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Journal of Oral and Maxillofacial Radiology / September-December 2013 / Vol 1 | Issue 3 111

A novel presentation of a supplemental premolar tooth with dens invaginatus and dens evaginatus and role of the CBCT in diagnosisAhmet Ercan Sekerci, Gozde Ozcan, Osman Sami Aglarci1

Departments of Oral and Maxillofacial Radiology, Faculty of Dentistry, Erciyes University, Kayseri, 1Sifa University, Izmir, Turkey

INTRODUCTION

Dens invaginatus (DI) is a dental malformation commonly thought to occur as a result of an infolding of the enamel organ into the adjacent dental papilla during the development of the tooth.[1] DI referred to as “dens in dente,”“dentoid in dente,”“dilated gestantodontome,” “tooth inclusion,” and “dilated composite odontome.” Several theories have been proposed for the etiology of DI. Some of them are including alterations in tissue pressure, trauma, infection, or local discrepancy in cellular hyperplasia.[2] The prevalence of DI in teeth has been reported to be between 0.3-10%.[3,4]

Maxillary lateral incisor appears to be the most frequently affected tooth, and there is also some evidence that the anomaly may be symmetrical.[5] The clinical appearance of DI varies considerably. Although the tooth may have a normal morphology of the crowns, it may show unusual

features such as a greater labio-lingual diameter or a cusp that is ‘peg-shaped,’‘barrel-shaped,’‘conical,’ or ‘talon-shaped.’[6] The risk of developing pulpal pathology is the most signifi cant clinical concern of DI.[7] The radiological evidence depends on the severity of the invaginatus.[8]

Dens evaginatus(DE)is a developmental anomaly, which can be defi ned as a tubercle, projecting from the occlusal or lingual surfaces of the affected tooth.[9] It is comprised of enamel and dentin that usually enclosingpulp tissue[10] and referred to as “Talon’s cusp” in the anterior teeth and “Leong’s premolar” in the premolar teeth.[11] Etiology of DE is not clear, but several researcher have suggested a familial or hereditary pattern.[12] Due to tubercular fractures inDE may havesome endodontic substances such ascomplications about pulpitis, pulp necrosis, and periapical periodontitis.Occlusal forces and attrition cause to develop these fractures, and they lead to direct pulp exposure in a non-carioustooth.[13]

Most cases of dens invaginatus are discoveredwith radiographic evaluation, because of the enamel lining that is more radiopaque than the surrounding tooth structure.It is easier to detect dens evaginatus as a tubercle of enamel on the occlusal surface clinically. The radiographic image shows the extension of dentin covered with opaque

A B S T R A C T

Dens evaginatus(DE) and dens invaginatus(DI) are rare developmental dental abnormalities. Though these variations in odontogenesis have been individually observed and reported, no case of concomitance of DE and DI in a supplemental premolar have been reported in the literature. For the clinicians, it is important to recognize these anomalies and to be knowledgeable about their management. The aims of this paper are to report the radiographic and tomographic fi ndings of a novel case of DE with type II and IIIDI and to discuss the importance of early identifi cation and effi cient management of these anomalies.

Key words:Key words: Cone beam computed tomography,dens invaginatus, dens evaginatus,dental anomaly,supplemental premolar

Address for correspondence: Dr. Ahmet Ercan Sekerci, Department of Maxillofacial Radiology, Faculty of Dentistry, Erciyes University, 38039, Kayseri, Turkey. E-mail: [email protected]

Case Report

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Sekerci, et al.: Dens invaginatus and dens evaginatus are in a supplemental premolar

Journal of Oral and Maxillofacial Radiology / September-December 2013 / Vol 1 | Issue 3112

enamel. But, the pulp horn cannot be seen because of the superimposition of the enamel.[14]

Cone beam computed tomography (CBCT) potentially provides the clinician with the ability to observe an area in three different planes with a practical tool for three-dimensional reconstruction imaging for use in endodontic applications and morphologic analyses. The combination of sagittal, coronal, and axial CBCT images helps to eliminate the superimposition of anatomic structures. Tooth morphology can be visualized in three dimensions;from this point, CBCT has been suggested to assist in identifying all of the dental anomalies.[15]

Although both DE and DI have been individually reported in the literature many times, we couldn’t fi nd any report about concurrence of DE and DI within the supplemental premolar tooth.

