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Department of Paedodontics & Preventive Dentistry, Narayana Dental College & Hospital, Nellore, India
Received date June 04, 2016; Accepted date June 16, 2016; Published date June 25, 2016
Citation: SVSG Nirmala, Tirupathi SP (2016) Rare Combination of Developing Unerupted Paramolar and Distomolar in Maxilla: A Case Report and Review of Literature. J Interdiscipl Med Dent Sci 4:201. doi: 10.4172/2376-032X.1000201
Copyright: ©2016 SVSG Nirmala, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
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Supernumerary molars are relatively rare entities in maxillofacial region which can be classified broadly into distomolars and paramolars. Usually these occur singly and unilaterally. Occurrence of both paramolar and distomolar together is a very rare finding. This paper reports an unusual occurrence of combination of developing unerupted paramolar and distomolar follicles in the maxilla which was an incidental finding in the Orthopantamograph of a 13 year old girl. Patient was asymptomatic, hence was kept under observation and follow up. This paper describes the incidence and prevalence, possible etiological factors, complications, treatment options for supernumerary molars along with review of literature.
Distomolar; Maxilla; Paramolar; Supernumerary molars; Supernumerary teeth
Supernumerary teeth are defined as those in addition to the normal series of deciduous or permanent dentition. This is also known as hyperdontia. Exact etiology of hyperdontia is unclear, but the most usual opinion is that supernumerary teeth develop due to horizontal proliferation or hyperactivity of the dental lamina . They may appear as a single tooth or multiple teeth, unilaterally or bilaterally, erupted or impacted and in mandible/maxilla or both the jaws .
Majority of supernumerary teeth occur in the median maxillary region and occurrence of supernumerary teeth in the molar region is very rare . Supernumerary teeth in the molar region are called as supernumerary molars which basing on their location can be divided into paramolars and distomolars.
A 13-year-old female patient visited a private clinic with a complaint of mild discomfort in the mandibular third molar region for which she was advised an Orthopantamograph (OPG) and was referred to department of paediatric dentistry. Family history was not significant and medical history was non-contributory. No abnormality detected on extra oral examination.
On clinical intra oral examination no abnormality was noted in mandibular third molar region and maxilla was also clinically normal but incidentally OPG revealed presence of bilateral developing supernumerary molar follicles in maxilla (Figure 1). Maxillary right central incisor had an Ellis Class-I fracture. Patient had angle’s class I molar relationship and according to the age of the patient teeth present were normal.
Right side of the maxillary arch revealed the presence of developing paramolar follicle which was in nolla’s stage 4 of calcification (twothird of crown completed) and left side of the maxillary arch showed developing distomolar follicle in nolla’s stage 6 of calcification (crown formation completed). No malalignment was noted in the maxillary molar region clinically.
Parent was informed regarding presence of paramolar and distomolars, possible complications and treatment options were explained pertaining to the particular condition. Preventive measures like oral prophylaxis was performed and oral hygiene instructions were given followed by topical fluoride application and fractured maxillary right central incisor was restored with composite resin.
To the best of our knowledge, presence of combination of unilateral paramolar and unilateral distomolar in maxilla is very rare. Case reports of supernumerary molars in developing follicular stage are not reported so far in the literature. As the supernumerary molars in our case are in still follicular developing stage and patient had no discomfort or symptoms associated with supernumerary molars, hence no treatment was advised but the patient was instructed to attend for regular follow ups every six months’ interval so that final path of eruption, eruption pattern, their final position in the dental arch can be evaluated.
Supernumerary teeth are defined as those in addition to the normal series of deciduous or permanent dentition. The prevalence of supernumerary teeth varies between 0.1% and 3.8% and is more common in the permanent dentition .
Supernumerary teeth in the molar region are called as Supernumerary molars (SM).
SM can be described based on the following factors:
B) Eruption status
E) Supplemental findings (Tables 1-4).
Any other supplemental associated findings like impaction of third molars, Fusion with other teeth, and absence of other teeth, any systemic or syndromic association should be noted.
