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Extraordinary medical findings have always stirred the spirits of both professional and lay public, and cases of teeth with extremely long roots (radiculomegaly, root gigantism) are no exception. One such case report was recently published in the SDJ, and the story was reported in several daily newspapers (Frankfurter Neue Zeitung, Deutsche Welle, Jutarnji list).
Lukas et al. (2019) described the management of a 63-year- old Croatian male patient with an abscess of the canine fossa caused by an avital right maxillary cuspid. No other medical is- sues were reported. Extraoral swelling reaching the infraorbital area, previous history of endodontic treatment, and the radio- graphically established extraordinary length of the tooth con- tributed to the final decision to extract the tooth. The extracted canine measured 37.2 mm in length. In odontometric studies, the maximum measured lengths of the maxillary canine were 32.0 mm (Black 1902) and 33.3 mm (Bjorndal et al. 1974). The published photograph of the tooth indicates that the crown length was about 11 mm, and the root length was about 26 mm.
A comparison with the average dimensions of the maxillary canine reported by De Jonge (1958) shows that only the root was exceptionally long (26 mm vs an average value of 16.1 mm), whereas the crown had an average length (11 mm vs an average value of 10.9 mm). The ratio of root length to crown length (2.4) far exceeded the average value for the maxillary canine (1.5). The external morphology of the extracted canine was normal. On the panoramic radiograph, it can be seen that the contralateral maxillary canine and both mandibular canines also have elongated roots. Another feature not mentioned by the authors is the taurodontic appearance of the left maxillary first molar.
According to Lukas et al. (2019), this was the longest tooth ever extracted from a human being. Unfortunately, this is far from the truth. Their claim is based on information from the Guinness Book of Records rather than a review of the scientific literature. Several published case reports describing much lon- ger extracted cuspids exist. Foremost is a case reported by Hay- ward (1980); the lengths of incisors and canines which were surgically removed from an African American girl were between 35 mm and 52 mm. Marashi & Gorlin (1990) presented maxillary canines extracted from a young female patient; the longest of them measured 47.0 mm. De Jonge (1958) reported a 45.7 mm long extracted maxillary cuspid. Wilkie & Chambers (1990) pre- sented a left maxillary cuspid with a length of 41.0 mm, which was extracted from an Australian female patient born in Hol- land. Weine (1986) presented a right maxillary cuspid with a length of 39.5 mm, which was extracted from a Canadian male patient. Schulze (1987) reported a 39 mm long extracted maxil- lary cuspid. Compared to these cases, the length of the tooth described by Lukas et al. (2019) – despite the laurels of the new Guinness record – is relatively modest.
Nevertheless, the article is a significant contribution to the dental literature, but from a point of view not mentioned by its authors. The patient they managed apparently had no develop- mental anomalies other than canine radiculomegaly and max- illary first molar taurodontism. According to a recent review by Smith et al. (2018), few cases of non-syndromic (isolated) radiculomegaly have been published to date. Radiculomegaly, especially of the canines, is in most cases a component of ocu- lo-facio-cardio-dental syndrome (OFCD syndrome) and is its most pathognomonic sign. Other dental anomalies observed in patients with this syndrome include retained primary teeth, delayed eruption of permanent teeth, hypodontia, and mal- occlusion (Gorlin et al. 2001). In addition to dental anomalies, OFCD syndrome is characterised by anomalies of the eyes (congenital cataract, microphthalmia or microcornea, second- ary glaucoma), heart (atrial and ventricular septal defects, mi- tral valve prolapse), and face (long and narrow face, laterally curved and thick eyebrows, high nasal bridge, sharp nose with bifid tip) (Gorlin et al. 2001). Some of the extremely long ante- rior teeth mentioned above belonged to patients with OFCD syndrome. Over ninety cases of OFCD syndrome were found in a literature survey by Smith et al. (2018). All patients were females because the syndrome is X-linked dominant and therefore lethal in males.
Finally, something must be clear: radiculomegaly is a rare but significant clinical finding. It should alert the dentist to the possibility of OFCD syndrome. In addition, a tooth with elongated roots poses more risks for extraction and endodon- tic treatment compared to a tooth with a normal root length.
Nevertheless, several authors performed endodontic treat- ment on 34–38 mm long canines with success (Barletta et al.
2010; Taramsari et al. 2017; Cardoso et al. 2019). As such treatment is more demanding, I would recommend referring the patient to a specialist endodontist.
