- Email: [email protected]
Double dens in dente in bilateral rudimentary supernumerary central incisors (mesiodens)
DOUBLE DENS JN DENTE IN SUPERNUMERARY CENTRAL Report W.
HARRY
ARCHER, ~IF,HTER
R/I.
BILATERAL INCISORS
RUDINUENTARY (MESIODENS)
of a Case
B.S., l>.U.S., M.S.,” YIWWWRGH, SILVERMAN, B.A., H.H.S., M.S.I).,“* SPRINGFIELD,
P,A.,
AND
ABASH.
ENS IN HENTK has been the subject of a number of articles in the recent dental literature. Conflicting theories relevant to its etiology have been propounded. Basically, t,wo theories have been developed. The cause of dens in dente, according to Kronfeld,’ is an invagination during the developmental stage of the tooth. The growth of the tooth germ is regarded as centrifugal in nature and the dens is resultant of localized retardation during the growth process followed by ingrowt,h of tooth tissue and its subsequent enclosure. Kitchin2, 3 elaborating on Kronfeld’s theory, described it as an abnormality of morphogenesis of the tooth, including the shaping of the root area. He further defined dens in dente as “the maldevelopment of a single tooth resulting from abnormal invagination and a subsequent degree of enclosure of tooth tissue normally confined to an outside surface. ” Swanson and McCarthy4 advanced a second theory. They “believe these malformations to be caused by a proliferation of the cells of the enamel organ into the dent,al papilla. ” This proliferation occurs during the stage of differentiation of the developing tooth germ at the inner enamel epithelium. Among the cases reported in the literature, Moralj cited a specimen of dens in dente in a supernumerary maxillary tooth. The first account of a bilateral dens in dente was published by Swanson and McCarthy.4 Supernumerary teeth are quite common in the maxillary incisor region. Those developing between the two central incisors, occurring singly or in pairs, have been named mesiodens by Balk.” The following case report illustrates a double dens in dente in bilateral rudimentary supernumerary cent,ral incisors. Their position in the maxilla may justify their placement in the category of bilateral mesiodens. A search of the literature reveals that no such case has been reported to date.
D
Case Report On presentation, permanent teeth. *Professor **Resident
of Oral in Oral
the patient’s Surgery, Surgery,
University Eye and
chief complaint of Ear 722
Pittsburgh. Hospital,
was delayed eruption
School Pittsburgh,
of
Dentistry. Pa.
of the
DOUBLE
DENS
IN
723
DENTE
Past History.-About one and one-half years previously, this g-year-old child was referred to an oral surgeon for the extraction of deciduous carious teeth. Nine teeth were extracted. No radiographs were taken. It was felt that following removal of the nine teeth the permanent maxillary incisors would erupt. However, the eruption process did not ensue. Recently the right and
A.
Fig.
Fig.
I.-A,
2.-Occlusal
B,
fllm
B.
and
C, Bilateral
demonstrating
dens
position indicative
in
c.
dente
of supernumerary
of bilateral dens of mesiodens.
me&l
maxillary
to the
teeth.
central
incisors,
left maxillary lateral incisors began to erupt. To determine the cause for the delayed eruption of the maxillary central incisors, radiographs were taken (Figs. 1 and 2). These revealed two odontomas ( ?) in the maxillary anterior region lying in the normal path of eruption of the maxillary central incisors. The patient was admitted to the hospital on Feb. 24, 1949, for treatment.
724
W.
HARRY
ARCHER
AND
LESTER
M.
SILVERMAN
revealed a well-developed, well-nourished Exa,mination.-Examination > gyea r-old child in no apparent distress : Eyes : Pupils, round, equal, reacted to L. and A. Ears : Normal. Nose : Free and clear. General physical examination : Negative and noncontributory. Mouth: In fair state of oral hygiene. Gingivae and oral mucosa appeared normal. The first permanent molars were carious. The per manent maxillary lateral incisors were partially erupted. The maxi11 ary The permanent n Iancentral incisors were not present in the arch. dibular incisors had erupted normally. Fig.
