International Journal of Oral & Maxillofacial Pathology.

2012;3(3):61-64 ISSN 2231 – 2250

Available online at http://www.journalgateway.com or www.ijomp.org

Case Report
Parastyle: Clinical Significance and Management of Two Cases
Syed Nabeel, Gazala Danish, Usha Hegde, Paras mull

Abstract
A paramolar cusp or tubercle is a supernumerary cusp occurring on the buccal or lingual surface
of upper or lower premolars and molars. A paramolar cusp occurring on the buccal surface of the
maxillary molars is specifically termed as a parastyle. We report two cases of parastyle, one
occurring on permanent maxillary second molar in a 32-year-old male patient and other in a 48-
year old female patient, both of South Indian origin. The clinical significance, nomenclature and
grading plaque about this rare entity are being discussed.

Key words: Teeth;Supernumerary;Tooth Abnormalities;Congenital Abnormalities;Tubercle;

Premolars;Molars.

Syed Nabeel, Gazala Danish, Usha Hegde, Paras mull. Parastyle: Clinical Significance and Management of
Two Cases. International Journal of Oral and Maxillofacial Pathology; 2012:3(3):61-64. ©International
Journal of Oral and Maxillofacial Pathology. Published by Publishing Division, Celesta Software Private
Limited. All Rights Reserved.

Received on: 10/05/2012 Accepted on: 30/08/2012

Introduction
Parastyle (Paramolar tubercle) is an permanent maxillary left second molar
accessory cusp expressed on the buccal showed a cusp-like triangular projection on
surface of the paracone (mesiobuccal cusp) the buccal surface of the mesiobuccal cusp.
of the upper molars. In rare instances it is (Fig 1) Carious lesion was present between
expressed on the metacone (distobuccal the cusp-like projection and the buccal
1
cusp) of the upper molars. It is considered surface of the tooth mesially. No carious
as a cingulum derivative expressed on the lesion was evident on the other surfaces of
buccal surface of the paracone of the upper the tooth.
molars and thought to arise from an
1,2
accessory enamel knot at the surface. Case 2: A 48-year old female patient, who
There is limited information about racial had reported to our dental clinic for the
differences in the frequencies of paramolar treatment of bleeding gums, had a cusp-like
tubercles, because of their apparently low triangular projection seen on the buccal
2
overall occurrence. However, one study has surface of the mesiobuccal cusp of the left
reported higher occurrence in Indians as permanent maxillary second molar. (Fig 2)
2,3
compared to other populations. As in case 1, carious lesion was evident
along the groove between the cusp-like
The significance of parastyle is that they projection and the mesiobuccal cusp.
may in general provide insights into dental
1
evolution and development. These In both the cases, the unilateral paramolar
structures pose clinical problem such as structure on the buccal surface of the upper
dental caries, gingivitis or periodontitis, second molar was diagnosed as the
interference in orthodontic banding etc. paramolar tubercle, and more specifically as
Hence, it is important to diagnose and parastyle, since they are present on the
institute a preventive and/or restorative buccal aspect of a maxillary molar. In the
treatment if required. Two cases of parastyle buccal view, the tubercle forms a triangular
occurring in Indian population are being prominence with its base below the gingival
reported here. margin and its apex oriented occlusally.
Mesiodistally, it was located in the centre of
Case Reports the mesiobuccal cusp, and occluso-
Case 1: A 32-year old male patient reported gingivally it extended from the clinical
with a chief complaint of sensitivity in his cervical line to about 2mm short of the
upper left back tooth region. History mesiobuccal cusp tip. It was separated from
revealed that the sensitivity was present on the tooth surface forming a free cusp tip at
taking cold or hot food which subsided on the occlusal third. The free cusp tip was
removal of the stimulus. The family and more pointed in case 1 and rounded in case
medical history of the patient were not 2. A deep developmental groove was seen
significant. On intraoral examination, the between the tooth surface and the free cusp

