Case Report

By Dr. Doddi Lopamudra , Dr. Kami Shetty Shekar , Dr. Ravi Chandra , Dr. Md Mohammed Khwaja Moinuddin , Dr. Karthik Prasad , Dr. Shanti Priya , Dr. Smitha
Corresponding Author Dr. Doddi Lopamudra
Conservative and endodontics , Sri sai Dental College, Sri sai Dental College - India
Submitting Author Dr. Lopamudra Doddi
Other Authors Dr. Kami Shetty Shekar
Sri Sai College of Dental Surgery, Sri Sai College of Dental Surgery, Vikarabad - India

Dr. Ravi Chandra
Sri Sai College of Dental Surgery, - India

Dr. Md Mohammed Khwaja Moinuddin
Sri Sai College of Dental Surgery, - India

Dr. Karthik Prasad
Sri Sai College of Dental Surgery, - India

Dr. Shanti Priya
Sri Sai College of Dental Surgery, - India

Dr. Smitha
Sri Sai College of Dental Surgery, - India


Endodontic Management by Cone Beam Computed Tomography and Vista scan of Maxillary Second Molar with Parastyle ?A Case report

Lopamudra D, Shekar K, Ravi Chandra, Mohammed Khwaja Moinuddin M, Karthik Prasad, Shanti Priya, et al. Endodontic Management by Cone Beam Computed Tomography and Vista scan of Maxillary Second Molar with Parastyle - A Case report. WebmedCentral DENTISTRY 2016;7(6):WMC005134

This is an open-access article distributed under the terms of the Creative Commons Attribution License(CC-BY), which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Submitted on: 29 Jun 2016 10:51:14 AM GMT
Published on: 29 Jun 2016 10:52:08 AM GMT


Lopamudra1, ShekarK1, RaviChandra2, MohammedKhwajaMoinuddin2, KarthikPrasad3, ShantiPriya3, Smitha4

Thorough knowledge of the root canal anatomy and its complexities is essential to provide successful root canal treatment. Variations in tooth form and anatomy may be found in the form of anomalous cusps or additional roots. In permanent molars, changes in the tooth morphology may occur either in the form of an additional tooth (paramolar) or supernumerary cusp (paramolar tubercle). The knowledge of the internal anatomy of the paramolar tubercles is very important as they influence the treatment outcome. This case report investigates the anatomical and morphological characteristics of a case with well-developed lobulated cusp occurring on the buccal surface of maxillary left second molar with the aid of CBCT and Vistascan.


Paramolar tubercle is additional cusp present on buccal surface of a permanent molar2. Dahlberg in 1945 introduced paleontologic nomenclature where he referred to this structure as “parastyle” when additional cusp presents in the upper molars and “protostylid” when additional cusp presents in the lower molars3. Morphologically they attain a shape called tuberculate i.e. barrel shaped crown with rudimentary root, often paired. Incidence of paramolar tubercle varies from 0% to 0.1% in maxillary first molars, 0.4% to 2.8% in maxillary second molars and 0% to 4.7% in maxillary third molars3.Variations in tooth morphology and anatomy makes endodontic treatment challenging. Hence, a proper understanding of these variations is important in order to ensure success in endodontic treatment.  Conventional intraoral radiographs have  their own inherent  limitation  that  may  restrict  their  use in  the  management  of  certain complicated  cases . To avoid these limitations Vista scan and Cone  beam computed tomography (CBCT) had been used in this study as an adjunctive tool in the interpretation of this root canal anatomy. This  article  presents  a  case  report  on  the endodontic  management  of   maxillary second  molar  fused  to  paramolar  tubercle that was successfully managed with the aid of cone  beam  computed  tomography  and  Vistascan.

Case report

A 25-year-old female patient reported to the department  of  conservative  dentistry  and  endodontics  with  a  chief  complaint  of  pain  in  the upper left back region of the oral cavity for the past 1 week. Patient underwent incomplete endodontic access opening one year back and discontinued the treatment. On clinical examination, the left maxillary second molar was tender on percussion and it showed unusual crown morphology with a paramolar tubercle fused between the mesiobuccal and distobuccal cusp. Based on clinical and radiographic evaluation tooth showed slight periapical radiolucency and diagnosis of periapical abscess with periodontal widening was made. Patient was given medication for 5days.

Patient was recalled after 5 days and local anesthetic agent was administered for the patient.  Under rubber dam isolation, conventional endodontic access cavity was made using Endo access bur in tooth 27 and its fused counterpart. After  access  preparation,  four canals  were located with 10 size k file; namely, the mesiobuccal  (MB),  distobuccal  (DB),  and  palatal canal  (P) and a separate  canal  in  the fused  paramolar  tubercle Fig:1 . To  know whether  the  communication  existed  between the  canals,  a  CBCT (Kodak CS 9300 Care stream) 84kvp,10mA,FOV 5×5cm   analysis  was  performed with the patient’s consent Fig:2.

