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CASE REPORT
Year : 2017  |  Volume : 35  |  Issue : 4  |  Page : 374-377
 

Unilateral fourth, fifth, sixth, and seventh molar in a nonsyndromic patient: A rare and unusual case report


1 Department of Oral Pathology and Microbiology, Sarjug Dental College, Darbhanga, Bihar, India
2 Department of Oral Surgery, Sarjug Dental College, Darbhanga, Bihar, India
3 Department of Dentistry, Darbhanga Medical College, Darbhanga, Bihar, India
4 Department of Pedodontics, Himachal Institute of Dental Sciences, Paonta Sahib, Himachal Pradesh, India

Date of Web Publication15-Sep-2017

Correspondence Address:
Pallav Singhal
T-29, Sector-12, Noida, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JISPPD.JISPPD_186_16

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   Abstract 


Multiple supernumerary teeth are rare developmental anomalies which are often associated with syndromes. Only few examples of nonsyndromic supernumerary teeth have been reported with fourth, fifth, sixth, and seventh molar rarest of all. The cause, frequency, complications, and surgical operation of supernumerary teeth are always interesting subjects for study and research. Literature reports increased occurrence of the supernumeraries in the maxilla, but here, a unique and unusual case report of 12-year-old female patient with unilateral multiple impacted supernumerary teeth in the mandible in otherwise healthy individual has been presented.


Keywords: Distomolars, hyperdontia, permanent, supernumerary, supplemental


How to cite this article:
Singhal P, Sah VK, Kumar A, Garg A. Unilateral fourth, fifth, sixth, and seventh molar in a nonsyndromic patient: A rare and unusual case report. J Indian Soc Pedod Prev Dent 2017;35:374-7

How to cite this URL:
Singhal P, Sah VK, Kumar A, Garg A. Unilateral fourth, fifth, sixth, and seventh molar in a nonsyndromic patient: A rare and unusual case report. J Indian Soc Pedod Prev Dent [serial online] 2017 [cited 2019 Oct 15];35:374-7. Available from: http://www.jisppd.com/text.asp?2017/35/4/374/214918





   Introduction Top


Hyperdontia is a developmental anomaly characterized by increased number of teeth, and the teeth that exceed the normal dental complement, regardless of their location, and morphology are termed as supernumerary teeth. These may occur singly, multiply, unilaterally, or bilaterally, erupted or impacted, in deciduous and permanent dentition or in one or both jaws.[1],[2] The prevalence of supernumerary teeth varies between 0.3% and 1.9% in primary dentition and 0.1% and 3.6% in permanent dentition.[3] In permanent dentition, they are two times more common in males than in females and occur 8.2–10 times more frequently in maxilla than in mandible, commonly affecting premaxillary region.[1],[3],[4]

Multiple supernumeraries are very rare with <1% of the cases reported.[2],[3],[4] The condition is commonly associated with systemic disorders such as Gardner syndrome, Ehlers–Danlos syndrome, Cleidocranial dysplasia, cleft lip and cleft palate, Tricho–rhino–phalangeal syndrome, Ellis–van Creveld syndrome, Fabry–Anderson's syndrome, incontinentia pigmenti, and megadontia.[2],[4] Nonsyndromic multiple supernumerary teeth is a further rare anomaly.[4]

Although nonsyndromic multiple supernumeraries are rare, their occurrence may cause various clinical problems such as crowding, swelling, delayed eruption, cystic lesions, diastema, rotations, and resorption of the adjacent teeth. Therefore, appropriate treatment after proper clinical and radiographic evaluation is essential.

This case report presents a unique case of unusual occurrence of supernumerary teeth unilaterally distal to mandibular permanent molar in a 12-year-old child in the absence of any syndrome.


