Paramolar concrescence and periodontitis.

Concrescence is a developmental anomaly of dental hard tissues. It is a condition showing union of adjacent teeth by cementum. The concrescence leads to a loss of gingival architecture leading to the development of funnels, which may cause plaque accumulation thus, resulting in periodontal tissue destruction. There is a slight predilection for the mandible especially in the premolar area followed by the molar and anterior regions. Awareness of these developmental disturbances with proper diagnosis and treatment is very essential because it can compromise the periodontal attachment and can lead to the tooth loss. This article highlights the presence of a concrescence between mandibular second molar and the supernumerary fused teeth with their clinical and radiographic findings, along with its management.

INTRODUCTION

Supernumerary teeth may be defined as any teeth or tooth substance in excess of the usual configuration of 20 deciduous, and 32 permanent teeth.[1] Such a surplus can also be accompanied by a deficit of other teeth. Supernumerary teeth may occur singly, multiply, unilaterally or bilaterally, and in one or both jaws.[2] Rajab and Hamdan reported in their study that males were more affected than were females, the sex ratio being 2.2:1. Mitchell reported a 2:1 ratio in favor of males. Hongstrum and Anderson and Brook also reported a 2:1 ratio of sex distribution, whereas Luten found a sex distribution of 1.3:1.

The occurrence of multiple supernumerary teeth without any associated systemic conditions or syndromes; however, is a rare phenomenon. Single supernumeraries occur in 76-86% of cases, double supernumeraries in 12-23% of cases, and multiple supernumeraries in less than 1% of cases[25] Tooth fusion is the result of the union of two distinct dental entities that occurs at any stage of dental organ development. This process involves epithelial and mesenchymal germ layers resulting in irregular tooth morphology Rajendran, 2006. The teeth may be fused with dentine or cementum, the latter case being called as concrescence.

Concrescence of teeth is actually a form of fusion which occurs after root formation has been completed. In this condition, teeth are united by cementum only and is thought to arise as a result of traumatic injury or crowding of teeth with resorption of the interdental bone so that the two roots/supernumerary teeth are in approximate contact and become fused by the deposition of cementum between them.[3] The concrescence leads to a loss of gingival architecture leading to the development of funnels which may cause plaque accumulation thus, resulting in periodontal tissue destruction.

Most fusions between a molar and a supernumerary tooth require surgical removal due to the abnormal morphology and excessive mesiodistal width that causes problems with crowding, alignment and occlusal function. These teeth are also predisposed to caries and periodontal disease.

This article highlights the presence of a concrescence between mandibular second molar and a supernumerary tooth, with its clinical and radiographic findings and a multidisciplinary approach required for its management.

CASE REPORT

A male patient aged about 30 years reported to Department of Periodontics, Sri Siddhartha Dental College, and Tumkur with a chief complaint of swelling in the lower right back teeth region and discharge. A thorough medical history was taken and was found to be negative. The patient had taken antibiotics.

Clinical examination revealed the presence of an irregular morphology of the permanent mandibular second molars. The morphology suggested the presence of a concrescence of a supernumerary cusp with mesio-buccal cusp of right mandibular second molar #47 [Figures 1 and 2].

Figure 1

Paramolar occlusal view showing extra cusp in relation to #47

Figure 2

Paramolar occlusal view [Close -up] showing extra cusp in relation to #47

In addition, increased mesio-distal crown width and distinct developmental occluso-gingival grooves on the labial and lingual surfaces were noticed. The remaining maxillary and mandibular permanent teeth were normal in shape.

The gingiva around #47 appeared to be reddish in color, with the loss of stippling and inflamed. The fusion lead to the groove formation, which favored plaque accumulation. A deep pocket was seen in relation to the buccal aspect of #47 [Figure 3].

Figure 3

Probing pocket depth as measured with a University of North Carolina-PCP 15 probe

Radiographic examination showed the union of a supernumerary tooth with the second permanent molar, suggesting bilateral fusion and the presence of an extensive periradicular lesion associated only with #47 [Figure 4].

