L4 Dental Anomalies

Dental Anomalies¹

Dental anomalies represent a fascinating and clinically significant category of developmental variations affecting the hard tissues of the teeth. While often undiagnosed, these conditions can have profound impacts on oral health, ranging from unexpected endodontic complications to significant aesthetic concerns.

Presentation Overview

This presentation covers the second part of the series on Dental Anomalies.

Presenter Credentials

• Dr. Jilen Patel
  • BDSc (Hons) WA, DClinDent, MRACDS, FADI, FICD, FPFA, SFHEA
  • Specialist Paediatric Dentist
  • Consultant, Perth Children’s Hospital
  • Senior Lecturer, UWA Dental School

Introduction and Overview²³

Correlation Between Dental Anomalies and Developmental Stages

Specific dental anomalies can be traced back to the particular stage of tooth development in which the disruption occurs:

• Initiation Stage
  • Anodontia
• Bud Stage
  • Hypodontia
  • Supernumerary teeth
• Bud to Cap Stage
  • Fusion
  • Gemination
• Cap to Bell Stage
  • Evaginatus
• Bell Stage
  • Taurodontism
  • Dens invaginatus
  • Talon cusp
• Root Formation Stage
  • Dilaceration
  • Hypercementosis
• Eruption Stage
  • Concrescence

Classification of Morphological Anomalies

Dental anomalies affecting the shape of the tooth are categorized as follows:

• Double Tooth Formations
  • Fusion
  • Gemination
• Accessory Cusps
  • Talon cusp
  • Evaginated odontome (dens evaginatus)
• Structural Invaginations
  • Invaginated odontome (dens invaginatus)
• Root and Chamber Alterations
  • Taurodontism

Anomalies occur at various stages of tooth development. Conditions such as fusion, gemination, and evaginatus arise during crown formation, while others affect root development. Understanding the embryological timing helps explain the clinical presentation and associated complications.

Key Clinical Impact

A seemingly healthy, unrestored dental arch may present with a large radiolucency associated with a premolar, indicative of chronic periapical periodontitis. Despite the absence of obvious carious lesions or restorations, the tooth may be pulpless and infected. This scenario exemplifies how developmental anomalies—specifically dens evaginatus—can lead to catastrophic dental outcomes without early detection.

General Principles of Diagnosis

• Systematic Examination: Always examine radiographs methodically—from the condyle down the ramus, across the body of the mandible, evaluating sinuses, septum, and hard palate, then counting teeth and assessing pulp spaces systematically.
• Anomaly Clusters: If one anomaly is detected, suspect others. Anomalies in the primary dentition frequently predict anomalies in the permanent dentition (e.g., missing permanent teeth).
• Umbrella Terminology: When uncertain, use broad diagnostic terms initially (e.g., “double tooth” rather than immediate classification as fusion or gemination; “developmental defect of enamel” before specifying molar incisor hypomineralization).

Double Tooth^4567891011

Definition

Double teeth are formed of two or more elements diagnosed clinically by evidence of incisal notching with labial grooving and radiographically by pulpal bifurcation (Winter, 1969).

This term serves as a clinical umbrella diagnosis. It is safer to initially document a “double tooth” before pursuing definitive classification through radiographic investigation.

Alternative Terminology

• Connate (Tomes, 1859)
• Linking tooth (Sprinz, 1953)
• Schizodontia (DeJonge, 1955)
• Fusion (Levitas, 1965)
• Gemination (Levitas, 1965)
• Connation (Hitchin and Morris, 1966)
• Dichotomy (Schulze, 1970)
• Other terms: conjoined teeth, double formations

Etiology

• Inherited factors
• Local factors (Milano et al. 1999):
  • Union resulting from the fusion of two adjacent tooth buds
  • Partial splitting of one tooth bud into two
  • Tooth germs moving together due to crowding or trauma
• Trauma to the tooth bud may cause splitting or grooving of the developing tooth

Prevalence and Distribution

• Gender: Equal occurrence in males and females (M = F)
• Primary dentition: 0.1 – 3.0% (Brook, 1974; Buenviaje, 1984; Cheng, 2003; Sekerci et al. 2011)
• Permanent dentition: 0.1 – 0.8% (Chung et al. 1972; Brook, 1974; Tsai, 1996)

Clinical observation suggests that actual prevalence rates may be higher than statistical reports indicate.

