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Fourth molars in the maxilla and mandible
EXODONTIA .
.
.
.
FOURTH Henry
.
.
MOLARS
R. Mittelman,
.
.
.
.
.
.
.
IN THE MAXILLA D.D.S., MS.,*
.
.
.
.
.
.
.
.
.
.
.
AND MANDIBLE
and M. Poliak,
D.D.S., Chicago, Ill.
T
HE recognition of irregularities in human dentition has become commonplace, especially since oral roentgenographic examinations have been used routinely. The presence of supernumerary teeth is not uncommon, but the occurrence of four fourth molars is rare. 6pI1 Most supernumerary teeth show only rudimentary development and are small in size, but occasionally teeth of from normal size and structure are found. *s 3~lo, I1 Whether this proliferation the dental lamina is a genetic anomaly is not known,” 2~5l lo as no further evidence is available. Thoma,2f l1 Shafer and associates,4 and Shiras recommend the early removal of such supernumerary teeth. Early surgical treatment, as a rule, involves less trauma and eliminates possible future complications. Of course, by proper evaluation of the roentgenograms, it is possible for the surgeon to be alerted to any probable complication. These may arise from the position of the tooth in relation to other areas or structures, such as the infeorior alveolar artery and nerve. Other hazards are excessive hemorrhage or infection, jaw fracture, paralysis or anesthesia due to nerve involvement, or perforation into the pterygomaxillary space, the maxillary sinus, and the orbit. CASE
REPORT
Patient N. B., aged 20 years, was referred after a routine oral roentgenographic examination had revealed the presence of four fourth molars in addition to the normal complement of thirty-two teeth (Fig. 1). The fourth molars were impacted in both the maxilla and the mandible. The position of both mandibular third molars was slightly mesioangular and low, with the mesial cusps at the level of the cementoenamel junction of the second molars. The fourth molars in the mandible were positioned horizontally in the retromolar area of the ramus, above the oeelusal plane of the teeth. The right maxillary third molar was in a slightly distoangular position, and the supernumerary tooth was high above in the tuberosity, almost at a level with the floor of the orbit.7 The left maxillary third molar was in an extreme distoangular position, with the fourth molar lying on the distal convex surface of the impacted third molar crown in a bucco-mesio-angular relationship. *Adjunct Attending Oral Surgeon, Mt. Surgeon, American Hospital, Chicago, Ill.
Sinai 1297
Hospital,
Chicago,
Ill.,
and
Attending
Oral
tubcrosity Fig. I.--Bilateral third and fourth molars. A, Right maxillary molar in slightly distoangular position and fourth molar high in the tubcrositllevel than the left molar. Note close contact with the sinus.
v-ith
thircl
at x lowr~t~
Prom a diagnostic standpoint, the roentgenograms indicated that great dare must 1~ exercised in the surgical removal of these teeth, especially in the case of the maxillary fourth molars which were positioned close to the floor of the orbit. \Ve decided to remove the mandibular third and fourth molars bilaterally, operating on each side in a separate session, and in the maxilla to remove only the third molars. If the fourth molars were positioned as high as the roentgenograms indicated and not readily seen during the surgical procedure, their removal could be postponed in the hop that they would move down into a more favorable position later. The procedure was undertaken under local anesthesia with a block of the inferior alveolar and long buccal nerves. For t,he removal of the third and fourth molars in the left mandible, an incision wan made in the retromolar area with the cut extending high up along the ramus, and the tissues were reflected. The bone was exposed and, after a cut had been bone was excised, the follicular sac made bucco-occlusally with a bur, the thin overlying was dissected, and the teeth, appearing to be of normal size and shape, were removed. The area was d6brided until free bleeding occurred. Gelfoam was placed, tetracycline was sprayed over the area, and the tissues were re-apposrd after a small iodoform gauze drain had been placed into the wound. The wound was closed with 3-O black silk. There was no postoperative pain, very little swelling, and no hematoma or ecchymosis. The drain wtts removed after 48 hours; recovery was uneventful (Fig. 2). Postoperatively. aspirin was the only drug prescribed.
Volume 16 Number 11
FOURTH
MOLARS
IN
Fig. 2. Fig. 2.-Postoperatire roentgenogram surgical procedure. Fig. I.-Postoperative roentgenogram surgical procedure.
Figs.
4 and
Fig. 4. S.-Roentgenograms
Fig. B.-Immediate
taken
MAXlLLA
of of
the
AND
left
mandibular
the right
mandibular
si$ bTm&hs
1299
MANDIBLE
PostoPeratively,
Fig. 3. site immediately site
immediately
Fig. 5. showing
postoperative view of the upper right third molar area, showing ing fourth molar high in the tuberosity.
good
after after
healing
the remain-
More than a month later the same procedure was carried out on the right side (Fig. 3). Both the third and fourth molars were removed. Again, recovery and healing were uneventful. Postoperative roentgenograms, taken after 6 months, showed satisfactory healing (Figs. 4 and 5).
