REVSTO-210; No of Pages 3
Received: 3 February 2015 Accepted: 12 May 2015
Available online at
ScienceDirect www.sciencedirect.com
Case report
Bilateral mandibular fourth molars: A case report Quatrie`mes molaires mandibulaires bilate´rales : a` propos d’un cas A. Costantinoa, G.M. Fonsecab,c,*, M. Cantı´nc,d,e a
Magister Program in Oral Implantology, Faculty of Dentistry, National University of La Plata, La Plata, Argentina b Department of Oral Pathology, Faculty of Dentistry, National University of Cordoba, Cordoba, Argentina c CIMA Research Group, Faculty of Dentistry, Universidad de La Frontera, Temuco, Chile d Doctoral Program in Morphological Sciences, CEMyQ, Faculty of Medicine, Universidad de La Frontera, Temuco, Chile e Center of Research in Biomedical Sciences, Universidad Auto´noma de Chile, Temuco, Chile
Summary
Re´sume´
Introduction. Fourth molars are supernumerary teeth located distal to the third molars that may cause local alterations. Therefore an adequate diagnosis and treatment are essential. Removal of the supernumerary tooth and, in selected cases, maintenance of the tooth on the arch and frequent observation are the preferred treatments. If the extraction is recommended, it should be performed carefully by experienced oral surgeons to prevent damage to the anatomical structures. Observation. The oral examination of a 26-year-old woman revealed a left partially impacted mandibular molar responsible for pain and infection. Although it was assumed it was a third molar, the panoramic radiograph showed that the real third molar was completely impacted and that two partially impacted mandibular fourth molars were present bilaterally. Both of them were removed without complications and the left third molar was extracted after fragmentation to avoid any injury of the contiguous inferior alveolar nerve. Discussion. The extraction of the left fourth molars solved the pain. Even if the right fourth molar was asymptomatic, the patient accepted its extraction because of the evident radiographical pericoronitis and to avoid further complications. ‘‘Asymptomatic’’ does not mean
Introduction. Les quatrie`mes molaires sont des dents surnume´raires situe´es en arrie`re des troisie`mes molaires. Elles peuvent eˆtre responsables de le´sions locales, raison pour laquelle un diagnostic et un traitement approprie´s sont essentiels. L’extraction de la dent surnume´raire et, dans certains cas particuliers, le maintien de la dent sur l’arcade et la mise en route d’une surveillance re´gulie`re sont les traitements de re´fe´rence. Si l’extraction est recommande´e, celle-ci doit eˆtre re´alise´e par des chirurgiens oraux expe´rimente´s pour e´viter d’endommager les structures anatomiques. Observation. L’examen endo-buccal d’une femme de 26 ans a re´ve´le´ la pre´sence d’une molaire mandibulaire gauche en de´sinclusion responsable de douleurs et d’une infection. Alors que cliniquement il semblait s’agir d’une troisie`me molaire, l’orthopantomogramme a montre´ que la ve´ritable troisie`me molaire e´tait totalement incluse et que deux quatrie`mes molaires mandibulaires partiellement incluses e´taient pre´sentes de manie`re bilate´rale. Ces deux dents surnume´raires ont e´te´ extraites sans complications et la troisie`me molaire gauche a e´te´ extraite apre`s fragmentation pour e´viter toute atteinte du nerf alve´olaire infe´rieur sous-jacent. Discussion. L’extraction de la quatrie`me molaire gauche a re´solu le proble`me douloureux. La patiente a accepte´ l’extraction concomitante de la quatrie`me molaire droite asymptomatique en raison de
* Corresponding author. El Tirol 180, Casa 43, Altos del Maipo 3, 4780000 Temuco, Chile. e-mail: [email protected] (G.M. Fonseca). http://dx.doi.org/10.1016/j.revsto.2015.05.001 Rev Stomatol Chir Maxillofac Chir Orale 2015;xxx:1-3 2213-6533/ß 2015 Published by Elsevier Masson SAS.