Clinical Characteristics

• Occurrence can be unilateral or bilateral
• Predominantly located in the incisor and canine region
• More common in the maxilla
• Bilateral in primary dentition: Associated with a greater likelihood of anomalies in the permanent dentition

Clinical Presentation

• Presentation varies from a minor notch in the incisal edge of an abnormally wide incisor to the appearance of almost two separate crowns.
• Gemination: Identified if the double tooth is present alongside a normal complement of teeth in the same quadrant.
• Fusion: Identified if the total number of teeth in the quadrant is reduced.

Radiographic Assessment

• Radiographs are necessary to determine if there is a union of the pulp chambers.

• Result of the embryological persistence of the dental lamina between two tooth buds (Hitchen and Morris, 1966).

• Result of an unsuccessful attempt of two tooth buds to fuse into one (Kelly, 1978).

Fusion¹²¹³

Developmental Timing

• Early Odontogenesis: The two developing teeth unite to form a single tooth of almost normal size.
• Late Odontogenesis: Results in a tooth that can be up to twice the size of a normal tooth, or a tooth with a bifid crown.

Clinical Manifestations

• Fused teeth may possess either one or two pulp chambers.
• Commonly exhibit vertical grooves on both labial and lingual crown surfaces.
• If the affected tooth is counted as a single unit, there is typically one tooth less than the normal count for the given dental age.

Characteristics of Gemination

• Formation of two teeth from the same follicle (Ravn, 1971).
• Presence of one common pulp chamber (Kelly, 1978).
• More common in the maxilla.
• In the permanent dentition, these teeth usually present as macrodonts.
• Diagnosis of root canal morphology may be aided by Cone Beam Computed Tomography (CBCT), as plain films can be difficult to interpret.

Gemination^14151617

Clinical Problems (Hattab, 2014)

• Caries within the groove dividing the bifid crown
• Periodontal disease resulting from the extension of the groove to the root surface
• Excess arch space and diastema when normal teeth are fused
• Crowding of the dental arch if fusion involves a normal tooth and a supernumerary tooth
• Aplasia of the permanent successor in cases of primary tooth fusion
• Delayed exfoliation and root resorption of primary double teeth
• Impaction of the permanent successor
• Malocclusion
• Esthetic concerns
• Extraction risks: Assuming a single root when two exist risks root fracture during forceps extraction; surgical approaches may be required
• Endodontic complexity: Abnormal pulp chamber morphology increases the risk of missed canal systems during root canal treatment

Management Strategies

• Application of fissure sealants
• Use of flowable composite resin
• Hemi-section
• Reshaping or reduction (applicable for double teeth with a single canal)
• Orthodontic treatment and/or prosthetic replacement
• Extraction followed by implant replacement

Concrescence

A rare variant where unity occurs only at the cementum level; the enamel and cementoenamel junction (CEJ) remain separate. The joining occurs at the root level through cementum deposition.

• Mandatory radiographic evaluation (periapical, OPG, or CBCT) before extraction or endodontic therapy

Talon Cusp^{18192021222324252627282930}

Definitions

• Morphological Definition: A “process of horn-like shape” curving from the base to the “cutting edge” on the palatal surfaces of the incisors (Mitchell, 1892).
• Etymology: The term “talon cusp” was proposed because the shape of the anomaly resembles an eagle’s talon (Mellor and Ripa, 1970).
• Clinical Criteria: A cusp-like projection from the palatal surface of an anterior tooth that extends at least half the distance from the cemento-enamel junction to the incisal edge (Davis and Brook, 1985

While talon cusp refers to anterior teeth, the equivalent outfolding on posterior teeth is termed dens evaginatus. ).

