Clinics and Practice 2012; volume 2:e46

Ectopic enamel pearl

Vandana Rathva Department of Periodontics, K.M.Shah dental college and hospital, Piparia, Vadodara, Gujarat, India

enamel), composite enamel pearls or enamel dentin pearls (formed by enamel and dentin) and enamel-dentin-pulp pearls (formed by enamel, dentin and pulpal tissue). Most enamel pearls are composite enamel pearls appear as well-derived, radiopaque round masses.2 They are suggested as a cause of periodontitis because they obtrude connective tissue attachment, allowing only a hemidesmosomal junction less resistant to periodontal breakdown.

Correspondence: Vandana Rathva, 56, Gajanan Park, Near Manjalpur Water Tank, G.I.D.C. Road, Manjalpur, Vadodara-390011,Gujarat, India. Tel: +91.9825593509 - Fax:+91.2668.245069. E-mail: drvandana07@hotmail.com Key words: enamel pearls, localized periodontitis, root enamel. Received for publication: 20 December 2011. Revision received: 28 February 2012. Accepted for publication: 1 March 2012. Conflict of interests: the author declares no potential conflict of interests. This work is licensed under a Creative Commons Attribution NonCommercial 3.0 License (CC BYNC 3.0). Copyright V. Rathva, 2012 Licensee PAGEPress, Italy Clinics and Practice 2012; 2:e46 doi:10.4081/cp.2012.e46

Abstract
Enamel pearls are one of a number of different enamel structures that can be found on the roots of deciduous and permanent teeth. They have a distinct predilection for the furcation areas of molar, particularly the maxillary third and second molars. However, they have been found less commonly on the apical portions of the root. This report describes an unusual case of enamel pearl on apical third of mandibular molar teeth. Enamel pearl was confirmed as predisposing factor for the cause of localized periodontitis; it is very important to recognize their radiographic aspect to ensure proper treatment of involved teeth.

Case Report
A 30-year-old man systemically healthy presented with chief complaint of bleeding gums. Periapical radiograph revealed severe bone loss around the mandibular first molar. The presence of one enamel pearl on the first right molar on mesial root surface (Figure 1). Periodontal probing showed local bleeding on interproximal areas. A diagnosis of chronic localized severe periodontitis was established. Non-surgical periodontal therapy (scaling and root planning) was done. After one month periodontal regenerative surgical therapy with odontoplasty was planned (Figure 2). Reevaluation and follow up planned.

Enamel pearls are a developmental anomaly of teeth, also known as enamelous, enamel droplets, enamel globules, enamel nodules, enamel knots and enamel exostoses.1,2 They are ectopic globules of enamel on the root surface; on rare occasions, they may occur within dentin and in these cases they are referred to as intradental, interdental, or intradentinal enamel pearls.1-3 The mean prevalence of enamel pearls is 2.69%; when referring to only molars, it is 2.28%.1,4 Enamel pearls have a predilection for molars and are rarely associated with premolars, canines or incisors.1 In 20% of cases, multiple teeth are involved; 10.8% have two molars involved; 2.7% have five.4 In 8.7% of cases, it is possible to find more than one pearl per molar with as many as four pearls on the same tooth.3 Enamel pearls occur mainly in permanent teeth, but primary teeth can also be affected.3 Their cause remains obscure. A theory suggests that they develop because of residual Heartwigs epithelial root sheath.1,2,4 Macroscopically, enamel pearls appear as small, well-defined globules of enamel, generally round, white, smooth and glass-like, that adhere to the tooth via a sessile base. The diameter can vary between 0.3 and 4 mm (mean 1.7 mm).1,2 Histologically, enamel pearls are classified as true enamel pearls (formed entirely of

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Figure 1. Radiographically, enamel pearl seen as radiopaque mass on mesial surface of root of mandibular first molar. Figure 2. Clinically, after reflection of flap, enamel pearl seen as globule attached to root cementum. [Clinics and Practice 2012; 2:e46]

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Discussion
This rare case of enamel pearl present on apical third of mandibular teeth showed that it had facilitated the progression of periodotntitis. It is well established that anatomical or iatrogenic factors can predispose a particular site to periodontitis. Enamel pearls preclude connective tissue attachment.1,4,5 An early diagnosis of enamel pearls is important for better prognosis. Once detected should be surgically eliminated. Moreover, odontoplasty, tunneling, root separation or resection are indicated.

References
1. Moskow BS, Canut PM. Studies on root enamel (2). Enamel pearls. A review of their morphology, localization, nomenclature, occurrence, classification, histogenesis and incidence. J Clin Periodontol 1990; 17:275-81. 2. Kupietzky A, Rozenfarb N. Enamel pearls in the primary dentition: report of two cases. ASDC J Dent Child 1993;60:63-6. 3. Cavanha AO. Enamel pearls. Oral Surg Oral Med Oral Pathol 1965;19:373-82. 4. Darwazeh A, Hamasha AA. Radiographic evidence of enamel pearls in Jordanian dental patients. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2000;89:255-8. 5. Goldstein AR. Enamel pearl as contributing factor in periodontal breakdown. J Am Dent Assoc 1979;99:210-1.