1
REVSTO-210; No of Pages 3
A. Costantino et al.
absence of disease, but the patient’s consent is mandatory before any decision. ß 2015 Published by Elsevier Masson SAS.
Rev Stomatol Chir Maxillofac Chir Orale 2015;xxx:1-3
l’image radiographique de pe´ricoronarite et pour e´viter de futures complications. Le caracte`re « asymptomatique » ne ne signifie pas l’absence de maladie mais le consentement du patient est impe´ratif avant toute de´cision the´rapeutique. ß 2015 Publie´ par Elsevier Masson SAS.
Keywords: Case reports, Fourth molars, Oral surgery Mots cle´s : Cas clinique, Quatrie`me molaire, Chirurgie orale
acute pericoronal infection. Although it was assumed that this tooth was the third molar because of its position and state, the panoramic radiograph revealed that the left third molar was completely horizontally impacted and that two additional supernumerary teeth were partially and bilaterally impacted in the mandibular arch (fig. 1). Their morphology was normal, but they were smaller than the regular molars and the roots of the impacted third molar and both fourth molars were complete. The left fourth molar was partially impacted in a distally inclined direction over the third molar. Family history did not reveal any particular findings and medical examination was carried out to rule out presence of any systemic condition or syndromes. Because the left third and fourth molars were symptomatic, extraction of both molars was considered. Extractions were performed under local anaesthesia. The left fourth molar was not joined to the third molar and it was extracted without difficulties. The tooth had five cusps and a single root, and it had a molar configuration. By contrast, the third molar was severely impacted and it had two roots. Bone removal and a tooth section technique were performed to reduce the tooth size and to minimize the risk of damage to the contiguous inferior alveolar nerve. Complete recoveries without any complication were achieved. Although the right fourth molar was asymptomatic, the patient accepted its extraction because of the radiographic evidence of pericoronitis. It was extracted without difficulties and it had the same
Introduction Supernumerary teeth are those that develop in addition to the normal set of teeth. They seem to be more frequent unilaterally in the permanent dentition, in the maxilla and in males [1–4]. Supernumerary teeth can cause alterations in the neighbouring teeth, lead to retained teeth or delayed eruption, ectopic eruptions, dental malpositions, occlusal problems, diastema, rotations of adjacent teeth, cyst lesions or resorption of contiguous teeth. Therefore an early diagnosis and an adequate treatment are essential [2,5]. When multiple supernumerary teeth are present, an associated systemic condition or syndrome must be considered [1,2,5]. They can be classified as either supplemental or rudimentary. Supplemental ones have a morphology similar to a normal tooth and rudimentary ones are small and conical [4]. Depending on their location on the dental arch, they can be classified as mesiodens, paramolar and distomolar. Distomolars (‘‘fourth molars’’) are situated distal to the third molars, frequently in the maxillary region [4,6]; they have a rudimentary shape and are usually seen at an impacted stage [3]. Treatment can take two forms: removal and, in selected cases, maintenance of the tooth on the arch and frequent observation. If extraction is recommended, it should be performed carefully by experienced oral surgeons to prevent damage to the anatomical structures [4,7]. In mandibular distomolars, the surgeon must avoid damage to adjacent permanent teeth and to the inferior alveolar artery and nerve and jaw fracture [3]. Cases of bilateral mandibular fourth molars with normal morphology are extremely rare and have seldom been reported in the dental literature [3,8]. We present an infrequent case of bilateral mandibular fourth molars in a woman without particular systemic conditions or syndrome. The management of this rare condition is discussed.
[(Figure_1)TD$IG]
Observation A 26-year-old woman presenting with pain and food impaction in the mandibular left posterior region was referred to our Department of Oral Surgery. Clinical oral examination revealed the presence of a left partially impacted molar with
2
Figure 1. Preoperative panoramic radiograph showing an impacted right fourth molar and a left fourth molar partially impacted over an impacted third molar.
