|Year : 2015 | Volume
| Issue : 4 | Page : 271-274
Multiple bilateral impacted distomolars in nonsyndromic condition: A rare case report
Amirhossein Moaddabi1, Mohammad Hassan Samandari2, Mohammad Javad Shirani3, Parisa Soltani3
1 Department of Oral and Maxillofacial Surgery, Torabinejad Dental Research Center, School of Dentistry, Isfahan University of Medical Sciences, Isfahan, Iran
2 Department of Oral and Maxillofacial Surgery, Dental Implants Research Center, School of Dentistry, Isfahan University of Medical Sciences, Isfahan, Iran
3 Dental Students Research Center, School of Dentistry, Isfahan University of Medical Sciences, Isfahan, Iran
|Date of Web Publication||23-Nov-2015|
Last-Year Student of Dentistry, School of Dentistry, Isfahan University of Medical Science, Hezar Jerib Street, Isfahan
Source of Support: None, Conflict of Interest: None
The presence of multiple supernumerary teeth in nonsyndromic patients is uncommon. In these patients, the prevalence of extra teeth in the molar regions of both jaws is rare. This study aimed to present a rare case of a 27-year-old woman, with nonsyndromic multiple distomolar supernumerary teeth causing vague and diffuse pain in periauricular, temporomandibular joint, and temporal regions. Impacted third molar and distomolar that were in a close contact with inferior alveolar nerve canal were extracted with minimum bone removal.
Keywords: Distomolar, orofacial pain, supernumerary teeth, surgical extraction
|How to cite this article:|
Moaddabi A, Samandari MH, Shirani MJ, Soltani P. Multiple bilateral impacted distomolars in nonsyndromic condition: A rare case report. SRM J Res Dent Sci 2015;6:271-4
|How to cite this URL:|
Moaddabi A, Samandari MH, Shirani MJ, Soltani P. Multiple bilateral impacted distomolars in nonsyndromic condition: A rare case report. SRM J Res Dent Sci [serial online] 2015 [cited 2022 May 24];6:271-4. Available from: https://www.srmjrds.in/text.asp?2015/6/4/271/170292
| Introduction|| |
Supernumerary teeth are defined as extra teeth when compared to the normal series of 20 deciduous and 32 permanent teeth.  Despite the advances in understanding different stages of tooth differentiation, the etiologic factors responsible for the formation of supernumerary teeth are not completely understood. ,,, Some studies suggest environmental factors as contributing agents while others emphasize the role of genetic patterns in the etiology of supernumerary teeth. Sometimes these extra teeth are considered as the third dental series, although important genes are not completely recognized. ,,,
Supernumerary teeth may be single or multiple, occur unilaterally or bilaterally, in one or both jaws. , The condition of multiple supernumerary teeth is usually a result of developmental disorders such as cleft lip and palate, cleidocranial dysostosis, and Gardner's syndrome.  According to previous studies nonsyndromic multiple supernumerary teeth (NSMST) is an uncommon condition. ,,,, In NSMST patients, the prevalence of extra teeth in the molar regions of both jaws is rare.  Although the prevalence of NSMST is twice in men, there is no difference in number and the site of extra teeth between the genders. , Supernumerary teeth can cause esthetic imperfections, dislocation or rotation of permanent teeth, crowding, dilaceration, dental problems, occlusal inconsistencies, functional problems, obstruction or retardation of permanent tooth eruption, and incidence of tooth impaction. ,,, Teeth that are embedded in the alveolar bone and their eruption is hindered, are defined as impacted teeth. Impacted teeth can result in decay, pulp disease, periapical and periodontal disease, temporomandibular disorders, mandibular fracture, infection of fascial spaces, root resorption of adjacent teeth, and even oral and maxillofacial tumors. , Therefore, some studies recommend that management of this condition needs thorough clinical and radiographic evaluations and regular follow-up visits for prevention while others suggest the prophylactic surgical extraction of supernumerary teeth as the treatment of choice. ,,,
This report presents a rare case with nonsyndromic multiple distomolar supernumerary teeth. The article also enumerates the surgical procedures for extraction of impacted third molar and distomolar is described.