CASE REPORT

A 30-year-old woman was referred by her general dental practitioner because of the impacted mandibular third molars and supernumerary teeth in the mandibular premolars region. No abnormalities in general growth and development or history of trauma were noted. She was very much apprehensive because of the presence of extra premolar and third molar teeth. Shehadalso complained of pain due to the areas of left premolar and third molar teeth. The lingual position of the supplemental premolars was confi rmed by clinical examination. A hard, immobile, painless swelling was detected on the lingual aspect of mandible between 34 and 35 on palpation. To dental check-up, a panoramic radiograph was obtained. Then, all of the permanent teeth as well as two supernumerary premolars, which one on either side of the mandibular arch, were found in the premolar region [Figure 1]. The appearance of tooth located at right side was so similar

to the associated premolars, which made the teeth to be considered as supplemental. The other one located at the left side had unusual morphology.The presence of supplemental premolars and impacted third molars and the surgical procedure for removing the teeth were explained to the patient. With the consent of the patient, to determine the relationship between the mentioned teeth and the periphery structures, a CBCT (Newtom VG, QP, Verona, Italy) scan was performedfor the area of interest.

The cross-sectional images of CBCT scan of the left supplemental premolar tooth in all orthogonal planes are indicated type II and III dens invaginatus and dens evaginatus. The type III invagination was separated from the wall of the root canal throughout its entire length by a narrow width of pulp space, which encircled the infolding sac [Figure 2 a-d].

The extraction of all mentioned tooth was planned, and patient expedited to surgery clinic.

DISCUSSION

Inpresent article, a novel case of DE with type II and III DI within the same tooth was reported.

The etiology of DI is controversial and remains unclear. Several theories have been put forward for the pathogenesis of the condition has been proposed, but there seems to be little agreement. The possible factors responsible area consequence of uncontrolled growth of a portion of the enamel epithelium,[16] rapid in-growth of a portion of the internal enamel epithelium into the developing adjacent dental

Figure 1: Panoramic radiograph showing bilateral supplemental premolars teeth in relation to lower premolars. In the right side, novel case of DE with type II and III DI was observed [arrow]

Figure 2: A lingual aspect of the mandibula (a), reformatted view of the invaginated [red allows] and type III evaginated [white allows] supplemental premolar tooth (b, c) and cross-sectional and axial slices at various points denoted on the sagittal section (d). Type II DI was also shown in cross-sectional image [red asterisk]. The CBCT images showed a highly complex morphology of the root canal and invagination

a

b c

d




Journal of Oral and Maxillofacial Radiology / September-December 2013 / Vol 1 | Issue 3 113

papilla,[17] external forces exerted on the developing tooth germ by the growing dental arch,[3] adjacent developing tooth germs,[18] absence of certain inter-cellular signal molecules causing dental anomalies,[19] trauma,[20] and infection during tooth development.[21] Alongwiththesefactors,there is signifi cant evidence suggesting a genetic component in the development of DI.[19]

Numerous studies have examined the prevalence of dens invaginatus.The prevalence of DI in teeth has been reported to be between 0.04-10%with a femaletomalepredilectionintheratio of 3:1.[22] In permanent dentition, it commonly occurs in maxillary lateral incisors followed by the maxillary central incisors, premolars, canines, and less often in the molars.[23] Invagination of posterior teeth is infrequent;[24] reported that 6.5% of affected teeth were posterior.Invagination of mandibular incisors is even more uncommon[25] and in primary teeth.[5] DI may occur bilaterally[24] and can also occur in combination with other dental abnormalities.[26]

The clinical presentation of dens invaginatus varies.The clinical presentation of dens invaginatus varies according to its severity.[27] In affected teeth, the morphology of the crowns can appear normal or it can also show unusual forms such as a slightly deeper than normal cingulum pit, a greater buccolingual dimension, peg-shaped form, barrel-shaped form, conical shapes, and talon cusps,[28]

a complex fi ssure pattern on posterior teeth.[29] A deep foramen cecum might be the fi rst clinical sign indicating the presence of an invaginated tooth. As this area is diffi cult to access and clean,[30] patients may initially present with signs or symptoms associated with pulpitis and apical or marginal periodontitis.[5]