Alternative Terminology

• Cusp-like projection (Mitchell, 1892)
• Hyperplastic cingulum (Worth, 1963)
• Palatal accessory cusp (Ooshima et al. 1996)
• Projection on the facial surface of the anterior teeth (Tsutsumi 1991)
• Evaginated odontome (Lee, 1968)
• Cusped cingulum (Barnes, 1969)
• Accessory cusp (Schulze, 1970)
• Dens evaginatus (Shey and Eytel, 1983)
• Supernumerary lingual tubercle (Harris and Owsley, 1991)
• T-cingulum
• Y-shaped cingulum

Frequency and Distribution

• Gender Predilection:

  • Male > Female (al-Omari et al. 1999)
  • Male to Female ratio of 1.9 : 1 (Lee et al. 2007)

• Prevalence by Dentition:

  • Primary dentition: Rare, occurring in 0.5 – 0.6% of cases (Chen, 1986; Ooshima et al. 1996; Liu, 1996).
  • Permanent dentition: 1 – 2.5% (Ooshima et al. 1996; Mavrodisz et al. 2003; King et al. 2010).

• Location: Observed only in the maxillary anterior teeth, involving the incisors and canines

However, mandibular occurrences have also been documented. The condition shows etiological overlap with supernumerary teeth, with males tending toward “bigger teeth” anomalies and females toward “missing teeth” anomalies. .

Etiology

• The exact cause is unknown.
• Multifactorial: Involves both genetic and environmental factors (Davis and Brook, 1986; al-Omari et al. 1999).
• Developmental Folding: May occur due to an outward folding of the inner enamel epithelial cells and a transient focal hyperplasia of the mesenchymal dental papilla (Hattab et al. 1996).
• Dental Lamina Activity: Hyperactivity of the dental lamina, commonly in the anterior region (Rantanen, 1971).
• Fusion: May result from the fusion of a normal tooth and a supernumerary tooth (Hennekam and Van Doorne, 1990).

Classification (Hattab et al. 1996)

• Type 1 - Talon: A morphologically well-defined additional cusp that prominently projects from the palatal surface of a primary or permanent anterior tooth and extends at least half the distance from the cemento-enamel junction to the incisal edge.

• Type 2 - Semi-talon: An additional cusp of a millimeter or more but extending less than half the distance from the cemento-enamel junction to the incisal edge. It may blend with the palatal surface or stand away from the rest of the crown.

• Type 3 - Trace talon: Presents as an enlarged and prominent cingulum and its variations (e.g., conical, bifid, or tubercle-like).

Modified Classification (Hsu et al. 2001)

• Type 1 - Major talon: A morphologically well-defined additional cusp projecting from the facial or palatal/lingual surface of an anterior tooth, extending at least half the distance from the cemento-enamel junction to the incisal edge.
• Type 2 - Minor talon: A morphologically well-defined additional cusp projecting from the facial or palatal/lingual surface of an anterior tooth, extending more than one-fourth but less than half the distance from the cemento-enamel junction to the incisal edge.
• Type 3 - Trace talon: Enlarged or prominent cingula and variations occupying less than one-fourth the distance from the cemento-enamel junction to the incisal edge.

Note: These may occur on facial, lingual, or both facial and lingual surfaces (Mallineni et al. 2014

Classification Terminology

The terminology Major/Minor/Trace is preferred over numerical classifications (Type 1/2/3) to avoid confusion between the Hattab and Hsu systems.).

Radiographic Appearance

• Resembles a radio-opaque V-shaped structure pointing towards the incisal edge of the tooth.
• The structure is superimposed on the normal image of the crown.
• The cusp image is outlined by two distinct white lines (representing enamel) converging from the cervical area toward the incisal edge.

Differentiation from Supernumerary Teeth

Differentiation from superimposed supernumerary teeth may require:

• Horizontal tube shift (parallax) technique
• CBCT imaging to confirm continuity with the main tooth structure

Associated Syndromes

Talon cusp is prevalent in the following conditions:

• Rubinstein-Taybi syndrome
• Mohr syndrome (Oral-facial-digital II)
• Sturge-Weber syndrome (Encephalo-trigeminal angiomatosis / Sturge-Weber angiomatosis)
• Incontinentia pigmenti achromians
• Ellis-van Creveld syndrome (Chondroectodermal dysplasia)
• Hypomelanosis of Ito
• Alagille’s syndrome
• Berardinelli-Seip

Clinical Complications (Hsu, 2001)

• Esthetic and Functional Issues:

  • Compromised esthetics (facial talon cusp)
  • Traumatic occlusion
  • Displacement of affected and opposing teeth
  • Irritation of tongue during speech and mastication
  • Interference with tongue space
  • Speech disturbance
  • Breast-feeding problems
  • TMJ joint pain due to excessive occlusal forces