Becauseof school programming, it Bay necessary to delay tim removal I)~ tlu: nmxillar~ teeth until vacation time. The right maxillary third molar \I’as rcwlovc~~l :lft<.r t llc, usual tuberosity incision, and the fourth molar sac was visualized. Its position was such that it \sas deemed safer to allow the tooth to move caudally by natural forces (Fig. ti), since t,lu: hazards of orbital and sinus involvement were considered tuo csritical at this time. l’ostoperatively, Empirin compound with codeine was prescribed. No swelling or ccchymosis was apparent. The left upper third molar and probably the left upper fourth molar will be removed in a few weeks. DISCUSSIOX
The foregoing case illustrates an unusual proliferation of the dental lamina with the development of four fourth molars, a phenomenon not, frequently I’(‘ported in the literature.G This case has shown the desirability of good planning and conservatism in surgical treatment. I believe, us do others, that early surgical removal of such teeth is advisable. Careful evaluation of the roentgenograms in such cases prevents avoidahlc complications and, therefore, cannot be overemphasized. REFERENCES and Embryology, St. Louis, 1953, The C. V. Mosby Company, 1. Orban, B.: Oral Histology pp. 43-49. Thoma, K. H.: Oral Surgery, ed. 2, St. Louis, 1958, The C. V. Mosby Company, pp. 35-37. ;: Toto, P. D.: Personal Communication. 4. Shafer, W. G., Nine, M. K., and Levy, B. M.: A Textbook of Oral Pathology, Philadelphia, 1958, W. B. Saunders Company, pp. 35-37. Anatomy, ed. 6, Philadelphia, 1954, W. B. Saunders Company, 5. Areys, L. B.: Developmental pp. 2x-222. ORAL SIJRG., ORAL MED. & ORAL PATH. 16: 46-47, 1963. 6. Traiger, J. : Roentgeno-Oddities, Supernumerary Mandibular 7. Poyton, H. G., Morgan, G. A., and Crouch, S. A.: Recurring Premolars, ORAL SURG., ORAL MED. & ORAL PATH. 13: 964-965, 1960. Interpretation as an Aid in Oral Surgery Procedures, 8. Shira, R. B.: Roentgenographic J. Am. Dent. A. 65: 449-455, 1962. St. Louis, 1952, The C. V. Mosbv Company. 9. Sicher, H. : Oral Anatomy, of Oral Disease, St. Louis, 1955, The C. 1’. Mosby 10. Bernier, J. L.: The Management Company, pp. 757-758. 11. Thoma, K. H.: Oral Pathology, ed. 4, St. Louis, 1954, The C. V. Mosby Compsny, pp. 2-26. 4737 NORTH BROADWAY
.
.
.
FOURTH Henry
.
.
MOLARS
R. Mittelman,
.
.
.
.
.
.
.
IN THE MAXILLA D.D.S., MS.,*
.
.
.
.
.
.
.
.
.
.
.
AND MANDIBLE
and M. Poliak,
D.D.S., Chicago, Ill.
T
HE recognition of irregularities in human dentition has become commonplace, especially since oral roentgenographic examinations have been used routinely. The presence of supernumerary teeth is not uncommon, but the occurrence of four fourth molars is rare. 6pI1 Most supernumerary teeth show only rudimentary development and are small in size, but occasionally teeth of from normal size and structure are found. *s 3~lo, I1 Whether this proliferation the dental lamina is a genetic anomaly is not known,” 2~5l lo as no further evidence is available. Thoma,2f l1 Shafer and associates,4 and Shiras recommend the early removal of such supernumerary teeth. Early surgical treatment, as a rule, involves less trauma and eliminates possible future complications. Of course, by proper evaluation of the roentgenograms, it is possible for the surgeon to be alerted to any probable complication. These may arise from the position of the tooth in relation to other areas or structures, such as the infeorior alveolar artery and nerve. Other hazards are excessive hemorrhage or infection, jaw fracture, paralysis or anesthesia due to nerve involvement, or perforation into the pterygomaxillary space, the maxillary sinus, and the orbit. CASE
REPORT
Patient N. B., aged 20 years, was referred after a routine oral roentgenographic examination had revealed the presence of four fourth molars in addition to the normal complement of thirty-two teeth (Fig. 1). The fourth molars were impacted in both the maxilla and the mandible. The position of both mandibular third molars was slightly mesioangular and low, with the mesial cusps at the level of the cementoenamel junction of the second molars. The fourth molars in the mandible were positioned horizontally in the retromolar area of the ramus, above the oeelusal plane of the teeth. The right maxillary third molar was in a slightly distoangular position, and the supernumerary tooth was high above in the tuberosity, almost at a level with the floor of the orbit.7 The left maxillary third molar was in an extreme distoangular position, with the fourth molar lying on the distal convex surface of the impacted third molar crown in a bucco-mesio-angular relationship. *Adjunct Attending Oral Surgeon, Mt. Surgeon, American Hospital, Chicago, Ill.