©2012 International Journal of Oral and Maxillofacial Pathology. Published by Publishing Division, Celesta Software Private Limited. All Rights Reserved
62 Syed Nabeel et al.,
tips. The affected teeth in case 1 showed
early response to vitality test and normal
response in case 2. Calculus deposits were
seen around the teeth and the gingiva was
inflamed. A pre-operative intra-oral
periapical radiograph in both the cases did
not reveal any signs of periapical pathology.
The parastyle appeared as a faint v-shaped
radio-opacity superimposing the crown of
the tooth.
Based on the clinical and radiographic
findings, diagnosis of moderate caries with
reversible pulpitis in case 1 and caries in
case 2 was made. In both the cases
following oral prophylaxis, caries was
excavated with round steel burs. As there
were no signs of pulpal involvement, indirect
pulp capping was planned. A liner of calcium
hydroxide (Dycal, Dentsply Caulk) was
placed and the cavities were restored with
glass ionomer cement. (GC Fuji II). On the
follow-up visits, after 6 months both the
patients were asymptomatic.
Figure 1: The Buccal surface of tooth #27
showing paramolar tubercle (arrow) on
mesiobuccal cusp (Mirror view)
Figure 2: The paramolar cusp (arrow) noted
on mesiobuccal cusp of tooth #27.
ISSN 2231 - 2250
Discussion
Dental morphology, particularly the study of
nonmetric dental traits (NDT), involves
genetically-modulated trait expressions that
can be used for comparisons within and
2
among populations. Many NDT of dental
crowns and roots have been described using
1
various methodologies. The study of these
NDT is of importance, since they possess
high taxonomic value and they can be used
to evaluate population differences according
to micro-evolutionary processes, that, in
turn, generate information about human
movements and contacts that have
2
produced groups ethnic variation.
Parastyle (paramolar tubercle) is a crown
trait considered as a cingulum derivative
expressed on the buccal surface of the
paracone of the upper molars. Historically,
Bolk in 1916 first described an additional
cusp occurring on the buccal surfaces of
upper and lower permanent molars and
4
termed it as the paramolar tubercle.
Dahlberg in 1945 introduced a more specific
paleontologic nomenclature. When these
structures occurred on maxillary molars he
termed them as parastyle and as protostylid
5
when they occurred on mandibular molars.
Again in 1950 Dahlberg clearly defined
paramolar tubercle as a term applied non-
specifically to a style or cusp of
supernumerary character that is developed
on the buccal or lingual surfaces of the
2
upper and lower premolars and molars.
Kustaloghi OA, in his study found that the
upper paramolar cusp formation varied in its
size and pattern from a furrow or groove
delineation to various stages of cusp
formation. Therefore he felt it was
appropriate to refer these as Upper
paramolar structure or Upper paramolar
3
complex. Adloff, Dahlberg and Jorgensen
have analysed this structure as a derivative
3
of cingulum. Turner and Harris opine that
the paramolar tubercle arise during the
morphogenesis process starting from an
accessory enamel knot, developed at the
2
surface where the feature's apex forms.
In the study conducted by Kustaloghi OA,
Indians showed a higher occurrence in both
deciduous and permanent dentition when
compared to other populations. Overall the
upper paramolar structures are rare in
modern hominids, they occur quite
frequently in the dentitions of primitive
3
primates and mammals. According to
ISSN 2231 – 2250
Kustaloghi’s findings, paramolar structures
were found to be very low in upper first
molars as compared to upper second and
third molars. There was a tendency for
bilateral occurrence in deciduous dentition in
contrast to prevalent unilateral occurrence in
3
the permanent dentition.
The varied clinical presentation of a
parastyle is best described by the plaque
developed by Joseph F Katich and Turner
6
(1974)
0: Buccal surfaces of the cusps 2 and 3 are
smooth*
1: A pit is present in or near the buccal
groove between cusps 2 and 3.
2: Small cusp present with attached apex,
usually on the cusp 2.
3: Medium sized cusp present with free apex
anywhere on the buccal surface.
4: Large cusp present with free apex
anywhere on the buccal surface
5: Very large cusp present with free apex
anywhere on the buccal surface.
6: Free peg shaped crown is present,
attached to the third molar root.
* Note: Cusp 2 - paracone / mesiobuccal
cusp; Cusp 3 - metacone/distobuccal cusp
As these structures are thought to arise from
the buccal cingulum, they probably
represent the remnants of the cingulum of
7
mammals and lower primates. The
significance of paramolar tubercles is
unknown. Although these structures may
