Review articleDens Evaginatus: Literature Review, Pathophysiology, and Comprehensive Treatment Regimen
Section snippets
Pathophysiology
DE is thought to develop from an abnormal proliferation and folding of a portion of the inner enamel epithelium and subjacent ectomesenchymal cells of the dental papilla into the stellate reticulum of the enamel organ during the bell stage of tooth formation (24, 25, 26). The resultant formation is defined as a tubercle, or supplemental solid elevation on some portion of the crown surface.
To establish a proposed embryologic etiology for this unusual entity, it is important to review the most
Morphology
The DE tubercles of posterior teeth average 2.0 mm in width (37) and up to 3.5 mm in length (9), and up to 3.5 mm in width and 6.0 mm in length for anterior teeth (17). Other than the cusp-like variable sized and shaped tubercle of teeth with DE, the remaining portion of the crown has a normal anatomy (6). This is an additional distinguishing characteristic from the accessory cusp of Carabelli, that when present, the associated teeth are often larger than normal mesiodistally (1). However,
Clinical Issues
Because the DE tubercle may extend above the occlusal surface up to 3.5 mm (6.0 mm for anterior teeth), malocclusion with the opposing tooth upon the cusp-like elevation occurs as involved teeth erupt into the dental arches. The resultant occlusal traumatic force causes abnormal wear or fracture of the tubercle, and is the usual manner of pulp exposure for this anomaly. Caries has historically not been a factor for consideration regarding pulpal involvement for this entity. A pathology report
Treatment of DE
Teeth presenting with a normal pulp and a mature apex (type I) should have the opposing occluding surface reduced to eliminate traumatic occlusion with the tubercle, followed by an application of topical fluoride to increase the enamel’s hydroxyapatite resistance to acid breakdown. Then, incremental layering of an acid-etched flowable light-cured resin (AEFLCR) is applied to the tubercle and surrounding surface (Fig. 2, tooth #21 and Fig. 6, tooth #28). Reevaluation at 6-month intervals is
Prophylaxis
Prevention of pulpal involvement in cases of DE is preferred over more invasive techniques. Because pulp exposure of the tubercle resulting from occlusal forces occurs soon after eruption, prophylactic intervention will prevent the need for treatment of teeth with immature apices and thin, weak roots. Even when pulp exposure is avoided past the period of complete root formation, the tubercles are still susceptible to fracture. Past treatment modalities suggested have had inconsistent results.
Case Study
The authors believe this to be a rare documented case of DE in a patient of Mestizo heritage. The earliest reported DE case in an individual with this familial heritage is by Priddy et al. in 1976 (37). However, early articles are devoid of the phraseology currently used to depict individuals of this heritage (14, 37, 78). In September 2003, a 13-year-old Mestizo female presented to the University of Tennessee College of Dentistry patient clinic. She presented with DE involving all four
Discussion
The treatment regimen for cases of type III through type VI can also be applied to traumatized teeth presenting with fractured crowns and pulp exposure. All of the considerations for evaluating the pulpal status and extent of root maturity when diagnosing these traumatized teeth are similar to patients who present with fractured tubercles as a complication of DE.
America’s largest minority, the Hispanic/Latino/mestizo people, constitutes 13.7% (40 million) of the US population. Since 1980, their
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