Table 1: a) supernumerary posteriors based on location.
|i)||DISTOMOLAR||A distomolar is a supernumerary tooth located distally or distolingually to a third molar. It is also called as fourth molar.|
|ii)||PARAMOLAR||A paramolar is a supernumerary molar situated buccally or lingually/palatally to one of the molars or present in the interproximal space between two molars.|
|Paramolars can be present between first and second molar or they can be present between second and third molar also inter proximally.|
Table 1:b) Supernumerary molars based on relation to permanent molars.
|i)||ERUPTED||Complete crown is visible in oral cavity clinically.|
|ii)||PARTIALLY ERUPTED||Only occlusal part or cusp tip is visible in oral cavity clinically.|
|iii)||IMPACTED||Not clinically visible, noticed only during radiographic observation.|
Table 2: Based on eruption status.
Table 3: Based on Orientation.
|ii)||Tuberculate||Tuberculate type SM are generally rudimentary in shape, are smaller in size, and display more than one cusp|
|iii)||Supplemental||Supernumerary which resemble normal morphology, they are called supplemental teeth.|
Table 4: Shape of supernumery molars.
Differential diagnosis of supernumerary molar
Parapremolar: Supernumerary tooth in premolar region .
Paramolar tubercle: Paramolar is different from paramolar tubercle which is additional cusp present on buccal surface of a permanent molar. Paramolar tubercle if present on maxillary molar it is called as Parastyle and if it is present on the mandibular molar it is called as protostylid [5,6]. This structure is usually present on the buccal surface of the mesiobuccal cusp (paracone) and rarely on the distobuccal cusp (metacone). Its significance is unknown but it is reported that as paramolar tubercles arise from the buccal cingulum, these structures in human dentition probably represent the remnants of the cingulum of mammals and the lower primates . During diagnosis, an attempt should be made to differentiate and rule out other structures that may occur in the molar region like a paramolar tubercle or a fused supernumerary tooth . Formation supradentalis: A condition in which supernumerary cusp is associated with a supernumerary root in a molar .
Odontoma: Although an odontoma may be considered a type of defective tooth development inclusion of odontomas in the morphologic categories of supernumerary teeth is controversial .
Prevalence of supernumerary molars: There were only few studies considering prevalence of supernumerary molar teeth [1,8- 12]. Basing on the collected data from available studies, prevalence of supernumerary molars (SM) is ranging between 0.001% to 0.57% [3,8- 12]. Only few studies report prevalence of more than 0.5% i.e., 2.1% . In supernumerary molars distomolars were more common than paramolars in most of the studies on Turkish population [1,8,9,12]. Paramolars were more common than distomolars in only few studies reported by Cassetta on Italian Caucasian population  and Kumar and Gopal  study on Chennai population India.
Incidence of supernumerary molars was observed more in males than in females [9-11,14]. No gender predilection for distomolars were observed. But occurrence of paramolars were more prevalent in females than in males .
Occurrence of supernumerary molars is more in maxilla than in mandible [3,8-12]. Unilateral SM is more common than bilateral SM, and Bimaxillary SM show least prevalence. The prevalence of paramolar teeth was slightly higher on the left side than on right side as reported in few studies . No such predilection was observed for distomolar.
Location of PM (Mesio-distal orientation): Paramolars were mostly located around the third molar or in between third and second molar. Prevalence of occurrence of paramolar in between first and second molar is relatively less but a few case reports show their presence in between first and second molar [3,4,15-19]. No data exists on location of PM bucco-lingually or bucco-palatally buccally [20,21] or lingually  or palatally placed .
Most of supernumerary molars were impacted hence can be found only incidentally on radiographic observation . Most of the maxillary and mandibular Distomolars were impacted completely [1,17,19]. Only few cases have shown eruption of distomolars . Mandibular paramolars were found to be impacted to a greater extent than maxillary paramolars which showed partial or complete eruption .
Supernumerary molars showed varied morphology according to Kara et al. , conical shape was the most common shape of supernumerary molars followed by tuberculate and supplemental and irregular shape. Cassetta et al. , reported most of the distomolars in their study were tuberculate in shape (Table 5).
Causes of development
Several theories have been suggested for their occurrence such as the phylogenetic theory, the dichotomy theory, hyperactive dental lamina , and a combination of genetic and environmental factors unified etiologic explanation .