REVSTO-210; No of Pages 3
Bilateral mandibular fourth molars: A case report
configuration as the left one. The clinical checks at 7 days, 15 days, 1 month and 3 months showed an uneventful postoperative course.
great challenge [5]. Even though the removal of supernumerary teeth can eliminate possible complications [10], the appropriate management should be considered carefully [5]. The final decision of extraction belongs to the patient.
Discussion Disclosure of interest The supernumerary teeth appearing distally to the third molar were classified as fourth molars. Their incidence is rare with only a 0.02% reported at the mandible [6]. The present case is similar to few previous reports [5,6]. The exact aetiology of supernumerary teeth is unknown. However, several theories have been suggested: an abnormal reaction to a local traumatic episode, environmental factors, a phylogenetic theory, horizontal proliferation of the dental lamina, dichotomy of tooth germ, and hereditary disorders [2,3]. The present case consists in a non-syndromic multiple supplemental supernumerary teeth. Usually, supernumerary teeth are removed surgically, often due to retention of underlying permanent teeth. In cases where the supernumerary teeth do not cause alterations in the eruption, position or integrity of permanent dentition, a conservative approach is preferred, and close observation with regular X-ray controls is recommended [2]. In this case report, the patient was satisfied after extraction of the left third and fourth molars as it solved the problem of food impaction and pain. Even though the right fourth molar was asymptomatic, its extraction was recommended because of the evident pericoronitis and to avoid further complications or pain. Clementine et al. mentioned that maintenance of the tooth on the arch and frequent observation can be a form of treatment [3]. The fourth molars should be managed much like an impacted third molar [3], and we agree with Dodson who considers that the term ‘‘asymptomatic’’ is ambiguous and insufficient as the absence of symptoms does not equal the absence of disease [9]. In this case, we believe that the removal of the right fourth molar was necessary even with the absence of pain, but the patient’s consent is not a minor issue. We also agree with Reddy et al. who consider that the management of multiple supernumerary teeth is a
The authors declare that they have no conflicts of interest concerning this article.
References [1]
[2]
[3]
[4] [5]
[6]
[7]
[8]
[9]
[10]
Yadav RK, Rao J, Yadav L, Hasija M. Non-syndromic multiple supernumerary teeth in permanent dentition: a rare phenomenon. BMJ Case Rep 2013. http://dx.doi.org/10.1136/bcr-2013009026 [Published on line: May 22; 2013]. Agrawal JM, Agrawal MS, Nanjannawar LG, Adaki RV. Nonsyndromic multiple supernumerary teeth: a rare entity. BMJ Case Rep 2013. http://dx.doi.org/10.1136/bcr-2012-007796 [Published on line: Jan 10; 2013]. Clementini M, Ottria L, Pandolfi C, Agrestini C, Barlattani A. Four impacted fourth molars in a young patient: a case report. Oral Implantol (Rome) 2013;5:100–3. Hopcraft M. Multiple supernumerary teeth. Case report. Aust Dent J 1998;43:17–9. Reddy GS, Reddy GV, Krishna IV, Regonda SK. Nonsyndromic bilateral multiple impacted supernumerary mandibular third molars: a rare and unusual case report. Case Rep Dent 2013;857147. Ohata H, Hayashi K, Iwamoto M, Muramatsu K, Watanabe A, Narita M, et al. Three cases of distomolars. Bull Tokyo Dent Coll 2013;54:259–64. Bachmann H, Ca´ceres R, Mun ˜ oz C, Uribe S. Complications during third molar surgery between the years 2007-2010 in an urban hospital, Chile. Int J Odontostomat 2014;8:107–12. Shultsman M, Taicher S. Fourth molars in the maxilla and mandible: a rare phenomenon. Refuat Hapeh Vehashinayim 2003;20:35–7 [80]. Dodson TB. How many patients have third molars and how many have one or more asymptomatic, disease-free third molars? J Oral Maxillofac Surg 2012;70:S4–7. Visconti MAPG, Junqueira RB, Verner FS, Rodrigues AAS, Devito KL, Visconti Filho RF. Cone-Beam computed tomography as complementary tool in diagnosis and surgical planning of centigerous cyst: case report. Int J Odontostomat 2014;8:85–91.