• Dental and Periodontal Health:

  • Plaque retention
  • Caries susceptibility in developmental grooves
  • Pulpal necrosis
  • Hypersensitivity
  • Periodontal problems
  • Attrition of opposing teeth
  • Accidental cusp fracture
  • Periapical pathosis due to excessive attrition

Management Strategies

• Preventive Care: Application of fissure sealants or flowable composite resin to prevent caries in the grooves between the cusp and the tooth.
• Immediate application upon eruption is recommended to seal developmental grooves. Additionally, composite reinforcement may be applied to support the cusp structure and prevent fracture.
• No Treatment: Required if there is no occlusal interference.
• Management of Occlusal Interference:
  • Gradual, periodic reduction of enamel (to avoid pulp exposure) combined with fluoridation as a desensitizing agent.

Pulp Extension Risk

Pulp tissue frequently extends into the talon cusp; fracture leads to exposure, bacterial contamination, and potential necrosis. When performing gradual reduction, conduct over 2-3 appointments to allow tertiary dentine formation between sessions.

• Elective pulpotomy.
• Partial pulpectomy.
• Extraction followed by orthodontic treatment.

(Mellor and Ripa, 1970; Pitts and Hall, 1983)

Research Study: Primary Maxillary Incisors and Permanent Successors

Study Title: The relationship between a primary maxillary incisor with a talon cusp and the permanent successor: a study of 57 cases (Lee CK, King NM, Lo EC, Cho SY; Int J Paediatr Dent. 2007).

• Background: Most reported talon cusps in primary dentition involve maxillary central incisors where successors are unaffected. However, cases involving primary lateral incisors are often associated with supernumerary permanent successors.
• Aim: To describe the relationship between primary maxillary talon cusps and the morphology/number of permanent successors in Chinese children.
• Results:
  • 58 primary maxillary incisors with talon cusps were reviewed.
  • Central Incisors: 32 of 35 (91.4%) underlying permanent successors had no odontogenic abnormalities.
  • Lateral Incisors: 18 of 23 cases (78.3%) showed odontogenic abnormalities; 14 of these were associated with supernumerary teeth.
• Conclusion: A high proportion of underlying permanent successors can be expected to exhibit odontogenic abnormalities when a talon cusp is present on a primary maxillary lateral incisor

Additional Research Findings

Broader studies indicate that talon cusps on primary maxillary incisors (prevalence ~3%) are associated with other anomalies in 80% of cases, with 60% of patients having supernumerary teeth elsewhere in the dentition..

Case Study: The "Perfect Teeth" Abscess

Endodontist referrals of 13-14-year-old children with pristine dentition, acute abscesses, immature apices, and no trauma history revealed dens evaginatus with fractured tubercles. In adolescents with “perfect” premolars presenting with acute infection, this condition should be the primary differential diagnosis. Early detection and preventive composite capping can prevent catastrophic infection.

Case Study: Bilateral Evaginatus with Early Eruption

A 10-12-year-old patient with partially erupted maxillary premolars (teeth 14 and 24) displaying pronounced bilateral tubercles and trace talon cusps on central incisors. Management included fissure sealants and careful caries excavation with caution regarding pulp extension into talon cusps.

Dens Evaginatus^{3132333435363738}

Definition and Terminology

Dens evaginatus is an enamel-covered tubercle projecting from the occlusal surface of a premolar and, in rare instances, canines and molars (Lau, 1955; Allright, 1958).

Alternative Terminology

• Interstitial cusp (Yumikura and Yoshida, 1936)
• Leong premolar (Leong, 1946)
• Occlusal enamel pearl (Pedersen, 1949)
• Dilated composite Odontome (Tratman, 1949)
• Odontome of axial core type (Lau, 1955; Allwright, 1958)
• Tuberculated premolar (Ohlers, 1956)
• Cone-shaped Supernumery cusp (Moorress, 1957)
• Dens evaginatus (Oehlers, 1967)
• Evaginated Odontome (Oehlers, 1967)
• Mongoloid or oriental premolar (Curzon, 1970)

Etiology

• The exact cause remains unknown.
• Multifactorial: association with racial and genetic factors.
• Histologically represents an outfolding of the enamel epithelium during crown formation
• Abnormal proliferation of the inner enamel epithelium into the stellate reticulum of the enamel caused by:
  • An outflowing of the enamel epithelium
  • Or by a transient focal hyperplasia of the primitive pulpal mesenchyme (King et al. 2010).