   Case Report Top


A 12-year-old female patient reported to the dental clinic with chief complaint of swelling on the left side of the face for 1 month. Extraoral examination revealed the presence of diffuse, firm, and nontender swelling over the left body of mandible [Figure 1]. Intraoral examination revealed multiple missing teeth and buccal cortical plate expansion in relation to 36–38 teeth region [Figure 2]. Clinically, in the third quadrant, permanent central and lateral incisor, deciduous first molar, and permanent first molar were visible. Family history, medical history, extraoral examination, and systemic investigations which include routine blood examination did not reveal any disease/syndrome. Aspiration was negative. Based on the clinical finding, a provisional diagnosis of benign odontogenic tumor was considered.
Figure 1: Photograph showing extraoral swelling on the left side of the face

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Figure 2: Intraoral swelling on the left side of mandible with the absence of multiple teeth

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Radiographic evaluation included orthopantomograph which showed the presence of multiple impacted teeth in the third quadrant which includes permanent canine, first premolar, second premolar, and permanent second molar and third molar and four supernumerary molars (fourth, fifth, sixth, and seventh molar). Impacted supernumerary molars showed homogenous radiolucent halo around the crown with a thin outer radiopaque border suggesting a follicle [Figure 3]. The patient was informed of existing condition and extraction of these multiple supernumerary teeth was advised along with the third molar. Modified ward incision was given extending up to anterior border of the ramus. Mucoperiosteal flap was raised and peripheral ostectomy was performed. The lesion was enucleated along with the fibrous tissue and multiple teeth followed by curettage and bone filing. All the four supernumerary teeth and third molar in the third quadrant were extracted [Figure 4]a and [Figure 5], and the surgical site was secured by suturing [Figure 4]b.
Figure 3: Radiograph showing multiple impacted molars

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Figure 4: Paroperative view (a) and postoperative view (b)

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Figure 5: Gross specimen

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To rule out the possibility of any odontogenic cyst or tumor, the surgical specimen was labelled and was sent for histopathological examination [Figure 5]. The tissue was processed and sections thus obtained were stained by the hematoxylin and eosin (H and E) stain. Microscopic examination of the H and E stained sections revealed the presence of fibrous connective tissue stroma. Stroma shows evenly spaced, plump fibroblasts that are set against a background of delicate collagen fibers along with variable amounts of ground substance. Thus, overall histopathological features were suggestive of odontogenic ectomesenchyme [Figure 6]. The postoperative follow-up was uneventful for the past 6 months.
Figure 6: Photomicrograph (H and E stain, ×10)

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   Discussion Top


The prevalence of supernumerary molars has been reported to be 1%–2% and it has been documented that supernumerary molars are very rare in young patients and that too in mandible.[5] Occurrence of supernumerary teeth still remains unclear, but many explanations concerning the etiology of the supernumerary teeth have been proposed such as atavism or reversion (phylogenetic theory), aberrations during embryologic formation, dichotomy theory, dental lamina hyperactivity, and genetic and environmental factors.[6],[7],[8] Hyperactivity theory is the most commonly accepted.[7],[8] It states that supernumerary teeth are result of localized and independent conditional hyperactivity of dental lamina.[6],[7] Based on this theory, eumorphic or supplemental tooth arises from the lingual extension of additional tooth bud whereas proliferation of epithelial remnants of dental lamina gives rise to rudimentary form.[6]

The classification of supernumerary teeth according to chronology can be predeciduous, similar to deciduous, postpermanent, or complementary. According to morphology, it can be supplemental/eumorphic (similar to size and shape of the associated deciduous or permanent tooth) and rudimentary/dysmorphic having abnormal shape and small size (odontome, conical, tuberculate, and molariform). Topographically, they can be subclassified as mesiodens, supernumerary premolars, paramolars, and distomolars.[2],[6],[7] The following case presents with supplemental type of distomolars.

