|Year : 2016 | Volume
| Issue : 1 | Page : 53-56
Endodontic management of maxillary second molar with fused paramolar tubercle and two palatal roots: An unusual case report
Bhuvan Shome Venigalla1, Radhika Venigalla2, Pinnamreddy Jyothi1, Prathibha Mudalapuram1
1 Department of Conservative Dentistry and Endodontics, Sri Sai College of Dental Surgery, Vikarabad, India
2 Dental Surgeon, Jewel Dental Clinic, Hyderabad, Telangana, India
|Date of Web Publication||21-Jun-2016|
Bhuvan Shome Venigalla
Turquoise 1210, My Home Jewel, Madinaguda, Hyderabad, Telangana
Source of Support: None, Conflict of Interest: None
Morphological variations are frequently observed in the crown as well as in the roots of maxillary molars. One such diversity is the prescence of a supernumerary cusp termed as "paramolar tubercle." The clinician must have a thorough knowledge of the external as well as internal tooth morphology and novel diagnostic aids like cone-beam computed tomography aids in the successful management of these cases. This case report describes the successful diagnosis and treatment of a four-rooted maxillary second molar with paramolar tubercle and five root canals. The maxillary second molar tooth had two palatal roots with individual canals in addition to the extra canal of tubercle. This combination is very rare and first of its kind to be reported in the literature.
Keywords: Cone beam computed tomography; maxillary second molar; paramolar tubercle; supernumerary cusp; two palatal roots.
|How to cite this article:|
Venigalla BS, Venigalla R, Jyothi P, Mudalapuram P. Endodontic management of maxillary second molar with fused paramolar tubercle and two palatal roots: An unusual case report. Endodontology 2016;28:53-6
|How to cite this URL:|
Venigalla BS, Venigalla R, Jyothi P, Mudalapuram P. Endodontic management of maxillary second molar with fused paramolar tubercle and two palatal roots: An unusual case report. Endodontology [serial online] 2016 [cited 2020 Sep 19];28:53-6. Available from: http://www.endodontologyonweb.org/text.asp?2016/28/1/53/184342
| Introduction|| |
Morphological variations such as anomalous cusps or roots can be found in deciduous as well as permanent dentition. Paramolar tubercle, first described by Prof. Bolk, refers to the supernumerary cusp on the buccal surface of upper and lower premolars and molars.  Dahlberg referred it as "parastyle" when seen on the buccal surface of upper molars and "protostylid" when seen on lower molars. , Parastyle is considered as a derivative of cingulum and due to wide variability in its delineation from a furrow or groove to various stages of cusp formation, it is referred to as upper paramolar structure or complex. Its incidence ranges from 0% to 0.1%, 0.4% to 2.8%, and 0% to 4.7% in first, second, and third maxillary molars, respectively. 
Maxillary second molars generally have two buccal roots and one palatal root.  In a retrospective study by Peikoff et al., two palatal roots were observed in 1.4% of maxillary second molars.  The maxillary second molar reported in this article presented a paramolar tubercle in addition to two palatal roots, i.e., a combination of two rare traits and had not been reported in the literature.
| Case Report|| |
A 33-year-old female patient of South Western Indian origin walked into our clinic with the chief complaint of spontaneous pain in the upper right molar region for the past 2 days. Clinical examination revealed no visual signs of caries on maxillary right first and second molars. The maxillary second molar was wider buccopalatally and exhibited unusual crown morphology with a paramolar tubercle attached on the mesiobuccal (MB) aspect. Both the molars showed an exaggerated response to thermal and electric pulp tests and were tender on percussion. Radiological observation showed periapical radiolucency in relation to palatal root of first molar and widening of periodontal ligament space in relation to second molar. A final diagnosis of acute irreversible pulpitis with apical periodontitis was made in relation to both maxillary right first and second molars. A two visit root canal therapy was planned followed by isolation with cotton rolls, saliva ejectors, and throat pack since rubber dam placement was not possible. Local anesthetic was administered, access cavities were prepared on both molars and separate access was done for paramolar tubercle. Three canals were located in first molar, namely, MB, distobuccal (DB) and palatal (P), whereas, in second molar, two buccal canals and two palatal canals were negotiated using the International Organization for Standardization #10 K file, namely, MB, DB, mesiopalatal (MP), distopalatal (DP), and a separate canal was located in the fused paramolar tubercle of second molar[Figure 1]a.
