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 Table of Contents  
Year : 2016  |  Volume : 5  |  Issue : 1  |  Page : 43-45

Rare presentation of accessory tubercles on permanent maxillary second molar

1 Department of Oral and Maxillofacial Surgery, Subharti Dental College and Hospital, Meerut, Uttar Pradesh, India
2 Department of Periodontology, Subharti Dental College and Hospital, Meerut, Uttar Pradesh, India

Date of Web Publication1-Jul-2016

Correspondence Address:
Dhruvakumar Deepa
Department of Periodontology, Subharti Dental College and Hospital, Meerut - 250 005, Uttar Pradesh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/2277-4696.185187

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Tooth malformations may be related to heredity or injury during formation. Such morphological abnormalities may be found in the crown either in the form of anomalous cusps or in an increased number of roots, which in some cases are associated with an anomalous cusp. Cone-like enlargements on the buccal cusp of maxillary molar is one such anomaly. This case presents the anatomical and morphological characteristics of a rare case of three lobulated tubercles on the buccal surface of permanent maxillary right second molar tooth.

Keywords: Accessory cusps, extra cusp, maxillary second molar, paramolar tubercle

How to cite this article:
Arunkumar KV, Deepa D. Rare presentation of accessory tubercles on permanent maxillary second molar. J Dent Allied Sci 2016;5:43-5

How to cite this URL:
Arunkumar KV, Deepa D. Rare presentation of accessory tubercles on permanent maxillary second molar. J Dent Allied Sci [serial online] 2016 [cited 2023 Jan 30];5:43-5. Available from: https://www.jdas.in/text.asp?2016/5/1/43/185187

  Introduction Top

Variations in the morphological features and forms of teeth are observed in both primary and permanent dentition. Such changes may be found in the crown either in the form of anomalous cusps or in an increased number of roots, which in some instances are associated with an anomalous cusp.[1] The term “paramolar tubercle” has been applied to any stylar anomalous cusp, supernumerary inclusion, or eminence occurring on the buccal surfaces of both upper and lower premolars and molars.[2] The occurrence of paramolar tubercle is relatively uncommon. They usually present unilaterally in the permanent dentition. The occurrence of this structure is very low in upper first molars (0-0.1%) as compared with upper second molars (0.4-2.8%) or upper third molars (0-4.7%) in all the given populations.[3],[4]

Early diagnoses of these cusps are clinically significant since they may be associated with other anomalies and syndromes. Apart from posing difficulties in maintaining the oral hygiene, they may lead to secondary pathology that manifests as pulpitis, periodontitis and periostitis, and other serious consequences.[5]

A rare case of three accessory tubercles on the buccal surface of permanent maxillary right second molar has been presented in this article.

  Case Report Top

A 28-year-old female patient presented to the Department of Periodontology with a chief complaint of inability to maintain the oral hygiene in the maxillary right back teeth region. The patient was systemically healthy, and familial history was non-contributory. On clinical examination, three lobulated tubercles were found on the buccal cusp of the right maxillary second molar tooth. The tubercles and were clearly delineated with a groove. The tips of these accessory cusps were below the occlusal plane, and the buccal aspect of the tubercles was smooth [Figure 1]. Attrition of these tubercles was also evident. Enamel overlying the tubercle was clearly demarcated. There was no caries or periodontal pockets. Intraoral periapical radiograph confirmed the rare occurrence of extra tubercles on a permanent maxillary second molar (on buccal surface) [Figure 2]. Radiograph did not show any evidence of the extension of pulp horns into the tubercles. No abnormality was present on remaining teeth.
Figure 1: Preoperative photograph showing the presence of accessory cusps on maxillary right second molar

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Figure 2: Preoperative intraoral periapical radiograph showing accessory cusps

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After scaling and root planing, the patient was motivated for recontouring of the extra tubercles on the buccal cusp of right maxillary second molar. Full thickness flap was raised under local anesthesia, the extra tubercles on the maxillary second molar were reduced using a carbide bur with copious irrigation to control the heat produced during contouring [Figure 3]. The thickness of enamel was high and hence a thin layer of enamel after trimming the tubercles was available. After the reduction of the tubercles, flaps were closed with sutures [Figure 4]. The patient reported no symptoms of sensitivity. The patient is under follow-up.
Figure 3: Intraoperative photograph showing reduction of crowns and contouring of the crown