3
Received: 3 February 2015 Accepted: 12 May 2015
Available online at
ScienceDirect www.sciencedirect.com
Case report
Bilateral mandibular fourth molars: A case report Quatrie`mes molaires mandibulaires bilate´rales : a` propos d’un cas A. Costantinoa, G.M. Fonsecab,c,*, M. Cantı´nc,d,e a
Magister Program in Oral Implantology, Faculty of Dentistry, National University of La Plata, La Plata, Argentina b Department of Oral Pathology, Faculty of Dentistry, National University of Cordoba, Cordoba, Argentina c CIMA Research Group, Faculty of Dentistry, Universidad de La Frontera, Temuco, Chile d Doctoral Program in Morphological Sciences, CEMyQ, Faculty of Medicine, Universidad de La Frontera, Temuco, Chile e Center of Research in Biomedical Sciences, Universidad Auto´noma de Chile, Temuco, Chile
Summary
Re´sume´
Introduction. Fourth molars are supernumerary teeth located distal to the third molars that may cause local alterations. Therefore an adequate diagnosis and treatment are essential. Removal of the supernumerary tooth and, in selected cases, maintenance of the tooth on the arch and frequent observation are the preferred treatments. If the extraction is recommended, it should be performed carefully by experienced oral surgeons to prevent damage to the anatomical structures. Observation. The oral examination of a 26-year-old woman revealed a left partially impacted mandibular molar responsible for pain and infection. Although it was assumed it was a third molar, the panoramic radiograph showed that the real third molar was completely impacted and that two partially impacted mandibular fourth molars were present bilaterally. Both of them were removed without complications and the left third molar was extracted after fragmentation to avoid any injury of the contiguous inferior alveolar nerve. Discussion. The extraction of the left fourth molars solved the pain. Even if the right fourth molar was asymptomatic, the patient accepted its extraction because of the evident radiographical pericoronitis and to avoid further complications. ‘‘Asymptomatic’’ does not mean
Introduction. Les quatrie`mes molaires sont des dents surnume´raires situe´es en arrie`re des troisie`mes molaires. Elles peuvent eˆtre responsables de le´sions locales, raison pour laquelle un diagnostic et un traitement approprie´s sont essentiels. L’extraction de la dent surnume´raire et, dans certains cas particuliers, le maintien de la dent sur l’arcade et la mise en route d’une surveillance re´gulie`re sont les traitements de re´fe´rence. Si l’extraction est recommande´e, celle-ci doit eˆtre re´alise´e par des chirurgiens oraux expe´rimente´s pour e´viter d’endommager les structures anatomiques. Observation. L’examen endo-buccal d’une femme de 26 ans a re´ve´le´ la pre´sence d’une molaire mandibulaire gauche en de´sinclusion responsable de douleurs et d’une infection. Alors que cliniquement il semblait s’agir d’une troisie`me molaire, l’orthopantomogramme a montre´ que la ve´ritable troisie`me molaire e´tait totalement incluse et que deux quatrie`mes molaires mandibulaires partiellement incluses e´taient pre´sentes de manie`re bilate´rale. Ces deux dents surnume´raires ont e´te´ extraites sans complications et la troisie`me molaire gauche a e´te´ extraite apre`s fragmentation pour e´viter toute atteinte du nerf alve´olaire infe´rieur sous-jacent. Discussion. L’extraction de la quatrie`me molaire gauche a re´solu le proble`me douloureux. La patiente a accepte´ l’extraction concomitante de la quatrie`me molaire droite asymptomatique en raison de
* Corresponding author. El Tirol 180, Casa 43, Altos del Maipo 3, 4780000 Temuco, Chile. e-mail: [email protected] (G.M. Fonseca). http://dx.doi.org/10.1016/j.revsto.2015.05.001 Rev Stomatol Chir Maxillofac Chir Orale 2015;xxx:1-3 2213-6533/ß 2015 Published by Elsevier Masson SAS.