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Case Report
loss was minimal. The patient tolerated the procedure well and post operation was in good course. Three months later the patient underwent a left retroperitoneal laparoscopic radical nephrectomy. Utilizing 4 port technique, the procedure was uncomplicated and performed with no trouble associating with the repaired AAA (Figure 3). Estimated blood loss was only 94 mL. Post nephrectomy, retroperitoneal abscess was occurred, but it was cured by percutaneous drainage. The patient recovered well after drainage. Pathology revealed clear cell carcinoma in solid masses of 4 cm and 5 cm, which were presumed to be T1bN0M0 renal cell carcinoma. S-creatinine (mg/dL) was elevated from baseline of 1.1-1.5 to 1.7 in 6 months as expected. prosthesis is potentially life threatening and dangerous for elderly and high-risk patients. This disadvantage is not less relevant in patients, which can be treated laparoscopic surgery or EVAR than open surgery. In our case, considering high age and the comorbidities, EVAR has been shown to be associated with a lower procedural mortality and morbidity in the short term, addition to shorter admission times and quicker recovery and offers the possibility of excluding the AAA rapture before treating the nephrectomy. Furthermore, left radical nephrectomy through retroperitoneal approach was very useful and safe with a good orientation of AAA in which endograft was inserted. Thus, the risk of direct graft contamination and rupture appears to be more markedly reduced. Therefore we recommend a combination of minimally invasive treatments of EVAR and laparoscopic surgery in a staged approach, which allowed a prompt selective patient recovery.

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Figure 3. Intraoperative photograph of laparoscopic nephrectomy after endovascular aneurysm repair. (A) Before nephrectomy; (B) After nephrectomy. AAA, abdominal aortic aneurysm.

Case Report
An 82-year-old male patient with hypertension (HT) and hyperlipidemia (HL) was referred to the department of vascular surgery in our hospital because of an incidental finding of left renal tumors and AAA, following an ultrasonography for medical work up by his physician. Computed tomography angiography of the abdomen/pelvis revealed an AAA and enhancing 5.1 cm and 4.6 cm left renal masses (Figure 1). A single renal artery that originates from the abdominal aorta supplied left kidney. Left renal cell carcinoma was suspected and the patient was referred to our department. From these findings, he was clinically diagnosed left renal cell carcinoma stageT1bN0 M0). His significant past medical history included HT, HL, and chronic renal insufficiency (S-cre; 1.2 mg/dL). He was deemed a candidate for EVAR by his vascular surgeon team. Considering his comorbidities and high age, a staged approach that consisted of EVAR followed by retroperitoneal laparoscopic radical nephrectomy was planned. The patient underwent successful placement of an aortic endograft through bilateral femoral artery exposure under general anesthesia (Figure 2). Blood

Laparoscopic radical nephrectomy has become an international standard of care for medium to large renal tumors in academic and urban centers. Until now, many renal laparoscopic procedures were carried out via two approaches, transperitoneal and retorperitoeal. Each approach has its advantages and disadvantages.3,4 There have been no controlled randomized studies that have compared the two approaches. In this case, considering the large AAA, retroperitoneal approach was easier and safer than transperitoneal with respect to the approach to renal artery. Partial nephrectomy is currently considered the standard for most T1a (4cm) renal tumors and acceptable alternative to radical nephrectomy for select T1b (>4cm) renal tumors.5 As the result of considering with double tumors and each tumor size >4cm, we concluded partial nephrectomy was very risky and hard. Finally, we concluded that retroperitoneal laparoscopic radical nephrectomy was the optimal procedure for him. Recently, EVAR to exclude AAA was introduced for patients of poor health status considered unfit for major surgery, and the qualified patient has also quickly replaced open aneurysm surgery for the management of AAA.6 The diagnosis of AAA and synchronous solid neoplasm is rare. This association is reported about 0.1-3% for real neoplasm.1 Most cases have been treated with one-staged procedure. In most of the previous cases, open nephrectomy and AAA surgery have been reported.7 One-staged open procedure in the patients with AAA and renal tumors may be associated with an increased risk of infection of the vascular prosthesis. Infection of vascular

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References
1. Veraldi GF, Tasselli S, De Manzoni G, Cordiano C. Surgical treatment of abdominal aortic aneurysm with concomitant renal cell carcinoma: a single-centre experience with review of the literature. J Cardiovasc Surg (Torino) 2006;47:643-9. 2. Porcellini M, Nastro P, Bracale U, et al. Endovascular versus open surgical repair of abdominal aortic aneurysm with concomitant malignancy. J Vasc Surg 2007;46: 16-23. 3. Ng CS, Gill IS, Ramani AP, et al. Transperitoneal versus retroperitoneal laparoscopic partial nephrectomy: patient selection and perioperative outcomes. J Urol 2005;174:846-9. 4. Wright JL, Porter JR. Laparoscopic partial nephrectomy: comparison of transperitoneal and retroperitoneal approaches. J Urol 2005;174:841-5. 5. Ljungberg B, Cowan NC, Hanbury DC, et al. EAU guidelines on renal cell carcinoma: the 2010 update. Eur Urol 2010;58:398-406. 6. United Kingdom EVAR Trial Investigators, Greenhalgh RM, Brown LC, et al. Endovascular versus open repair of abdominal aortic aneurysm. N Engl J Med 2010;362: 1863-71. 7. Hafez KS, El Fettouh HA, Novick AC, Ouriel K. Management of synchronous renal neoplasm and abdominal aortic aneurysm. J Vasc Surg 2000;32:1102-10.

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