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Figure 4: Sutures placed

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  Discussion Top

Accessory cusps on maxillary second molars are relatively rare in occurrence. The exact etiology of extra cusp formation or abnormal shape is unknown. However, previously, it was said that genetically these features are probably due to over activity of the dental lamina. However, now it is believed that the PAX and MSX genes are responsible for the abnormal shape of the teeth.[6] Current embryological evidence suggests that tooth morphogenesis is characterized by transient signaling centers in the epithelium, consisting of epithelial cell clusters that correspond to the initiation of individual cusps.[7],[8]

The accessory tubercles are clinically relevant as they influence the treatment modalities and associated problems in various dental disciplines. These additional tubercles are sites for plaque retention as maintenance of oral hygiene in these areas is difficult, and recurrence of dental caries, gingival inflammation, and localized periodontitis is more often possible. The grooves that separated the tubercles from the teeth may extend onto the root surfaces to various depths resulting in vertical bone loss along the groove. The premature contact and occlusal interferences if any should be removed to prevent habitual posturing of the jaws.

When pulp is present in a paramolar tubercle, the relationship between the pulp of the tubercle and that of the tooth must be determined. When the canal of the tubercle is connected with the main canals then both should be treated at the same time.[9],[10],[11] During orthodontic treatment, additional tubercles interfere with cementation of the brackets and correct alignment of orthodontic arch wires and often necessitates its removal by ameloplasty. These tubercles even pose problem in the preparation of a tooth for the setting of an artificial crown.

In the present case, the accessory cusps were contoured to prevent any further complications associated with this dental anomaly. There was no radiographic evidence of extension of pulp horns into the tubercles. However, the thickness of enamel was high and hence a thin layer of enamel after trimming the tubercles was available. Hence, patient did not report with symptoms of sensitivity after the procedure, and also, there was no requirement of further procedures like root canal treatment followed by prosthesis.

  Conclusion Top

Developmental anomalies of the teeth are clinically evident abnormalities and hence a careful, and thorough examination of the oral cavity and regular monitoring of the attrition, and pulp vitality of the involved tooth are necessary. Early diagnosis of such morphological abnormalities and their correction prevents further caries, periodontal disease, and other consequences.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Kallay J. Extra cusp formation in the human dentition. J Dent Res 1966;45:1381-94.  Back to cited text no. 1
Dahlberg AA. The evolutionary significance of the protostylid. Am J Phys Anthropol 1950;8:15-25.  Back to cited text no. 2
Kustaloglu OA. Paramolar structures of the upper dentition. J Dent Res 1962;41:75-83.  Back to cited text no. 3
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.  Back to cited text no. 4
Kocsis GS, Marcsik A, Kokai EL, Kocsis KS. Supernumerary occlusal cusps on permanent human teeth. Acta Biol Szeged 2002;46:71-82.  Back to cited text no. 5
Sedano HO, Ocampo-Acosta F, Naranjo-Corona RI, Torres-Arellano ME. Multiple dens invaginatus, mulberry molar and conical teeth. Case report and genetic considerations. Med Oral Patol Oral Cir Bucal 2009; 14:E69-72.  Back to cited text no. 6
Jernvall J, Thesleff I. Reiterative signaling and patterning during mammalian tooth morphogenesis. Mech Dev 2000;92:19-29.  Back to cited text no. 7
Weiss KM, Stock DW, Zhao Z. Dynamic interactions and the evolutionary genetics of dental patterning. Crit Rev Oral Biol Med 1998;9:369-98.  Back to cited text no. 8
Ohishi K, Ohishi M, Takahashi A, Kido J, Uemura S, Nagata T. Examination of the roots of paramolar tuberoles with computed tomography. Oral Surg Oral Med Oral Pathol 1999;88:479-83.  Back to cited text no. 9
Thompson BH. Endodontic therapy of an unusual maxillary second molar. J Endod 1988;14:143-6.  Back to cited text no. 10
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.  Back to cited text no. 11


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

This article has been cited by
1 Evaluation of the internal anatomy of paramolar tubercles using cone-beam computed tomography
G. Colakoglu,I. Kaya Buyukbayram,M. A. Elcin,M. Kazak,H. Sezer
Surgical and Radiologic Anatomy. 2019;
[Pubmed] | [DOI]


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