The document reports a rare case of a patient with bilateral maxillary buccal exostosis, polydactyly, and distomolars who was treated with surgical resection of the exostoses. The patient presented with swelling in the upper jaw for 12 years. Examination found polydactyly in hands and feet as well as distomolars. Surgical treatment involved removing the bony exostoses to improve aesthetics and oral hygiene.
The document reports a rare case of a patient with bilateral maxillary buccal exostosis, polydactyly, and distomolars who was treated with surgical resection of the exostoses. The patient presented with swelling in the upper jaw for 12 years. Examination found polydactyly in hands and feet as well as distomolars. Surgical treatment involved removing the bony exostoses to improve aesthetics and oral hygiene.
The document reports a rare case of a patient with bilateral maxillary buccal exostosis, polydactyly, and distomolars who was treated with surgical resection of the exostoses. The patient presented with swelling in the upper jaw for 12 years. Examination found polydactyly in hands and feet as well as distomolars. Surgical treatment involved removing the bony exostoses to improve aesthetics and oral hygiene.
The document reports a rare case of a patient with bilateral maxillary buccal exostosis, polydactyly, and distomolars who was treated with surgical resection of the exostoses. The patient presented with swelling in the upper jaw for 12 years. Examination found polydactyly in hands and feet as well as distomolars. Surgical treatment involved removing the bony exostoses to improve aesthetics and oral hygiene.
A rare case report with surgical treatment of bilateral maxillary
buccal exostosis in patients with polydactyly and distomolar Abdalla Aly*1
1 Masinde Muliro University Of ABSTRACT: Science And Technology, Kenya *Corresponding author Buccal exostosis is bony prominence located on buccal side of alveolar ridge of maxilla or mandible. It is commonly seen in maxilla than mandible, whereas the etiology remains unclear. This article presents a rare case of bilateral maxillary buccal exostosis, distomolars and polydactyly along with surgical management of exostosis. A 39-year-old male patient came to the dental OPD with a chief complain of swelling in the right and left back region of upper jaw from 12 years, which was a cosmetic concern to the patient. Patient was medically healthy with no familial history of gingival overgrowth. On examination, patient had polydactyly and bilateral mandibular distomolars. These isolated findings couldn’t be related to any syndrome after thorough examination and medical consultation. Finally, the treatment plan consisted of, oral hygiene instructions, mechanical debridement and periodontal resective osseous surgery, so as to reduce gingival inflammation and improve esthetic by removing the exostosis. Nonsurgical periodontal therapy alone did not reduce the gingival enlargement because of the bony nature of enlargement, thus necessitating surgical intervention. Post-operative evaluation at 1, 3 and 12 months reveled an uneventful healing and no sign of recurrence at surgical sites.
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A rare case report with surgical treatment of bilateral maxillary buccal exostosis in patients with polydactyly and distomolar 27
INTRODUCTION; (Figure 1). The overgrowth was a major cosmetic
concern to the patient. Whereas, the area serves as Tori and exostoses are nodular protuberances a good nidus for food lodgment, thus causing of calcified bone designated according to their difficulty in oral hygiene practice by the patient. anatomic location. Torus palatinus (TP) and torus Detailed personal and family history of the patient mandibularis (TM) are the two most common revealed that the enlargement was not familial in types of intraoral osseous overgrowths [1]. Buccal nature. The patient didn’t reveal any history of exostosis is a bone prominence located on the medication and reported no known drug allergies. buccal aspect of alveolar ridge of the maxilla or mandible and usually consists of dense cortical On extra-oral examination we found that bone that are relatively avascular. It usually patient had a high and broad smile line (1st molar occurs bilaterally and seen in the premolar and to 1st molar). The general examination revealed molar region. It is more commonly seen in maxilla the patient had a Polydactyly in both hand and feet than mandible (5.1:1) and