| Case report|| |
A 27-year-old woman was referred to the Dental Hospital of Isfahan University of Medical Sciences with the chief complaint of pain during eating and drinking water and spontaneous nocturnal pain in the left side of the mandible. The patient also complained of vague and diffuse pain in temporomandibular joint and temporal regions and left ear. Medical history revealed the use of the folic acid tablet for anemia, propranolol, allergy to penicillin, and history of a migraine and septorhinoplasty done 2 years before the referral. The patient had been examined by a physician regularly in 2-month periods. Although there was a history of dental treatment, the patient did not remember any tooth extractions. Extraoral examinations did not reveal any abnormal finding. Furthermore, there was no sign of syndromes. On intraoral examination, the oral mucosa was coral pink in color, firm, and elastic. Normal form and eruption of the teeth from the central incisors to the second premolars was also observed. In view of the absence of the right maxillary first molar, the adjacent teeth had tilted to the edentulous space. On the right side of the mandible, the fourth molar was seen at some distance from the second molar. The left maxillary third molar was absent and on the left side of the mandible, coronal part of a partially erupted tooth was seen posterior to the second molar. After taking panoramic radiograph [Figure 1], two impacted distomolar teeth were seen on both sides of the maxilla, and two impacted third and fourth molars on the left side of the mandible. There was no evidence of the similar condition in the members of the patient's family. As for acceptable root canal treatment of the mandibular first and second molars, absence of caries or lesions in the left maxillary and mandibular quadrants, little inflammation around the crown of the partially erupted tooth, and possibility of infection and pathologic fracture of mandibular angle, surgical extraction of impacted third and fourth molars was advised. ,, Due to close relation of the whole length of mesial surface of the left mandibular third molar and the inferior alveolar nerve canal in panoramic radiograph, cone beam computed tomography (CBCT) was requested for the left side of mandible.  CBCT [Figure 2] showed the following findings:
- Crown and root of lower tooth (probably 8) in contact with inferior alveolar nerve; however, cortical bone of alveolar canal is intact.
- Pericoronal space is reduced, but there is no ankylosis.
- There is no root resorption, and the roots are complete.
- Third molar: Crown at lingual and root at buccal.
- Fourth molar: Crown and root both are lingual.
- Both teeth are normal (without gemination or dilaceration) and are separated.
- Bone quality: D3 in Misch classification.
Initially, lips and surrounding area were disinfected with iodophor, and the oral cavity was isolated by a surgical drape. After conscious sedation using midazolam and meperidine, the patient had been ready for initiation of surgery by inferior alveolar and long buccal anesthetic injections.
The sulcular incision was performed from mesial to the second molar extending distally to the retromolar area. After retracting the tissue, buccal bone of the fourth molar was removed using a round bur. The crown was dissected from the roots by fissure bur. Subsequently, the crown and the root were extracted separately. In order to decrease the amount of bone removal, the crown of the third molar was dissected into three parts, which were extracted separately. After creating a purchase point in the remaining root, it was extracted. Then the follicle was extracted, and the site was irrigated abundantly with normal saline [Figure 3]. Afterward, the tissue was held in place using three sutures located distal to the second molar, mesial to the second molar and in the distal region of the envelope flap. The next step was the insertion of effective pack and prescription of a single-dose dexamethasone (IM) and gelofen analgesic capsule. , The patient was discharged after resolving from the sedation.
| Discussion|| |
The etiology of supernumerary teeth is not completely understood. Both environmental and genetic factors are considered responsible. Hereunto, theories such as atavism, dichotomy, dental lamina hyperactivity, traumatic local event, and genetic factors are suggested as explanations for nonsyndromic supernumerary teeth. ,
Supernumerary teeth are categorized into four groups regarding their sites: Mesiodens, parapremolar, distomolar, and paramolar.  Extra molar teeth are called distomolars when located distal to the third molar, and paramolar when buccal or lingual to the molars.  Although single supernumerary teeth are more prevalent in anterior parts of the maxilla, ,, in NSMST cases, mandibular premolar region is mostly involved (45.29%). In these cases, supernumerary teeth are least common in the mandibular molar region (0.05%) and anterior parts of the mandible (0.04%). 
