Rare cases 1

UNUSUAL AND
RARE CASES
CASE PRESENTATION & DISCUSSION
DR. OSAMA ALKHALIFA

UNUSUAL ROOT PATTERN
• A primary upper right second molar was
extracted from a 11-year-old male patient due to
extensive caries and severe pain.
• Two years later another primary upper right
second molar was extracted from a 9-year-old
male patient due to extensive caries and chronic
abscess
• It was noticed that both teeth had four well-
defined roots

VARIATION OF PRIMARY UPPER
SECOND MOLAR ROOT PATTERN
{THREE-ROOTED}
BUCCAL ASPECT MESIAL ASPECT
MAJOR M. ASH
DENTAL ANATOMY, PHYSIOLOGY AND OCCLUSION
7TH EDITION 1993

FOUR-ROOTED PRIMARY UPPER
SECOND MOLAR
MD
P

SECOND MOLAR
MB D
BDB

SECOND MOLAR
• A similar root pattern of a primary upper
right second molar has been reported by
Kavanagh and O’sullivan in 1998 and they
assumed that the accessory root is the
mesiopalatal one because it had distinctly
rounded cross sectional profile and may
represent extreme example of bifurcation
which sometimes occur in the mesiobuccal
root

SECOND MOLAR
• Four-rooted upper molar have either a
bifurcated mesiobuccal root or an
accessory palatal root, usually located
mesiopalatally.
Kavanagh, O’sullivan
Int. J. Paed Dent.1998

CASE 2
UNUSUAL ROOT FRACTURE
IN NON-ENDODONTICALLY
TREATED TEETH

IN NON-ENDODONTICALLY TREATED TEETH
• A 74-year-old male patient presented with
a complaint of pain in the upper right
quadrant on taking cold or hot drinks and
foods
• Medical history: Nil relevant.
• Dental history: The patient is reasonable
dental attender and had restorations done
before
• No history of trauma

IN NON-ENDODONTICALLY TREATED TEETH
• Examination revealed generalized attrition
and mild gingival recession
• Radiograph showed horizontal root
fracture of tooth 14

WHAT IS THE CAUSE OF ROOT
FRACTURE IN THIS CASE?

FATIGUE ROOT FRACTURE
Yeh CJ, Br Dent J 1997
 The new term 'fatigue root fracture' is used to describe
a fracture that results from an excessive, repetitive,
heavy masticatory stress applied to a tooth
 root fracture in 51 non-endodontically treated teeth of
46 patients were studied:
• All of the patients had chewing habits which induced a
unique root fracture
• The majority (80%) of cases of this kind of fracture are
vertical and occur mainly (96%) in persons over the
age of 40. In addition, all the teeth affected were
posterior teeth, and the majority (51%) were
mandibular first molars.

Chan CP ET AL, J Endod 1998
 VRFs may result from excessive or repetitive
masticatory force due to damaging chewing habits
 A clinical study was done on 64 cases of VRFs in 61
Chinese patients in teeth without endodontic
treatment:
• Fractures occurred most often in first molars of
patients between 40 and 69 yr of age.
• Fractured teeth were frequently attrited with no
restorations.
• Nonendodontic VRFs seem to occur more frequently
than earlier believed and may represent an
underdiagnosed clinical entity deserving of our
attention.

Borelli, Alibrandi, J Endod. 1999
• One vertical and two horizontal root fractures of teeth
16, 26, and 27 were discovered during a routine full-
mouth radiographic survey . The teeth all tested normal
to cold and electric pulp tests. The patient reported no
history of accidental trauma.
• All teeth were asymptomatic and in good function.
During the 11 yrs that followed, there was no dental
treatment, except for routine periodontal maintenance.
The patient had one abscess that occurred after 9 yrs on
tooth 16, which had to be extracted. The upper left
molars are surprisingly still in function and asymptomatic

Borelli, Alibrandi, J Endod. 1999
• Either occlusal or lateral trauma may be the
cause of these fractures. This would strongly
suggest night guard appliances for patients
who clench or grind. A psychological
evaluation of the patient might reveal neurosis,
anxiety, or stress situations affecting teeth.

CASE 3
UNUSUAL
CONSEQUENCE OF
DENTAL TRAUMA

UNUSUAL CONSEQUENCE OF DENTAL
TRAUMA
• A 34-year-old male patient presented with a
complaint of pain in the upper incisor region on
taking cold and hot drinks and foods
• Medical history: insignificant
• Dental history: the patient is not regular dental
attender and did not receive any treatment
before
• The patient reported history of trauma when he
was 17 years old

UNUSUAL CONSEQUENCE OF DENTAL
TRAUMA
• Examination revealed presence of caries
on teeth 11 and 12 with yellowish
discolouration of tooth 11 which proved to
be vital and slightly tender to percussion

WHAT IS THE DIAGNOSIS OF
THIS CASE?