Fig. Fig xillary Fig
3.-Apical appearance incisors. Each contains 4.--Appearance of labial
Lab Ioratory
of partially a double surface
3
4.
Complete(l CI‘Owns of bilateral dens in dente. Dens in dente are partly of teeth.
examination: Urine : Negative Blood: R.B.C., 4,500,OOO; W.B.C., 6,800; Hb., 91 per cent Bleeding time, 1 minute, 20 seconds Coagulation time, 4 minutes
supernunu visible.
2rar.y
725
DOUBLE DENS IN DENTE
ary
Fig. Fig. central
5.-Appearance B.-Appearance incisors.
of incisal of lingual
Fig.
‘I.-Radiographs
of
dens
Fig.
8.-Radiographs
of
dens
Fig. process.
surface surface
Fig.
5.
Fig.
6.
of
the rudimentary of the incompletely
supernumerary formed rudimentary
teeth. supernumer-
Fig. 8.
7. in in
dente dente
following following
extraction, extraction.
outlining
the
invagination
726
W.
HARRY
ARCHER
AND
LESTER
M.
SILVERMAN
The patient was scheduled for surgery on February 25, with routine preoperative orders. Penicillin therapy, 300,000 units intramuscularly daily, was instituted. Operation Record.-A preoperative diagnosis of bilateral rudimentary teeth had been made, and an operation for their surgical removal was scheduled. Under Avertin-ether anesthesia, the face and mucous membrane were prepared with tincture of Merthiolate, and lips coated with petrolatum. A Molt mouth prop was inserted into the mouth, and jaws separated. The tongue was grasped by gauze held between the fingers, and brought forward exposing the tip which was scrubbed dorsally and ventrally with tincture of Merthiolate. A curved needle with No. 0 plain catgut suture was passed through the midline of the tongue one inch from the tip and brought forward for a distance of 6 inches. The needle was cut from the suture; a knot was tied in the ends of the four strands; a hemostat was clamped on this knot and held to the cover sheet by a towel clip. Oropharyngeal partition was then placed. An incision was made along the crest of the ridge from the right cuspid to the left cuspid region, and thence at a 45O angle to the mucobuccal fold. A mucoperiosteal flap was reflected labially, and overlying bone was removed with a chisel and mallet. Two rudimentary teeth were then exposed. These were removed by means of exolevers. On examination these were found to contain partially formed rudimentary teet,h within themselves, indicative of dens in dente (Figs. 3, 4, 5, and 6). The wound was debrided with curettes and the process trimmed with rongeurs and b,one files. Crystalline sulfanilamide was sprinkled into the cavity. The tissues were approximated, coapted, and sutured with 000 catgut. The patient left the operating room in good condition. The patient followed a normal postoperative course. Moderate edema of the right and left buccal fascial spaces subsided in several days. The patient experienced slight pain and discomfort. He was discharged on Feb. 27, 1949, to be followed at the office. Radiographs taken of the rudimentary teeth following extraction demonstrated the outline of the invagination process. The reverse relationship of A careful enamel and dentine in a dens was clearly outlined in the radiographs. study of the radiographs revealed not one but two dens in each rudimentary tooth (Figs. 7 and 8). summary A case of double dens in dente in bilateral rudimentary supernumerary central incisors has been presented. As demonstrated by radiographic evidence, this case may also be classified as a mesiodens.
References Dens in Dente, J. D. Res. 14: 49-65, 1934. R.: P. C.: Dens in Dente, J. D. Res. 15: 17-21, 1935. P. C.: Dens in Dente, ORAL SURG., ORAL MED. AND ORAL PATH. 2: 1181-1193, 1949. Bilateral Dens in Dente, J. D. Res. 26: 4. Swanson, W. F., and McCarthy, F. M., Jr.: 167-171, 1947. Eine selten Zahnmissbildung, O-U. Vrtljschr. f. Zahnh. 34: 1, 1918. 5. Moral, Hans: 6. Bolk, L.: Die uberzahligen oberen Ineivivi des Menschen, Deutsche Monatschr. f. Zahnh. 35: 185, 1917.