1
REVSTO-210; No of Pages 3
A. Costantino et al.
absence of disease, but the patient’s consent is mandatory before any decision. ß 2015 Published by Elsevier Masson SAS.
Rev Stomatol Chir Maxillofac Chir Orale 2015;xxx:1-3
l’image radiographique de pe´ricoronarite et pour e´viter de futures complications. Le caracte`re « asymptomatique » ne ne signifie pas l’absence de maladie mais le consentement du patient est impe´ratif avant toute de´cision the´rapeutique. ß 2015 Publie´ par Elsevier Masson SAS.
Keywords: Case reports, Fourth molars, Oral surgery Mots cle´s : Cas clinique, Quatrie`me molaire, Chirurgie orale
acute pericoronal infection. Although it was assumed that this tooth was the third molar because of its position and state, the panoramic radiograph revealed that the left third molar was completely horizontally impacted and that two additional supernumerary teeth were partially and bilaterally impacted in the mandibular arch (fig. 1). Their morphology was normal, but they were smaller than the regular molars and the roots of the impacted third molar and both fourth molars were complete. The left fourth molar was partially impacted in a distally inclined direction over the third molar. Family history did not reveal any particular findings and medical examination was carried out to rule out presence of any systemic condition or syndromes. Because the left third and fourth molars were symptomatic, extraction of both molars was considered. Extractions were performed under local anaesthesia. The left fourth molar was not joined to the third molar and it was extracted without difficulties. The tooth had five cusps and a single root, and it had a molar configuration. By contrast, the third molar was severely impacted and it had two roots. Bone removal and a tooth section technique were performed to reduce the tooth size and to minimize the risk of damage to the contiguous inferior alveolar nerve. Complete recoveries without any complication were achieved. Although the right fourth molar was asymptomatic, the patient accepted its extraction because of the radiographic evidence of pericoronitis. It was extracted without difficulties and it had the same
Introduction Supernumerary teeth are those that develop in addition to the normal set of teeth. They seem to be more frequent unilaterally in the permanent dentition, in the maxilla and in males [1–4]. Supernumerary teeth can cause alterations in the neighbouring teeth, lead to retained teeth or delayed eruption, ectopic eruptions, dental malpositions, occlusal problems, diastema, rotations of adjacent teeth, cyst lesions or resorption of contiguous teeth. Therefore an early diagnosis and an adequate treatment are essential [2,5]. When multiple supernumerary teeth are present, an associated systemic condition or syndrome must be considered [1,2,5]. They can be classified as either supplemental or rudimentary. Supplemental ones have a morphology similar to a normal tooth and rudimentary ones are small and conical [4]. Depending on their location on the dental arch, they can be classified as mesiodens, paramolar and distomolar. Distomolars (‘‘fourth molars’’) are situated distal to the third molars, frequently in the maxillary region [4,6]; they have a rudimentary shape and are usually seen at an impacted stage [3]. Treatment can take two forms: removal and, in selected cases, maintenance of the tooth on the arch and frequent observation. If extraction is recommended, it should be performed carefully by experienced oral surgeons to prevent damage to the anatomical structures [4,7]. In mandibular distomolars, the surgeon must avoid damage to adjacent permanent teeth and to the inferior alveolar artery and nerve and jaw fracture [3]. Cases of bilateral mandibular fourth molars with normal morphology are extremely rare and have seldom been reported in the dental literature [3,8]. We present an infrequent case of bilateral mandibular fourth molars in a woman without particular systemic conditions or syndrome. The management of this rare condition is discussed.
[(Figure_1)TD$IG]
Observation A 26-year-old woman presenting with pain and food impaction in the mandibular left posterior region was referred to our Department of Oral Surgery. Clinical oral examination revealed the presence of a left partially impacted molar with
2
Figure 1. Preoperative panoramic radiograph showing an impacted right fourth molar and a left fourth molar partially impacted over an impacted third molar.
REVSTO-210; No of Pages 3
Bilateral mandibular fourth molars: A case report
configuration as the left one. The clinical checks at 7 days, 15 days, 1 month and 3 months showed an uneventful postoperative course.
great challenge [5]. Even though the removal of supernumerary teeth can eliminate possible complications [10], the appropriate management should be considered carefully [5]. The final decision of extraction belongs to the patient.