Nayak et al.  have reported presence of a maxillary paramolar in a 22-year-old man with an unremarkable systemic health problem. In one recent case report, a rare conditions of bilateral multiple impacted supernumerary teeth as normal-sized molars were seen in the molar region of the mandible of a 22-year-old man.  In 2009, McCrea  reported the concomitant presence of two dentigerous cysts around third and fourth mandibular molars in a 60-year-old woman without any developmental syndromes. Dentigerous cyst, the most common odontogenic cyst in jaws, is associated with the crown of permanent teeth, especially third molars. In an interesting report of the case, a 22-year-old woman had 17 extra teeth, 12 in the maxilla, and 5 in the mandible, of which only 5 of those were impacted, and others were erupted.  In another report, a male was presented with multiple supernumerary fourth molars in both jaws.  A condition of a follicular space around two impacted molars with the occlusal surfaces facing each other was termed kissing molars in 1973. Sα Fortes et al.  reported an interesting case of bilateral kissing molars and concomitant dentigerous cysts in the mandible.
Atavism and dichotomy theories have been disapproved.  Furthermore, since the trauma and associated scars were not seen in the patient's history and examination, the traumatic local event was rejected. Some studies put emphasis on genetic factors. Hence, the history of the family was assessed carefully , but no similar condition was found in the patient's family. Therefore, according to history and examinations, dental lamina hyperactivity theory, which most studies support  was considered as the cause of this condition in the patient.
The reported case had four distomolars placed bilaterally in both jaws, which is less prevalent in NSMST patients. One of the limitations of this study was lack of an objective method to determine whether the third molars, especially the absent one on the right side was previously extracted, or there was no tooth in the place according to the patient's allegation. Of course clinical examinations and panoramic radiograph showed that the tooth had existed and was formerly extracted, as the adjacent teeth had tilted toward the edentulous space.
One important issue in extracting mandibular impacted teeth is a relation of the teeth to the mandibular canal. In the presented case, after noticing the close relation of the tooth and the inferior alveolar nerve canal in the panoramic radiograph, CBCT was requested.  CBCT is helpful in the pretreatment evaluation of supernumerary teeth. In CBCT scan, insignificant 2.4 mm distance between the mesial surface of the tooth and the mandibular canal was assessed, indicating a high possibility of injury to the nerve during the surgery. Therefore, treatment planning was devised to avoid contact between the bur and the nerve.
The management of supernumerary teeth is important, , as the condition can cause esthetic and functional problems. In the presented case, the utmost effort was made to extract the teeth with minimal bone removed so that the possibility of mandibular angle fracture is minimized. In this surgery, the extraction of the third molar was undertaken after extracting the distomolar without any bone removal. It was extracted by dissecting the crown into three pieces, without injury to surrounding structures.
The presence of impacted teeth may lead to orofacial pain. In this condition, the extraction of these teeth is indicated.  Dull and diffuse orofacial pain extending to the temporomandibular and auricular area may be associated with impacted mandibular teeth. Therefore, the extraction of these impacted teeth may lead to the alleviation of the pain. In the presented case, the pain vanished 1-week after the surgery and in 1-month and 3-month follow-up intervals.
| Conclusion|| |
Dentists must be aware of different types and conditions of supernumerary teeth. Moreover, appropriate and timely diagnosis and the management of supernumerary teeth are of considerable importance. Vague and diffuse orofacial pain extending to the temporomandibular and auricular area may be associated with impacted mandibular teeth. Hence, the extraction of these impacted teeth may lead to the alleviation of the pain.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]