In my previous post “The Little Devil Horn,” I showed a case of fractured Dens Evaginatus (DE) that had resulted in pulpal necrosis in an 11 years old girl. In almost all cases the tubercles fracture off as soon as the teeth come into occlusion. The resultant pulp exposure goes unnoticed until patient develops pain and symptoms and a combined endodontic-restorative procedures would then be necessary. Therefore, observation alone is not an acceptable approach.
The endodontic treatment for necrotic teeth with immature roots is either regenerative endodontics or MTA apexogenesis depending on many factors. The latter was used to treat the case of fractured DE with pulpal necrosis.
So, what should we do if we face a vital tooth with an intact tubercle?
Some evidence suggest gradually shaving off the tubercle over a period of few months in order to allow tertiary dentin formation is the treatment of choice. However, tertiary dentinogenesis may not provide a complete seal of the pulp chamber as this process lays down an irregularly formed dentinal structure.
Another approach (demonstrated below) would be to remove the tubercle mechanically under RD isolation and to seal off the resultant mechanical exposure, if any, with pulp capping material (such as BioDentin or MTA) and/or bonding material (if pinpoint exposure). This approach was performed for the same young patient for tooth #3-5.