Multiple dens evanginatus
A case of multiple dens evaginatus.
CC: none (patient and guardian was unaware)
Dx: dens evaginatus on #5, 13, 21, 28 (possibly on #4/12/20/29)
Tx: spot grinding (see alternative treatments below)
Dens evaginatus is a congenital condition of a tooth characterized by a cusp-like anomaly on the occlusal surface. The cusp/tubercle is composed of an outer enamel layer, an inner dentin layer, and possibly an extension of a pulp horn (30% do not possess a pulp horn). It is this extension of the pulpal horn that lies at the root (no pun intended) of the problem because through normal occlusal wear (and possible fracture of the thin cusp), a pulpal exposure can result that would otherwise not happen if the tubercle was not present. Let’s look at the treatment options from most to least conservative:
Monitor - This is hoping that occlusal wear will naturally reduce the tubercle slow enough and stimulate reparative dentin fast enough to prevent pulpal exposure. This is the most conservative but runs the risk for spontaneous pulpal exposure and infection outside of a clinical setting so I would not recommend this.
Spot grinding - In this tx, we are carefully reducing the height of the tubercle over a period of months (stimulating natural occlusal wear but faster). This has the advantage of being done in a clinical setting and if pulpal exposure were to occur, then it can be addressed immediately (#3 below) and minimizing risk for infection and maximizing tooth prognosis. Once the tubercle has been completely removed and if no pulpal exposure is detected, a sealant can be placed to protect the dentin and pulp. If the patient can return for multiple dental visits, this would be my preferred tx.
Prophylactic Cvek pulpotomy - In this tx, the entire tubercle is removed in one visit and if pulpal exposure were to occur, then a Cvek pulpotomy can be performed as we are treating this as a traumatic pulpal exposure as opposed to a carious pulpal exposure. See my post on 6/17/2019 to see what a Cvek pulpotomy looks like. In my opinion, this tx is reserved for patients where access to care may be an issue and they would not be able to return for multiple visits.
Endodontic therapy - This is your traditional RCT. In my opinion, this would only have a place in the treatment of dens evaginatus if there was an existing carious pulpal exposure and periapical pathology is noted (in which case this is the only option anyway).
In this case, after presenting the treatment options, the patient and parent opt for treatment #2.
Levitan, Marc E., and Van T. Himel. "Dens evaginatus: literature review, pathophysiology, and comprehensive treatment regimen." Journal of Endodontics 32.1 (2006): 1-9.
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