Prevalence and Distribution

• Mostly found on permanent teeth.
• Typically occurs on premolar teeth.
• Demonstrates marked mandibular predominance.
• Teeth with dens evaginatus usually occur bilaterally.
• Most commonly identified in children aged 10-13 years as premolars erupt
• Tubercles are often worn down by the time of clinical examination due to occlusal wear in teenagers, appearing as an accessory cusp in the central occlusal area
• Prevalence ranges between 0.1% to 4.7%.
• Frequently seen in Mongoloids, Asians, the Inuit, and Native Americans; rare in Whites (Lau, 1955; Goto et al. 1979; Ooshima et al. 1996; King et al. 2010).
• Though teeth usually occur bilaterally, asymmetric wear may mask this bilaterality
• Historical studies suggest higher prevalence in specific populations such as Southern Chinese, though contemporary evidence requires cautious interpretation

Classification (Lau, 1955)

By Location

• Tubercle can arise from the lingual ridge of the buccal cusp.
• Tubercle is located in the center of the occlusal surface.

By Form of Projection The evagination may be:

• Smooth
• Grooved
• Terraced
• Ridged

Classification by Pulp Content (Oehlers, 1967)

Oehlers identified the evagination according to the pulp contents within the tubercle:

• Wide pulp horns: 34%
• Narrow pulp horns: 22%
• Constricted pulp horns: 14%
• Isolated pulp horn remnants: 20%
• No pulp horn: 10%

Risk Stratification

Wide and superficial pulp horns represent the highest risk for pulp exposure following tubercle fracture.

Radiographic Examination and Pathologies

• The pulp tissue in the tubercle is normal unless the tubercle has been fractured or worn down, permitting bacterial invasion and consequent pulpal necrosis (Merrill, 1964).
• Standard radiographs may fail to visualize the tubercle due to superimposition of enamel
• The pulp chamber extension into the tubercle is often obscured on conventional radiographs
• Necrosis of pulp tissue can lead to acute or chronic dentoalveolar abscess.

Other Clinical Findings

• Osteomyelitis (Allwright, 1958)
• Thickening of the periodontal

Case Study: Fused Primary Molars

A child presented with dental pain and obvious carious lesions. Systematic examination revealed an unusual presentation in the posterior quadrant with an abnormal tooth sequence.

Critical Diagnostic Finding

Counting the teeth revealed an abnormal sequence: 7, 5, 7, 4, 7, 3, 7, 2, 7, 1, 8, 1, 8, 2 (where 8,1 and 8,2 appeared joined).

Clinical Findings:

• Unusual caries pattern extending across what appeared to be two teeth
• Frontal view revealed a single large tooth with a distinct groove

Diagnosis: Fusion of primary molars.

Critical Implications:

• Risk of treating as two separate teeth during extraction
• High probability of a missing permanent premolar underneath due to the genetic basis of the anomaly
• Necessity for OPG investigation to assess the permanent dentition membrane
• Periapical rarefaction
• Incomplete root formation
• Fracture of the root
• Cyst formation
• Dilaceration (Oehlers, 1967)
• Submandibular cellulitis potentially requiring hospitalization
• Immature apex complications necessitating apexification or regenerative endodontic procedures

Management Strategies

• Composite reinforcement: Supporting the sides of the tubercle with composite resin; this should be performed before the tooth comes into complete occlusion.
• Grinding of tubercle: If the tubercle causes occlusal interference, grinding followed by fissure sealing may be performed in some cases.
• Pulp Exposure Management: If trauma or attrition results in pulp exposure, an elective (Cvek) pulpotomy can be performed to allow normal root formation
• Sequential grinding: Gradual reduction with intervals for dentine formation (as with talon cusps), applying calcium hydroxide if dentine is exposed
• Advanced imaging: CBCT imaging recommended for treatment planning to assess pulp extension.
• Revascularization: An alternative treatment for pulp involvement.
• Extraction: May be considered after orthodontic consultation.

Dens Invaginatus^{39404142434445}

Definition and Terminology

An infolding of the enamel and dentin towards the pulp (Tomes, 1859).