affects men more than (Figure 2) and the radiographic examination women (1.66:1). [1,2,5] The overgrowth is usually showed bilateral distomolars in lower arch (Figure asymptomatic but may cause esthetic concern to 3). These isolated findings couldn’t be related to the patient. The area serves as a good nidus for any syndrome after thorough examination and food lodgment, thus causing difficulty in oral consultation. The overgrowth was an esthetic hygiene practice by the patient. No consensus has problem to the patient due to the broad smile line. been reached to determinate the etiology of buccal There was a generalized gingival inflammation in exostosis but it is believed that the reason is the upper and lower arch, and the probing depths multifactorial, including environmental elements were in the range of 3–4 mm with areas of 5 mm acting in unclear relationship with genetic factors in the upper left first molars. There was Glickman [3,4,6,12] . The diagnosis of a buccal exostosis is grade I furcation involvement in both maxillary based on the clinical examination along with left and right first molars. radiographic interpretations. Radiograph of exostosis appears as well-defined round or oval After obtaining a medical clearance calcified structure superimposing the roots of regarding the isolated findings, periodontal teeth. [1,3] treatment was planned as patient education and Polydactyly is a condition of physical motivation by oral hygiene instructions, scaling anomaly in humans resulting in the presence of and root planing and periodontal resective osseous extra fingers and/or toes. The extra finger is surgery. The patient was prescribed 0.2% commonly seen in the ulnar (little finger) side of chlorhexidine gluconate two times daily so as to the hand [7]. Distomolar is a supernumerary tooth reduce plaque and gingival inflammation. Re- which is located in the distal aspect of third evaluation after four week showed normal molars. It appears more frequently in men than in gingival characteristics, whereas the gingival women. This case report presents a rare case of enlargement failed to regress. After explaining the buccal exostosis associated with distomolars and risks and benefits of surgery to the patient, an polydactyly along with surgical management of informed consent was obtained. After exostosis. [8],9] administration of local anesthesia, full thickness mucoperiosteal flap was reflected in order to gain CASE REPORT; complete access to the exostosis.
A 39-year-old male patient was referred to Resective osseous surgery was performed the Department of Periodontology, College of in the following steps: 1) Vertical grooving: It was Dentistry, King Khalid University with the done in order to reduce the thickness of the complaint of swelling in the right and left alveolar housing and to provide relative posterior region of upper jaw from 12 years prominence to the radicular aspects of the teeth. It MCHA | Volume 01 | Issue 01 A rare case report with surgical treatment of bilateral maxillary buccal exostosis in patients with polydactyly and distomolar 28
is the first step of the resective process because it Fig 2: Polydactyle in both hands and feet will define the general thickness and subsequent form of the alveolar housing. It was performed by rotary instruments using round carbide burs with high speed under copious saline irrigation. 2) Radicular blending: This was an extension of vertical grooving in an attempt to gradualize the bone over the entire radicular surface so as to provide the best results from vertical grooving. It helps in providing a smooth surface for good flap adaptation. 3) Flattening of interproximal bone: This step is indicated when interproximal bone levels vary horizontally and requires the removal of minimal supporting bone. 4) Gradualizing marginal bone: It is the last step in which the marginal bone was gradualized to provide even base for gingival tissue to follow. Fig 3: Panoramic radiograph showing Bilateral Distomolars in lower arch: .After removing the exostosis, surgical site was checked to determine any further recontouring. On obtaining the final result, the flap was sutured with 3-0 vicryl suture material. Postoperative medications and instructions were given to the patient. Patient was recalled after 10 days for suture removal. Post-operative evaluation at 1, 3, 6 and 12 months reveled an uneventful healing at all surgical sites without any reported complication and clinical sign of recurrence.