provide insights into dental evolution and
development, the anthropological potential
1
of this trait has yet to be demonstrated.
During orthodontic treatment, the paramolar
tubercles are often removed by
enameloplasty, as they interfere with
cementation of brackets and correct
alignment of orthodontic arch wires. This
clinical procedure should be considered as
the last option, since it involves mutilation of
an epigenetic variant of the dental
2
morphology. When these structures pose a
clinical problem such as dental caries, as in
the present case, a definitive treatment in
line with the general principles of caries
management has to be undertaken.
The two cases reported here are in
accordance with the findings of Kustaloghi
OA, regarding a higher occurrence of
parastyle in the Indian population and on the
maxillary second molars. The parastyles
reported here are large with free apex on the
buccal surface and thus are graded 4, as per
Parastyle: Clinical Significance and Management of... 63
the plaque given by Joseph F Katich and
Turner.
Cusps of supernumerary nature or character
occurring on buccal or lingual surfaces of
posterior teeth have been described by
various terminologies, which need specific
distinction. The term paramolar tubercle or
Bolk`s tubercle or paramolar cusp or
paramolar structure is used for the cusps of
supernumerary nature, occurring on buccal
or lingual surfaces of any of the premolars or
molars in either jaw. Upper paramolar
structure or upper paramolar complex
describes similar cusps occurring only on
upper posterior teeth. More specifically when
such a cusp occurs on the buccal surface of
paracone (mesiobuccal cusp) it is called as
parastyle. It is termed as protostylid when it
occurs on the buccal surface of the
protocone (mesiobuccal cusp) of the lower
1
molars.
Conclusion reserves the term “paramolar” or
“paramolar tooth” to supernumerary tooth
found anywhere around the upper or lower
premolars or molars, either freely or
attached to the adjacent teeth and the term
“paramolar cusp “or “paramolar tubercle” or
“paramolar structure” or “parastyle” to the
cusp of supernumerary nature on buccal or
lingual surfaces of premolars or molars of
either jaw. Also, whenever root formation is
seen associated with a paramolar cusp, it is
termed as a paramolar tooth rather than as
paramolar cusp with root formation. We
have reported two cases of parastyle, which
are of rare occurrence in modern hominids.
We hope it will increase the awareness
among dental practitioners about this rare
entity regarding its identification, patient
education, management and forensic
recognition when required.
Sometimes rare features which are
deviations from normal are encountered on
keen observation. Many a times contemplate
and research of these uncommon structures
leads to understanding more about their
development, racial distribution and so on. It
is thus true that definitely “there are signs for
those who ponder.”
Author Affiliations
1. Dr.Syed Nabeel Mail, Director, 2. Dr.Gazala
Danish Mail, Consultant Oral Diagnostician
and Radiologist, 3. Dr.Usha Hegde Mail,
Consultant Oral & Maxillofacial Pathologist, 4.
Dr.Paras mull Mail, Consultant Endodontist,
Smile Maker Clinics, MG Road, Udayagiri,
Mysore - 570 019, India.
64 Syed Nabeel et al.,
Acknowledgement
We would like to thank all the staff members from
Smile Maker Clinics for their support &
cooperation.
References
1. Scott GR, Turner CG II. Description and
classification of permanent crown and
root traits. In: The Anthropology of
Modern Human Teeth- Dental
Morphology and its variation in recent
human populations. 1st ed. Cambridge;
Cambridge University Press: 1997. 15-
69p.
2. Carolina R, Freddy M. Paramolar
tubercle in the left maxillary second
premolar: a case report. Dental
Anthropol 2006;19:65-9.
3. Kustaloghi OA. Paramolar Structures of
the Upper Dentition. J Dent Res
1962;41:75-83.
4. Bolk L. Problems of Human Dentition.
Am J Anat 1916;19:91.
Source of Support: Nil, Conflict of Interest: None Declared.
ISSN 2231 - 2250
5. Dahlberg AA. The Paramolar Tubercle
(Bolk). Am J Phys Anthropol 1945;32:97.
6. Turner CG, Regan M, Irish J. Chapter
nine: Physical Anthropology Analysis.
Roosevelt Platform Mound Study: A
Laboratory Plan for Salado Research.
Archaeological Research Institute -
Arizona State University. Internet
resource:
http://archaeology.asu.edu/library/lab/ch
apter_nine.pdf (Accessed on 18/4/2011).
7. Nagaveni NB, Umashankar KV, Radhika
NB, Reddy PB, Manjunath S. Maxillary
paramolar: report of a case and
literature review. Arch Orafac Sci
2010;5:24-8.
Corresponding Author
Dr.Syed Nabeel Mail,
Director, Smile Maker Clinics,
#187, 2nd Stage, MG Road,
nd
2 Main, Udayagiri,
Mysore - 570 019, India,
Email: sssmilemaker@gmail.com