Figure 4

Pre-operative radiograph showing periapical radiolucency in relation to #47

The case was diagnosed to be of a cemental fusion of a supernumerary paramolar with mesio-buccal cusp of permanent molar, which resulted in loss of gingival architecture thus, creating funnels for accumulation of plaque. The tooth was vital so treatment was solely aimed at elimination of the local plaque retentive factor and regenerating the lost periodontium by bone graft.

The treatment plan was devised. The abscess was drained and a thorough scaling and root planing was performed. This was followed by the root canal treatment. The patient was re-evaluated at 3 and 6 months so as to check for the periapical radiolucency. After the radiolucency had subsided, resection of the tooth was carried out under local anesthesia. A full thickness flap was reflected, and the extra cusp was eliminated using a bur and hand piece [Figure 5].

Figure 5

A full thickness mucoperiosteal flap reflected

This excision led to a large defect on the buccal aspect of #47, which was subsequently filled with bone graft [Figure 6]. The flap was sutured using the black braided silk suture and a non-eugenol periodontal pack (Coe pack) was given. After 10 days, the sutures were removed. Post-operatively the patient did not complain of any discomfort with the tooth and the healing was satisfactory. The patient at 6 month recall showed significant reductions in probing pocket depth [Figure 7]. A permanent restoration was planned and a stainless crown was fabricated and cemented on #47 [Figure 8].

Figure 6

Post resection with bone graft

Figure 7

Post-operative probing depth at 3 month recall

Figure 8

Permanent restoration fabricated and cemented

DISCUSSION

The terminology dental fusion and concrescence are used to define two different morphological dental anomalies, characterized by the formation of a clinically wide tooth. Despite the considerable number of cases reported in the literature, the differential diagnosis between these abnormalities is difficult.[4] Case history and clinical and radiographic examinations can provide the information required for the diagnosis of such abnormalities. After a judicious evaluation of all information, we can report that this case represents concrescence of right second mandibular molars with supernumerary teeth.

Concrescence is clinically nearly impossible to be detected. Due to lack of enamel involvement, the crowns of the affected teeth, if erupted, appear normal. Concrescence may defy radiographic detection as well; they may be misdiagnosed as simple radiographic overlap or superimposition of teeth.[5] In addition, a normal amount of cementum involved in the concrescence may also contribute to an inaccurate diagnosis. A diagnostic consideration; however, not a rule is that supernumerary teeth are often slightly aberrant and present a cone shaped clinical appearance. Thus, fusion between a supernumerary tooth and a normal tooth will generally show the difference in the two halves of the crown.[6]

This case of concrescence between supernumerary paramolar and the permanent molar is very rare and to our knowledge there are only few cases reported in the periodontal literature where concrescence is one of the local etiologic factors for localized periodontal destruction. In cases of fusion, the factors to be considered in detail before planning the treatment is the presence of normal complement of teeth, level of separation of fusion of tooth, depth and extent of caries, level of co-operation/motivation of the patient and in children, age of the patient.[7]

The morphology of fused teeth is so varied that can only outline possibilities. If normal complements of teeth are present and fusion does not extend apically, sectioning can be attempted. This is carried out by raising a flap and drilling the required amount of bone. While sectioning, cutting should be carried out, naturally at the expense of the tooth to be removed. Subsequent recontouring of the retained root may also be carried out at the same time to forestall periodontal complication. Bone removal should be minimal so as not to compromise the attachment apparatus of the retained root. The iatrogenic defect due to section can be treated orthodontically by moving the tooth into the defect. If typically a tooth is missing the option of recontouring the tooth with composites or by crowns will be needed for esthetics. In cases of third molars then best treatment is extraction.

The present case was of cemental fusion of a supernumerary paramolar with the mesiobuccal cusp of permanent molar. A multidisciplinary approach was needed to eliminate the tooth anomaly along with successful restoration of the tooth function.

CONCLUSION

It is extremely imperative for us as clinicians that we do all we can to save the teeth which are vitally placed in the dental arch. Different cases require a variety of knowledge about alternative operative techniques and abilities. A multidisciplinary approach with different practitioners working together can contribute to the success of the treatment plan.