Association with syndromes
The presence of multiple supernumerary teeth may be part of developmental disorders such as Cleft lip and palate, Cleidocranialdysostosis, Gardner's syndrome, Fabry- Anderson's syndrome, Ellis-Van Creveld syndrome, Chondroectodermal dysplasia, Ehlers-Danlos syndrome, Incontinentia Pigmenti, Tricho-Rhino- Phalangeal syndrome . Our patient did not show any syndromic association (Tables 6-8).
Orthopantamograph with additional radiographs such as anterior occlusal views and or periapical radiographs will assist in localisation of supernumerary molar . Spiral computed tomography for diagnosis will give exact localisation and will reveal internal morphology of supernumerary molars .
1. Supernumerary molars might be associated with the following complications .
2. Surrounding soft tissue inflammation, localized periodontitis, caries, and Horizontal bone loss can also have associated with presence of paramolar .
3. Retention or ectopic eruption of adjacent teeth. Displacement or rotation of adjacent teeth.
4. Crowding due to insufficient space for the eruption of other teeth.
5. Interdental spacing between molars.
6. Traumatic bite when buccally positioned causes laceration of the buccal mucosa.
7. Interference during orthodontic treatment.
8. Dilaceration or delayed or abnormal root development of associated permanent teeth.
9. Follicular cyst formation from the degeneration of the follicular sac of the supernumerary tooth .
10. Trigeminal neuralgia when the paramolar compresses the nerve, pulp necrosis, and root resorption of adjacent tooth due to the pressure exerted by the paramolar tooth.
11. Dental caries due to plaque retention in inaccessible areas in the region of supernumerary molars.
|S. No||Authors||Year||Screened Population||Prevalance|
|1||Bereket et al. ||2015||111,293 patients||0.00%|
|Retrospective study||Distomolar common than paramolar|
|Non syndromic Turkish population||Maxilla > mandible|
|2||Kaya et al. ||2014||10,111 Non-syndromic Turkish subpopulation||0.29% of male|
|Maxillary distomolars were more frequently encountered than mandibular teeth.|
|3||Cassetta et al. ||2014||25,186 Italian Caucasian population||Prevalence is 0.18%|
|Males > females|
|Maxilla > mandible|
|4||Kumar and Gopal ||2013||5,000patients, Chennai India||Paramolars>distomolars|
|5||Thomas et al. ||2013||1,000 Kerala, India||2.1% prevalence of distomolars.|
|6||Kara et al. ||2012||104,902 retrospective analysis,Turkey||0.33%|
|7||Purcårea et al. ||2012||2,267 subjects, Caucasian adults in Romania.||Prevalence of distomolar is 0.26%|
|8||Celikoglu et al. ||2010||3,491 retrospective analysis, Turkish population||Distomolars>paramolars|
|9||Arslan and Ahmet ||2009||4,023 patients||Prevalenceof distomolars 0.57%|
Table 5: Studies on prevalence of supernumerary molars.
|Maxilla / Mandible|
|1||Moreira DD et al. ||2015||UNILATERAL||Unilateral Distomolar in an inverted position, atypically fused to the left maxillary third molar as a disto-palatal root, with the canal of the third molar ending at the pulp chamber of the distomolar|
|2||Ohata et al. ||2013||UNILATERAL||One case of Unilateral mandibular right distomolar|
|One case of unilateral mandibular left distomolar|
|One case of unilateral maxillary left distomolar.|
|3||Wang and Pan ||2013||BILATERAL||Bilateral mandibular distomolar|
|4||Clementini et al. ||2013||BILATERAL||Bilateral distomolars in both maxilla and mandible(impacted)|
|5||Szkaradkiewicz et al. ||2012||BILATERAL||Maxillary bilateral distomolars vertically impacted|
|6||Prakash et al. ||2012||UNILATERAL||Unilateral Left mandibular impacted distomolar fused with third molar and associated with paradental cyst|
|7||Zeylabi et al. ||2010||UNILATERAL||Fused mandibular third molar and unilateral distomolar|
|8||Ferreira-Junior et al. ||2009||UNILATERAL||Fused mandibularright third molar and rightmandibular distomolar|
|9||Refoua et al. ||2006||BILATERAL||Total 5 distomolars(bilaterally in both maxillary and mandibular arches)|
|Maxillary right side has two distomolars|
|10||Kokten et al. ||2003||BILATERAL||Maxillary bilateral distomolar|
|11||Kokten et al. ||2003||UNILATERAL||Maxillary unilateral right side double distomolar (two distomolars )|
|12||Turell and Zmener||1999||UNILATERAL||Fused mandibular molar with unilateral distomolar|
Table 6: Table showing distomolar case reports.