Canal orifices were enlarged using Protaper SX (Dentsply). Working length of both the molars was estimated using intraoral periapical radiograph and verified with an apex locator (Root ZX, J Morita Inc., USA). The instruments placed in MB canal and orifice of tubercle met midway suggesting a fusion of canals. All the canals were cleaned and shaped using Protaper Universal rotary files (Dentsply) till F2 in buccal canals and F3 in palatal canals under 3% NaOCl irrigation. Additional debridement of the communication between canals was carried out using EndoActivator (Dentsply). Calcium hydroxide intracanal medicament was then placed inside the canals and access cavity was sealed with Cavit. Patient was referred for a cone-beam computed tomography (CBCT) examination (Kodak Care stream Dental, US) which clearly showed the presence of four individual roots MB, DB, MP, and DP. The fifth canal from paramolar tubercle merged with MB canal in middle third [Figure 2]a and b.
|Figure 1: Clinical images of maxillary right first and second molars: (a) Maxillary second molar with five canals, red arrow pointing orifice of extra canal of paramolar tubercle; (b) postendodontic restoration; (c) tooth preparation for porcelain-fused-to-metal crown|
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|Figure 2: Cone beam computed tomography images showing the presence of four roots in maxillary second molar (a). White arrows pointing towards two palatal canals and red arrow showing fusion between mesiobuccal canal and canal of paramolar tubercle (b)|
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On recall after a week, intracanal medicament was completely removed from the root canals. Appropriate master cones were selected and obturation of both the teeth was done using corresponding Protaper GP points and AH Plus sealer (Dentsply) [Figure 3]a. Access cavities of first and second molars were sealed with miracle mix (GC Corporation, Japan) and posterior composite (Filtek P60, 3M ESPE) respectively [Figure 1]bTooth preparation for the porcelain-fused-to-metal (PFM) crown was done for both the molars on recall visit after 10 days [Figure 1]c and PFM crowns were cemented in the subsequent appointment. Eighteen months follow-up radiograph revealed the healthy status of periapical tissues [Figure 3]b.
|Figure 3: (a) Postobturation radiograph, (b) 18 months follow-up radiograph|
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| Discussion|| |
The etiology of paramolar tubercles is considered to be multifactorial. Local metabolic interferences, genetic predisposition as well as traumatic incidents occurred during morphodifferentiation of tooth germ may be responsible for the development of a paramolar tubercle.
Enamel knots are the sites of nondividing cells that occur in stellate reticulum.  Recent work in molecular biology revealed that primary enamel knot configures the morphology of occlusal table of premolars and molars and secondary enamel knots constitute the cusps during amelogenesis. Paramolar tubercle is known to develop from an accessory enamel knot developed during this process. , The varied clinical presentation of parastyle is best described by a classification developed by Joseph F Katich and Turner (1974) according to which the present case can be graded as Grade 4 (large cusp present with free apex anywhere on the buccal surface).  A high incidence of paramolar tubercle was seen in South Western Indians both in deciduous as well as permanent dentition compared to other populations.  Thus, it may aid in the forensic investigation when required and is also of value in phylogenetic studies.  There was also a tendency for bilateral occurrence in deciduous dentition in contrast to the unilateral occurrence in permanent dentition as seen in this case.  Nagaveni et al. who conducted a study on the prevalence of paramolar tubercle in primary molars of Indian children reported the very rare occurrence of this trait with preponderance toward the right side.  Ooshima et al. studied the paramolar tubercle prevalence in Japanese children and reported the condition in 2.5% of primary and 1.6% of permanent dentition with no sex difference in both the dentitions. It was mostly seen on a maxillary second molar in permanent dentition and on a maxillary first molar in primary dentition.  Similar findings were observed in a paramolar tubercle case series in North Indian population reported by Desai et al. with high incidence on maxillary second molars, no significant difference in sex predilection and preponderance toward the right side.  There are little data available regarding racial differences, frequency, sexual predominance as well as size and pattern of paramolar tubercle because of their overall very low incidence, therefore, prevalence studies, as well as pedigree analysis, are recommended in this area.  The case reported in this article showed a very rare combination of paramolar tubercle and two palatal roots in a maxillary second molar. Curzon stated that extra rooted molar condition also has high genetic predisposition. 
Paramolar tubercle exhibits wide variability in morphological expression both regarding the crown as well as the root. ,, Bolk reported that paramolar tubercles in maxillary molars generally possess a fused root, whereas mandibular molars tend to possess their own roots. He also stated that paramolar tubercles in maxillary molars mostly unite with the mesio buccal cusp and its roots are mostly fused with the mesio buccal root as observed in the present case.  The huge array of diversity in the crown morphology and root canal anatomy of paramolar tubercles necessitates the need for further research.