Discussion Disclosure of interest The supernumerary teeth appearing distally to the third molar were classified as fourth molars. Their incidence is rare with only a 0.02% reported at the mandible [6]. The present case is similar to few previous reports [5,6]. The exact aetiology of supernumerary teeth is unknown. However, several theories have been suggested: an abnormal reaction to a local traumatic episode, environmental factors, a phylogenetic theory, horizontal proliferation of the dental lamina, dichotomy of tooth germ, and hereditary disorders [2,3]. The present case consists in a non-syndromic multiple supplemental supernumerary teeth. Usually, supernumerary teeth are removed surgically, often due to retention of underlying permanent teeth. In cases where the supernumerary teeth do not cause alterations in the eruption, position or integrity of permanent dentition, a conservative approach is preferred, and close observation with regular X-ray controls is recommended [2]. In this case report, the patient was satisfied after extraction of the left third and fourth molars as it solved the problem of food impaction and pain. Even though the right fourth molar was asymptomatic, its extraction was recommended because of the evident pericoronitis and to avoid further complications or pain. Clementine et al. mentioned that maintenance of the tooth on the arch and frequent observation can be a form of treatment [3]. The fourth molars should be managed much like an impacted third molar [3], and we agree with Dodson who considers that the term ‘‘asymptomatic’’ is ambiguous and insufficient as the absence of symptoms does not equal the absence of disease [9]. In this case, we believe that the removal of the right fourth molar was necessary even with the absence of pain, but the patient’s consent is not a minor issue. We also agree with Reddy et al. who consider that the management of multiple supernumerary teeth is a
The authors declare that they have no conflicts of interest concerning this article.
References [1]
[2]
[3]
[4] [5]
[6]
[7]
[8]
[9]
[10]
Yadav RK, Rao J, Yadav L, Hasija M. Non-syndromic multiple supernumerary teeth in permanent dentition: a rare phenomenon. BMJ Case Rep 2013. http://dx.doi.org/10.1136/bcr-2013009026 [Published on line: May 22; 2013]. Agrawal JM, Agrawal MS, Nanjannawar LG, Adaki RV. Nonsyndromic multiple supernumerary teeth: a rare entity. BMJ Case Rep 2013. http://dx.doi.org/10.1136/bcr-2012-007796 [Published on line: Jan 10; 2013]. Clementini M, Ottria L, Pandolfi C, Agrestini C, Barlattani A. Four impacted fourth molars in a young patient: a case report. Oral Implantol (Rome) 2013;5:100–3. Hopcraft M. Multiple supernumerary teeth. Case report. Aust Dent J 1998;43:17–9. Reddy GS, Reddy GV, Krishna IV, Regonda SK. Nonsyndromic bilateral multiple impacted supernumerary mandibular third molars: a rare and unusual case report. Case Rep Dent 2013;857147. Ohata H, Hayashi K, Iwamoto M, Muramatsu K, Watanabe A, Narita M, et al. Three cases of distomolars. Bull Tokyo Dent Coll 2013;54:259–64. Bachmann H, Ca´ceres R, Mun ˜ oz C, Uribe S. Complications during third molar surgery between the years 2007-2010 in an urban hospital, Chile. Int J Odontostomat 2014;8:107–12. Shultsman M, Taicher S. Fourth molars in the maxilla and mandible: a rare phenomenon. Refuat Hapeh Vehashinayim 2003;20:35–7 [80]. Dodson TB. How many patients have third molars and how many have one or more asymptomatic, disease-free third molars? J Oral Maxillofac Surg 2012;70:S4–7. Visconti MAPG, Junqueira RB, Verner FS, Rodrigues AAS, Devito KL, Visconti Filho RF. Cone-Beam computed tomography as complementary tool in diagnosis and surgical planning of centigerous cyst: case report. Int J Odontostomat 2014;8:85–91.
3