|1||Sulabha and Sameer||2015||BILATERAL||Bilateral maxillary paramolars (between first and second molars) associated with microdont third molar on one side and missing third molar on other side.|
|2||Ghogre and Gurav ||2014||UNILATERAL||Mandibular unilateral paramolar fused with 2nd permanentmandibular molar.|
|3||Dhull et al. ||2014||BILATERAL||Bilateral mandibular lingually placed paramolar between first and second molar and third molar absent.|
|4||Venugopal et al. ||2013||UNILATERAL||Unilateral mandibular right paramolar fused with 47|
|5||Komalpuri et al. ||2013||UNILATERAL||Unilateral maxillary left paramolar erupted buccally between second and third molar with multiple supernumerary premolars bilaterally in both maxilla and mandible.|
|6||Nayak et al. ||2012||UNILATERAL||Left maxillary palatally placed paramolar|
|7||Dhull et al. ||2012||BILATERAL||Bilateral maxillary buccallyparamolar between second and third molar.|
|8||Rudagi et al. ||2012||UNILATERAL||Unilateral left buccally placed mandibular paramolar fused with mandibular left second molar and absent third molars bilaterally.|
|9||Shetty et al. ||2012||BILATERAL||Bilateral maxillary palatally placedparamolar between 1st and 2nd molars|
|10||Salem et al. ||2010||UNILATERAL||Unilateral left mandibular paramolar fused with second molar associated with missing mandibular central incisors and mandibular third molars.|
|11||Rosa et al. ||2010||UNILATERAL||Fused mandibular unilateral paramolar with impacted mandibular first molar|
|12||Ballal S et al. ||2007||UNILATERAL||Fused mandibular second molar and paramolar|
|13||Ghoddusi et al. ||2006||UNILATERAL||Fusion of unilateral buccally placed mandibular leftparamolar to mandibular left second molar|
|14||Nunes et al. ||2002||BILATERAL||Bilaterally fused mandibular paramolar with second molar|
|15||Dubuk et al. ||1996||UNILATERAL||Miniature 4 mm unilateral mandibular paramolar|
|16||Kumasaka et al. ||1988||UNILATERAL||Unilateral Double paramolar in mandible right side|
Table 7: Table showing paramolar case reports.
|1||Present Case||2015||Combination of developing uneruptedparamolaron the maxillary right side anddistomolaron maxillary left side.|
|2||Reddy et al. ||2013||Mandibular bilateral Paramolar(between 1st molar and 2nd molar) + mandibular bilateral distomolar. Partially erupted distomolars on both sides with impacted second molars on both sides|
|3||Omal et al. ||2011||Bilateral maxillary paramolar between second and third molar and bilateral impacted maxillary distomolar in same patient (total four)|
|4||Mayfield and Casamassimo ||1990||Bilateralparamolars and distomolars|
Table 8: Table showing combination of distomolar and paramolar case reports.
12. Gingival inflammation and localized periodontitis in the surrounding soft tissues .
The clinical management of patients with supernumerary molar usually depends upon the position of the supernumerary molar and on its effect or potential effect on adjacent teeth and important anatomical structures. Treatment options for supernumerary molar as like any other supernumerary teeth may include observation or extraction or endodontic treatment. Observation involves no treatment other than monitoring the patient clinically and radiographically. This is true if the supernumerary molar is asymptomatic and is not causing any problem. If any complications are evident, it is advisable to extract the supernumerary molar.
Accurate diagnosis and treatment planning are very important to manage supernumerary teeth especially in children. Clinician should be aware of dental anomalies involving the numbers, size, and shape and should manage them appropriately to minimize the complications.
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