The most widely used classifi cation of dens invaginatus was proposed byOehlers.[29] He described DI based on the radiographicinterpretation of the degree of invagination into three types: Type I, Type II, and Type III. Type I indicates a minor enamel lined invagination that isrestricted within the crown of the tooth and does not extend beyond the level of the externalcemento-enamel junction. Type II: Enamel lined and extendsinto the pulp chamber without any communications to either the pulpal orperiodontal ligament.TypeIII: An invagination seen runninginto the root,perforatingthe apical area and having a second foramen in the apical orperiodontal area, but there is no immediate communicationwith the pulp.[31] Among the different types of DI, Type IIIDI are relatively rare, constituting only 5% incomparison to Type I (79%) and Type II (15%).[32]

The radiological appearance depends on the severity of the invaginatus. The invagination may appear simply as a radiographicrepresentation of the occlusal or palatal pit.[33]

Other radiographic appearances include a loop invagination confi ned within the tooth and pointing towards its apex,[22]

a radiolucent pocket with or without a radiopaque border[23] or an enamel lined fi ssure of variable length running all the way to the periodontal ligament laterally or apically, giving theappearance of a ‘pseudocanal.’[34] As the enamel lining seen radiopaque in radiographs, CBCT is useful in order to eliminate superimpositions.[14]

DE is a rare odontogenic dental anomaly that can be defi ned asa tubercle or protuberance from the involved surface of the tooth and consists of an outer layer of enamel, a core of dentin, and sometimes, a slender extension of pulp tissue.[10] The exact etiology of these variations remains unclear. However, the probable role of genetics and environmentalfactors, such as trauma or other localized insults affectingthe tooth germ, have been suggested.[35]

A review of the relevant literature reports revealed a high incidence of the presence of DE among populations of Asian descent [including Chinese, Malay, Thai, Japanese, Filipino, and Indian populations], with a frequency between 0.5% and 4.3%.[36] This additional cusp has a rare occurrence in Caucasians and African-Americans, whereas in populations with North American Indian populations and in specifi c Eskimos, this anomaly has higher prevalence rates [up to 15%].[37] It is more common in mandibular premolars than in maxillary premolars [more than twice as many], and about 50% of cases have bilateral involvement of collateral teeth.[36]

Early diagnosis and management of DE is important to preventa variety of clinical problems such as stagnation of food, caries, periapical lesions, other soft tissue irritation, breast feeding problems, compromised esthetics, occlusal interference, which may lead to accidental cusp fracture, displacement of the affected tooth, irritation of the tongue during speech, and mastication. Occlusal interference can damage the periodontium, cause infra-occlusion of the opposing tooth, and also temporomandibular joint pain.[38]

Oehlers reported that abnormalocclusal forces on the crown can produce subluxation,leading to dilaceration of the root at the apical onethirdlevel.[39] Severe attrition or fracture of the enamel surface can cause exposure of the dentine–pulp complex and consequently pulp necrosis. Various prophylactic treatments have been proposed to treat these teeth before pulp infection occurs: Selective grinding of the tubercles, application of resin to reinforce the tubercles, placement of prophylactic amalgam or




Journal of Oral and Maxillofacial Radiology / September-December 2013 / Vol 1 | Issue 3114

composite restorations after removal of the tubercles, and cavity preparations.[38]

CONCLUSION

Although DE and DI are relatively commonanomalies, the combination of both in a supplemental tooth isanovelty.The present report highlights the need for careful consideration of DE and DI before making an actual diagnosis using CBCT.In addition, it is necessary for dentists to be reasonably well-informed on the radiographic appearances of the DE and DI. An accurate assessment of this morphology was made with the help ofCBCT.

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Cite this article as: Sekerci AE, Ozcan G, Aglarci OS. A novel presentation of a supplemental premolar tooth with dens invaginatus and dens evaginatus and role of the CBCT in diagnosis. J Oral Maxillofac Radiol 2013;1:111-4.

Source of Support: Nil. Confl ict of Interest: None declared.



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