Sinai 1297
Hospital,
Chicago,
Ill.,
and
Attending
Oral
tubcrosity Fig. I.--Bilateral third and fourth molars. A, Right maxillary molar in slightly distoangular position and fourth molar high in the tubcrositllevel than the left molar. Note close contact with the sinus.
v-ith
thircl
at x lowr~t~
Prom a diagnostic standpoint, the roentgenograms indicated that great dare must 1~ exercised in the surgical removal of these teeth, especially in the case of the maxillary fourth molars which were positioned close to the floor of the orbit. \Ve decided to remove the mandibular third and fourth molars bilaterally, operating on each side in a separate session, and in the maxilla to remove only the third molars. If the fourth molars were positioned as high as the roentgenograms indicated and not readily seen during the surgical procedure, their removal could be postponed in the hop that they would move down into a more favorable position later. The procedure was undertaken under local anesthesia with a block of the inferior alveolar and long buccal nerves. For t,he removal of the third and fourth molars in the left mandible, an incision wan made in the retromolar area with the cut extending high up along the ramus, and the tissues were reflected. The bone was exposed and, after a cut had been bone was excised, the follicular sac made bucco-occlusally with a bur, the thin overlying was dissected, and the teeth, appearing to be of normal size and shape, were removed. The area was d6brided until free bleeding occurred. Gelfoam was placed, tetracycline was sprayed over the area, and the tissues were re-apposrd after a small iodoform gauze drain had been placed into the wound. The wound was closed with 3-O black silk. There was no postoperative pain, very little swelling, and no hematoma or ecchymosis. The drain wtts removed after 48 hours; recovery was uneventful (Fig. 2). Postoperatively. aspirin was the only drug prescribed.
Volume 16 Number 11
FOURTH
MOLARS
IN
Fig. 2. Fig. 2.-Postoperatire roentgenogram surgical procedure. Fig. I.-Postoperative roentgenogram surgical procedure.
Figs.
4 and
Fig. 4. S.-Roentgenograms
Fig. B.-Immediate
taken
MAXlLLA
of of
the
AND
left
mandibular
the right
mandibular
si$ bTm&hs
1299
MANDIBLE
PostoPeratively,
Fig. 3. site immediately site
immediately
Fig. 5. showing
postoperative view of the upper right third molar area, showing ing fourth molar high in the tuberosity.
good
after after
healing
the remain-
More than a month later the same procedure was carried out on the right side (Fig. 3). Both the third and fourth molars were removed. Again, recovery and healing were uneventful. Postoperative roentgenograms, taken after 6 months, showed satisfactory healing (Figs. 4 and 5).
Becauseof school programming, it Bay necessary to delay tim removal I)~ tlu: nmxillar~ teeth until vacation time. The right maxillary third molar \I’as rcwlovc~~l :lft<.r t llc, usual tuberosity incision, and the fourth molar sac was visualized. Its position was such that it \sas deemed safer to allow the tooth to move caudally by natural forces (Fig. ti), since t,lu: hazards of orbital and sinus involvement were considered tuo csritical at this time. l’ostoperatively, Empirin compound with codeine was prescribed. No swelling or ccchymosis was apparent. The left upper third molar and probably the left upper fourth molar will be removed in a few weeks. DISCUSSIOX
The foregoing case illustrates an unusual proliferation of the dental lamina with the development of four fourth molars, a phenomenon not, frequently I’(‘ported in the literature.G This case has shown the desirability of good planning and conservatism in surgical treatment. I believe, us do others, that early surgical removal of such teeth is advisable. Careful evaluation of the roentgenograms in such cases prevents avoidahlc complications and, therefore, cannot be overemphasized. REFERENCES and Embryology, St. Louis, 1953, The C. V. Mosby Company, 1. Orban, B.: Oral Histology pp. 43-49. Thoma, K. H.: Oral Surgery, ed. 2, St. Louis, 1958, The C. V. Mosby Company, pp. 35-37. ;: Toto, P. D.: Personal Communication. 4. Shafer, W. G., Nine, M. K., and Levy, B. M.: A Textbook of Oral Pathology, Philadelphia, 1958, W. B. Saunders Company, pp. 35-37. Anatomy, ed. 6, Philadelphia, 1954, W. B. Saunders Company, 5. Areys, L. B.: Developmental pp. 2x-222. ORAL SIJRG., ORAL MED. & ORAL PATH. 16: 46-47, 1963. 6. Traiger, J. : Roentgeno-Oddities, Supernumerary Mandibular 7. Poyton, H. G., Morgan, G. A., and Crouch, S. A.: Recurring Premolars, ORAL SURG., ORAL MED. & ORAL PATH. 13: 964-965, 1960. Interpretation as an Aid in Oral Surgery Procedures, 8. Shira, R. B.: Roentgenographic J. Am. Dent. A. 65: 449-455, 1962. St. Louis, 1952, The C. V. Mosbv Company. 9. Sicher, H. : Oral Anatomy, of Oral Disease, St. Louis, 1955, The C. 1’. Mosby 10. Bernier, J. L.: The Management Company, pp. 757-758. 11. Thoma, K. H.: Oral Pathology, ed. 4, St. Louis, 1954, The C. V. Mosby Compsny, pp. 2-26. 4737 NORTH BROADWAY