The working length was determined   and radiograph was taken with Vistascan Fig:3. Cleaning and shaping was performed using protaper NiTi instruments in a crown down manner. Irrigation was done with normal  saline,  5ml  of  2.5%  of  Sodium  hypocholorite  and  17%  EDTA and 2% chlorhexidine. Canals  were  medicated  with  calcium  hydroxide  (RC  cal  ) using  lentulo spiral and the access cavity was sealed with  Cavit . The patient remained asymptomatic. Patient was recalled after 10days. Through debridement of canals using chlorhexidine and saline was done. Canals were dried with paper points and obturation was performed using F2 gutta percha points and zinc oxide eugenol sealer and radiograph was taken with Vistascan(DURR).  Access   cavity was restored with light cure composite (Filtek P60)Fig:4.


Paramolar tubercles have been recognized as structural characteristics confined to certain ethnic, geographical affiliations and racial background which may play an important role in its occurrence. Incidence of paramolars are reported to be infrequent among Africans, Europeans, and their descendants in America where as they are common in group of Native Americans from the southwest (Pima) and in Indians. Since they are of low occurrence they should not be classified as anomalous structure since they are normal morphological features of the dentition. Due to its low prevalence there is limited information available about the anatomical and morphological characteristics of these tubercles or its relation with the pulp chamber and root canals of the tooth with which it is associated3.

Bolk reported that paramolar tubercles in maxillary molars are more likely to unite at the root but in mandibular molars they tend to possess their own roots. He also stated that a paramolar tubercle was always united with the anterior buccal cusp of the molar and its roots were attached to mesiobuccal roots. In addition, he even reported that the paramolar root was often present without the tubercle in lower molars3.

Ohishi et al examined the root anatomy of 3 cases with paramolar tubercules in maxillary second molar with CBCT and stated that in all the three cases the root of the paramolar tubercle was united with the distobuccal root. All had their own pulp chamber and canals were combined with the distobuccal canal at various levels3.Gurudutt  Nayak  et  al   reported  the  anatomical and morphological characteristics of  paramolar  tubercle  using  spiral computed  tomography.  The  root  of  the  paramolar tubercle was fused to the MB and DB, but  the  canal  remained  independent  from  the main  root  canals.

 Preetham Jain  etal  reported two case reports  using CBCT to  know whether  the  communication  existed  between the  canals and stated fusion  between  the canal of paramolar tubercle, mesiobuccal canal  and  distobuccal  canal  at  the  middle  third level with a single portal of exit in one case report . In another case report   CBCT revealed fusion between the paramolar tubercle canal and the mesiobuccal canal (MB1) at the coronal one third. The   distobuccal canal (DB), second mesiobuccal canal (MB2) and the palatal canals (P) remained separate at this level1.

 In our case report  CBCT  and Vistascan had  shown separate  portals of  exit and no fusion was seen at any level and canal remain independent from main root canal. The case report  coincides with Ohishi et al and Gurudutt Nayak etal in number of root canal configuration.


Use  of  Vistascan and  CBCT  provided  precise information about the root canal anatomy and root canal configuration which aided in successful  endodontic  management  of  the  maxillary second molars with the paramolar tubercle.


1) Preetham Jain. Endodontic Management of Maxillary Second Molars Fused with Paramolar Tubercles Diagnosed by Cone Beam Computed Tomography - Two Case Reports JDT 2014. 11(6):726-732.
2) Parolia. Management of supernumerary teeth. Invited Review  J   Conserv Dent. 2011 Jul-Sept; 14(3):221-224.
3) Gurudutt Nayak. Paramolar tubercle: A diversity in canal configuration identified with the aid of spiral computed tomography. Eur  J Dent. 2013 Jan;7(1):139-44.
4) Dalhberg AA. The paramolar tubercle. Am J Phys Anthropol. 1945;3:97-103.
5) Syed Nabeel.Parastyle: Clinical Significance and Management of Two Cases. Int JOMP. 2012;3(3):61-64.
6) Sanjeev Tyagi. An Alternative Treatment Approach for a Supernumerary Tooth Fused to a Mandibular Second Molar: A Case Report . PJSR 2009 Jan;2(1).
7) Mahesh Kumar Duddu, Radhika Muppa, Prameela Bhupatiraju.Unusual Occurrence of Paramolar Tubercle on Deciduous Upper First Molar ? Report of Two Cases and Literature Review. Int J Oral-Med Sci  2012 ;11(1):54-56.

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