary teeth, impacted teeth and dilacerated roots has been described in a study by Sacks [50].
Comparing the frequency of supernumerary teeth in ancient and present times would help to better understand this phenomenon and the phylogenetic process behind it and also gain more knowledge regarding the hypothesis that, with evolution, hypodontia becomes more frequent and that humans tend to have less teeth and smaller jaws.
Considering the low prevalence in present-day populations, one can reasonably assume it was low in the past as well.

The Role of CBCT in Paleoimaging
Intraoral radiographic techniques, such as periapical and occlusal radiographs, have long been used for diagnostic purposes in dentistry. However, a correct diagnosis is sometimes impossible to achieve by using these techniques, mainly due to superimposing structural components. To overcome these shortcomings, more recently CBCT has been extensively used [31,51,52].
CBCT has been previously used in assessing archaeological samples [53,54], or for forensic purposes [55], mostly for the study of bone and dentition [56].
CBCT in studying ancient human remains has been limitedly used so far, despite the important role of diagnostic imaging (paleoimaging) in paleopathology and anthropology [57,58]. Multi-Slice Computed Tomography (MSCT) has proved its place in paleoimaging, whereas CBCT, despite its advantages, is still not widely used as an imaging technique for the study of ancient bone remains [59].
According to available literature data, to date, several papers reported the use of CBCT for paleopathological studies, describing diseases or malformations.
The study of Ceperuelo et al. [47] documented a case of hyperdontia using CBCT, namely a mandibular supernumerary distomolar in the mandible of a Chalcolithic male from Spain.
Kendall et al. [60] used CBCT to provide a differential diagnosis of an exostotic bony lesion within the left maxillary sinus of a Romano-British (3rd-4th centuries AD) adult male from Newport, Lincoln. The conclusion was that, more likely, the lesion was of odontogenic origin.
The case of dwarfism-related skeletal dysplasia in a Late Joseon Dynasty (South Korean) individual was reported by Woo et al. [61]. In this case, CBCT was used to scan the available cranial fragments, in order to obtain a 3D reconstructed image.
Giuffra et al. [62] explored the skeletal remains of an individual, dating to the 10th-12th century AD from the parish church of S. Pietro in Pava, Siena, Italy, presenting multiple osteomata on the skull and long bones. CBCT confirmed that the lesions consisted of compact bone, supporting the diagnosis.
Gaeta et al. [63] reported the use of CBCT in assessing the Italian mummy of Girolamo Macchi, dating from 18th century. The scan revealed that he suffered from atherosclerosis, affecting the abdominal arteries. For this reason, the arteries presented multiple calcifications, allowing to validly employ CBCT.
Izzeti et al. [59] used CBCT for studying an ancient child mandible discovered in an archaeological site in Northern Italy and made a comparison with MSCT in paleoimaging, emphasizing its role in imaging studies of ancient bone remains and encouraging its broader application in studying archaeological samples.
Based on the available literature data, CBCT represents a useful paleoimaging tool, for assessing mineralized human remains.

The "Individual 1" Case
The literature concerning crania and dentition studies of historical populations usually brings forward specimens presenting with severe dental wear, alveolar resorbtion, caries, linear enamel hypoplasia (LEH) and ante mortem tooth loss (AMTL) which are all quite common. There are still a number of dental pathologies that arise more frequently in more distant periods, such as excessive tooth wear and alveolar bone resorbtion, whereas in more recent times, probably because of the impact of agriculture and a softer diet, caries tend to be more frequent, as well as periapical lesions and AMTL [46,[64][65][66][67][68][69][70][71]. To our knowledge, so far, the oldest specimen of a human jaw presenting a mesiodens is that of a 13,000 year old skull with a mesiodens present in the vault of the palate [72]. Other reports of mesiodens in the literature come from later periods, such as the Middle Iron Age in Scotland, approximately 250-410 AD [73], the Medieval Age, belonging to human remains found in Norway [74,75] and the 7th century in Germany [14].
The previous literature findings dealing with ancient teeth and the analysis of the "Individual 1" jaws have proven to be coincident.
Calculus deposits, attrition facets and periodontal disease are all common findings for that period of time [67,68] but overall, it appears that "Individual 1"presented with a good masticatory function and a reasonably good oral health. None of our findings suggest any impediment to the person's capacity to eat, which, in those days, was probably the most important factor to consider.
The occlusion, as well, follows the general pattern of occlusion seen in most ancient jaws, that is a normal occlusion, with almost perfect intercuspation, except for the increased overjet. Also, the form of the mesiodens is in accordance with the literature regarding mesiodentes in present times [8,10,19,76,77]. According to the anthropological report, the individual presenting with the mesiodens was male, which also coincides with the data from the literature, mesiodentes being more frequently present in males [78].
By comparing the mesiodistal crown dimensions of the Eneolithic "Individual 1" to present-day populations, it can be concluded that the crown dimensions are very similar ( Table 4). The types of populations considered for comparison were Indo-European [79]. Thus, although his stature was rather small (159.2 ± 4.32 cm), the dimensions of his teeth are close to those of present-day population.  Table 5 compares the mesio-distal crown dimensions of "Individual 1" to presentday controls from the literature [80] with and without supernumeraries, and reveals that the dimensions of all compared teeth of "Individual 1" are closer to the control group that presented supernumerary teeth. This is consistent with Brook's and Khalaf's findings regarding the fact that patients with supernumerary teeth tend to have larger tooth dimensions [81]. Table 5. Mesio-distal crown dimensions (in mm) of "Individual 1" compared against data from the literature, i.e., permanent teeth in present-day patients with and without supernumeraries [64,69]. However, a statistically relevant comparison between the dimensions shown in these tables cannot be made, as the dimensions of the teeth of an Eneolithic individual are being compared to mean values of teeth belonging to modern populations.

Subject
Reports from the literature show that the most frequent complications associated with supernumerary teeth is root resorption of the adjacent teeth and delayed or failure of eruption of the adjacent teeth [8,24,77]. We have no indication as to whether the eruption of the central incisors was delayed or not, but there is clearly no root resorption associated, as the root of the central incisor present is intact (Figures 6 and 7).
Based on the analysis of the jaws and the dental arches, using the modern CBCT threedimensional imaging technique, which enables a high-quality study of the maxillofacial bone and dental structures [31], it may be stated that, in the case of "Individual 1", the mesiodens seems to have been quite harmoniously integrated in the masticatory system, without causing any major disturbance to the alignment of teeth or to the occlusion. The only abnormality noted caused by the mesiodens was an increased overjet. Additionally, the mesiodens itself had no space to erupt in a normal position, so it was rotated by 90 degrees.

Conclusions
According to the scientific literature, the mesiodens is an anomaly found throughout all historical periods, from the oldest archaeological sites to present days. The approximately 5500 year old, well preserved human jaws of "Individual 1" bring forward another proof of developmental anomalies from the past, which makes them relevant to discussions regarding ancient oral pathology, placing this old subject in a new perspective. In this view, the presence of any supernumerary teeth in old crania is of great importance in enabling creating a database to compare the frequency and pattern of this pathology in ancient versus modern times.