CALCIFIC METAMORPHOSIS
• Calcific metamorphosis is characterized by
deposition of hard tissue within the root
canal space and yellow discoloration of
the clinical crown
Amir, Gutmann, Witherspoon
Quintessence Int. 2001

Approximately 3.8% to 24% of traumatized teeth
develop varying degrees of CM. Studies indicate
that of these, approximately 1% to 16% will
develop pulpal necrosis

• Opinion differs among practitioners as to
whether to treat these cases upon early
detection of CM or to observe them until
symptoms or radiographic signs of pulpal
necrosis are detected.

• Most of the literature does not support
endodontic intervention unless
periradicular pathosis is detected or
the involved tooth becomes
symptomatic

• Obliteration of the pulp canal space may
make root canal treatment necessary
because of the development of apical
periodontitis or for cosmetic reasons
Cleen M,

CASE 4
UNUSUAL CASE OF
JOINED PRIMARY
TEETH

UNUSUAL CASE OF JOINED PRIMARY
TEETH
• A 10-year-old male presented with pain on tooth 84.
• Examination showed extensive caries on tooth 84 and
moderate mobility of both teeth 84 and 83
• His medical and dental histories were unremarkable
• Extraction was started with tooth 84, and it was
noticed that the tooth 83 is also moving, and the two
teeth were removed together, and found to be joined
with the remaining parts of their roots

FUSED PRIMARY CANINE AND FIRST MOLAR
(CONCRESCENCE)
Lingual aspect
Buccal aspect

CONCRESCENCE
• Concrescence is a form of fusion in
which the union is in the cementum
alone without confluence of the
underlying dentin
Killian
Quint Int 1990

CONCRESCENCE
• Concrescence is a twinning anomaly
involving the union of two teeth by
cementum only
Cassamasimo
Pediatric densitry. 3rd edn 1999

CONCRESCENCE
• Concrescence represents a rare
developmental anomaly in which two
fully formed teeth are joined along the
root surfaces by cementum
Gunduz
BDJ 2006

JOINED PRIMARY TEETH
• Fusion is more common than gemination
• More frequent in the mandibular than in
the maxillary arch
• Mainly located in the anterior region
• Usually unilateral
• About half of cases are followed by
anomalies of permanent successors

PREVALANCE OF JOINED PRIMARY TEETH
country Year Sample
size
age prevalence
Finland 1980
Jarvinen
1141 3 - 4 yrs 0.7%
Iceland 1984
Magnusson
927 3 - 4 0.7%
Croatia 1991
Skrinjaric
2987 3 - 6 yrs 0.34%
Japan 1997
Yonezu
2733 3 yrs 4.15%
China 2003
Chenq
4286 2 - 6 yrs 1.52%

Skrinjaric
Acta Stomatol Croat. 1991
• Fusion occurred in 66.7 percent and
germination in 33.3 percent in the sample
of children having double teeth.
• Analysis of radiographs revealed
anomalies of permanent successors in
53.3 percent of all children with double
primary teeth

Yonezu
Bull Tokyo Dent Coll. 1997
• All the fused teeth were located in the anterior region
and were more frequent in the mandibular than in the
maxillary arch
• Fused teeth were more common in boys than girls
• The prevalence of fused teeth and congenital missing
teeth were significantly higher in this study than in
studies of American and Scandinavian children. These
two anomalies are tending to increase in frequency in
Japan

Chenq
Shanghai Kou Qiang Yi Xue. 2003
• The fused teeth typically occurred unilaterally
(68.75 percent) and mainly located in the
anterior region, more frequently in the
mandibular (91.25 percent) than that in the
maxillary arch without sex predilection

Razak
Ann Acad Med Singapore 1986
• The study was carried out on 20 subjects with evidence of double
teeth, which included gemination and fusion, in the primary dentition.
The age of the subjects ranged from 2 1/2 to 9 years
• double teeth occurred more frequently in the males and that fusion
was much more prevalent than gemination
• About 79 percent of the occurrence was seen in the mandibular arch
• A high proportion of fusion was found to involve the lateral incisors
and canines
• In 50 percent of the occurrence, hypodontia of the permanent
dentition was observed, all of which involved the lateral incisors

CASE 5
UNUSUAL CASE OF
HYPODONTIA

UNUSUAL CASE OF HYPODONTIA
• A 9-year-old male presented with pain and
swelling related to infected tooth 36
• It was noticed during examination that both
primary lower central incisors were retained
• Radiological examination revealed congenital
absence of permanent successors
• His medical and dental histories were
unremarkable

HYPODONTIA
• Hypodontia is a condition in which teeth
are developmentally absent.
• The prevalence in the permanent dentition
is reported to be between 1.5% to 10.5%.
Kuang-Wei Hsu, Yu-Fu Shen
Chang Gung Med J 2004

