Paramolar concrescence and periodontitis
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
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
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
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.
This excision led to a large defect on the buccal aspect of #47, which was subsequently filled with bone graft. 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. A permanent restoration was planned and a stainless crown was fabricated and cemented on #47.
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.
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. In addition, a normal amount of cementum involved in the concrescence may also contribute to an inaccurate diagnosis.
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.
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