Jordi | Journal of Oral Diagnosis Online Submission Review an Article SOBEP - Sociedade Brasileira de Estomatologia e Patologia Oral
Volume 3 - 2018

Case Report

DOI: 10.5935/2525-5711.20180007

A rare case of enamel pearl in canine tooth

Ana Carolina Ramos Mariz1; Gabriela Meyge de Brito2; Daniela Adorno Farias3; André Wilson Machado2; Paulo Sérgio Flores Campos1

1. Federal University of Bahia, Dentistry and Health section, Department of Oral Radiology - Salvador - Bahia - Brasil
2. Federal University of Bahia, Dentistry and Health section, Department of Orthodontics - Salvador - Bahia - Brasil
3. University of Chile, Faculty of Dentistry, Department of Oral Pathology - Santiago - Santiago - Chile

Corresponding authors: Ana Carolina Ramos Mariz

Article received on July 12, 2018
Article accepted on July 18, 2018



The enamel pearl (EP) is a dental developmental anomaly that usually manifests in furcation areas, and is uncommon in uniradicular teeth. We present a case of EP on the vestibular surface of tooth 13 in a 38-year-old patient, who was submitted to multislice computed tomography (MSCT) for orthognathic surgery planning. The attenuation coefficient (3.070 HU) allowed the condition to be classified as a true EP.

Keywords: Tooth Abnormalities; Multidetector Computed Tomography; Tooth, Impacted



Enamel pearls (EPs) are ectopic deposits of enamel that normally manifest in the furcation region and close to the cemento-enamel junction1,2, and show a prevalence ranging between 0.82% and 5.1%1,3-5. They mainly affect the permanent maxillary molars4,6,7, especially the second and third molars1,2,8 and vary from 0.3 to 4 mm in diameter1,3,6. Microscopically, EPs present prismatic enamel and can be classified as true pearls (consisting of enamel only), enamel-dentin pearls (made up of enamel and tubular dentin) and enamel-dentin-pulp pearls1,3,5-7.

The etiopathogenesis of EPs is unknown, but the most widely accepted theory is that these pearls result from a localized developmental activity of the remnant of Hertwig's epithelial root sheath1-4,6,8-10. Ameloblasts are believed to differentiate into functioning cells that produce enamel deposits on tooth roots1-3,5,8-10. The possibility of the condition being of a hereditary nature has been admitted7,10,11.

The aim of this report was to relate a rare case of EP in a permanent canine tooth evaluated by computed tomography.


The patient, a 38-year-old woman was submitted to multislice computed tomography (MSCT) for the purpose of planning orthognathic surgery, which revealed an compound odontoma beneath tooth 83, tooth 43 impacted and localized below the molars, and an EP in the vestibular cervical region of tooth 13 (Figure 1).

Figure 1. 3D reconstruction showing tooth 43 in an ectopic position, compound odontoma beneath tooth 83, and PE on buccal aspect of tooth 13 (on detail).

The attenuation coefficient of the EP (3.070 HU) was shown to be equivalent to that of the enamel of tooth 18 (3.073 HU) (Figure 2), which led us to the diagnosis of a true EP.

Figure 2. Axial image, bone window, showing the measurement of HU on EP (point 1) and on enamel of tooth 18 (point 2).


The occurrence of EPs in uniradicular teeth is uncommon10,12, because prevalence studies have not reported cases of EP in uniradicular teeth1,5. To the best of our knowledge, only two cases of EP in uniradicular teeth have been reported: one in a mandibular central incisor12 and the other in a mandibular first premolar10. Among the 45.785 teeth in a human tooth bank, the following data were observed: 287 molars (0.627%) with one EP; 57 molars (0.125%) with EPs; and 1 molar (0.002%) with 3 EPs; 26 premolars (0.057%) with one EP and 4 canines (0.009%) with one EP4.

The ectopic enamel of both pearls and cervical enamel projections has frequently been associated with periodontal destruction in molars6,7,9,12,13. In these cases, attachment of the periodontal ligament does not occur appropriately, which makes it difficult to control biofilm and restricts access for root scaling and planing12, thus contributing to the formation of periodontal pockets6-8,10,12. Patients who present EP need follow-up and prevention programs for preventing the appearance of periodontal disease2,6. Some authors have suggested that EPs must be removed to allow appropriate biofilm control and prevent future (clinical) attachment loss6,10.

Radiographically, EPs are seen as dense, circumscribed radiopacities in the crown or root of the affected tooth5,6. The density, architecture and localization of the EP may be better defined by the high resolution of cone beam computed tomography (CBCT)1,9. This exam modality also helps to evaluate the distance between the EP and alveolar bone crest or furcation area, which provides a more precise prognosis of the future risk of periodontal bone loss12. The MSCT used in the present case showed only enamel in the constitution of the pearl, allowing us to classify it as a true pearl.


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