1. Kronfeld, 2. Kitchin, 3. Kitchin,
HARRY
ARCHER, ~IF,HTER
R/I.
BILATERAL INCISORS
RUDINUENTARY (MESIODENS)
of a Case
B.S., l>.U.S., M.S.,” YIWWWRGH, SILVERMAN, B.A., H.H.S., M.S.I).,“* SPRINGFIELD,
P,A.,
AND
ABASH.
ENS IN HENTK has been the subject of a number of articles in the recent dental literature. Conflicting theories relevant to its etiology have been propounded. Basically, t,wo theories have been developed. The cause of dens in dente, according to Kronfeld,’ is an invagination during the developmental stage of the tooth. The growth of the tooth germ is regarded as centrifugal in nature and the dens is resultant of localized retardation during the growth process followed by ingrowt,h of tooth tissue and its subsequent enclosure. Kitchin2, 3 elaborating on Kronfeld’s theory, described it as an abnormality of morphogenesis of the tooth, including the shaping of the root area. He further defined dens in dente as “the maldevelopment of a single tooth resulting from abnormal invagination and a subsequent degree of enclosure of tooth tissue normally confined to an outside surface. ” Swanson and McCarthy4 advanced a second theory. They “believe these malformations to be caused by a proliferation of the cells of the enamel organ into the dent,al papilla. ” This proliferation occurs during the stage of differentiation of the developing tooth germ at the inner enamel epithelium. Among the cases reported in the literature, Moralj cited a specimen of dens in dente in a supernumerary maxillary tooth. The first account of a bilateral dens in dente was published by Swanson and McCarthy.4 Supernumerary teeth are quite common in the maxillary incisor region. Those developing between the two central incisors, occurring singly or in pairs, have been named mesiodens by Balk.” The following case report illustrates a double dens in dente in bilateral rudimentary supernumerary cent,ral incisors. Their position in the maxilla may justify their placement in the category of bilateral mesiodens. A search of the literature reveals that no such case has been reported to date.
D
Case Report On presentation, permanent teeth. *Professor **Resident
of Oral in Oral
the patient’s Surgery, Surgery,
University Eye and
chief complaint of Ear 722
Pittsburgh. Hospital,
was delayed eruption
School Pittsburgh,
of
Dentistry. Pa.
of the
DOUBLE
DENS
IN
723
DENTE
Past History.-About one and one-half years previously, this g-year-old child was referred to an oral surgeon for the extraction of deciduous carious teeth. Nine teeth were extracted. No radiographs were taken. It was felt that following removal of the nine teeth the permanent maxillary incisors would erupt. However, the eruption process did not ensue. Recently the right and
A.
Fig.
Fig.
I.-A,
2.-Occlusal
B,
fllm
B.
and
C, Bilateral
demonstrating
dens
position indicative
in
c.
dente
of supernumerary
of bilateral dens of mesiodens.
me&l
maxillary
to the
teeth.
central
incisors,
left maxillary lateral incisors began to erupt. To determine the cause for the delayed eruption of the maxillary central incisors, radiographs were taken (Figs. 1 and 2). These revealed two odontomas ( ?) in the maxillary anterior region lying in the normal path of eruption of the maxillary central incisors. The patient was admitted to the hospital on Feb. 24, 1949, for treatment.
724
W.
HARRY
ARCHER
AND
LESTER
M.
SILVERMAN
revealed a well-developed, well-nourished Exa,mination.-Examination > gyea r-old child in no apparent distress : Eyes : Pupils, round, equal, reacted to L. and A. Ears : Normal. Nose : Free and clear. General physical examination : Negative and noncontributory. Mouth: In fair state of oral hygiene. Gingivae and oral mucosa appeared normal. The first permanent molars were carious. The per manent maxillary lateral incisors were partially erupted. The maxi11 ary The permanent n Iancentral incisors were not present in the arch. dibular incisors had erupted normally. Fig.
Fig. Fig xillary Fig
3.-Apical appearance incisors. Each contains 4.--Appearance of labial
Lab Ioratory
of partially a double surface
3
4.