The incidence of paramolar tubercle with an additional root canal necessitates the determination of its relationship with the main canal. Periapical radiographs may not clearly reveal the internal anatomy of paramolar tubercle as it superimposes on the normal tooth and in such cases, CBCT may be a useful diagnostic tool.  Effective debridement also becomes critical in these cases due to abnormal communications between canals, so EndoActivator was used in the present case. 
| Conclusion|| |
Prescence of paramolar tubercles demand alteration in the treatment modalities within various disciplines of clinical practice. They may act as potential plaque retention areas and may lead to dental caries as well as periodontal problems making its identification and proper management important. Prophylactic measures such as obliterating the groove by placing pit and fissure sealants may prevent future damage. These tubercles may also interfere with orthodontic treatment necessitating their removal by ameloplasty. They also exhibit a lot of variations in canal configuration; therefore, knowledge of its internal anatomy is very important when such cases require endodontic treatment.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Bolk L. Problems of human dentition. Am J Anat 1916;19:91-148.
Dahlberg AA. The paramolar tubercle (Bolk). Am J Phys Anthropol 1945;3:97-103.
Ooshima T, Ishida R, Mishima K, Sobue S. The prevalence of developmental anomalies of teeth and their association with tooth size in the primary and permanent dentitions of 1650 Japanese children. Int J Paediatr Dent 1996;6:87-94.
Kustaloglu OA. Paramolar structures of the upper dentition. J Dent Res 1962;41:75-83.
Magalee RE, Kramer S. The paramolar tubercle: A morphological anomaly with clinical considerations. N Y State Dent J 1984;50:564-6.
Peikoff MD, Christie WH, Fogel HM. The maxillary second molar: Variations in the number of roots and canals. Int Endod J 1996;29:365-9.
Jernvall J, Kettunen P, Karavanova I, Martin LB, Thesleff I. Evidence for the role of the enamel knot as a control center in mammalian tooth cusp formation: Non-dividing cells express growth stimulating Fgf-4 gene. Int J Dev Biol 1994;38:463-9.
Thesleff I, Keränen S, Jernvall J. Enamel knots as signaling centers linking tooth morphogenesis and odontoblast differentiation. Adv Dent Res 2001;15:14-8.
Ballal S, Sachdeva GS, Kandaswamy D. Endodontic management of a fused mandibular second molar and paramolar with the aid of spiral computed tomography: A case report. J Endod 2007;33:1247-51.
Scott GR, Turner CG 2 nd
. Description and classification of permanent crown and root traits. In: The Anthropology of Modern Human Teeth- Dental Morphology and its Variation in Recent Human Populations. 1 st
ed. Cambridge: Cambridge University Press; 1997. p. 15-69.
Omal PM, Philipose L, Mathew AL, Nair S, Varghese AK, Babu SS, et al
. Parastyle in a permanent maxillary first molar tooth: A rare entity. J Indian Acad Oral Med Radiol 2013;25:137-40.
Nagaveni NB, Umashankara KV, Poornima P, Reddy VS. Paramolar tubercle (parastyle) in primary molars of Davangere (India) children: A retrospective study. Int J Oral Health Sci 2014;4 (1):18.
Desai VD, Gaurav I, Das S, Kumar MS. Paramolar complex-the microdental variations: Case series with review of literature. Ann Bioanthropol 2014;2:65.
Rodríguez C, Moreno F. Paramolar tubercle in the left maxillary second premolar: A case report. Dent Anthropol 2006;19:65-9.
Patel S, Dawood A, Ford TP, Whaites E. The potential applications of cone beam computed tomography in the management of endodontic problems. Int Endod J 2007;40:818-30.
Ohishi K, Ohishi M, Takahashi A, Kido J, Uemura S, Nagata T. Examination of the roots of paramolar tubercles with computed tomography: Report of 3 cases. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1999;88:479-83.
Nayak G, Shetty S, Singh I. Paramolar tubercle: A diversity in canal configuration identified with the aid of spiral computed tomography. Eur J Dent 2013;7:139-44.
Curzon ME. Miscegenation and the prevalence of three-rooted mandibular first molars in the Baffin Eskimo. Community Dent Oral Epidemiol 1974;2:130-1.
Castagnola R, Lajolo C, Minciacchi I, Cretella G, Foti R, Marigo L, et al
. Efficacy of three different irrigation techniques in the removal of smear layer and organic debris from root canal wall: A scanning electron microscope study. G Ital Endod 2014;28:79-86.
Halkai K, Halkai R, Chaudary TM. Endodontic management of maxillary first molar with two palatal canals and two mesiobuccal canals diagnosed with the aid of spiral computed tomography - A case report. Endodontology 2013;1:115-20.
[Figure 1], [Figure 2], [Figure 3]