Iztok Štamfelj, MSc, PhD, CertEndo Assistant Professor
Department of Dental Diseases and Dental Morphology, University of Ljubljana, Ljubljana, Slovenia
Centre for Operative Dentistry and Endodontics, University Medical Centre Ljubljana, Ljubljana, Slovenia
iztok.stamfelj@mf.uni-lj.si
Letter to the Editor
The longest extracted human tooth? Definitely not!
SDJ Vol. 129, 10
P201 9, pages 817-820
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SWISS DENTAL JOURNAL SSO VOL 129 12 P 2019
Literature
Barletta F B, Grecca F S, Wagner M H, Ferreira R, Lopez F U: Endodontic treatment of a 36 mm long upper cuspid: clinical case report. Rev Odonto Ciênc 25: 412–416 (2010)
Bjorndal A M, Henderson W G, Skidmore A E, Kell- ner F H: Anatomic measurements of human teeth extracted from males between the ages of 17 and 21 years. Oral Surg Oral Med Oral Pathol 38: 791–803 (1974)
Black G V: Descriptive anatomy of the human teeth. 4th ed. Philadelphia The S. S. White Den- tal Manufacturing Co., pp. 16–21 (1902) Cardoso R M, Vieira T M, Da Silva Limoeiro A G,
Bastos H, Tomaziho L F, De Albuquerque D S:
An alternative technique to endodontic treat- ment for long teeth: a case report. J Surg Clin Dent 17: 8–10 (2019)
Gorlin R J, Cohen M M, Hennekam R C M: Syn- dromes of the head and neck. 4th ed. Oxford Oxford University Press, pp. 1107–1108 (2001) Hayward J R: Cuspid gigantism. Oral Surg Oral Med
Oral Pathol 49: 500–501 (1980)
De Jonge T E: Anatomie der Zähne. In: Die Zahn-, Mund- und Kieferheilkunde. Häupl K, Meyer W, Schuchardt K, eds. München-Berlin Verlag Ur- ban u. Schwarzenberg, pp. 169–232 (1958) Lukas M, Ehlers V, Becker T: Der längste extra-
hierte menschliche Zahn der Welt. Swiss Dent J 129: 817–820 (2019)
Marashi A H, Gorlin R J: Radiculomegaly of ca- nines and congenital cataracts – a syndrome?
Oral Surg Oral Med Oral Pathol 70: 802–803 (1990)
Schulze C: Anomalien und Mißbildungen der menschlichen Zähne. Berlin Quintessenz Ver- lags-GmbH, pp. 83–84 (1987)
Smith M H, Cohen D M, Bhattacharyya I, Islam N M, Kashtwari D: Radiculomegaly: a case report of this rare dental finding with review of the asso- ciated oculo-facio-cardio-dental syndrome.
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Taramsari M, Kajan Z D, Yeganeh L A B: An oculo- faciocardiodental syndrome: challenges in end- odontic treatment. J Dentomaxillofacial Radiol Pathol Surg 6: 77–82 (2017)
Weine F S: A very long cuspid! J Endod 12: 80–81 (1986)
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159–160 (1990)
Antwort der Autoren
Sehr geehrter Kollege Iztok Štamfelj,
vielen Dank für Ihre aufwendige Recherche. Leider fehlt mir momentan die Möglichkeit, die von Ihnen aufwendig heraus- gesuchten, zum Teil etwa 120 Jahre alten Quellen als Original- text in Augenschein zu nehmen, um die genauen Umstände und Vermessungstechniken beurteilen zu können. Ich gehe davon aus, dass die Recherche sehr gründlich war und Sie da- für einige Zeit investiert haben. Es ist doch vollkommen klar, dass es längere Zähne gibt als der von mir mit 37,2 mm publi- zierte Caninus. Bei der Anzahl an Menschen auf diesem Plane- ten und der Anzahl an durchgeführten Extraktionen ist dies doch auch kaum verwunderlich. Ich habe lediglich die vom Guinnessbuch geforderten Beweise und beglaubigten Messun-
gen durchführen lassen und konnte nach einiger Zeit den handfesten Beweis dafür liefern, dass der bisherige Zahn aus Indien nicht mehr der längste menschliche Zahn ist. Ich möchte allerdings anmerken, dass ich den Eintrag aus dem Guinnessbuch habe entfernen lassen, um die Diskussion um dieses Thema abschliessen zu können. Schlussendlich bleibt nur zu sagen, dass es sich um einen 37,2 mm langen Eckzahn handelt und nicht mehr.
Mit freundlichen Grüssen, Dr. Max Lukas
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