HYPODONTIA
• Oligodontia = severe hypodontia
• Syndromic and non-syndromic
• More common in permanent teeth
• Most commonly missing teeth mandibular
2nd premolar and maxillary lateral incisor
• Mostly unilateral
• Higher prevalence among females

Prevalence of hypodontia in the permanent dentition in different countries
Trevor J Pemberton, Braz J Oral Sci. 2005
Country / year Tooth most frequently missing Prevalence
Saudi Arabia / 1994 Lower second premolar 2.5%
Norway / 2002 Lower second premolar 4.5%
Australia / 1990 Lower second premolar 6.3%
Kenya / 2001 Lower second premolar 6.3%
Sweden / 2001 Lower second premolar 7.4%
Iceland / 1977 Lower second premolar 7.9%
Malaysia / 1989 Upper lateral incisor 2.8%
N. America / 2004 Upper second premolar 3.9%
China / 1993 Lower central incisor 6.9%

TREATMENT PLAN
Treatment plan is influenced by:
• The shape and length of the root
• The position and integrity of the clinical crown
• The periodontal condition and the mobility of
the retained tooth
• Patient preference
• Specialist availability
Kuang-Wei Hsu, Yu-Fu Shen
Chang Gung Med J 2004

TREATMENT PLAN
Options:
• Extraction
i. Close the space orthodontically
ii. Fixed or removable prosthesis
• Full crown coverage
• Composite resin and porcelain veneers

CASE 6
UNUSUAL CASE OF
DENTOALVEOLAR
TRAUMA

SEVERELY INTRUDED PERMANENT
MAXILLARY RIGHT CENTRAL INCISOR
• A 13-year-old healthy male was brought 15
minutes after a fall at home which has
resulted in:
• A 13 mm intrusion of tooth 11 with
Complicated crown fracture
• Fracture of labial plate of alveolar bone
• Severe gingival laceration

18 mm

LUXATION
There are five subcategories of this type of
injury:
• Concussion: The tooth is sensitive to
percussion but has not been displaced and is
not abnormally mobile.
• Subluxation: The tooth has increased mobility
but has not been displaced. (A)
• Lateral luxation: The tooth has been
displaced and may be very firm. (C)
• Extrusive luxation: The tooth is very mobile
because of partial displacement out of the
socket. (B)
• Intrusive luxation: The tooth has been forced
apically and is firmly embedded in bone. (D)
Application of the international classification of
diseases and stomatology 3rd ed. Geneva:
World Health Organization; 1992

TREATMENT OF TRAUMATICALLY INTRUDED PERMANENT
INCISOR TEETH IN CHILDREN
GUIDELINES OF THE ROYAL COLLEGE OF SURGEONS OF ENGLAND 1997
• Repositioning of teeth with
incomplete apex
1. Mildly intruded (less than 3mm)
 Leave to re-erupt.
2. Moderately intruded (3-6mm)
 Orthodontic repositioning in approximately 2
weeks.
3. Severely intruded (greater than 6mm)
 Surgical repositioning.

TREATMENT OF TRAUMATICALLY INTRUDED PERMANENT
INCISOR TEETH IN CHILDREN
GUIDELINES OF THE ROYAL COLLEGE OF SURGEONS OF ENGLAND 1997
Repositioning of teeth with complete Apex
1. Mildly intruded (less than 3mm)
 Orthodontic repositioning in approximately 2 weeks.
2. Moderately intruded (3-6mm)
 Orthodontic repositioning in approximately 2 weeks.
3. Severely intruded (greater than 6mm)
 Surgical repositioning.

• The tooth was
immediately
repositioned, soft
tissue wound
sutured and tooth
splinted with
composite
5 mm

• The patient was prescribed amoxycillin
250 mg 6 hourly, metronidazole 250 mg
three times daily for 5 days and then
tetracycline HCL 250 mg for more 5 days.
Also analgesic and chlorhexidine
mouthwash were prescribed.
• The patient was advised to maintain good
oral hygiene.

• 6 days later pulp was
extirpated and calcium
hydroxide paste placed
in the canal and access
cavity closed with glass
ionomer

Splint was removed after 4 weeks

AFTER 2 MONTHS

• Definitive root canal
treatment was
accomplished after
two months and one
week later a post
was inserted in the
canal and the crown
built up with
composite

IMMEDIATELY AFTER FINISHING TREATMENT

At 6 months the followings were noted:
• Gingival retraction
• Decreased tooth mobility
• High-pitched sound on percussion
• No infraocclusion
• Radiographically absence of PDL space
was seen

6 MONTHS AFTER FINISHING TREATMENT

At 12months the followings were noted:
• Gingival retraction
• Decreased tooth mobility
• High-pitched sound on percussion
• Infraocclusion
• Radiographically absence of PDL space
was seen

12 MONTHS AFTER FINISHING TREATMENT

RADIOGRAPHIC CHANGES
1 week
2 months
6 months
12 months

Rare cases 1

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