This anomaly represents the inverse of evaginatus, with enamel folding into the pulp chamber.

Alternative Terminology:

• Warty teeth (Salter, 1855)
• Invagination of the enamel (Hallet, 1953)
• Dens in dente (Salter, 1855; Shepard, 1968)
• Invaginated odontome
• Dilated composite Odontome (Worth, 1963)
• Dents telescopes (Augsberger and Brandebura, 1978)
• Gestant Odontome (Augsberger and Brandebura, 1978)

Etiological Theories

• Growth Pressure (Euler, 1939; Atkinson, 1943):

  • Buckling of the enamel organ might be caused by growth forces in the developing arch.
  • Disproportion between jaw size and the total length of the dental arch.

• Focal Growth Retardation (Kronfeld, 1934):

  • Invagination results from a focal failure of growth of the internal enamel epithelium.
  • The surrounding normal epithelium continues to proliferate and engulfs the static area, eventually enclosing it.

• Focal Proliferation (Rushton, 1937):

  • Invagination is the result of an invasion of the dental papilla by a rapid and aggressively proliferating area of internal enamel epithelium.

Among these theories, invagination of the dental papilla is considered the most accepted mechanism of formation.

• Local Causes:

  • Trauma (Gustafson & Sundberg, 1950).
  • Infection (Fischer 1936, Sprawson 1937).

• Genetic Factors: (Grahnen et al. 1959, Casamassimo et al. 1978, Hosey & Bedi 1996).

Prevalence

Primary Dentition: 0.1% (Brook, 1974)

• Distribution: Male = Female.
• Commonly affected teeth: Primary canine, maxillary central incisor, mandibular second molar.

Permanent Dentition: 0.2-10.0%

• Distribution: Male > Female.
• Commonly affected teeth: Maxillary lateral incisors, maxillary central incisors, and canines.

While traditional literature suggests male predominance, clinical observation often reveals female predominance in affected patients.

(Atkinson, 1943; Grahnen et al. 1959; Poyton and Morgan, 1966; Kong, 1972; Lepprecht et al. 1986; King et al. 2010)

Rushton’s Classification (1937)

Coronal Dens Invaginatus:

• An anomalous infolding of the enamel organ into the dental papilla.
• Results in the folding of hard tissue within the tooth.
• Characterized by enamel lining the fold and covering the dentin peripheral to it.

Radicular Dens Invaginatus:

• Results from the invagination of Hertwig’s epithelial root sheath, leading to the accentuation of normal longitudinal root grooves.
• The invagination is lined by cementum.
• The root sheath may bud off a sac-like invagination, resulting in a circumscribed cementum defect in the root.

Oehlers’s Classification (1957)

1. Type 1: Invagination is confined to the crown of the tooth.
2. Type 2: Invagination extends beyond the cemento-enamel junction (CEJ) but does not involve the periapical tissues.
   • Remains within the root and does not reach the apex
3. Type 3: Invagination extends past the CEJ and perforates the tooth structure:
   • Type 3a: Perforates laterally at a foramen.
     • Creates a communication into the periodontal ligament
   • Type 3b: Perforates apically at a foramen.

Radiographic Features

Produces striking radiographic appearances ranging from subtle infoldings to complex "tooth within a tooth" structures with apical radiolucencies. Type 2 appears as an enamel-lined tract extending apically from the crown.

Clinical Implications

High Risk for Complications

Dens invaginatus is responsible for more adverse events in children than any other dental anomaly.

Complications:

• The infolded enamel creates a conduit for bacteria to enter the pulp system, leading to:
  • Early pulp necrosis (often shortly after eruption)
  • Periapical abscess formation
  • Prognostic challenges: Complex internal anatomy makes conventional endodontics difficult or impossible

Management:

• Early Detection: Critical for prevention. Examine all erupting maxillary lateral incisors for subtle crown distortions.
• Treatment Options:
  • Prophylactic sealing of the invagination if detected early
  • Autotransplantation: (e.g., transplanting a premolar to replace a failed lateral incisor)
  • Endodontic therapy: Complex due to conical morphology and accessory canals; CBCT essential
  • Extraction: May be the only viable option for Type 3b with periapical involvement - Communicates with the periapical tissues, creating a "tooth within a tooth" appearance

Footnotes

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