Fig 1: Preoperative view showing enlargement
Fig 4: Resective osseous surgery of maxillary at maxillary left and right buccal region: right and left buccal exostosis:
MCHA | Volume 01 | Issue 01
A rare case report with surgical treatment of bilateral maxillary buccal exostosis in patients with polydactyly and distomolar 29
They are commonly seen in premolar and molar
region. [1,2,5]
Polydactyly is defined as a condition in
which a person has more than five fingers per hand or five toes per foot. It is considered to be the most common birth defect of the hand and foot. Surgery may be considered for poorly formed digits or very large extra digits. Surgical management depends on the complex level of the Fig 5: 12 months postoperative view showing deformity.[7] absence of enlargement in maxillary left and right buccal region: Distomolar is a supernumerary tooth which is located distal to third molars. It usually appears in male more than female. The “Dental lamina hyperactivity theory” to be the most accepted theory to explain this Condition. Distomolars are usually impacted. They can be asymptomatic or cause complications. Radiographs are important diagnostic tool for the detection of distomolars. Treatment involves the removal of the distomolar if there are associated complications otherwise to keep under observation. [8,9]
A differential diagnosis of Fibrous
dysplasia and Gardner syndrome was given. Gardner syndrome was excluded due to no appearance of multiple polyposis of the large intestine; osteomas of the bones; multiple epidermoid or sebaceous cyst of the skin. Clinical DISCUSSION; appearance of bilateral nodular growth on the buccal surface of the maxilla under the In this case report on examination, patient muccobuccal fold over which the mucosa revealed polydactyly and bilateral mandibular appeared blanched ruled out fibrous dyslasia. . distomolars and maxillary buccal exostosis. [10,11] According to the patient's medical and dental history, it was difficult to relate the exostosis to a In this case report, phase I periodontal direct cause. The patient was medically healthy therapy alone did not reduce the gingival and not under any medications. Exostosis was not enlargement because it was bony enlargement, in the family as the patient didn’t mention any that thus surgical intervention was needed. Vertical any family member had gingival overgrowth. grooving was the first step of the resective osseous surgery to reduce the thickness of the Buccal exostosis is a benign outgrowth, alveolar housing and to provide relative which is usually seen in the facial aspect of the prominence to the radicular aspects of the teeth. upper jaw as compared to the lower jaw [1,2]. Cooling with sterile saline must be done so that These outgrowths are usually asymptomatic, but the temperature of the bone is not raised beyond sometimes may increase in size and cause 47°C. Radicular blending was done next which is cosmetic concern. They are commonly seen in an extension of vertical grooving in an attempt to male population compared to female population. MCHA | Volume 01 | Issue 01 A rare case report with surgical treatment of bilateral maxillary buccal exostosis in patients with polydactyly and distomolar 30
gradualize the bone over the entire radicular [6] Eggen S. Torus mandibularis: An estimation surface to provide the best results from vertical of the degree of genetic determination. Acta grooving. Gradualizing marginal bone was the Odontol Scand 1989;47:409-15. minimal bone removal to provide a regular base [7] Kaneshiro, Neil K. "Polydactyly - Overview". for gingiva to follow [14,15]. Post-operative University of Maryland Medical Center (UMMC). evaluation visits at 1, 3, 6 and 12 months revealed Retrieved 5 January 2013. uneventful healing at all surgical sites without any reported complication and clinical sign of [8] Kurt H, Suer TB, Senel B, Avsever H (2015) recurrence. A retrospective observational study of the frequency of distomolar teeth in a population. CONCLUSION; Cumhur Dent J 18: 335-342 The case report presented above illustrates a [9] Kaya E, Güngör K, Demirel O, Özütürk Ö unique and rare presentation of bilateral exostoses (2015) Prevalence and characteristics of non- on the buccal side of the maxillary premolar - syndromic distomolars: a retrospective study. J molar region. Resective osseous surgery was Investig Clin Dent 6: 282-286 performed to correct the bony architecture. The procedure resulted in successful establishment of [10] Shafer WG, Hine MK, Levy BM. Textbook the normal bony contour without any unwanted of Oral Pathology. 4 th ed. Philadelphia: WB complications. Saunders; 1983. p. 2-85.
Conflict of interest: [11] Shafer WG, Hine MK, Levy BM. Textbook of Oral Pathology. 4 th ed. Philadelphia: WB The author declare that they have no conflicts of Saunders; 1983. p. 674-718. interest. [12] Johnson OM. Tori and masticatory stress. J REFERENCES; Prosthet Dent 1959;9:975-7. [1] Carranza FA, Hogan EL. Gingival [13]. Stephen TS, Robert CF, Leslie ST. enlargement. In: Newman MG, Takei H, Carranza Evaluation and management of diseases of the FA, Carranza F, editors. Carranza’s Clinical oral mucosa. In: Principle and Practice of Oral Periodontology. 9 th ed. Philadelphia: WB Medicine. 1 st ed. Philadelphia: WB Saunders Saunders; 2003. p. 279-96. Company; 1984. p. 476-7. [2] Jainkittivong A, Langlais RP. Buccal and [14] Bathla S, editor. Resective osseous surgery. palatal exostoses: Prevalence and concurrence In: Periodontics Revisited. 1 st ed. New Delhi: with tori. Oral Surg Oral Med Oral Pathol Oral Jaypee Brothers Medical Publishers; 2011. p. 366- Radiol Endod 2000;90:48-53. 70. [3] Suzuki M, Sakai T. A familial study of torus [15] Ochsenbein.C, A primer for osseous surgery palatinus and torus mandibularis. Am J Phys Int J Periodontics Restorative Dent. Anthropol 1960;18:263-72.
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