Numerous complications are associated with supernumerary teeth which may erupt normally or remain impacted. They may lead to crowding, malocclusion, delayed eruption, spacing, localized periodontitis, caries, root resorption, diastema, pain, swelling, and pathological problems such as dentigerous cyst, ameloblastomas, fistulae, and odontomas.[9],[10]

Detailed history and clinical examination followed by thorough investigation are mandatory to prepare an appropriate treatment plan. Treatment depends on the type and location of the supernumerary teeth and on its potential effect on adjacent hard- and soft-tissue structures and thus requires interdisciplinary approach. Treatment may include observation with yearly radiographic review if they do not cause any complication and will not likely interfere in tooth eruption and orthodontic tooth treatment. If any of the aforementioned complications are evident, it is advisable to extract them.[11],[12] Extraction should be performed carefully to prevent damage to adjacent permanent teeth, which may cause ankylosis and maleruption of these teeth.[9]

Our case presented with swelling, impaction, and delayed eruption, and thus, extraction of all the supernumerary teeth was carried out to facilitate the eruption of the second molar followed by histopathological evaluation of the excised specimen to rule out any odontogenic tumor or cyst.


   Conclusion Top


It is to conclude that the occurrence of the fourth, fifth, sixth, and seventh molar is an extremely rare phenomenon, the clinical management of which poses a great challenge to clinicians. Supernumeraries can cause a various complications. Clinicians should be aware of the associated problems to formulate a sound treatment plan with a multidisciplinary approach by thorough clinical and radiographic investigations so as to minimize further complications.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Dhull KS, Dhull RS, Panda S, Acharya S, Yadav S, Mohanty G. Bilateral mandibular paramolars. Int J Clin Pediatr Dent 2014;7:40-2.  Back to cited text no. 1
    
2.
Puri K, Bansal M, Jain D, Kumar A, Khatri M, Gupta G. Nonsyndromic multiple supernumerary premolars and Paramolars: An overview and report of 2 cases. Indian J Dent Sci 2013;5:54-6.  Back to cited text no. 2
    
3.
Kasat VO, Saluja H, Kalburge JV, Kini Y, Nikam A, Laddha R. Multiple bilateral supernumerary mandibular premolars in a non-syndromic patient with associated orthokeratised odontogenic cyst – A case report and review of literature. Contemp Clin Dent 2012;3 Suppl 2:S248-52.  Back to cited text no. 3
    
4.
Nayak G, Shetty S, Singh I, Pitalia D. Paramolar – A supernumerary molar: A case report and an overview. Dent Res J (Isfahan) 2012;9:797-803.  Back to cited text no. 4
    
5.
Qaradaghi IF. Supernumerary tooth: Report of a rare case of a fourth mandibular molar. Rev Clín Pesqui Odontol 2009;5:157-60.  Back to cited text no. 5
    
6.
Mallineni SK. Supernumerary teeth: Review of literature with recent updates. Conf Papers Sci 2014;2014:1-6.  Back to cited text no. 6
    
7.
Sulabha AN, Sameer C. Unusual bilateral paramolars associated with clinical complications. Case Rep Dent 2015;2015:851765.  Back to cited text no. 7
    
8.
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;2013:857147.  Back to cited text no. 8
    
9.
Parolia A, Kundabala M, Dahal M, Mohan M, Thomas MS. Management of supernumerary teeth. J Conserv Dent 2011;14:221-4.  Back to cited text no. 9
[PUBMED]  [Full text]  
10.
Asutay F, Acar AH, Kirtay M, Alan H, Atalay Y. Multiple bilateral 11 supernumerary teeth with forth molars in a nonsyndromic patient: An unusual case report. J Dent Appl 2015;2:207-9.  Back to cited text no. 10
    
11.
Amarlal D, Muthu MS. Supernumerary teeth: Review of literature and decision support system. Indian J Dent Res 2013;24:117-22.  Back to cited text no. 11
[PUBMED]  [Full text]  
12.
Shah A, Gill DS, Tredwin C, Naini FB. Diagnosis and management of supernumerary teeth. Dent Update 2008;35:510-2, 514-6, 519-20.  Back to cited text no. 12
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]



 

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