Complete(l CI‘Owns of bilateral dens in dente. Dens in dente are partly of teeth.
examination: Urine : Negative Blood: R.B.C., 4,500,OOO; W.B.C., 6,800; Hb., 91 per cent Bleeding time, 1 minute, 20 seconds Coagulation time, 4 minutes
supernunu visible.
2rar.y
725
DOUBLE DENS IN DENTE
ary
Fig. Fig. central
5.-Appearance B.-Appearance incisors.
of incisal of lingual
Fig.
‘I.-Radiographs
of
dens
Fig.
8.-Radiographs
of
dens
Fig. process.
surface surface
Fig.
5.
Fig.
6.
of
the rudimentary of the incompletely
supernumerary formed rudimentary
teeth. supernumer-
Fig. 8.
7. in in
dente dente
following following
extraction, extraction.
outlining
the
invagination
726
W.
HARRY
ARCHER
AND
LESTER
M.
SILVERMAN
The patient was scheduled for surgery on February 25, with routine preoperative orders. Penicillin therapy, 300,000 units intramuscularly daily, was instituted. Operation Record.-A preoperative diagnosis of bilateral rudimentary teeth had been made, and an operation for their surgical removal was scheduled. Under Avertin-ether anesthesia, the face and mucous membrane were prepared with tincture of Merthiolate, and lips coated with petrolatum. A Molt mouth prop was inserted into the mouth, and jaws separated. The tongue was grasped by gauze held between the fingers, and brought forward exposing the tip which was scrubbed dorsally and ventrally with tincture of Merthiolate. A curved needle with No. 0 plain catgut suture was passed through the midline of the tongue one inch from the tip and brought forward for a distance of 6 inches. The needle was cut from the suture; a knot was tied in the ends of the four strands; a hemostat was clamped on this knot and held to the cover sheet by a towel clip. Oropharyngeal partition was then placed. An incision was made along the crest of the ridge from the right cuspid to the left cuspid region, and thence at a 45O angle to the mucobuccal fold. A mucoperiosteal flap was reflected labially, and overlying bone was removed with a chisel and mallet. Two rudimentary teeth were then exposed. These were removed by means of exolevers. On examination these were found to contain partially formed rudimentary teet,h within themselves, indicative of dens in dente (Figs. 3, 4, 5, and 6). The wound was debrided with curettes and the process trimmed with rongeurs and b,one files. Crystalline sulfanilamide was sprinkled into the cavity. The tissues were approximated, coapted, and sutured with 000 catgut. The patient left the operating room in good condition. The patient followed a normal postoperative course. Moderate edema of the right and left buccal fascial spaces subsided in several days. The patient experienced slight pain and discomfort. He was discharged on Feb. 27, 1949, to be followed at the office. Radiographs taken of the rudimentary teeth following extraction demonstrated the outline of the invagination process. The reverse relationship of A careful enamel and dentine in a dens was clearly outlined in the radiographs. study of the radiographs revealed not one but two dens in each rudimentary tooth (Figs. 7 and 8). summary A case of double dens in dente in bilateral rudimentary supernumerary central incisors has been presented. As demonstrated by radiographic evidence, this case may also be classified as a mesiodens.
References Dens in Dente, J. D. Res. 14: 49-65, 1934. R.: P. C.: Dens in Dente, J. D. Res. 15: 17-21, 1935. P. C.: Dens in Dente, ORAL SURG., ORAL MED. AND ORAL PATH. 2: 1181-1193, 1949. Bilateral Dens in Dente, J. D. Res. 26: 4. Swanson, W. F., and McCarthy, F. M., Jr.: 167-171, 1947. Eine selten Zahnmissbildung, O-U. Vrtljschr. f. Zahnh. 34: 1, 1918. 5. Moral, Hans: 6. Bolk, L.: Die uberzahligen oberen Ineivivi des Menschen, Deutsche Monatschr. f. Zahnh. 35: 185, 1917.
1. Kronfeld, 2. Kitchin, 3. Kitchin,