CopjriKhr 0 Munksguurd 1998

Endodontics & Dental Ik?rrmotology

ISSN 0109-2502

Case report

A case of combined dental development abnormalities: importance of a thorough examination Jimenez-Rubio A, SeguraJJ, FeitoJ. A case of combined dental development abnormalities: importance of a thorough examination. Endod Dent Traumatol 1998; 14: 99-102. 0 Munksgaard, 1998.

Abstract - This report describes a case of combined dental develop- ment abnormalities. A patient with a previous ectopically erupted supernumerary maxillary canine presented a new ectopically erupted supernumerary premaxillary tooth with dens invaginatus (Oehlers' type 2) and an aberrant coronal morphology, including a pit in the distal portion of the palatal surface. This tooth would have been diagnosed earlier if a panoramic radiograph had been taken at the first visit 5 months before. This case represents a good example of combined dental development abnormalities, i.e., a nu- merical anomaly (the supernumerary tooth), an alteration of den- tal position (the ectopic eruption), an alteration of dental mor- phology (the aberrant coronal shape), and the invagination. This case highlights the importance of a thorough examination, includ- ing complementary radiography, of patients with a dental an- omaly.

A. JiinCez-Rubio, J. J. Segura, J. J. Feito Department of Dental Pathology and Therapeutics. School of Dentistry. University of Seville. Seville, Spain

Key words: dens invaginatus; dental abnormalities; supernumerary tooth; tooth morphology Alicia JimBnez-Rubio, Patologia y Teraphtica Dental, Avda. Cruz del Campo, 41, 41005-Sevilla, Spain Tel: +34 (95) 4573797 E-mail: Rubioman@sc.cica.es Accepted November 11, 1997

Supernumerary teeth develop as a consequence of the ' xoliferation of epithelial cells from the dental lamina I 1) and are relatively common in the m d a r y incisor (ind molar areas. However, bilateral ectopic, f d y :rupted supernumerary teeth are relatively rare (2).

'Dens invaginatus is a developmental anomaly result- !mg fiom an invagination of the surface of a tooth 'xown before calcification has occurred (3). The aeti- 'o\ogy of tkis dental anomaly is most probably a deep 'folding of the foramen caecum during tooth develop- ment, which in some cases may even result in a sec- ond apical foramen. It may be caused by increased localized external pressure, focal growth retardation or focal growth stimulation in certain areas of the tooth bud (4). Traumatic events at an early age may also lead to developmental dental anomalies associ- ated with ectopic tooth eruption (5). Dens invaginatus

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has been reported in the m d a r y central and lateral incisors, canines, and bicuspids, and the mandibular incisors and bicuspids (6). The maxillary lateral in- cisors are the teeth most frequently involved in dens invaginatus, sometimes symmetrically, and the con- currence of dens invaginatus in supernumerary pre- maxillary teeth is also frequent (4, 7).

The purpose of this report is to describe a case of combined dental development abnormalities. A pa- tient, with a previous ectopically erupted supernumer- ary canine, presented a new ectopically erupted supernumerary premaxillary tooth with dens inva- ginatus which could have been diagnosed earlier if a panoramic radiograph had been taken. The radio- graphic examination of dens invaginatus affecting the ectopically erupted supernumerary premaxillary tooth is reported.

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Fg. 2. Penapical radiograph showing dens invaginatus in the right supernumerary p"r"axillary tooth with incomplete root formation. Fig. 1. Bucco-palatal radiograph of the left supernumerary pre-

maxillary tooth. Note the root dilaceraaon distally and the absence of any internal anomaly.

Case report A 15-year-old white man sought treatment for the ectopic eruption of a maxillary tooth. Clinical explo- ration showed a supernumerary canine partially erupted on the left side of the hard palate. A panor- amic radiograph was not taken. The tooth was ex- tracted, and clinical and radiographic examination did not show any dental anomaly (Fig. 1). Five months later the patient returned with another ec- topically erupting tooth in the contralateral side of the palate. A new supernumerary tooth was initiating its eruption in the right palatal region between the cen- tral and the lateral incisors. Radiographic examin- ation revealed a tooth with incomplete root formation and an invagination of enamel evident distal to the pulp space (Fig. 2). A clinical diagnosis was estab- lished of a supernumerary maxillary tooth with an Oehlers' type 2 dens invaginatus (8). The tooth was extracted and the visual examination showed ab- errant coronal morphology including a pit evident in the distal portion of the palatal surface (Fig. 3).

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Fg. 3. occlusal view of the crown of the supernumerary tooth with dens invenams. Note the disto-~dad pit.

To study the invagination better, radiographs of the extracted tooth were taken and then projected onto a screen to determine the dimensions of the invagina- tion. In the bucco-palatal projection (Fig. 4) the inva-

Combined dental abnormalities

Fg. 4. Bucco-palatal radiograph of the right supernumerary pre- m d a r y tooth with dens invaginatus.

&. 5. Mesio-distal radiograph of the right supernumerary pre- maxillary tooth with dens invaginatus.

gination was located on the distal side and seemed to extend 1 mm apically beyond the cementoenamel junction but remained confined within the root as a blind sac. The invagination was 6.3 mm long and 2.1 mm wide (external measurements). In agreement with the intraoral radiograph no communication with the pulp was evident. In the mesio-distal projection (Fig. 5) the invagination appeared not to extend apically beyond the cementoenamel junction and also ap- peared to remain confined within the root as a blind sac without communication with the pulp. On this radiograph the invagination was 6.4 mm long and 2.1 mm wide (external measurements).

Discussion

The case reported here represents a good example of combined dental development abnormalities. Four anomalies of dental development are associated, i.e., a numerical anomaly (the supernumerary tooth), an alteration of dental position (the ectopic eruption), an

alteration of dental morphology (the aberrant coronal shape), and the invagination.

The combination of these abnormalities probably indicates that common factors were involved in their aetiology. Traumatic injuries at an early age may lead to developmental dental anomalies and ectopic tooth eruption (5, 9, 10); nevertheless, in our case no evi- dence of a previous traumatic injury could be demon- strated.

In Oehlers’ classification (8) of dens invaginatus, all the crown invaginations in which the invagination does not extend beyond the cementoenamel junction are termed type 1. The invagination presented in this case exceeded the level of the cementoenamel junc- tion and did not communicate with the pulp. Accord- ing to Oehlers’ classification the dens invaginatus re- ported here belongs to type 2. In this type of dens invaginatus “the invagination extends apically beyond the cementoenamel junction but remains confined within the root as a blind sac” (8). Although it seemed that the invagination did not communicate with the pulp in this case, communication usually exists be-

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tween the root canal and the invagination (7, 11). A radiographic examination will usually disclose this condition since the invaginated enamel is recogniz- able because of its greater radiopacity (12).

The association of a tooth with combined dental development abnormalities and the previous ec- topically erupted supernumerary canine demonstrates the importance of a thorough examination of patients who present with a dental anomaly (6). In our case, the second supernumerary premaxillary tooth would have been diagnosed earlier X, at the first visit 5 months before, a panoramic radiograph had been taken. Thus when a patient presents with a simple dental abnormality, a complete radiographic examin- ation should be performed to eliminate the possibility of additional dental anomalies.

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